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Differences in Cardiovascular Risk, Coronary Artery Disease, and Cardiac Events Between Black and White Individuals
Lili Zhang1,2, Devvora Olalere1, Thomas Mayrhofer1,3
1Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Black individuals with stable chest pain had a higher cardiovascular risk burden but similar rates of major adverse cardiac events compared to White individuals. Coronary artery calcium, stenosis, and high-risk plaque were less prevalent in Black persons despite greater risk factors.
Area of Science:
- Cardiology
- Medical Research
- Health Disparities
Background:
- Race and ethnicity are recognized risk factors for cardiovascular disease.
- Limited understanding exists regarding differences in risk factors, coronary artery disease, and cardiac events between Black and White individuals undergoing noninvasive testing.
Purpose of the Study:
- To evaluate disparities in cardiovascular risk burden, coronary plaque characteristics, and major adverse cardiac events (MACE) between Black and White patients with stable chest pain.
- To compare outcomes between Black and White individuals undergoing coronary computed tomography angiography (CCTA) or functional testing.
Main Methods:
- A nested observational cohort study within the PROMISE trial included 1071 Black and 7693 White participants with stable chest pain.
- Data were collected from 193 outpatient sites in North America between February 2015 and November 2021.
- The primary endpoint was a composite of death, myocardial infarction, or hospitalization for unstable angina over a median 24.4-month follow-up.
Main Results:
- Black participants exhibited a higher cardiovascular risk burden (hypertension, diabetes) but experienced similar MACE rates (3.0% vs. 3.2%) compared to White participants over a median 2-year follow-up.
- Despite higher risk, Black individuals showed lower prevalence of coronary artery calcium (45.1% vs. 63.2%), significant coronary stenosis (8.7% vs. 14.6%), and high-risk plaque (37.6% vs. 52.4%) on CCTA compared to White individuals.
- Sensitivity analyses confirmed these findings in subgroups not receiving statin therapy or with normal/mildly abnormal noninvasive test results.
Conclusions:
- Despite a greater cardiovascular risk burden, Black individuals demonstrated lower prevalence of coronary artery calcium, stenosis, and high-risk plaque compared to White individuals.
- These findings indicate significant differences in cardiovascular risk burden and coronary plaque characteristics between Black and White individuals presenting with stable chest pain.
- Further research is needed to understand the underlying mechanisms driving these observed disparities.
Importance:
Race and ethnicity have been studied as risk factors in cardiovascular disease. How risk factors, epicardial coronary artery disease, and cardiac events differ between Black and White individuals undergoing noninvasive testing for coronary artery disease is not known.
Objective:
To assess differences in cardiovascular risk burden, coronary plaque, and major adverse cardiac events between Black and White individuals assigned to receive coronary computed tomography angiography (CCTA) or functional testing for stable chest pain.
Design, Setting, And Participants:
A nested observational cohort study within the PROMISE trial was conducted at 193 outpatient sites in North America. A total of 1071 non-Hispanic Black (hereafter Black) and 7693 non-Hispanic White (hereafter White) participants with stable chest pain undergoing noninvasive cardiovascular testing were included. This analysis was conducted from February 13, 2015, to November 2, 2021.
Main Outcomes And Measures:
The primary end point was the composite of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 24.4 months.
Results:
Among 1071 Black individuals (12.2%) (women, 646 [60.3%]; mean [SD] age, 59 [8] years) and 7693 White individuals (87.8%) (women, 4029 [52.4%]; mean [SD] age, 61.1 [8.4] years), Black participants had a higher cardiovascular risk burden (more hypertension and diabetes), yet there was a similarly low major adverse cardiovascular events rate over a median 2-year follow-up (32 [3.0%] vs 243 [3.2%]; P = .84). Sensitivity analyses restricted to the 79.8% (6993 of 8764) individuals with a normal or mildly abnormal noninvasive testing result and the 54.3% (4559 of 8396) not receiving statin therapy yielded similar findings. In comparison of Black and White individuals in the CCTA group (n = 3323), significant coronary stenosis (hazard ratio [HR], 7.21; 95% CI, 1.94-26.76 vs HR, 4.30; 95% CI, 2.62-7.04) and high-risk plaque (HR, 3.47; 95% CI, 1.00-12.06 vs HR, 2.21; 95% CI, 1.37-3.57) were associated with major adverse cardiovascular events in both Black and White patients. However, with respect to epicardial coronary artery disease burden, Black individuals had a less-prevalent coronary artery calcium score greater than 0 (45.1% vs 63.2%; P < .001), coronary stenosis greater than or equal to 50% (32 [8.7%] vs 430 [14.6%]; P = .001), and high-risk plaque (139 [37.6%] vs 1547 [52.4%]; P < .001).
Conclusions And Relevance:
The findings of this study suggest that, despite a greater cardiovascular risk burden in Black persons, rates of coronary artery calcium, stenosis, and high-risk plaque observed via CCTA were lower in Black persons than White persons. This result suggests differences in cardiovascular risk burden and coronary plaque in Black and White individuals with stable chest pain.
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