African-Americans more likely to die at first coronary event

African-American men and women continue to have higher risks of dying at the first presentation of heart disease compared with their white counterparts, according to a study published in the Journal of the American Medical Association.

Researchers from the National Institutes of Health (NIH)-supported Reasons for Geographic and Racial Differences in Stroke (REGARDS) study found that African-American men and women were about twice as likely to die from coronary heart disease compared with their age-matched white counterparts. African-American women had a higher incidence of fatal and nonfatal coronary disease than white women. The findings are based on an analysis of 24,443 men and women.

Health Disparity Programs

“This is very similar to reports on people in the 1990s,” Monika Safford, MD, professor of medicine at the University of Alabama at Birmingham, and lead author of the study, told Formulary. “Our efforts in the past 10 years to eliminate this health disparity through programs like Healthy People 2010 did not work as well as we may have hoped. The good news is that most of this excess risk in our study was due to the burden of well-established risk factors, including diabetes, smoking, cholesterol, and high blood pressure. Effective programs to reduce these risk factors exist, so we now need to figure out how to better get them to people in African-American communities.”

The REGARDS study was originally designed to study differences in stroke. Dr Safford and colleagues collaborated with the study lead investigators to create an ancillary study on differences in heart disease.

“These differences are long-standing, but past studies come from an era when statin medications were not in wide use,” Dr Safford said. “Also, the past 10 years saw a lot of emphasis on eliminating health disparities. So a fresh look at this issue was warranted.” The ancillary study was funded by the National Heart, Lung and Blood Institute.

REGARDS participants were recruited between 2003 and 2007 from all over the continental United States using an unusual approach, according to Dr Safford.

“Rather than asking people to come to us as is usually done in research studies, we went to them,” she explained. “We partnered with a company that provides insurance physicals in the home, and their trained staff went to people’s homes to collect our data. This allowed us to include people in REGARDS who live far away from academic centers and therefore have not been included in past studies.”

Study participants answered questions about their medical history and lifestyle on the phone, and then underwent an in-home examination to collect blood pressure, height and weight, an electrocardiogram, and blood and urine samples.

“We are now calling people every 6 months to check on them, and if they were hospitalized, we obtain their medical records to let our expert team adjudicate whether a heart attack occurred,” Dr Safford said.

According to Dr Safford, a major contributor to the excess risk in African-Americans was risk factors that are familiar. “Diabetes, hypertension, kidney disease-consequences of hypertension-and smoking were all more common in African-Americans,” she said. “Many of these risk factors can be controlled with medications. This is especially true for cholesterol, where statins have really changed the landscape of risk reduction. Blood pressure is very hard to control without medications, and many people need several to achieve control. Smoking cessation is very difficult, and can be facilitated through medications. Of course it is very important that people eat healthier and exercise more, but as critical as that is, it is often very difficult to accomplish.”

Dr Safford’s study included a lot of heart attack events that were not detectable in the past. “One unusual finding related to technologic advances in the laboratory assays used to detect troponin, the cardiac biomarker that is now most widely used to monitor people having a heart attack. These assays have been perfected in recent years so that very tiny amounts of troponin can now be routinely detected.  We described that about 30% of modern heart attacks were not detectable in the past. How these tiny heart attacks affect the study of health disparities is an emerging area of research,” she said.

It is going to take some work to eliminate this disparity in health, according to Dr Safford. “It is tragic that so many people still die at their first presentation with heart disease, and that African-Americans are at such high risk of this health outcome,” she said. “We need to redouble our efforts to create programs specifically targeted at African-American communities that help people optimize their risk factors and seek medical care at the earliest signs of a heart problem.” ■