Disparities in Cardiovascular Disease Risk in the United States

Author(s): Garth Graham

Journal Name: Current Cardiology Reviews

Volume 11 , Issue 3 , 2015

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Graphical Abstract:


This is a comprehensive narrative review of the literature on the current science and evidence of population-level differences in risk factors for heart disease among different racial and ethnic population in the United States (U.S.). It begins by discussing the importance of population-level risk assessment of heart disease in light of the growth rate of specific minority populations in the U.S. It describes the population-level dynamics for racial and ethnic minorities: a higher overall prevalence of risk factors for coronary artery disease that are unrecognized and therefore not treated, which increases their likelihood of experiencing adverse outcome and, therefore, potentially higher morbidity and mortality. It discusses the rate of Acute Coronary Syndrome (ACS) in minority communities. Minority patients with ACS are at greater risk of myocardial infarction (MI), rehospitalization, and death from ACS. They also are less likely than non-minority patients to receive potentially beneficial treatments such as angiography or percutaneous coronary intervention. This paper looks at the data surrounding the increased rate of heart disease in racial and ethnic minorities, where the risk is related to the prevalence of comorbidities with hypertension or diabetes mellitus, which, in combination with environmental factors, may largely explain CHF disparity. The conclusion is that it is essential that healthcare providers understand these various communities, including nuances in disease presentation, risk factors, and treatment among different racial and ethnic groups. Awareness of these communities’ attributes, as well as differences in incidence, risk factor burdens, prognosis and treatment are necessary to mitigate racial and ethnic disparities in heart disease.

Keywords: Acute coronary, syndrome heart disease, health disparities, hypertension.

Bureau USC. An Older and More Diverse Nation by Midcentury 2009.http://web.archive.org/web/20080822044429/http://wwwcensus.gov/Press-Release/www/releases/archives/population/ 012496. html Accessed July 18, 2011]
Mayberry R, Boone L. Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Henry J. Kaiser Family Foundation; October 2002.
Vivo RP, Krim SR, Liang L, et al. Short- and long-term rehospitalization and mortality for heart failure in 4 racial/ethnic populations. J Am Heart Assoc 2014; 3(5)e001134
Lurie N, Fremont A, Jain AK, et al. Racial and ethnic disparities in care: the perspectives of cardiologists. Circulation 2005; 111(10): 1264-9.
Nasir K, Shaw LJ, Liu ST, et al. Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality. J Am Coll Cardiol 2007; 50(10): 953-60.
Watkins LO. Epidemiology and burden of cardiovascular disease. Clin Cardiol 2004; 27(6)(Suppl. 3): 1112-6.
Yeo K, Li Z, Amsterdam EA. Abstract 3117: Clinical Characteristics and Operative Mortality Among Whites, Hispanics, Asians and Blacks in the 2003 California Coronary Artery Bypass Graft Surgery Outcomes Reporting Program. Circulation 2006; 114: 11-658.
Kurian AK, Cardarelli KM. Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis 2007; 17(1): 143-52.
Bonow RO, Grant AO, Jacobs AK. The cardiovascular state of the union: confronting healthcare disparities. Circulation 2005; 111(10): 1205-7.
Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation 2005; 111(10): 1233-41.
Roger VL, Go AS, Lloyd-Jones DM, et al. Executive Summary: Heart Disease and Stroke Statistics 2011 Update: A Report from the American Heart Association. Circulation 2011; 123: 459-63.
Wyatt SB, Williams DR, Calvin R, Henderson FC, Walker ER, Winters K. Racism and cardiovascular disease in African Americans. Am J Med Sci 2003; 325(6): 315-31.
Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension 2007; 49(1): 69-75.
Redmond N, Baer HJ, Hicks LS. Health behaviors and racial disparity in blood pressure control in the national health and nutrition examination survey. Hypertension 2011; 57(3): 383-9.
Kidambi S, Kotchen JM, Grim CE, et al. Association of adrenal steroids with hypertension and the metabolic syndrome in blacks. Hypertension 2007; 49(3): 704-11.
Bibbins-Domingo K, Gupta R, Na B, Wu AH, Schiller NB, Whooley MA. N-terminal fragment of the prohormone brain-type natriuretic peptide (NT-proBNP), cardiovascular events, and mortality in patients with stable coronary heart disease. JAMA 2007; 297(2): 169-76.
Astor BC, Yi S, Hiremath L, et al. N-terminal prohormone brain natriuretic peptide as a predictor of cardiovascular disease and mortality in blacks with hypertensive kidney disease: the African American Study of Kidney Disease and Hypertension (AASK). Circulation 2008; 117(13): 1685-92.
Krim SR, Vivo RP, Krim NR, et al. Racial/Ethnic differences in B-type natriuretic peptide levels and their association with care and outcomes among patients hospitalized with heart failure: findings from Get With The Guidelines-Heart Failure. JACC Heart Fail 2013; 1(4): 345-52.
Kaul P, Lytle BL, Spertus JA, DeLong ER, Peterson ED. Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease. Circulation 2005; 111(10): 1284-90.
Shaw LJ, Shaw RE, Merz CN, et al. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry. Circulation 2008; 117(14): 1787-801.
McSweeney JC, O’Sullivan P, Cody M, et al. Abstract 3306: Black, Hispanic, and White Women’s Symptoms of Coronary Heart Disease. Circulation 2006; 114: 11-702.
Finkelstein EA, Khavjou OA, Mobley LR, Haney DM, Will JC. Racial/ethnic disparities in coronary heart disease risk factors among WISEWOMAN enrollees. J Womens Health (Larchmt) 2004; 13(5): 503-18.
van Ryn M, Burgess D, Malat J, Griffin J. Physicians’ perceptions of patients’ social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease. Am J Public Health 2006; 96(2): 351-7.
Slater J, Selzer F, Dorbala S, et al. Ethnic differences in the presentation, treatment strategy, and outcomes of percutaneous coronary intervention (a report from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol 2003; 92(7): 773-8.
Popescu I, Cram P, Vaughan-Sarrazin MS. Differences in admitting hospital characteristics for black and white medicare beneficiaries with acute myocardial infarction. Circulation 2011; 123(23): 2710-6.
Bahrami H, Kronmal R, Bluemke DA, et al. Differences in the incidence of congestive heart failure by ethnicity: the multi-ethnic study of atherosclerosis. Arch Intern Med 2008; 168(19): 2138-45.
Franciosa JA, Taylor AL, Cohn JN, et al. African-American Heart Failure Trial (A-HeFT): rationale, design, and methodology. J Card Fail 2002; 8(3): 128-35.
Taylor AL, Ziesche S, Yancy CW, et al. Early and sustained benefit on event-free survival and heart failure hospitalization from fixed-dose combination of isosorbide dinitrate/hydralazine: consistency across subgroups in the African-American Heart Failure Trial. Circulation 2007; 115(13): 1747-53.
Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol 2007; 49(2): 198-207.
Gillum R. Stroke in blacks. Stroke 1988; 19: 1-9.
Kleindorfer DO, Khoury J, Moomaw CJ, et al. Stroke incidence is decreasing in whites but not in blacks: a population-based estimate of temporal trends in stroke incidence from the Greater Cincinnati/Northern Kentucky Stroke Study. Stroke 2010; 41(7): 1326-31.
Bravata DM, Wells CK, Gulanski B, et al. Racial disparities in stroke risk factors: the impact of socioeconomic status. Stroke 2005; 36(7): 1507-11.
Ferris A, Robertson RM, Fabunmi R, Mosca L. American Heart Association and American Stroke Association national survey of stroke risk awareness among women. Circulation 2005; 111(10): 1321-6.
Howard G, Prineas R, Moy C, et al. Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study. Stroke 2006; 37(5): 1171-8.
Mitchell BD, Stern MP, Haffner SM, Hazuda HP, Patterson JK. Risk factors for cardiovascular mortality in Mexican Americans and non-Hispanic whites. San Antonio Heart Study. Am J Epidemiol 1990; 131(3): 423-33.
Liao Y, Cooper RS, Cao G, Kaufman JS, Long AE, McGee DL. Mortality from coronary heart disease and cardiovascular disease among adult U.S. Hispanics: findings from the National Health Interview Survey (1986 to 1994). J Am Coll Cardiol 1997; 30(5): 1200-5.
Allison MA, Budoff MJ, Wong ND, Blumenthal RS, Schreiner PJ, Criqui MH. Prevalence of and risk factors for subclinical cardiovascular disease in selected US Hispanic ethnic groups: the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 2008; 167(8): 962-9.
Carnethon MR, Gulati M, Greenland P. Prevalence and cardiovascular disease correlates of low cardiorespiratory fitness in adolescents and adults. JAMA 2005; 294(23): 2981-8.
Swenson CJ, Trepka MJ, Rewers MJ, Scarbro S, Hiatt WR, Hamman RF. Cardiovascular disease mortality in Hispanics and non-Hispanic whites. Am J Epidemiol 2002; 156(10): 919-28.
Haffner SM, Stern MP, Hazuda HP, Rosenthal M, Knapp JA. The role of behavioral variables and fat patterning in explaining ethnic differences in serum lipids and lipoproteins. Am J Epidemiol 1986; 123(5): 830-9.
Bild DE, Detrano R, Peterson D, et al. Ethnic differences in coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 2005; 111(10): 1313-20.
Reaven PD, Thurmond D, Domb A, Gerkin R, Budoff MJ, Goldman S. Comparison of frequency of coronary artery calcium in healthy Hispanic versus non-Hispanic white men by electron beam computed tomography. Am J Cardiol 2003; 92(10): 1198-200.
Morales LS, Leng M, Escarce JJ. Risk of cardiovascular disease in first and second generation Mexican-Americans. J Immigr Minor Health 2011; 13(1): 61-8.
Mochari-Greenberger H, Mosca L. Racial/Ethnic Differences in Medication Uptake and Clinical Outcomes Among Hospitalized Cardiovascular Patients With Hypertension and Diabetes. Am J Hypertens 2014; •••hpu101
Vivo RP, Krim SR, Cevik C, Witteles RM. Heart failure in Hispanics. J Am Coll Cardiol 2009; 53(14): 1167-75.
Vivo RP, Krim SR, Krim NR, et al. Care and outcomes of Hispanic patients admitted with heart failure with preserved or reduced ejection fraction: findings from get with the guidelines-heart failure. Circ Heart Fail 2012; 5(2): 167-75.
Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2002; 287(3): 356-9.
Ingelsson E, Arnlov J, Lind L, Sundstrom J. Metabolic syndrome and risk for heart failure in middle-aged men. Heart 2006; 92(10): 1409-13.
Parikh SV, Enriquez JR, Selzer F, et al. Abstract 916: Association of a Unique Cardiovascular Risk Profile with Outcomes in Hispanic Patients Referred for PCI: Results from the NHLBI Dynamic Registry. Circulation 2008; 118: S_632..
Krim SR, Vivo RP, Krim NR, et al. Regional differences in clinical profile, quality of care, and outcomes among Hispanic patients hospitalized with acute myocardial infarction in the Get with Guidelines-Coronary Artery Disease (GWTG-CAD) registry. Am Heart J 2011. 162(6): 988-995 e984
Riegel B, Carlson B, Romero T. Abstract 2508: Designing Disease Management Programs for Hispanics with Heart Failure. Circulation 2006. 114: II_517-II_518.
Ueshima H, Sekikawa A, Miura K, et al. Cardiovascular disease and risk factors in Asia: a selected review. Circulation 2008; 118(25): 2702-9.
Palaniappan LP, Araneta MR, Assimes TL, et al. Call to action: cardiovascular disease in Asian Americans: a science advisory from the American Heart Association. Circulation 2010; 122(12): 1242-52.
Ajjan R, Carter AM, Somani R, Kain K, Grant PJ. Ethnic differences in cardiovascular risk factors in healthy Caucasian and South Asian individuals with the metabolic syndrome. J Thromb Haemost 2007; 5(4): 754-60.
Heald AH, Anderson SG, Ivison F, Laing I, Gibson JM, Cruickshank K. C-reactive protein and the insulin-like growth factor (IGF)-system in relation to risk of cardiovascular disease in different ethnic groups. Atherosclerosis 2003; 170(1): 79-86.
Bartys S, Baker D, Lewis P, Middleton E. Inequity in recording of risk in a local population-based screening programme for cardiovascular disease. Eur J Cardiovasc Prev Rehabil 2005; 12(1): 63-7.
D’Agostino RB Sr, Grundy S, Sullivan LM, Wilson P, Group CHDRP. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. JAMA 2001; 286(2): 180-7.
Aarabi M, Jackson PR. Predicting coronary risk in UK South Asians: an adjustment method for Framingham-based tools. Eur J Cardiovasc Prev Rehabil 2005; 12(1): 46-51.
Tang H, Shimizu R, Chen MS Jr. English language proficiency and smoking prevalence among California’s Asian Americans. Cancer 2005; 104(12)(Suppl.): 2982-8.
Gupta M, Doobay AV, Singh N, et al. Risk factors, hospital management and outcomes after acute myocardial infarction in South Asian Canadians and matched control subjects. CMAJ 2002; 166(6): 717-22.
King KM, Khan NA, Quan H. Ethnic variation in acute myocardial infarction presentation and access to care. Am J Cardiol 2009; 103(10): 1368-73.
Zaman MJ, Crook AM, Junghans C, et al. Ethnic differences in long-term improvement of angina following revascularization or medical management: a comparison between south Asians and white Europeans. J Public Health (Oxf) 2009; 31(1): 168-74.
Chaturvedi N. Ethnic differences in cardiovascular disease. Heart 2003; 89(6): 681-6.
Eapen D, Kalra GL, Merchant N, Arora A, Khan BV. Metabolic syndrome and cardiovascular disease in South Asians. Vasc Health Risk Manag 2009; 5: 731-43.
Yancy CW, Wang TY, Ventura HO, et al. The coalition to reduce racial and ethnic disparities in cardiovascular disease outcomes (credo): why credo matters to cardiologists. J Am Coll Cardiol 2011; 57(3): 245-52.
Modesti PA, Agostoni P, Agyemang C, et al. Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings. J Hypertens 2014; 32(5): 951-60.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095-128.

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Year: 2015
Page: [238 - 245]
Pages: 8
DOI: 10.2174/1573403X11666141122220003
Price: $65

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