Prognostic Impact of Race in Patients Undergoing PCI: Analysis From 10 Randomized Coronary Stent Trials

ObjectivesThe aim of this study was to assess race-based differences in patients undergoing percutaneous coronary intervention from a large pooled database of randomized controlled trials.BackgroundData on race-based outcomes after percutaneous coronary intervention are limited, deriving mainly from registries and single-center studies.MethodsBaseline characteristics and outcomes at 30 days, 1 year, and 5 years were assessed across different races, from an individual patient data pooled analysis from 10 randomized trials. Endpoints of interest included death, myocardial infarction, and major adverse cardiac events (defined as cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization). Multivariate Cox proportional hazards regression was performed to assess associations between race and outcomes, controlling for differences in 12 baseline covariates.ResultsAmong 22,638 patients, 20,585 (90.9%) were white, 918 (4.1%) were black, 404 (1.8%) were Asian, and 473 (2.1%) were Hispanic. Baseline and angiographic characteristics differed among groups. Five-year major adverse cardiac event rates were 18.8% in white patients (reference group), compared with 23.9% in black patients (p = 0.0009), 11.2% in Asian patients (p = 0.0007), and 21.5% in Hispanic patients (p = 0.07). Multivariate analysis demonstrated an independent association between black race and 5-year risk for major adverse cardiac events (hazard ratio: 1.28; 95% confidence interval: 1.05 to 1.57; p = 0.01).ConclusionsIn the present large-scale individual patient data pooled analysis, comorbidities were significantly more frequent in minority-group patients than in white patients enrolled in coronary stent randomized controlled trials. After accounting for these differences, black race was an independent predictor of worse outcomes, whereas Hispanic ethnicity and Asian race were not. Further research examining race-based outcomes after percutaneous coronary intervention is warranted to understand these differences.     

Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non‐Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non‐Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non‐Hispanic white ACS/MI patients were the 3 most‐studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.     

Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status

OBJECTIVES: To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES). DESIGN: Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge. PARTICIPANTS: Sixty-four North American EDs. RESULTS: A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced. CONCLUSION: Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.     

Clinical and nonclinical correlates of racial and ethnic differences in recommendation patterns for coronary revascularization

BACKGROUND: We sought to determine whether gender or racial differences exist in recommendations for coronary revascularization in a multiracial patient population undergoing their first coronary angiography at an academic institution from 1990-1993 for the evaluation of coronary artery disease (CAD). HYPOTHESIS: For patients with clinically significant CAD, no racial differences exist in the recommendation to revascularization following coronary angiography. METHODS: The main outcome measure was a recommendation for coronary revascularization such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) for patients with clinically significant CAD (n = 590). The primary multiple logistic regression analysis focused on only those patients with angiographically severe disease, defined as triple-vessel or left main CAD (n = 180). Race was trichotomized into Hispanic, black, and white to ascertain whether any differential effects of race/ethnicity existed while controlling for age, gender, ejection fraction, angina, diabetes, hypertension, and peripheral vascular disease. A medical record review for all patients with severe CAD, who were given a recommendation for medical therapy, was conducted to ascertain whether previously unmeasured clinical factors or nonclinical factors may have precluded a PTCA/CABG recommendation. RESULTS: Hispanics with severe disease were significantly less likely than whites to be given a recommendation for PTCA/CABG following angiography [odds ratio (OR) = 0.39; 95% confidence interval (CI) (0.17, 0.92)]. Blacks were 67% as likely as whites to be given such a recommendation [OR = 0.67; 95% CI (0.17, 2.71)]. Medical records, reviewed for 35 of 40 of these patients given a recommendation for medical therapy, revealed that 6 patients eventually had PTCA/CABG within 6 months due to precipitating ischemic events; 9 had such severe or diffuse disease that revascularization did not appear to be an alternative, and 2 patients opted for medical therapy. CONCLUSIONS: Racial differences were manifested in the recommendations made following angiography and may be explained by previously unmeasured clinical as well as nonclinical factors.     

Impact of hospital volume on racial disparities in cardiovascular procedure mortality.

OBJECTIVES: We assessed use of low-volume hospitals by race and ethnicity for major cardiovascular procedures and determined whether hospital volume is an important factor explaining racial and ethnic differences in post-procedure mortality. BACKGROUND: Low hospital volume predicts mortality for cardiovascular procedures and could be a mediator of racial and ethnic differences in procedure outcomes. METHODS: We analyzed data from 719,679 hospitalizations for cardiac artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) from 1998 to 2001 using the Nationwide Inpatient Sample. We used multivariate logistic regression to assess whether race predicts use of low-volume hospitals and the relative contribution of hospital volume to racial disparity in post-procedure in-hospital mortality. RESULTS: Black and Hispanic patients were more likely than white patients to receive cardiovascular procedures in low-volume hospitals. Black patients had greater risk-adjusted mortality than white patients after elective AAA repair (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.20 to 2.84), CABG (OR, 1.19; 95% CI, 1.06 to 1.33), and CEA (OR, 1.56; 95% CI, 1.07 to 2.27), but not PTCA. Hispanic patients did not have higher risk-adjusted mortality than white patients. Adjusting for hospital volume did not substantially reduce the relative risk of death for black patients compared with white patients. CONCLUSIONS: Black and Hispanic patients were more likely to receive cardiovascular procedures in low-volume hospitals, but hospital volume did not explain a large proportion of racial differences in post-procedure mortality. Additional research is needed to determine why black patients have increased mortality after cardiovascular procedures and how these mortality rates can be reduced.     

Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty

OBJECTIVE: The utilization of joint arthroplasty for knee or hip osteoarthritis varies markedly by patient race/ethnicity. Because of concerns about surgical risk, black patients are less willing to consider this treatment. There are few published race/ethnicity-specific data on joint arthroplasty outcomes. The present study was undertaken to examine racial/ethnic differences in mortality and morbidity following elective knee or hip arthroplasty. METHODS: Using information from the Veterans Administration National Surgical Quality Improvement Program database, data on 12,108 patients who underwent knee arthroplasty and 6,703 patients who underwent hip arthroplasty over a 5-year period were analyzed. Racial/ethnic differences were determined using prospectively collected data on patient characteristics, procedures, and short-term outcomes. The main outcome measures were risk-adjusted 30-day mortality and complication rates. RESULTS: Adjusted rates of both non-infection-related and infection-related complications after knee arthroplasty were higher among black patients compared with white patients (relative risk [RR] 1.50, 95% confidence interval [95% CI] 1.08-2.10 and RR 1.42, 95% CI 1.06-1.90, respectively). Hispanic patients had a significantly higher risk of infection-related complications after knee arthroplasty (RR 1.64, 95% CI 1.08-2.49) relative to otherwise similar white patients. Race/ethnicity was not significantly associated with the risk of non-infection-related complications (RR 0.97, 95% CI 0.68-1.38 in blacks; RR 1.18, 95% CI 0.60-2.30 in Hispanics) or infection-related complications (RR 1.27, 95% CI 0.91-1.78 in blacks; RR 1.22, 95% CI 0.63-2.36 in Hispanics) after hip arthroplasty. The overall 30-day mortality was 0.6% following knee arthroplasty and 0.7% following hip arthroplasty, with no significant differences by race/ethnicity observed for either procedure. CONCLUSION: Although absolute risks of complication are low, our findings indicate that, after adjustment, black patients have significantly higher rates of infection-related and non-infection-related complications following knee arthroplasty, compared with white patients. In addition, adjusted rates of infection-related complications after knee arthroplasty are higher in Hispanic patients than in white patients. Such differences between ethnic groups are not seen following hip arthroplasty. These groups do not appear to differ significantly in terms of post-arthroplasty mortality rates.     

Racial/ethnic variation in hypertension-related lifestyle behaviours among US women with self-reported hypertension

Healthy lifestyles such as regular physical activity, frequent consumption of fruits and vegetables, weight control/weight loss and limited alcohol consumption are effective and recommended in hypertension control. Using data collected from a total of 131 788 female participants (aged >/=18 years) of the 2003 Behavioral Risk Factor Surveillance System, we examined the racial/ethnic disparities in hypertension-related lifestyle behaviours in 36 770 US women with self-reported hypertension from five races/ethnicities (non-Hispanic white (29 237), non-Hispanic black (4288), Asian (445), American Indian/Alaska native (553) and Hispanic (2247)). The prevalence of hypertension varied by race/ethnicity, with the highest seen in non-Hispanic black population (36.9 versus 20.2-26.8% in other racial/ethnic groups). Of all hypertensive women, using non-Hispanic white women as the referent, we found that non-Hispanic black (adjusted odds ratio (AOR): 0.65; 95% confidence interval (CI): 0.55-0.77), American Indian/Alaska native (AOR: 0.72; 95% CI: 0.52-1.00) and Hispanic women (AOR: 0.70; 95% CI: 0.57-0.86) were significantly less likely to engage in physical activity at recommended levels; non-Hispanic black women were more likely to consume>/=8 servings per day of fruits and vegetables (AOR: 1.70; 95% CI: 1.24-2.34), and less likely to report losing weight (AOR: 0.61; 95% CI: 0.53-0.71). In addition, Hispanic hypertensive women were significantly more likely than non-Hispanic white women to receive weight-loss advice (AOR: 1.97; 95% CI: 1.60-2.44). In contrast, non-Hispanic white women were significantly more likely than those from other races/ethnicities to consume alcoholic beverages or engage in binge drinking. Our results demonstrate that race/ethnicity is an independent predictor of lifestyle behaviours related to hypertension control among American women with hypertension.Journal of Human Hypertension (2008) 22, 608-616; doi:10.1038/jhh.2008.52; published online 22 May 2008.     

Ethnic differences in the prognostic value of stress technetium-99m tetrofosmin gated single-photon emission computed tomography myocardial perfusion imaging

OBJECTIVES: This study was designed to evaluate the differential prognostic value of gated single-photon emission computed tomographic imaging (SPECT) imaging in an ethnically diverse multicenter registry. BACKGROUND: Ethnic minority patient populations have reportedly higher coronary heart disease mortality with greater comorbidity and a clustering of risk factors at a significantly younger age when compared with Caucasian, non-Hispanic patients. Despite our increasingly diverse population, the predictive accuracy of cardiac imaging in ethnic minority patients is ill-defined. METHODS: A total of 7,849 patients were prospectively enrolled in a registry of patients undergoing exercise (44%) or pharmacologic stress (56%) technetium-99m tetrofosmin SPECT. Scans were scored using a 20-segment myocardial model with a 5-point severity index. Multivariable Cox proportional hazards models were employed to assess time to death or myocardial infarction. RESULTS: A total of 1,993 African-American, 464 Hispanic, and 5,258 Caucasian non-Hispanic patients underwent SPECT imaging. African-American and Hispanic patients more often had a history of stroke, peripheral arterial disease, angina, heart failure, diabetes, hypertension, and smoking at a younger age. Moderate or severely abnormal SPECT scans were noted in 21%, 17%, and 13% of African-American, Hispanic, and Caucasian non-Hispanic patients, respectively (p < 0.0001). Cardiovascular death rates were highest for ethnic minority patients (p < 0.0001). Annual rates of ischemic heart disease death ranged from 0.2% to 3.0% for Caucasian non-Hispanic and 0.8% to 6.5% for African-American patients with low-risk to severely abnormal SPECT scans (p < 0.0001). For post-stress ejection fraction <45%, annualized risk-adjusted death rates were 2.7% for Caucasian non-Hispanic patients versus 8.0% and 14.0% for African-American and Hispanic patients (p < 0.0001). CONCLUSIONS: The current results from a large observational registry reveal that exercise and pharmacologic stress SPECT effectively predicts major cardiovascular events in a large cohort of African-American and Hispanic patients evaluated for suspected myocardial ischemia. These results provide further evidence that ethnic minority patient populations have a worsening outcome related to cardiovascular disease.     

The effect of race/ethnicity, sex, and social circumstances on coronary revascularization preferences: a vignette comparison

Disparities in cardiac care cannot be explained by clinical factors alone. We previously found that physicians' perceived nonclinical factors such as patient preferences influenced decisions for coronary revascularization. For this study, we mailed a questionnaire to a random sample of family medicine physicians, internists, cardiologists, and cardiothoracic surgeons to examine whether the patient's sex, race/ethnicity, and social circumstances impacted treatment preferences for different physician subgroups. All physicians were randomized to receive 1 of 4 questionnaires that contained a vignette describing certain hypothetical situations (desire for an active lifestyle, heavy career or family demands) for a 50-year patient who was a candidate for coronary revascularization who was 1) female, 2) male, 3) black male, or 4) white male. The response rate was 70% (544 of 777). The patient's race/ethnicity and sex did not significantly affect the physicians' treatment preferences. However, significant differences were found according to the social circumstance. More male physicians (78%) than female physicians (66%) recommended revascularization for patients with heavy family demands (P < 0.05). In logistic regression analyses, if the patient desired an active lifestyle, black and Hispanic physicians and fee-for-service physicians preferred revascularization less often than white and salaried physicians, respectively (odds ratio [OR] = 0.45 [0.21-0.94] for black/Hispanic; OR = 0.40 [0.18-0.86] for fee-for-service). Based on these results, certain social circumstances might influence treatment preferences among physician subgroups more than sex- or race-based patient factors. Research examining for causes of disparities in cardiac care should consider the effects of sociocultural issues on management decisions.     

Racial differences among high-risk patients presenting with non-ST-segment elevation acute coronary syndromes (results from the SYNERGY trial)

Management and outcomes of patients with acute coronary syndromes (ACSs) may vary according to patient race and ethnicity. To assess racial differences in presentation and outcome in high-risk North American patients with non-ST-segment elevation (NSTE) ACS, we analyzed baseline racial/ethnic differences and all-cause death or nonfatal myocardial infarction (MI) in 6,077 white, 586 African-American, and 344 Hispanic patients through 30-day, 6-month, and 1-year follow-up. Frequencies of hypertension were 66% for whites, 83% for African-Americans, and 78% for Hispanics (overall p <0.001). Use of angiography was similar across groups. Use of percutaneous coronary intervention (46% for whites, 41% for African-Americans, and 45% for Hispanics, overall p = 0.046) and coronary artery bypass grafting (20% for whites, 16% for African-Americans, and 22% for Hispanics, overall p = 0.044) differed. African-American patients had significantly fewer diseased vessels compared with white patients (p = 0.0001). Thirty-day death or MI was 14% for whites, 10% for African-Americans, and 14% for Hispanics (overall p = 0.034). After adjustment for baseline variables, African-American patients had lower 30-day death or MI compared with white patients (odds ratio 0.73, 95% confidence interval 0.55 to 0.98). There were no differences in 6-month death or MI across racial/ethnic groups. In conclusion, baseline clinical characteristics differed across North American racial/ethnic groups in the SYNERGY trial. African-American patients had significantly better adjusted 30-day outcomes but similar 6-month outcomes compared with white patients.     

Laboratory abnormalities at the onset of treatment of end-stage renal disease: are there racial or socioeconomic disparities in care?

BACKGROUND: Laboratory abnormalities at the start of treatment of end-stage renal disease (ESRD) have been reported as worse in racial/ethnic minorities than in white patients, suggesting racial disparities in care. It is not known whether these differences are attributable to racial/ethnic differences in socioeconomic status (SES). METHODS: We tested associations between race/ethnicity, SES, and type of medical insurance and serum creatinine level, estimated glomerular filtration rate, serum albumin level, and hematocrit at the start of treatment of ESRD and use of epoietin before ESRD treatment in a large national population-based sample. Data on 515 561 patients beginning ESRD treatment between January 1, 1996, and June 30, 2004, were obtained for this cross-sectional survey from the United States Renal Data System. RESULTS: Race/ethnicity had a much stronger association than SES with each laboratory measure. Adjusted mean serum creatinine levels were lowest in white patients (7.5 mg/dL [663.0 micromol/L]; 95% confidence interval [CI], 7.45-7.49) and highest in black patients (8.9 mg/dL [786.7 micromol/L]; 95% CI, 8.92-8.97) (P<.001 across racial/ethnic groups). Adjusted mean hematocrit for white patients (29.5%; 95% CI, 29.4%-29.6%) was significantly higher and for black patients (28.3%; 95% CI, 28.2%-28.4%) significantly lower than that of all other racial/ethnic groups (P<.001 across racial/ethnic groups). Less marked differences were present for estimated glomerular filtration rate and serum albumin level. In contrast, predialysis use of epoietin was associated with race/ethnicity (black vs white: odds ratio, 0.80; 95% CI, 0.78-0.81; Hispanic vs white: odds ratio, 0.87; 95% CI, 0.85-0.89) and showed a graded decrease with decreasing SES (odds ratio for the lowest vs highest socioeconomic quartile 0.68; 95% CI, 0.67-0.70). Patients without medical insurance had more abnormal laboratory values than those with insurance, but these associations were weaker than those of race/ethnicity. CONCLUSIONS: Minorities, particularly black patients, had more severe laboratory abnormalities at the start of ESRD treatment than white patients. These differences were not readily attributable to SES differences. Absence of medical insurance, SES, and race/ethnicity were associated with the likelihood of predialysis use of epoietin.     

Project Match treatment participation and outcome by self-reported ethnicity

BACKGROUND: There is a lively ongoing debate concerning the need for culturally congruent alcohol treatment, with the assumption that such treatment would meaningfully address treatment outcome disparities among ethnic minorities. Although valid on the face of it, no randomized clinical trials have yet prospectively investigated and documented whether, in fact, different ethnic groups actually fare better or worse from one another when offered mainstream, culturally "incongruent" treatment. The purpose of this study was to contrast Hispanic, black, and white client treatment engagement and outcome in an effort to identify potential health disparities related to client ethnicity. METHODS: The Project Match outpatient (N = 952) and aftercare (N = 774) samples were divided according to self-reported ethnicity: Hispanic (n = 141; 8%), black (n = 168; 10%), and white (n = 1380; 80%). Controlling for socioeconomic status using the Hollingshead Occupational scale, the three ethnic groups were contrasted on pretreatment characteristics, rates of treatment attendance, three scales of therapeutic alliance, satisfaction with treatment, and drinking outcomes for the 12 months after treatment. RESULTS: Ethnic differences in rates of therapy attendance were not robust and dissipated after controlling for socioeconomic status. No mean ethnic differences in ratings of therapeutic bonding and agreement with therapy goals were obtained, but blacks and Hispanics reported higher agreement on the value of therapeutic tasks relative to whites. Nevertheless, whites reported significantly higher global satisfaction with treatment relative to Hispanics and blacks. No ethnic main effect was found in drinking intensity during the 12-month follow-up. In contrast and only in the outpatient sample, blacks (n = 51) reported significantly higher rates of monthly abstinence relative to whites (n = 679). CONCLUSIONS: Pretreatment characteristics predictive of positive treatment outcome favored white clients relative to Hispanic and black clients, but Hispanic and black clients fared at least as well as white clients during the 12-month follow-up, at least on two measures of drinking behavior. The absence, then, of poorer drinking outcomes for the ethnic minorities suggests that they may mobilize (1). different behavior change strategies and/or (2). additional social resources to achieve comparable drinking outcomes with white clients. Specific recommendations for future research are made.     

Racial and ethnic differences in the treatment and outcome of cardiogenic shock following acute myocardial infarction

We investigated the association between race/ethnicity on the use of cardiac resources in patients who have acute myocardial infarction that is complicated by cardiogenic shock. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial examined the effect of reperfusion and revascularization treatment strategies on mortality. Patients screened but not enrolled in the SHOCK Trial (n = 1,189) were entered into the SHOCK registry. Of the patients in the United States registry (n = 538) who had shock due to predominant left ventricular failure, 440 were characterized as white (82%), 42 as Hispanic (8%), 34 as African-American (6%), and 22 as Asian/other (4%). The use of invasive procedures differed significantly by race/ethnicity. Hispanic patients underwent coronary angiography significantly less often than did white patients (38 vs 66%, p = 0.002). Among those patients who underwent coronary angiography, there were no race/ethnicity differences in the proportion of patients who underwent revascularization (p = 0.353). Overall in-hospital mortality (57%) differed significantly by race/ethnicity (p = 0.05), with the highest mortality rate in Hispanic patients (74% vs 65% for African-Americans, 56% for whites, and 41% for Asian/other). After adjustment for patient characteristics and use of revascularization, there were no mortality differences by race/ethnicity (p = 0.262), with all race/ethnicity subgroups benefiting equally by revascularization. In conclusion, the SHOCK registry showed significant differences in the treatment and in-hospital mortality of Hispanic patients who had cardiogenic shock, with these patients being less likely to undergo percutaneous coronary intervention. Therefore, early revascularization should be strongly considered for all patients, independent of race/ethnicity, who develop cardiogenic shock after acute myocardial infarction.     

The evolving pattern of symptomatic coronary artery disease in the United States and Canada: baseline characteristics of the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial

Major improvements in medical therapy and percutaneous coronary intervention for coronary artery disease (CAD) have emerged during the previous 2 decades, but no randomized trial in patients with stable CAD has been powered to compare these 2 strategies for the hard clinical end points of death or myocardial infarction (MI), and previous studies have not evaluated the effect of coronary stents and intensive medical therapy on cardiac events during long-term follow-up. Between 1999 and 2004, 2,287 patients with documented myocardial ischemia and angiographically confirmed CAD were randomized to the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial, with a principal hypothesis that a strategy of percutaneous coronary intervention plus intensive, guideline-driven medical therapy would be superior to a strategy of intensive medical therapy alone. The primary end point was a composite of all-cause mortality or acute MI (time to first event) during a 2.5- to 7-year (median 5) follow-up. Baseline characteristics were a mean age of 62 +/- 5 years, 85% men, and 86% Caucasian. Mean duration of angina before randomization was 26 months (average 10 episodes/week), and 29% of patients were smokers, 67% had hypertension, 38% had previous MI, 71% had dyslipidemia, 34% had diabetes, 27% had previous revascularization, and 69% had multivessel CAD. Approximately 55% of patients met established criteria for the metabolic syndrome. In conclusion, baseline characteristics of the COURAGE trial study population indicate a highly symptomatic group of patients with CAD who have a significant duration and frequency of antecedent angina pectoris and a high prevalence of cardiac risk factors.     

Serum androgen levels in black, Hispanic, and white men

CONTEXT: Racial/ethnic differences in androgen levels could account for differences in prostate cancer risk, body composition, and bone loss. OBJECTIVE: The objective of the study was to investigate racial/ethnic variations in testosterone, bioavailable testosterone, dihydrotestosterone (DHT), SHBG, and dehydroepiandrosterone sulfate (DHEAS) levels. DESIGN: The Boston Area Community Health (BACH) Survey was a multistage stratified cluster random sample, recruiting from 2002 to 2005. SETTING: The study was a community-based sample of Boston. PARTICIPANTS: Participants included black, Hispanic, or white individuals, aged 30-79 yr, competent to sign informed consent and literate in English/Spanish. Of 2301 men recruited, 1899 provided blood samples (538 black, 651 Hispanic, 710 white). INTERVENTION: Intervention consisted of data obtained during in-person at-home interview, conducted by a bilingual phlebotomist/interviewer. MAIN OUTCOME MEASURE(S): Testosterone, bioavailable testosterone, DHT, DHT to testosterone ratio, SHBG, and DHEAS were measured. RESULTS: With or without adjustment for covariates, there were no significant differences in testosterone, bioavailable testosterone, or SHBG levels by race/ethnicity. DHEAS levels differed by race/ethnicity before covariate adjustment; after adjustment this difference was attenuated. Before adjustment, DHT and DHT to testosterone ratios did not significantly differ by racial/ethnic group. After adjustment, there was evidence of racial/ethnic differences in DHT (P = 0.047) and DHT to testosterone (P = 0.038) levels. Black men had higher DHT levels and DHT to testosterone ratios than white and Hispanic men. CONCLUSIONS: Because there are no racial/ethnic differences in testosterone levels, normative ranges need not be adjusted by race/ethnicity for androgen deficiency diagnosis for men aged 30-79 yr. Further investigation is needed to determine whether differences in DHT levels and DHT to testosterone ratio can help explain racial/ethnic variations in prostate cancer incidence, body composition, and bone mass.     

C-reactive protein levels among women of various ethnic groups living in the United States (from the Women's Health Study)

The distribution of C-reactive protein (CRP) levels was compared among 24,455 white, 475 black, 357 Asian, and 254 Hispanic women, all of whom are participants in the Women's Health Study. Median CRP levels were significantly higher among black women (2.96 mg/L, interquartile range [IQR] 1.19 to 5.86) than among their white (2.02 mg/L, IQR 0.81 to 4.37), Hispanic (2.06 mg/L, IQR 0.88 to 4.88), and Asian (1.12 mg/L, IQR 0.48 to 2.25) counterparts. As expected, women taking hormone replacement therapy had higher baseline CRP levels than women not taking hormone replacement therapy. No differences in low-density lipoprotein cholesterol or total cholesterol levels were observed between ethnic groups. In multivariate regression models, body mass index was a significant (p <0.001) predictor of elevated CRP concentrations among all race/ethnic groups, and control for body mass index substantially attenuated the differences noted in CRP levels across race/ethnic groups, particularly among black women. Control for all measured modifiable risk factors for cardiovascular disease did not entirely explain CRP differences. Among these women, the distribution of CRP levels varied significantly between the various race/ethnic groups.     

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)

Information about the impact of race/ethnicity on adverse outcomes after percutaneous coronary intervention (PCI) in the modern era is limited. Using consecutive patients from the National Heart, Lung, and Blood Institute Dynamic Registry, this study investigated differences in clinical presentation, treatment strategy, and acute and long-term outcomes in 3,669 white, 446 black, 301 Hispanic, and 201 Asian patients who underwent PCI. All comparisons were made to whites. Blacks were more likely than whites to be younger, women, and to present with a higher prevalence of cardiovascular risk factors (hypertension, diabetes, and smoking). Hispanics tended to be younger, hypertensive, diabetic, and to be undergoing their first cardiovascular procedure. Asians were, on average, younger, men, and presented more often with hypertension and diabetes than whites. Although the rate of stent implantation was significantly lower in blacks compared with whites (63% vs 74%, p <0.001), angiographic and procedural success rates were high (> or =95%) and did not differ by race/ethnicity. In-hospital mortality (0.2% vs 1.7%, p <0.05) and death/myocardial infarction (MI)/coronary artery bypass grafting (CABG) (3.1% vs 5.5%, p <0.05) were lower in blacks. All other in-hospital complications were similar to whites. At 1 year, there were no statistical differences in cumulative adverse event rates by ethnicity; however by 2 years there was a modestly higher mortality rate (adjusted RR 1.87; 95% confidence interval 1.15 to 3.04) and adverse event rate (death/MI, death/MI/CABG) among black patients. Thus, although differences in patient demographics, clinical presentation, angiographic characteristics and treatment strategies did not impact the incidence of acute and 1-year adverse outcomes of non-whites, there appears to be a significant reduction in event-free survival among blacks by 2 years.     

Hypertension Management in Minority Communities: A Clinician Survey

BACKGROUND: Rates of blood pressure (BP) control are lower in minority populations compared to whites. OBJECTIVE: As part of a project to decrease health-related disparities among ethnic groups, we sought to evaluate the knowledge, attitudes, and management practices of clinicians caring for hypertensive patients in a predominantly minority community. DESIGN/PARTICIPANTS: We developed clinical vignettes of hypertensive patients that varied by comorbidity (type II diabetes mellitus, chronic renal insufficiency, coronary artery disease, or isolated systolic hypertension alone). We randomly assigned patient characteristics, e.g., gender, age, race/ethnicity, to each vignette. We surveyed clinicians in ambulatory clinics of the 4 hospitals in East/Central Harlem, NY. MEASUREMENTS: The analysis used national guidelines to assess the appropriateness of clinicians' stated target BP levels. We also assessed clinicians' attitudes about the likelihood of each patient to achieve adequate BP control, adhere to medications, and return for follow-up. RESULTS: Clinicians' target BPs were within 2 mm Hg of the recommendations 9% of the time for renal disease patients, 86% for diabetes, 94% for isolated systolic hypertension, and 99% for coronary disease. BP targets did not vary by patient or clinician characteristics. Clinicians rated African-American patients 8.4% (p = .004) less likely and non-English speaking Hispanic patients 8.1% (p = .051) less likely than white patients to achieve/maintain BP control. CONCLUSIONS: Clinicians demonstrated adequate knowledge of recommended BP targets, except for patients with renal disease. Clinicians did not vary management by patients' sociodemographics but thought African-American, non-English-speaking Hispanic and unemployed patients were less likely to achieve BP control than their white counterparts.     

Management of coronary artery disease: therapeutic options in patients with diabetes

OBJECTIVES: The aim of this review is to discuss the particularities of coronary artery disease (CAD), the effect of intensive medical management and the outcome of percutaneous and surgical revascularization in patients with diabetes mellitus (DM). BACKGROUND: CAD represents the leading cause of death in patients with DM. Numerous clinical, biological and angiographic risk factors have been shown to be associated with CAD in diabetic patients. METHODS: Metabolic abnormalities in patients with DM including insulin resistance, hyperglycemia and dyslipidemia are briefly discussed. Then the potential roles of medical management and of percutaneous and surgical coronary revascularization are more extensively reviewed. RESULTS: More vigorous control of hyperglycemia, hyperlipidemia, hypertension and other risk factors may be of crucial importance for risk reduction. Despite remarkable progress in recent years, the choice of a coronary revascularization strategy remains a challenge in these patients. Diabetic patients with CAD are predisposed to higher cardiovascular events after balloon angioplasty. Whether stenting and new antiplatelet drugs improve the results of percutaneous revascularization in this population needs further evaluation. The superiority of the surgical approach is also not definitely established. Therefore, many aspects of coronary revascularization are still unclear in these patients. CONCLUSIONS: The results of ongoing randomized trials comparing multiple coronary stents to bypass surgery will likely provide some answers to our questions and additional randomized trials evaluating intensive diabetic control with or without coronary revascularization are needed to determine the best therapeutic approach in these patients.