Heart Disease - References

N Engl J Med 1999 Jul 22;341(4):285-7

Race, sex, and physicians' referrals for cardiac catheterization.

Davidoff F

Publication Types:

• Letter

PMID: 10419387, UI: 99328504

N Engl J Med 1999 Jul 22;341(4):285; discussion 286-7

Race, sex, and physicians' referrals for cardiac catheterization.

Helft G, Worthley SG, Chokron S

Publication Types:

• Letter

PMID: 10419386, UI: 99328503

N Engl J Med 1999 Jul 22;341(4):279-83; discussion 286-7

Misunderstandings about the effects of race and sex on physicians' referrals for cardiac catheterization.

Schwartz LM, Woloshin S, Welch HG

VA Outcomes Group, White River Junction, VT 05009, USA.

PMID: 10413743, UI: 99328502

Am J Cardiol 1999 Jul 1;84(1):31-6

Prediction of coronary heart disease mortality in blacks and whites: pooled data from two national cohorts.

Liao Y, McGee DL, Cooper RS

Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, Illinois 60153, USA. yliao@wpo.it.luc.edu

Statistical models used to predict personal risk of death from coronary heart disease (CHD) have been based on studies among white populations. We compared the predictive functions derived from black and white men and women, using the pooled data of 2 national cohorts: the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study and the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study. The participants included 6,937 white men, 940 black men, 9,202 white women, and 1,463 black women aged 30 to 74 years who were free of CHD at baseline. The 2 cohorts were followed for 20 and 15 years, respectively. There were no significant differences between blacks and whites in the magnitude of the Cox coefficients for most of the personal risk factors (i.e., age, systolic blood pressure, serum total cholesterol, smoking, and diabetes mellitus status) for men and women. The receiver operating characteristic (ROC) analyses, with all risk factors considered collectively, suggest that the models have similar ability to rank personal relative risk among blacks and whites. The areas under the ROC curve were 0.77 and 0.76 for white and black men, respectively, and 0.84 and 0.82 for white and black women, respectively. However, the equation derived from white men overestimated the 15-year cumulative CHD mortality in black men by about 60%. Thus, predictive functions derived from 1 demographic group (e.g., whites) can be applied to another subgroup (e.g., blacks) to rank personal risk. However, prediction of absolute risk is less accurate.

PMID: 10404847, UI: 99331733

Arterioscler Thromb Vasc Biol 1999 Jul;19(7):1776-83

The relationship of fibrinogen and factors VII and VIII to incident cardiovascular disease and death in the elderly: results from the cardiovascular health study.

Tracy RP, Arnold AM, Ettinger W, Fried L, Meilahn E, Savage P

Departments of Pathology and Biochemistry and the Laboratory for Clinical Biochemistry Research, University of Vermont College of Medicine, Burlington, Vermont, USA. rtracy@salus.uvm.edu

Little is known about the prospective associations of fibrinogen, factor VII, or factor VIII with cardiovascular disease (CVD) and mortality in the elderly. At baseline in the Cardiovascular Health Study (5888 white and African American men and women; aged >/=65 years), we measured fibrinogen, factor VIII, and factor VII. We used sex-stratified stepwise Cox survival analysis to determine relative risks (RRs) for CVD events and all-cause mortality (up to 5 years of follow-up), both unadjusted and adjusted for CVD risk factors and subclinical CVD. After adjustment, comparing the fifth quintile to the first, fibrinogen was significantly associated in men with coronary heart disease events (RR=2.1) and stroke or transient ischemic attack (RR=1.3), and also with mortality within 2.5 years of follow-up (RR=5.8) and later (RR=1.7). Factor VIII was significantly associated in men with coronary heart disease events (RR=1.5) and mortality (RR=1.8), and in women with stroke/transient ischemic attack (RR=1.4). For both factors, values were higher in those who died, whether causes were CVD-related or non-CVD-related, but highest in CVD death. Factor VII exhibited associations with incident angina (RR=1.44) in men and with death in women (RR, middle quintile compared with first=0.66). However, in general, factor VII was not consistently associated with CVD events in this population. We conclude that, if confirmed in other studies, the measurement of fibrinogen and/or factor VIII may help identify older individuals at higher risk for CVD events and mortality.

PMID: 10397698, UI: 99327071

Menopause 1999 Summer;6(2):147-55

Hormone replacement therapy for African American women: missed opportunities for effective intervention.

Nicholson WK, Brown AF, Gathe J, Grumbach K, Washington AE, Perez-Stable EJ

Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, MD 21202, USA.

OBJECTIVES: Because of the potential benefits and risks of hormone replacement therapy (HRT), information about the efficacy of HRT in different groups of women is important to patients and providers. The objectives of this study were to review the evidence on the benefits and risks of HRT in African American women and to present a quantitative analysis of the potential reduction in mortality from osteoporotic fractures and coronary heart disease and the potential increase in risk of breast and endometrial cancer. METHODS: A MEDLINE search of English-language observational studies and clinical trials on the effects of HRT on osteoporotic fractures and coronary heart disease (CHD) was conducted for the time period from 1966 to September 1998. Using available CHD mortality data for African American women and white women, potential reductions in mortality with HRT were explored for African American and white women. RESULTS: In the 30 studies on CHD and HRT, African American women were known to comprise only 173 (0.1%) of 148,437 participants. In 11 studies of HRT and osteoporotic fractures, only 128 (0.4%) of 40,299 participants were known to be African American women. An analysis of CHD mortality by decade intervals indicated that African American women, aged 55 to 64, are more likely to die from CHD each year than white women. Despite a lower incidence of breast and endometrial cancer among African American women, the mortality rates of African American women with these cancers is higher compared with white women. CONCLUSIONS: With the higher underlying CHD mortality rate among African American women, HRT is an important potential preventive therapy. The absence of African American women and other non-white women from clinical studies of HRT makes it difficult to fully assess the risks and benefits of HRT in this group of women.

Publication Types:

• Review
• Review, academic

PMID: 10374222, UI: 99302452

Am J Epidemiol 1999 May 1;149(9):853-62

Resting heart rate is a risk factor for cardiovascular and noncardiovascular mortality: the Chicago Heart Association Detection Project in Industry.

Greenland P, Daviglus ML, Dyer AR, Liu K, Huang CF, Goldberger JJ, Stamler J

Department of Preventive Medicine, Northwestern University Medical School, Chicago, IL 60611, USA.

In a prospective cohort study, associations of resting heart rate with risk of coronary, cardiovascular disease, cancer, and all-cause mortality in age-specific cohorts of black and white men and women were examined over 22 years of follow-up. Participants were employees from 84 companies and organizations in the Chicago, Illinois, area who volunteered for a screening examination. Participants included 9,706 men aged 18-39 years, 7,760 men aged 40-59 years, 1,321 men aged 60-74 years, 6,928 women aged 18-39 years, 6,915 women aged 40-59 years, and 1,151 women aged 60-74 years at the baseline examination in 1967-1973. Vital status was ascertained through 1992. For fatal coronary disease, multivariate-adjusted relative risks associated with a 12 beats per minute higher heart rate (one standard deviation) were as follows: for men aged 18-39 years, relative risk (RR) = 1.27 (95% confidence interval (CI) 1.08-1.48); for men aged 40-59 years, RR = 1.13 (95% CI 1.05-1.21); for men aged 60-74 years, RR = 1.00 (95% CI 0.89-1.12); for women aged 40-59 years, RR = 1.21 (95% CI 1.07-1.36); and for women aged 60-74 years, RR = 1.16 (95% CI 0.99-1.37). Corresponding risks for all fatal cardiovascular diseases were similar to those for coronary death alone. Deaths from cancer were significantly associated with heart rate in men and women aged 40-59 years. All-cause mortality was associated with higher heart rate in men aged 18-39 years (RR = 1.11, 95% CI 1.01-1.20), men aged 40-59 years (RR = 1.16, 95% CI 1.11-1.21), and women aged 40-59 years (RR = 1.20, 95% CI 1.13-1.27). Heart rate was not associated with mortality in women aged 18-39 years. In summary, heart rate was a risk factor for mortality from coronary disease, all cardiovascular diseases, and all causes in younger men and in middle-aged men and women, and for cancer mortality in middle-aged men and women.

PMID: 10221322, UI: 99236511

Stat Med 1999 Mar 30;18(6):655-79

Interpreting age, period and cohort effects in plasma lipids and serum insulin using repeated measures regression analysis: the CARDIA Study.

Jacobs DR Jr, Hannan PJ, Wallace D, Liu K, Williams OD, Lewis CE

University of Minnesota, Minneapolis 55454, USA. Jacobs@epivax.epi.umn.edu

Observed changes in health-related behaviours and disease risk factors may arise from physiological or environmental changes, or from biases due to sampling or measurement errors. We illustrate problems in the interpretation of such changes with longitudinal data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Mean plasma cholesterol was 14 mg/dl higher in 27- than in 20-year-old black men cross-sectionally, but longitudinally it declined by 4 mg/dl during the 7 years. To sort out these contradictory assessments of the effect of age/passage of time, we estimated age and period effects under the assumptions that age effects are a smooth function of age independent of period, and that period effects are changes common to persons across all ages. Simple estimates the age effect, such as the cross-sectional age slopes, may be confounded by cohort effects, by interactions of time and age after baseline, or by the occurrence of non-linearities in response after baseline. We note examples of each potential type of bias. The data and background literature support the assumption that cohort effects do not seriously compromise interpretation for these variables in the CARDIA study. Strong secular decreases in plasma cholesterol, apparently due to population-wide dietary change, mask increases with ageing. Age increases in triglycerides are largely explained by increases in body fatness. For these data, we cautiously accept the cross-sectional age slope as an estimate of ageing and the age-matched time trend as an estimate of secular trend.

Publication Types:

• Multicenter study

PMID: 10204196, UI: 99220397

Ann Epidemiol 1999 Apr;9(3):147-8

How do we evaluate and utilize data on ethnic differences?

Howard BV

Publication Types:

• Comment
• Editorial

Comments:

• Comment on: Ann Epidemiol 1999 Apr;9(3):149-58

PMID: 10192645, UI: 99206863

Am J Med Sci 1999 Mar;317(3):189-92

Traditional coronary risk factors in African Americans.

Potts JL, Thomas J

Department of Medicine, Meharry Medical College, Nashville, Tennessee 37208, USA.

The importance of traditional coronary artery disease risk factors in the development of coronary heart disease is well known. African Americans have a higher prevalence of such risk factors as hypertension, diabetes mellitus, obesity, cigarette smoking, and left ventricular hypertrophy, which might account for the disproportionate rate of coronary heart disease mortality in African Americans. Compelling data from randomized lipid-lowering trials show conclusively that lowering cholesterol levels, specifically low-density lipoprotein cholesterol, lowers coronary heart disease morbidity and mortality. Recent data has also demonstrated the beneficial effects of lowering blood pressure on cardiovascular mortality. Left ventricular hypertrophy, which results from elevated blood pressure, seems to raise coronary heart disease risks independently. Diabetes mellitus, cigarette use, physical inactivity, stress, and obesity play critical roles collectively and individually in increasing coronary heart disease, morbidity, and mortality. Clustering of coronary heart disease risk factors in African Americans must be strongly considered to play a critical role in the excess mortality from coronary heart disease seen in African Americans. New innovative approaches are required if the course of coronary heart disease is to be altered.

Publication Types:

• Review
• Review, tutorial

PMID: 10100693, UI: 99198792

Am J Med Sci 1999 Mar;317(3):168-75

Why is left ventricular hypertrophy so predictive of morbidity and mortality?

Benjamin EJ, Levy D

National Heart, Lung, and Blood Institute's Framingham Heart Study, MA 01702, USA. emelia@fram.nhlbi.nih.gov

The prevalence, prognosis, and predictors of left ventricular hypertrophy (LVH) are reviewed, and theories of the pathogenesis of the relation between LVH and poor prognosis are summarized to highlight controversies in the field. In the Framingham Heart Study, which consists largely of white people, echocardiographic LVH has a prevalence of 14% in men and 18% in women. The prevalence of LVH is reported to be elevated in African Americans compared with whites, although the higher prevalence has been attributed to the increased prevalence of hypertension and obesity. Echocardiographic LVH is independently associated with a variety of cardiovascular endpoints, including coronary heart disease and stroke. Furthermore, after adjusting for other cardiovascular disease risk factors, LVH is associated with a doubling in mortality in both white and African American cohorts. Despite the intensive investigation of LVH, there remain many unanswered questions: To what extent do genetic or other factors account for the large portion of the variance in LVH that remains unexplained? What is the prognosis of LVH and left ventricular geometry in a population-based African American cohort? How does the development and progression of LVH relate to other risk factors and their treatment? What is the relation of LVH to poor prognosis? The proposed Jackson Heart Study will help address many important unanswered questions regarding LVH.

Publication Types:

• Review
• Review, tutorial

PMID: 10100690, UI: 99198789

Am J Med Sci 1999 Mar;317(3):152-9

What is the role of dietary sodium and potassium in hypertension and target organ injury?

He J, Whelton PK

Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA. jhe@mailhost.tcs.tulane.edu

There is substantial evidence from both observational epidemiology studies and randomized controlled trials that dietary intake of sodium and potassium is important in the etiology of hypertension. However, the direct evidence for a direct link between dietary sodium and potassium and risk of cardiovascular and renovascular events is limited. Epidemiological studies should be designed to examine the relationship between dietary intake of sodium and potassium and risk of stroke, coronary heart disease, left ventricular hypertrophy, and renal disease in a prospective manner. In these studies, dietary intake of sodium and potassium should be estimated using multiple 24-hour urine collections. These studies should be focused on African Americans because they are at a disproportionately high risk of developing hypertension and blood pressure-related vascular disease. Moreover, this group has been underrepresented in most previous epidemiological studies.

Publication Types:

• Review
• Review, tutorial

PMID: 10100688, UI: 99198787

Am J Med Sci 1999 Mar;317(3):142-6

Overview of the Jackson Heart Study: a study of cardiovascular diseases in African American men and women.

Sempos CT, Bild DE, Manolio TA

Epidemiology and Biometry Program, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA. semposc@od.nih.gov

The Jackson Heart Study is a partnership among Jackson State University, Tougaloo College, the University of Mississippi Medical Center and the National Institutes of Health's National Heart, Lung, and Blood Institute (NHLBI) and Office of Research on Minority Health. The purposes of the study are to: (1) establish a single-site cohort study to identify the risk factors for the development of cardiovascular diseases, especially those related to hypertension, in African American men and women; (2) build research capabilities in minority institutions by building partnerships; (3) attract minority students to careers in public health and epidemiology; and (4) establish an NHLBI Field Site in Jackson, Mississippi, similar to those established for the Framingham Heart Study and the Honolulu Heart Program. The study will consist of participants from the Jackson site of the Atherosclerosis Risk in Communities (ARIC) Study and a sample of residents from the Jackson metropolitan area. The study will have a sample size of approximately 6,500 men and women aged 35-84 years and will include approximately 400 families. Exam 1 is scheduled to take place in the spring of the year 2000.

PMID: 10100686, UI: 99198785

Am J Public Health 1999 Mar;89(3):308-14

Evidence for a black-white crossover in all-cause and coronary heart disease mortality in an older population: the North Carolina EPESE.

Corti MC, Guralnik JM, Ferrucci L, Izmirlian G, Leveille SG, Pahor M, Cohen HJ, Pieper C, Havlik RJ

Epidemiology, Demography, and Biometry Program, National Institutes of Health, Bethesda, Md., USA.

OBJECTIVES: This cohort study evaluated racial differences in mortality among Blacks and Whites 65 years and older. METHODS: A total of 4136 men and women (1875 Whites and 2261 Blacks) living in North Carolina were interviewed in 1986 and followed up for mortality until 1994. Hazard ratios (HRs) for all-cause and cause-specific mortality were calculated, with adjustment for sociodemographic and coronary heart disease (CHD) risk factors. RESULTS: Black persons had higher mortality rates than Whites at young-old age (65-80 years) but had significantly lower mortality rates after age 80. Black persons age 80 or older had a significantly lower risk of all-cause mortality (HR of Blacks vs Whites, 0.75; 95% confidence interval [CI] = 0.62, 0.90) and of CHD mortality (HR 0.44: 95% CI = 0.30, 0.66). These differences were not observed for other causes of death. CONCLUSIONS: Racial differences in mortality are modified by age. This mortality crossover could be attributed to selective survival of the healthiest oldest Blacks or to other biomedical factors affecting longevity after age 80. Because the crossover was observed for CHD deaths only, age overreporting by Black older persons seems an unlikely explanation of the mortality differences.

PMID: 10076478, UI: 99175774

Am J Cardiol 1999 Jan 1;83(1):106-8, A8

Comparison of perception of angina pectoris during exercise testing in African-Americans versus Caucasians.

Sheffield D, Kirby DS, Biles PL, Sheps DS

Department of Internal Medicine, East Tennessee State University, Johnson City 37614-0622, USA.

In a sample of 142 patients with positive treadmill test results, we found that African-Americans reported anginal pain during exercise at nearly twice the rate of Caucasians, and had a significantly shorter time to angina. The mechanisms for these race differences remain to be elucidated, but may include underlying physiologic responses, ethnocultural differences, psychological state, socioeconomic differences, and experimenter bias.

PMID: 10073794, UI: 99171802

Genet Epidemiol 1999;16(2):165-78

Family history of coronary heart disease and pre-clinical carotid artery atherosclerosis in African-Americans and whites: the ARIC study: Atherosclerosis Risk in Communities.

Bensen JT, Li R, Hutchinson RG, Province MA, Tyroler HA

Department of Public Health Sciences, Bowman Gray School of Medicine and the Wake Forest University, Winston-Salem, North Carolina 27157, USA.

The association between family history of coronary heart disease (CHD) and morbidity and mortality due to atherosclerotic sequelae, although well documented in population-based samples of whites, has been little studied in African Americans. Less is known about the relationship between a family history of CHD and pre-clinical atherosclerosis. We report the relation between family history of CHD, summarized in a family risk score (FRS), and asymptomatic atherosclerosis at the extracranial carotid arteries, measured by B-mode ultrasound. The FRS was assessed in relatives of 3,034 African Americans and 9,048 white probands aged 45 to 64 years, in the four community-based cohorts of the ARIC Study. The analyses were restricted to individuals free of clinically manifest CHD. The distribution of CHD FRS by ethnic-gender groups was right skewed, with slightly higher mean values for white than African-American males, and for African-American than white females. In a series of multivariate linear regression models with mean carotid artery intima-media wall thickness (IMT) as the dependent variable, FRS was associated positively with IMT in white and African-American women and white men. In a multiple regression model, approximately one-half of the quantitative statistical relationship of the CHD FRS with IMT in whites was statistically explained by the major risk factors considered as intervening, explanatory variables in this analysis. This association in African-American women was fully explained by the major risk factors. The FRS was not, however, associated with atherosclerosis or major risk factors in African-American males, in the ARIC Study.

PMID: 10030399, UI: 99153470

JAMA 1999 Jan 6;281(1):53-60

The protective effect of moderate alcohol consumption on ischemic stroke.

Sacco RL, Elkind M, Boden-Albala B, Lin IF, Kargman DE, Hauser WA, Shea S, Paik MC

Department of Neurology, Sergievsky Center, Columbia University College of Physicians and Surgeons, New York, NY, USA. rls1@columbia.edu

CONTEXT: Moderate alcohol consumption has been shown to be protective for coronary heart disease, but the relationship between moderate alcohol consumption and ischemic stroke is more controversial. OBJECTIVE: To determine the association between alcohol consumption and risk of ischemic stroke. DESIGN: Population-based case-control study conducted between July 1993 and June 1997. SETTING: Multiethnic population in northern Manhattan, New York, NY, aged 40 years or older. PATIENTS AND OTHER PARTICIPANTS: Cases (n = 677) had first ischemic stroke and were matched to community controls (n = 1139) derived through random digit dialing by age, sex, and race/ethnicity. Mean +/- SD age of cases was 70.0+/-12.7 years; 55.8% were women; 19.5% were white, 28.4% black, and 50.7% Hispanic. MAIN OUTCOME MEASURE: First ischemic stroke (fatal or nonfatal). RESULTS: Moderate alcohol consumption, up to 2 drinks per day, was significantly protective for ischemic stroke after adjustment for cardiac disease, hypertension, diabetes, current smoking, body mass index, and education (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.39-0.67). This protective effect of alcohol consumption was detected in both younger and older groups, in men and women, and in whites, blacks, and Hispanics. In a quadratic model of stroke risk, increased risk of ischemic stroke was statistically significant among those consuming 7 or more drinks per day (OR, 2.96; 95% CI, 1.05-8.29). CONCLUSIONS: Moderate alcohol consumption was independently associated with a decreased risk of ischemic stroke in our elderly, multiethnic, urban subjects, while heavy alcohol consumption had deleterious effects. Our data support the National Stroke Association Stroke Prevention Guidelines regarding the beneficial effects of moderate alcohol consumption.

PMID: 9892451, UI: 99107469

J Behav Med 1998 Dec;21(6):527-44

Culture, socioeconomic status, and coronary heart disease risk factors in an African American community.

Dressler WW, Bindon JR, Neggers YH

Department of Anthropology, University of Alabama, Tuscaloosa 35487-0210, USA.

In this paper, cultural influences are examined in the relationship between socioeconomic status and health. Cultural definitions of material lifestyles are investigated as a correlate of disease risk in an African American community in the rural South. A new technique--called "cultural consensus analysis"--is used to test for a cultural model of lifestyles indicative of success. Survey data are then used to operationalize the degree to which individuals adhere in their own behavior to that cultural model; this measure is referred to as "cultural consonance in lifestyle." Cultural consonance in lifestyle is more strongly associated with hypertension and smoking (but not serum lipids) than are conventional measures of socioeconomic status (occupation, income, and education). These results suggest that the extent to which individuals are unable to live in accordance with cultural norms regarding lifestyles may contribute to the risk of coronary heart disease in the African American community.

PMID: 9891253, UI: 99108402

Am J Epidemiol 1998 Dec 15;148(12):1187-94

Body mass index, waist/hip ratio, and coronary heart disease incidence in African Americans and whites. Atherosclerosis Risk in Communities Study Investigators.

Folsom AR, Stevens J, Schreiner PJ, McGovern PG

Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55454-1015, USA.

To study the relation of the amount and distribution of body fat with incident coronary heart disease in two ethnic groups, the authors analyzed prospective data from the Atherosclerosis Risk in Communities Study. Among 14,040 participants aged 45-64 years and free of coronary disease at baseline in 1987-1989, we identified 398 events through 1994, an average of 6.2 years of follow-up. Among African-American women, the multivariable-adjusted relative risks of coronary heart disease across quartiles of body mass index were 1.0, 1.91. 1.54, and 2.15 (p for trend=0.27), and those for waist/hip ratio were 1.0, 2.07, 2.33, and 4.22 (p for trend=0.02). Among African-American men, these respective relative risks were 1.0, 1.03, 0.83, and 1.20 (p for trend=0.76) for body mass index and 1.0, 1.08, 1.87, and 1.68 (p for trend=0.06) for waist/hip ratio. Relative risks for whites were generally similar to those for African Americans. Relative risks were stronger for never smokers than for the overall cohort. Unlike some previous studies, our results suggest that Africa Americans, like whites, are not spared from the coronary heart disease risks accompanying obesity.

PMID: 9867265, UI: 99083154

Mor Mortal Wkly Rep CDC Surveill Summ 1998 Dec 11;47(5):35-69

Cardiovascular disease risk factors and preventive practices among adults--United States, 1994: a behavioral risk factor atlas. Behavioral Risk Factor Surveillance System State Coordinators.

Hahn RA, Heath GW, Chang MH

Division of Prevention Research and Analytic Methods, Epidemiology Program Office, National Center for Chronic Disease Prevention and Health Promotion, USA.

PROBLEM/CONDITIONS: Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death in the United States, and state rates of CVD vary by state and by region of the country. Several behavioral risk factors (i.e., overweight, physical inactivity, smoking, hypertension, and diabetes mellitus) and preventive practices (i.e., weight loss and smoking cessation) are associated with the development of CVD and also vary geographically. This summary displays and analyzes geographic variation in the prevalences of selected CVD risk factors. REPORTING PERIOD: 1994 (1992 for prevalence of hypertension). DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random-digit-dialing telephone survey of noninstitutionalized adults aged > or =18 years; 50 states and the District of Columbia participated in BRFSS in 1994, and 48 states and the District of Columbia participated in 1992. METHODS: Several different analyses were conducted: a) analysis of state risk factor and preventive practice prevalences by sex and race (i.e., black and white); b) mapping; c) cluster analysis; d) correlations of state prevalence rates by sex and race; and e) regression of state risk factor prevalences on state CHD and stroke mortality rates. RESULTS: Mapping the prevalence of selected CVD risk factors and preventive health practices indicates substantial geographic variation for black and white men and women, as confirmed by cluster analysis. Data for blacks are limited by small sample size, especially in western states. Geographic clustering is found for physical inactivity, smoking, and risk factor combinations. Risk factor prevalences are generally lower in the West and higher in the East. White men and white women are more similar in state risk factor rates than other race-sex pairs; white women and black women ranked second in similarity. State prevalences of physical inactivity and hypertension are strongly associated with state mortality rates of CVD. INTERPRETATION: Geographic patterns of risk factor prevalence suggest the presence (or absence) of sociocultural environments that promote (or inhibit) the given risk factor or preventive behavior. Because the risk factors examined in this summary are associated with CVD, further exploration of the reasons underlying observed geographic patterns might be useful. The BRFSS will continue to provide geographic data about cardiovascular health behaviors with a possible emphasis on more data-based small- area analyses and mapping. This will permit states to more adequately monitor trends that affect the burden of CVD in their regions and the United States. Mapping also facilitates the exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. Finally, by identifying those segments of the population with high levels of these risk factors and lower levels of the preventive health practices, public health personnel can better allocate resources and target intervention efforts for the prevention of CVD.

PMID: 9859955, UI: 99075298

Am J Epidemiol 1998 Dec 1;148(11):1062-8

Relation of self-image to body size and weight loss attempts in black women: the CARDIA study. Coronary Artery Risk Development in Young Adults.

Riley NM, Bild DE, Cooper L, Schreiner P, Smith DE, Sorlie P, Thompson JK

Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.

It has been suggested that the prevalence of obesity in black women is high partly because self-image in black women is not strongly dependent on body size. To determine associations between self-image, body size, and dieting behavior among black women, the authors assessed an Appearance Evaluation Subscale (AES) score (range, 1-5), a Body Image Satisfaction (BIS) score (range, 2-11), and reported dieting behavior in a population-based sample of 1,143 black women aged 24-42 years from the fourth follow-up examination (1992-1993) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Lower AES and BIS scores indicate poorer self-image and lower body size satisfaction, respectively. After adjustment for age, education, smoking, and physical activity, women in the lowest, middle, and highest tertiles of body mass index (weight (kg)/height (m)2) had mean AES scores of 3.7, 3.3, and 2.9, respectively (p < 0.001), and mean BIS scores of 7.8, 6.7, and 5.9, respectively (p < 0.001). After additional control for body mass index as a continuous variable, both AES and BIS scores were inversely related to ever dieting, current dieting, and previous weight loss of 10 pounds (4.5 kg) or more in all tertiles of body mass index. These results suggest that among black women, a higher body mass index is associated with poorer self-image and lower body size satisfaction and that these perceptions may be an avenue to promoting weight control.

PMID: 9850128, UI: 99065380

MMWR Morb Mortal Wkly Rep 1998 Nov 27;47(46):1005-8, 1015

Coronary heart disease mortality trends among whites and blacks--Appalachia and United States, 1980-1993.

Although heart disease-associated mortality has declined steadily since the 1960s, heart disease remains the leading cause of death for both men and women of all races/ethnicities in the United States. This report compares temporal trends in coronary heart disease (CHD) death rates for blacks and whites from 1980 to 1993 (the latest year for which data were available) in the Appalachian Region with trends for the entire United States. The findings indicate that among whites aged > or =35 years the burden of CHD is greater in Appalachia than in the entire United States, with the disparity increasing over time, and among blacks, only slight differences in CHD rates between Appalachia and the United States were observed.

PMID: 9843328, UI: 99057462

J Behav Med 1998 Oct;21(5):505-15

Cholesterol concentrations and cardiovascular reactivity to stress in African American college volunteers.

Clark VR, Moore CL, Adams JH

Department of Psychology, Morehouse College, Atlanta, Georgia 30314, USA.

Cholesterol levels and cardiovascular responses to emotionally arousing stimuli were examined in 60 healthy African American males and females. Cardiac output, stroke volume, contractile force, heart rate, and blood pressure were measured as the participants viewed two racially noxious scenes on videotape. Total serum cholesterol, high-density lipoproteins (HDL), low-density lipoproteins (LDL), and triglycerides were measured within 2 weeks of viewing the scenes. Multiple regression analysis showed that LDL and HDL were significant predictors of blood pressure responses. A correlation analysis revealed that total serum cholesterol and LDL were positively correlated with stroke volume, contractile force, and blood pressure reactivity. A possible relationship among stress, beta-adrenergic activity, and nonmetabolized free fatty acids is discussed. These findings suggest that cardiovascular reactivity to stress may be a new risk factor for heart and vascular diseases.

PMID: 9836134, UI: 99052854

Am J Cardiol 1998 Nov 1;82(9):1046-51

Markedly high prevalence of coronary risk factors in apparently healthy African-American and white siblings of persons with premature coronary heart disease.

Becker DM, Yook RM, Moy TF, Blumenthal RS, Becker LC

Center for Health Promotion and Division of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA.

Among persons with a family history of premature coronary heart disease (CHD), siblings bear an excess risk of CHD that is as high as 12 times that of the general population. Aggressive, new, national guidelines for CHD risk reduction have focused on high-risk families, yet little is known about actual remediable risk factors in siblings of persons with premature CHD. To determine the magnitude of the problem relative to the general population, we screened 846 unaffected siblings (ages 30 to 59 years) of persons with documented CHD before age 60 years and compared their risk factor values with population reference norms obtained in the Third National Health and Nutrition Examination Survey (NHANES III) and the National Health Interview Survey (NHIS). Mean levels of low-density lipoprotein cholesterol were 0.52 mmol/L (20 mg/dl) higher in siblings; the prevalence of low-density lipoprotein cholesterol > or =4.14 mmol/L (160 mg/dl) was nearly twice that of race, sex, and age-specific values from NHANES III. Levels of high-density lipoprotein cholesterol <0.91 mmol/L (35 mg/dl) were similar between siblings and NHANES III (11% and 12%, respectively). Only 4% of all siblings had triglyceride levels > or =4.52 mmol/L (400 mg/dl). Hypertension prevalence was twice as high among siblings as among the NHANES III. Current smoking was 33.9% in white siblings and 25.5% in the NHIS, whereas smoking in African-Americans was similar to that in the NHIS (31.1% vs 29.2%). A mere 13% to 29% of siblings were without any major remediable risk factors. The overwhelming need for risk factor modification in this easily identifiable high-risk population supports aggressive national guidelines and demonstrates the lack of adequate treatment of apparently healthy siblings of persons with premature CHD.

PMID: 9817479, UI: 99032417

Am J Cardiol 1998 Nov 1;82(9):1040-5

Premenopausal black women have more risk factors for coronary heart disease than white women.

Gerhard GT, Sexton G, Malinow MR, Wander RC, Connor SL, Pappu AS, Connor WE

Division of Endocrinology, Diabetes, and Clinical Nutrition, and General Clinical Research Center, Oregon Health Sciences University, Portland 97201, USA.

Premenopausal black women have a 2- to 3-fold greater rate of coronary heart disease (CHD) than premenopausal white women. The purpose of this study was to provide greater insight into the reasons for this difference, which are currently unclear. We compared CHD risk factors in 99 black and 100 white, healthy premenopausal women, aged 18 to 45 years, and of relatively advantaged socioeconomic status. Compared with white women, black women had a higher body mass index (32.0 +/- 9.2 vs 29.0 +/- 9.4 kg/m2, p = 0.021), and higher systolic (124 +/- 17 vs 115 +/- 14 mm Hg, p <0.0001) and diastolic (79 +/- 14 vs 75 +/- 11 mm Hg, p = 0.048) blood pressures. The mean plasma lipoprotein(a) concentration was markedly higher in the black women (40.2 +/- 31.3 mg/dl) than in the white women (19.2 +/- 23.7 mg/dl, p <0.0001). The plasma total homocysteine level was also higher in the black women (8.80 +/- 3.38 vs 7.81 +/- 2.58 micromol/L, p = 0.013). The black women, however, had lower plasma triglyceride levels (0.91 +/- 0.46 vs 1.22 +/- 0.60 mmol/L, p <0.0001), and a trend toward higher high-density lipoprotein (HDL) cholesterol levels (1.37 +/- 0.34 vs 1.29 +/- 0.31 mmol/L, p = 0.064) than the white women. Plasma total and low-density lipoprotein (LDL) cholesterol levels were similar, despite a greater consumption of saturated fat and cholesterol by the black women. Rates of cigarette smoking and alcohol intake were low and similar between the races. In summary, premenopausal black women had a higher mean body mass index, blood pressure, lipoprotein(a), and plasma total homocysteine level, and a greater consumption of saturated fat and cholesterol than white women. These differences in coronary risk factors may place the black women in our study at increased risk for CHD compared with the white women.

PMID: 9817478, UI: 99032416

Diabetes Care 1998 Nov;21(11):1812-8

Impaired glucose tolerance, type 2 diabetes, and carotid wall thickness: the Insulin Resistance Atherosclerosis Study.

Wagenknecht LE, D'Agostino RB Jr, Haffner SM, Savage PJ, Rewers M

Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA. lwagenkn@rc.phs.wfubmc.edu

OBJECTIVE: To assess whether people with impaired glucose tolerance (IGT) exhibit an increased risk of atherosclerosis as measured by the thickness of the carotid artery. RESEARCH DESIGN AND METHODS: We examined the relationship between glucose tolerance status and subclinical atherosclerosis in the Insulin Resistance Atherosclerosis Study (IRAS). The IRAS is an epidemiological study of 1,625 Hispanic, African-American, and white men and women, with approximately equal numbers of subjects with normal glucose tolerance (NGT), IGT, and type 2 diabetes as assessed by an oral glucose tolerance test. Half of those with diabetes were previously unaware of their condition and were defined as having new diabetes. Persons using insulin were excluded. The intima-media thickness (IMT) of the common carotid artery (CCA) and internal carotid artery (ICA) was measured as an index of subclinical atherosclerosis using B-mode ultrasonography. RESULTS: Adjusted for demographics and smoking, CCA-IMT increased most notably at the level of established diabetes (802, 822, 831, and 896 microm for NGT, IGT, new diabetes, and established diabetes, respectively). Adjustment for coronary heart disease (CHD) risk factors, which tended to worsen across glucose tolerance category, further minimized the slightly graded relationship. The relationship with the ICA-IMT was steeper and again suggested that the increased wall thickness is associated with diabetes, not with IGT. The relationship between glucose tolerance category and IMT was similar in men and women. CONCLUSIONS: We observed considerably greater IMT among persons with established diabetes but no significant increase in persons with IGT. These data suggest that the increased risk of CHD observed in persons with diabetes may largely develop after the onset of overt diabetes.

Publication Types:

• Multicenter study

PMID: 9802726, UI: 99017726

Diabetes Care 1998 Nov;21(11):1790-6

Association of hormone replacement therapy and carotid wall thickness in women with and without diabetes.

Dubuisson JT, Wagenknecht LE, D'Agostino RB Jr, Haffner SM, Rewers M, Saad MF, Laws A, Herrington DM

Physician Assistant Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

OBJECTIVE: Atherosclerosis is the major underlying cause of death for women with type 2 diabetes. We examined the relationship between use of postmenopausal hormone replacement therapy(HRT) and subclinical atherosclerosis among women with type 2 diabetes, impaired glucose tolerance (IGT), and normal glucose tolerance. RESEARCH DESIGN AND METHODS: A cross-sectional analysis was conducted among 623 postmenopausal women in the Insulin Resistance Atherosclerosis Study (IRAS). Current users of HRT, n = 200, were compared with 104 former users and 319 never users. Intimal-medial wall thicknesses (IMTs) of the common carotid (CCA) and internal carotid (ICA) arteries were used as measures of atherosclerosis. RESULTS: Significant differences between HRT user groups were noted for certain demographic, socioeconomic, and lifestyle factors. After adjustment for these and other coronary heart disease risk factors, current users had a 69 microm thinner ICA IMT than never users (P = 0.06). Former users had a 96 pm thinner ICA IMT than never users (P = 0.03). No significant difference was observed for the CCA. Although women with type 2 diabetes had thicker carotid IMT than women without diabetes, the association between HRT use and thinner IMT was similar in both groups. The difference between current and never users was attenuated by adjustment for HDL and LDL cholesterol. Neither duration of HRT use nor HRT regimen was associated with IMT in either artery. CONCLUSIONS: This analysis suggests that current and former use of HRT is associated with reduced atherosclerosis and that women with type 2 diabetes may receive the same benefit from HRI as women without diabetes.

Publication Types:

• Multicenter study

PMID: 9802722, UI: 99017722

Am J Epidemiol 1998 Oct 15;148(8):741-9

Published erratum appears in Am J Epidemiol 1999 Mar 1;149(5):489

Ethnic disparities in patient recall of physician recommendations of diagnostic and treatment procedures for coronary disease.

Sanderson BK, Raczynski JM, Cornell CE, Hardin M, Taylor HA Jr

Department of Medicine and Center for Health Promotion, University of Alabama at Birmingham, USA.

Despite the proven benefits of many cardiac procedures, some are used less frequently for African Americans than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham-Black Health Seeking for Coronary Heart Disease Project (1989-1990) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by multivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality.

PMID: 9786229, UI: 99000168

Am J Cardiol 1998 Oct 1;82(7):902-4

Risk factors for new coronary events in older African-American men and women.

Aronow WS, Ahn C

Hebrew Hospital Home, Bronx, New York 10475, USA.

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).

PMID: 9781976, UI: 98453237

Int J Epidemiol 1998 Aug;27(4):636-41

Sixteen-year coronary mortality in black and white men with diabetes screened for the Multiple Risk Factor Intervention Trial (MRFIT).

Vaccaro O, Stamler J, Neaton JD

Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy.

BACKGROUND: Risk of coronary heart disease (CHD) mortality associated with diabetes is high and it is unclear to what extent the high mortality is due to modifiable risk factors. To explore this, mortality and predictors of CHD death are compared in a large cohort of black and white men with diabetes. METHODS: In all, 610 black and 3997 white men who reported taking medication for diabetes and had no history of hospitalization for heart attack were screened by 22 centres for the Multiple Risk Factor Intervention Trial (MRFIT). At screening major risk factors for CHD were determined. Participants have been followed for an average of 16 years for vital status. Cause-specific mortality and predictors of CHD are compared for blacks and whites using proportional hazards regression. RESULTS: Serum cholesterol and systolic blood pressure levels were similar in blacks and whites with diabetes, while diastolic blood pressure and percentage of smokers were higher in blacks (89 versus 86 mmHg and 47% versus 34%) and median income was lower. Coronary heart disease was the leading cause of death, accounting for 31% (68/221) and 44% (564/1293) of deaths among blacks and whites, respectively. Adjusted relative risks of CHD death and all cause mortality for blacks compared to whites were 0.71 (95% CI: 0.53-0.95) and 0.94 (95% CI: 0.75-1.11). Differences in reporting cause of death probably account for some of the black/white difference in CHD. High serum cholesterol, high blood pressure, and smoking increased risk of CHD death similarly in blacks and whites. CONCLUSIONS: Serum cholesterol, blood pressure, and smoking are major influences on CHD mortality risk in both white and black men with diabetes. High prevalence of these factors indicates substantial potential for CHD prevention in both ethnic groups.

PMID: 9758118, UI: 98429085

Ann Epidemiol 1998 Oct;8(7):433-8

Relationship between changes in dietary sucrose and high density lipoprotein cholesterol: the CARDIA study. Coronary Artery Risk Development in Young Adults.

Archer SL, Liu K, Dyer AR, Ruth KJ, Jacobs DR Jr, Van Horn L, Hilner JE, Savage PJ

Northwestern University Medical School, Department of Preventive Medicine, Chicago, IL 60611, USA.

PURPOSE: Cross-sectional data from several observational studies have suggested that dietary sucrose may be inversely associated with high density lipoprotein cholesterol (HDL-C). This study examined associations between energy from dietary sucrose and HDL-C at baseline, year 7 and longitudinally (year 7 minus baseline) in a cohort of young black and white men and women from the Coronary Artery Risk Development in Young Adults (CARDIA) study. METHODS: The sample included 4734 black men, black women, white men and white women, ages 18-30 years, in 1985-86 (baseline); 3513 at year 7; and 3335 for longitudinal analyses. Multivariate analyses was used with adjustment for age, BMI, cigarettes smoked per day, physical activity score, and alcohol intake. RESULTS: Multivariate analyses indicated that energy intake from sucrose was inversely associated with HDL-C for each race-gender group at baseline, year 7, and longitudinally from baseline to year 7. This association was significant at baseline for black men, and white men and women (p < 0.01); at year 7 for white men and black women (p < 0.01), and longitudinally for white men, white women, and black women (p < 0.05). CONCLUSIONS: The consistent inverse associations between energy from dietary sucrose and HDL-C observed in both cross-sectional and longitudinal analyses, and in different race and gender groups in CARDIA suggest that lowering dietary sucrose intake may be beneficial for those who may have low HDL-C.

PMID: 9738689, UI: 98409069

Arch Intern Med 1998 Sep 14;158(16):1761-8

Time trends in the use of cholesterol-lowering agents in older adults: the Cardiovascular Health Study.

Lemaitre RN, Furberg CD, Newman AB, Hulley SB, Gordon DJ, Gottdiener JS, McDonald RH Jr, Psaty BM

Department of Medicine, University of Washington, Seattle, USA.

OBJECTIVES: To describe recent temporal patterns of cholesterol-lowering medication use and the characteristics that may have influenced the initiation of cholesterol-lowering therapy among those aged 65 years or older. SUBJECTS AND METHODS: A cohort of 5201 adults 65 years or older were examined annually between June 1989 and May 1996. We added 687 African American adults to the cohort in 1992-1993. We measured blood lipid levels at baseline and for the original cohort in the third year of follow-up. We assessed the use of cholesterol-lowering drugs at each visit. RESULTS: The prevalence of cholesterol-lowering drug use in 1989-1990 was 4.5% among the men and 5.9% among the women; these figures increased over the next 6 years to 8.1% and 10.0%, respectively, in 1995-1996. There was a 4-fold increase in the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors during the 6 years of follow-up, from 1.9% of all participants in 1989-1990 to 7.5% in 1995-1996. The use of bile acid sequestrants, nicotinic acid, and probucol declined from initial levels of less than 1% each. Among the participants who were untreated in 1989-1990, but eligible for cholesterol-lowering therapy after a trial of dietary therapy according to the 1993 guidelines of the National Cholesterol Education Panel, less than 20% initiated drug therapy in the 6 years of follow-up, even among subjects with a history of coronary heart disease. Among participants untreated at baseline but eligible for either cholesterol-lowering therapy or dietary therapy, initiation of cholesterol-lowering drug therapy was directly associated with total cholesterol levels, hypertension, and a history of coronary heart disease, and was inversely related to age, high-density lipoprotein cholesterol levels, and difficulties with activities of daily living. Other characteristics that form the basis of the 1993 National Cholesterol Education Panel guidelines-diabetes, smoking, family history of premature coronary heart disease, and total number of risk factors-were not associated with the initiation of cholesterol-lowering drug therapy. CONCLUSIONS: Given the clinical trial evidence for benefit, those aged 65 to 75 years and with prior coronary heart disease appeared undertreated with cholesterol-lowering drug therapy.

PMID: 9738605, UI: 98408985

Am J Public Health 1998 Sep;88(9):1308-13

Racial discrimination and skin color in the CARDIA study: implications for public health research. Coronary Artery Risk Development in Young Adults.

Krieger N, Sidney S, Coakley E

Department of Health and Social Behavior, Harvard School of Public Health, Boston, Mass 02115, USA. nkrieger@hsph.harvard.edu

OBJECTIVES: This study assessed whether skin color and ways of handling anger can serve as markers for experiences of racial discrimination and responses to unfair treatment in public health research. METHODS: Survey data on 1844 Black women and Black men (24 to 42 years old), collected in the year 5 (1990-1991) and year 7 (1992-1993) examinations of the Coronary Artery Risk Development in Young Adults (CARDIA) study, were examined. RESULTS: Skin color was not associated with self-reported experiences of racial discrimination in 5 of 7 specified situations (getting a job, at work, getting housing, getting medical care, in a public setting). Only moderate associations existed between darker skin color and being working class, having low income or low education, and being male (risk ratios under 2). Comparably moderate associations existed between internalizing anger and typically responding to unfair treatment as a fact of life or keeping such treatment to oneself. CONCLUSIONS: Self-reported experiences of racial discrimination and responses to unfair treatment should be measured directly in public health research; data on skin color and ways of handling anger are not sufficient.

PMID: 9736868, UI: 98408075

Lancet 1998 Mar 28;351(9107):934-9

Mortality differences between black and white men in the USA: contribution of income and other risk factors among men screened for the MRFIT. MRFIT Research Group. Multiple Risk Factor Intervention Trial.

Davey Smith G, Neaton JD, Wentworth D, Stamler R, Stamler J

Department of Social Medicine, University of Bristol, UK.

BACKGROUND: Studies of underlying differences in adult mortality between black and white individuals in the USA have been constrained by limitations of data or small study size. We investigated the extent to which differences in socioeconomic position between black and white men contribute to differences in all-cause and cause-specific mortality. METHODS: 361,662 men were screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, in 22 sites. Median family income of households by zipcode (postal) area of residence was available for 20,224 black and 300,685 white men as well as data on age, cigarette smoking, blood pressure, serum cholesterol, previous heart attack, and treatment for diabetes. We classified deaths during 16 years of follow-up into specific causes and compared differences in death rates between black men and white men, before and after adjustment for differences in income and other risk factors. FINDINGS: Age-adjusted relative risk of death (black vs white) was 1.47 (95% CI 1.42-1.53). Adjustment for diastolic blood pressure, serum cholesterol, cigarette smoking, medication for diabetes, and previous admission to hospital for heart attack decreased the relative risk to 1.40 (1.35-1.46). Adjustment for income but not the other risk factors decreased the risk to 1.19 (1.14-1.24) and adjustment for other risk factors did not alter this estimate. For cardiovascular death, relative risk on adjustment for income was decreased from 1.36 to 1.09; for cancer from 1.47 to 1.25; and for non-cardiovascular and non-cancer deaths from 1.71 to 1.26. For some specific causes of death, including prostate cancer, myeloma, and hypertensive heart disease, the higher death rates among black men did not seem to reflect differences in income. Rates of death for suicide and melanoma were lower among black than white men, as were those for coronary heart disease after adjustment for income. INTERPRETATION: Socioeconomic position is the major contributor to differences in death rates between black and white men. Differentials in mortality from some specific causes do not simply reflect differences in income, however, and more detailed investigations are needed of how differences are influenced by environmental exposures, lifetime socioeconomic conditions, lifestyle, racism, and other sociocultural and biological factors.

PMID: 9734939, UI: 98404008

Epidemiology 1998 Sep;9(5):557-62

Modeling disease incidence rates in families.

Siegmund KD, Province MA, Higgins M, Williams RR, Keller J, Todorov AA

Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA.

We apply an extended Cox model to study latent genes and measured environmental exposures simultaneously as risk factors for disease. Using this method, we assume Mendelian transmission of the genes and either dominant or recessive gene action. We compared the results from this model with those obtained under a model that includes the environmental variables and a family risk score. We demonstrate the method in samples of 1,433 Caucasian families (N = 6,791) and 206 African-American families (N = 771) from the National Heart, Lung, and Blood Institute Family Heart Study. In Caucasians, we found evidence suggesting that having ever smoked increased the risk of coronary heart disease only in individuals who carry a genetic susceptibility. We also noted that in both Caucasian and African-American families, the relative risk of coronary heart disease for ever-treated vs never-treated for high serum total cholesterol increased after including an unobserved susceptibility genotype in the model. This finding implied that there may be genes influencing coronary heart disease independent of those that influence total cholesterol. Such findings were not evident when genetic risk was summarized by the family history score. We also discuss the extension of the model to address the etiology of complex diseases.

PMID: 9730037, UI: 98397774

Med Care Res Rev 1998 Sep;55(3):314-33

Do black elderly Medicare patients receive fewer services? An analysis of procedure use for selected patient conditions.

Lee AJ, Baker CS, Gehlbach S, Hosmer DW, Reti M

University of Massachusetts, Amherst, USA.

PMID: 9727301, UI: 98396391

Soc Sci Med 1998 Aug;47(4):469-76

Residential segregation and mortality in New York City.

Fang J, Madhavan S, Bosworth W, Alderman MH

Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

The objective of this research was to determine the effect of residential racial segregation on all-cause and cardiovascular disease mortality in New York City. A cross-sectional study of residents in New York City was conducted linking mortality records from 1988 through 1994, to the 1990 United States Census data stratified by zipcode. All-cause and cardiovascular disease mortality rates for non-Hispanic blacks and whites were estimated by zipcode. Zipcodes were aggregated according to the degree of residential segregation (predominantly (> or = 75%) white and black areas) and mortality rates were compared. Multiple regression analysis was used to associate population characteristics with mortality. In New York City, although overall mortality rates of blacks exceed whites, these rates varied substantially by locality according to the pattern of racial segregation. Whites living in the higher (mainly white) socioeconomic areas had lower mortality rates than whites living in predominantly black areas (1473.7 vs 1934.1 for males, and 909.9 vs 1414.7 for females for all-cause mortality). This was true for all age groups. By contrast, elderly blacks living in black areas, despite their less favorable socioeconomic status, had lower mortality rates for all-cause, total cardiovascular disease, and coronary heart disease, than did those living in white areas, even after adjusting for available socioeconomic variables. Racial segregation in residence is independently associated with mortality. Within racially segregated areas, members of the dominant group, for all age, among whites and elderly blacks, enjoy outcomes superior both to members of the minority racial group of their community, and to members of the same race residing in other areas, where they are in the minority, independent of socio-economic status.

PMID: 9680230, UI: 98343824

Hypertension 1998 Jul;32(1):123-8

Hypertension among siblings of persons with premature coronary heart disease.

Yanek LR, Moy TF, Blumenthal RS, Raqueno JV, Yook RM, Hill MN, Becker LC, Becker DM

Center for Health Promotion, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA. lryanek@welchlink.welch.jhu.edu

To determine the extent to which the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) guidelines were implemented in high-risk families with premature coronary heart disease, we examined the prevalence of hypertension and associated coronary risk factors in asymptomatic siblings of persons with documented premature coronary disease (<60 years of age). A total of 859 apparently healthy siblings (51% male, 19% African American) were screened for coronary risk factors. Siblings were classified as normotensive or hypertensive (BP > or = 140/90 and/or current antihypertensive pharmacotherapy). The prevalence of hypertension, awareness, treatment, and control among siblings was compared with published national estimates from the third National Health and Nutrition Examination Survey. The prevalence of hypertension in siblings was 44%. Among all hypertensives, only 60% were aware of being hypertensive, 45% were being treated, and 16% were under control. A high prevalence of other coronary risk factors was found among hypertensive siblings: 72% were hypercholesterolemic; 61% were obese; 29% were current smokers; 82% were consuming >30% of calories from fat; and only 14% were participating in vigorous physical activity three or more times per week. Comparisons with the national reference population revealed siblings to have a significantly higher prevalence of hypertension, along with significantly lower levels of awareness, treatment, and control. These findings demonstrate the intersection of multiple risk factors among hypertensive siblings and emphasize the need for more aggressive screening and treatment in this easily identifiable high-risk population.

PMID: 9674648, UI: 98337405

Lancet 1998 Jul 11;352(9122):114-5

Nutrient intakes among UK African-Caribbeans: changing risk of coronary heart disease.

Sharma S, Cade J, Griffiths S, Cruickshank K

Publication Types:

• Letter

PMID: 9672282, UI: 98336026

J Health Soc Behav 1998 Jun;39(2):91-107

Neighborhood social context and racial differences in women's heart disease mortality.

LeClere FB, Rogers RG, Peters K

University of Notre Dame, IN 46556, USA.

Compared to white women, black women experience similar rates of heart disease morbidity, but higher rates of heart disease mortality. This puzzling relationship may be due to several factors working at varied levels to affect each race. For example, the high heart disease mortality rate may be due to individual health or socioeconomic risk factors or to social structural factors. We conduct a multi-level analysis to address these issues, using data from a newly released data file that links the National Health Interview Survey with death certificate information from the National Death Index, and with additional community level data from the 1990 Census STF-3A files. We are primarily interested in the effects of female-headship rates in the census tracts on coronary heart disease mortality (CHD) among black and white women. We find that women who live in communities with high concentrations of female-headed families are more likely to die of heart disease, net of other characteristics. For younger women, the effect appears to be routed primarily through poverty whereas for older women the effect of female-headship rates remains, net of other census tract characteristics. This study, then, highlights the importance of examining the effect of neighborhoods and their social content on mortality.

PMID: 9642901, UI: 98306871

Psychosom Med 1998 May-Jun;60(3):319-26

Inverse relationship of urinary cyclic GMP to blood pressure reactivity in the CARDIA study: vasodilatory regulation of sympathetic vasoconstriction. Coronary Artery Risk Development in Young Adults.

Markovitz JH, Tucker D, Lewis CE, Sanders PW, Warnock DG

Department of Medicine, University of Alabama at Birmingham, 35205, USA. jmarkovitz@cardia.dopm.uab.edu

OBJECTIVE: To determine whether urinary cyclic GMP (cGMP), which mediates the actions of the vasodilators nitric oxide and atrial natriuretic factor, is inversely related to blood pressure (BP) reactivity. In previous work, we found that urinary cGMP was inversely related to diastolic BP, but cGMP levels were higher among individuals presumed to have increased adrenergic activity, increased reactivity, and increased risk of hypertension (blacks, individuals with a family history of hypertension). METHOD: We measured 24-hour urinary cGMP levels in a substudy of 529 individuals in the Coronary Artery Risk Development in Young Adults (CARDIA) study; the sample was 23 to 35 years of age and approximately balanced for race (black/white) and gender. BP reactivity to stressors (video game, star-tracing, cold pressor) was tested 3 years earlier. Baseline BP was included as a covariate in all analyses. RESULTS: Diastolic BP reactivity to cold pressor was inversely related to cGMP excretion (p < .05); the relationship was strongest among black women with a family history of hypertension (partial r = -.33, p < .01). Systolic BP reactivity to star-tracing was also inversely related to cGMP (p < .01); the relationship for both star-tracing and video game stressors was strongest among black men (partial r values = -.25 and -.24, respectively; p values < .01). CONCLUSIONS: The results indicate that vasodilatory activity may impact the BP response to stress through modulation of adrenergic activation, particularly among blacks.

PMID: 9625219, UI: 98286883

Am J Public Health 1998 Jun;88(6):913-7

Coronary heart disease risk factors and attributable risks in African-American women and men: NHANES I epidemiologic follow-up study.

Gillum RF, Mussolino ME, Madans JH

Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD 20782, USA.

OBJECTIVES: This study assessed associations of risk factors with coronary heart disease incidence in African Americans. METHODS: The participants in the NHANES I Epidemiologic Follow-Up Study included in this analysis were 1641 Black and 9660 White persons who were aged 25 to 74 years when examined and who did not have a history of coronary heart disease. Average follow-up for survivors was 19 years. RESULTS: Significant, independent risk factors for coronary heart disease were age, systolic blood pressure, and smoking in Black women and age, systolic blood pressure, serum cholesterol, low education, and low family income in Black men. In this cohort, 19% of incident coronary heart disease in Black women and 34% in Black men might be prevented if systolic blood pressure were below 140 mm Hg. In Black men, attributable risk for low education (46%) was even higher than that for elevated blood pressure. CONCLUSIONS: Elevated systolic blood pressure and smoking were predictive of coronary heart disease incidence in African Americans. Estimates of population attributable risk were highest for elevated systolic blood pressure in women and education less than high school in men. Further studies of serum lipids, education, and coronary heart disease in Black women are needed.

PMID: 9618619, UI: 98282318

Am J Cardiol 1998 May 15;81(10):1246-9

Baseline serum total cholesterol and coronary heart disease incidence in African-American women (the NHANES I epidemiologic follow-up study). National Health and Nutrition Examination Survey.

Gillum RF, Mussolino ME, Sempos CT

Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA.

Proportional-hazards analyses for African-American women aged 25 to 74 revealed a variable association of coronary heart disease risk with baseline serum total cholesterol (after adjusting for age fifth vs first quintile: RR = 1.62, 95% confidence interval [CI] 0.89 to 2.98, p = 0.12; after adjusting for age, systolic blood pressure, body mass index, smoking, history of diabetes, low education, and low family income: RR = 1.88, 95% CI 1.02 to 3.45, p = 0.04). Perhaps due to the relatively small number of events, the association of serum total cholesterol with coronary heart disease incidence in African-American women was not consistently significant.

PMID: 9604962, UI: 98265998

Ethn Dis 1998 Winter;8(1):124-7

Calcium antagonists--clinical considerations.

Prisant LM

Hypertension Unit, Medical College of Georgia, Augusta, USA.

Calcium antagonists are useful for treating hypertension, stable exertional and vasospastic angina, and supraventricular arrhythmias. Recent studies have proven their ability to decrease the rate of nonfatal strokes. Short-acting calcium antagonists should be avoided with hypertensive emergencies and urgencies, unstable angina, and acute myocardial infarction. The use of calcium antagonists in systolic heart failure should not be as the primary therapy. Care must be taken in using non-dihydropyridines because of multiple drug-drug interactions. Prospective trials are in progress through the next decade that will compare traditional drugs such as diuretics and beta-blockers to calcium antagonists, converting enzyme inhibitors, and angiotensin II receptor blockers.

Publication Types:

• Review
• Review, tutorial

PMID: 9595257, UI: 98257613

Ethn Dis 1998 Winter;8(1):60-72

Lipoprotein(A) and coronary heart disease risk factors in a racially mixed population: the Johns Hopkins Sibling Study.

Weiss SR, Bachorik PS, Becker LC, Moy TF, Becker DM

Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA.

OBJECTIVES: To determine if heart disease risk factors differentially affect lipoprotein(a) concentration by race, we assessed the association of lipoprotein(a) with heart disease risk factors in healthy Caucasians and African Americans with family histories of premature heart disease. METHODS: Participants (403 Caucasian and 148 African American), all less than 60 years old and free of heart disease, were recruited through a brother or sister diagnosed with coronary heart disease before age 60. Risk factor information was elicited through an interview and medical examination. RESULTS: As expected, lipoprotein(a) was significantly higher among African Americans than among Caucasians. Mean lipoprotein(a) concentrations were positively associated with smoking status and age, and negatively associated with hypertension in African Americans. Smokers had lipoprotein(a) levels 38% higher than nonsmokers. Conversely, lipoprotein(a) concentrations were unrelated to heart disease risk factors among Caucasians. CONCLUSION: While this study confirms that lipoprotein(a) concentration is independent of CHD risk factors in Caucasians, lipoprotein(a) appears to be related to several CHD risk factors in African Americans at high risk for premature heart disease. Given the high levels of lipoprotein(a) in people of African descent and lipoprotein(a)'s link to cardiovascular diseases, more research is needed to understand the relationship of lipoprotein(a) to heart disease risk factors and the subsequent disease in African-American populations.

Publication Types:

• Clinical trial

PMID: 9595249, UI: 98257605

Ethn Dis 1998 Winter;8(1):36-42

Mortality among blacks living in census tracts with public housing projects in Hartford, Connecticut.

Polednak AP

Connecticut Department of Public Health, Hartford 06134-0308, USA.

OBJECTIVE: The study examined mortality among blacks (African Americans) living in census tracts with a large public housing project(s). DESIGN: Standardized mortality ratios (SMRs), or the ratios of observed to expected numbers of deaths, from all causes and from selected specific causes were analyzed. SETTING: SMRs were analyzed for 1988-91 for blacks in four census tracts in Hartford, CT. Expected numbers of deaths were based on age-specific death rates for all blacks in the city. RESULTS: The SMR for all causes of death combined was statistically significantly elevated for black male (but not black female) residents of the four census tracts combined, due in part to statistically significantly elevated SMRs for both cancer and cardiovascular diseases (and for the subcategory of coronary heart disease). However, differences in SMRs for black males were evident among the four census tracts, which did not appear to be explained by differences in black poverty rates among these tracts. CONCLUSION: Research is needed on quality of life and health care among black residents of different housing projects in Hartford, and in other U.S. cities.

PMID: 9595246, UI: 98257602

Am J Cardiol 1998 Apr 15;81(8):982-7

Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System.

Mirvis DM, Graney MJ

Department of Veterans Affairs Medical Center and the Department of Preventive Medicine, University of Tennessee, Memphis 38105, USA.

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients' local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged > or =70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

PMID: 9576157, UI: 98235690

Obstet Gynecol 1998 Mar;91(3):454-8

Correlates of postmenopausal female hormone use among black women in the United States.

Rosenberg L, Palmer JR, Rao RS, Adams-Campbell LL

Slone Epidemiology Unit, Boston University School of Medicine, Brookline, Massachusetts 02146, USA. lrosenberg@slone.bu.edu

OBJECTIVE: To assess correlates of the use of postmenopausal female hormone supplements among black women. METHODS: We assessed information obtained from 64,564 U.S. black women 21-69 years of age who enrolled in the Black Women's Health Study in 1995 by completing postal questionnaires. Included in the present analyses were 13,352 women 40-69 years of age who had ceased menstruating. Most resided in ten states, with 66% from California, New York, Illinois, Michigan, Georgia, and New Jersey; 41.0% had completed college. RESULTS: Among the 13,352 women 40 years of age or older who had ceased menstruating, 49.2% reported ever use of female hormone supplements and 33.3% were using them currently. Unopposed oral estrogens accounted for 63.4% of the medications being used currently. The use of supplements was highest in the western U.S. and lowest in the Northeast. The strongest correlate of use was menopause due to bilateral oophorectomy. Use peaked at 50-54 years of age and then declined, and also was associated positively with lower body mass index, greater years of education, participation in vigorous exercise, and past oral contraceptive use. Use was associated inversely with having a positive history of diabetes, heart attack, or breast cancer. Some of the drug use reported was at variance with suggested guidelines: unopposed estrogen was taken by some women who had a uterus, and estrogen together with a progestin was taken by some women who had had a hysterectomy. CONCLUSION: These data indicate that patterns of use of postmenopausal female hormone supplements among black women who participated in the present study are similar to those documented in white women. Women with risk factors for coronary artery disease were not more likely to use supplements than women at lower risk, a pattern that is not in accordance with suggestions that the greatest benefit of supplements may accrue to high-risk women. Because users differ from nonusers in important characteristics that may affect the incidence of coronary heart disease, breast cancer, and other illnesses, observational studies of the health effects of these medications must control carefully for correlates of use.

Comments:

• Comment in: Obstet Gynecol 1998 Jul;92(1):159-60

PMID: 9491877, UI: 98150841

Am J Cardiol 1998 Feb 15;81(4):453-9

Electrocardiographic findings in a healthy biracial population. Atherosclerosis Risk in Communities (ARIC) Study Investigators.

Vitelli LL, Crow RS, Shahar E, Hutchinson RG, Rautaharju PM, Folsom AR

Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55454, USA.

It has been well documented that the prevalence of certain electrocardiographic (ECG) findings among individuals free of coronary heart disease (CHD) differs by race. However, it is not known whether these differences exist independently of CHD risk factors (e.g., hypertension). We examined the ECG tracings of 2,686 apparently healthy, middle-aged African-American and white men and women who participated in the Atherosclerosis Risk in Communities Study and were at low risk of CHD. Using the Minnesota Code, among men, 46% of African-Americans, but only 25% of whites, had a minor ECG finding (p < 0.001). In women, 32% of African-Americans and 23% of whites had a minor ECG finding (p < 0.01). Specifically, the age-adjusted prevalences of high-amplitude R wave, ST elevation, T-wave findings, and prolonged P-R interval were statistically significantly higher in African-Americans. As for continuous ECG measurements, the R wave in leads V5 and V6, the S wave in V1, the J-point amplitude in leads V2 and V5, the P-R interval, and the Cornell voltage (S V3 + R aVL) for left ventricular hypertrophy were all significantly greater in African-Americans than in whites. However, in both men and women, the heart rate corrected QT interval was shorter in African-Americans than in whites. All of these findings remained statistically significant after further adjustment for traditional CHD risk factors. These results suggest that racial differences in electrocardiograms may not be explained entirely by differences in established CHD risk factors, and because current diagnostic ECG criteria are largely based on data from middle-aged white men and women, race should be considered in the interpretation of ECG findings.

Publication Types:

• Multicenter study

PMID: 9485136, UI: 98143670

Arterioscler Thromb Vasc Biol 1998 Feb;18(2):283-93

Differences in prevalence of and risk factors for subclinical vascular disease among black and white participants in the Cardiovascular Health Study.

Kuller L, Fisher L, McClelland R, Fried L, Cushman M, Jackson S, Manolio T

University of Pittsburgh, Pa 15261, USA. kuller+@pitt.edu

A composite measure of subclinical vascular disease has been developed in the Cardiovascular Health Study (CHS). In previous reports, we measured the prevalence of subclinical disease among the original 5201 participants in the CHS, the relationship of risk factors to subclinical disease, and the association of subclinical disease to clinical coronary heart disease. In 1992 to 1993 (year 4 of the study), a larger cohort of 424 black women and 248 black men was added to the study. In this study, we have compared the prevalence of subclinical disease among blacks and whites in the CHS and the association with cardiovascular risk factors. The prevalence of subclinical disease for all participants (aged > or =65 years) was 41.3% for white women, 39.7% for black women, 41.9% for white men, and 43.7% for black men. The prevalence increased with age. The risk factor associations for subclinical disease were similar among blacks and whites. In multivariate analysis, age, systolic blood pressure, LDL cholesterol, smoking, and family history of myocardial infarction were independently associated with subclinical disease among both black and white women, while for white men, systolic blood pressure, use of antihypertensive medication, smoking, body mass index, and diastolic blood pressure (inverse) were related to subclinical disease. In black men, blood triglyceride level, use of antihypertensive medications, and family history of myocardial infarction (inverse) were associated with subclinical disease.

PMID: 9484995, UI: 98143526

Public Health Rep 1998 Jan-Feb;113(1):12

Ethnic health differences persist. Causes are multiple.

Publication Types:

• News

PMID: 9475927, UI: 98136404

Am J Cardiol 1998 Feb 1;81(3):293-7

Influence of race on the prediction of cardiac events with stress technetium-99m sestamibi tomographic imaging in patients with stable angina pectoris.

Alkeylani A, Miller DD, Shaw LJ, Travin MI, Stratmann HG, Jenkins R, Heller GV

Division of Cardiology, Hartford Hospital, Connecticut 06102-5037, USA.

The prognostic value of myocardial perfusion imaging in African-Americans is unknown. This study compared the prediction of cardiac events of stress technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) imaging in symptomatic Caucasian and African-American patients. Prospectively collected stress Tc-99m sestamibi tomographic imaging data from 4 medical centers, with follow-up information in 1,086 Caucasian and African-American patients, were analyzed in a core statistical laboratory. Primary events of cardiac death and nonfatal myocardial infarction and secondary events of all-cause mortality were analyzed using Kaplan-Meier survival analysis and Cox proportional-hazards multivariable model. Normal images in both African-Americans and Caucasians were associated with a low-annual cardiac event rate, whereas abnormal images were significantly associated with a higher cardiac event rate. The highest predictor of cardiac events was multivessel abnormality in both races. Use of this technique could identify patients at high risk and potentially reduce the high-cardiac event rate in African-Americans by utilizing appropriate therapies.

PMID: 9468070, UI: 98127584

Adv Pract Nurs Q 1996 Fall;2(2):31-8

Bridging cultural boundaries: the African American and transcultural caring.

Morris RI

School of Nursing, San Diego State University, California, USA.

This article discusses how to bridge cultural boundaries in the African-American culture. It also explains the influences of cultural trends in America and Africa on health care. The importance of cultural assessment in clinical practice is discussed, including the preparation of graduate nurses to acquire cultural assessment skills. A cultural assessment interview, using a modified cultural assessment tool, is provided.

PMID: 9447071, UI: 98108311

Ethn Health 1996 Dec;1(4):327-35

Differences in weight gain in relation to race, gender, age and education in young adults: the CARDIA Study. Coronary Artery Risk Development in Young Adults.

Burke GL, Bild DE, Hilner JE, Folsom AR, Wagenknecht LE, Sidney S

Department of Public Health Sciences, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27157, USA.

OBJECTIVE: To assess ethnic differences in weight gain in young adults. DESIGN: Five-year weight change was assessed in 4207 young adults initially aged 18-30 years at the CARDIA Study baseline examination (1985-1986). RESULTS: Weight gain was significantly (p < 0.0001) greater in black versus white men (13.2 versus 9.1 lb) and in black versus white women (13.2 versus 7.4 lb). Baseline weight and year-five weight in all race and gender groups were strongly associated, suggesting a high degree of tracking of adiposity during young adulthood. Greater weight gain was noted in participants reporting baseline education of high school or less versus college graduates in black women (14.4 versus 10.0 lb, p < 0.05), white women (10.2 versus 5.2 lb, p < 0.0001) and white men (10.2 versus 7.8 lb, p < 0.001). Significantly greater weight gain was observed in younger (18-24 years) versus older (25-30 years) men, but no age-related difference was seen in women. The racial differences in weight gain remained after adjustment for age and level of education. The above trends were confirmed for other measures of body size, i.e. body mass index and skinfold thickness. CONCLUSION: These data indicate that young adults are at high risk of weight gain, and that weight gain was greatest among African Americans and among less educated participants. These high-risk groups can be identified and targeted for primary prevention of adult obesity in addition to population wide efforts that will be required to counteract the secular trend of increased obesity observed in US adults.

Publication Types:

• Multicenter study

PMID: 9395577, UI: 98051759

Ethn Dis 1997 Spring-Summer;7(2):91-105

Racial and gender differences in use of procedures for black and white hospitalized adults.

Harris DR, Andrews R, Elixhauser A

Westat, Inc., Rockville, Maryland, USA.

A number of studies have found that blacks and females with coronary heart disease are less likely to undergo major diagnostic and therapeutic procedures than whites and males, even after controlling for severity of illness and other indicators of physical condition. This investigation examined 78 conditions treated in acute care hospitals to identify possible variations in medical treatment by race and gender among blacks and whites. The study is unique in examining such a wide range of conditions and in using an all-payer national sample. The study examines over 1.7 million inpatient discharge abstracts from the Hospital Cost and Utilization Project, a national sample of about 500 hospitals in the United States. Logistic regression modeling was used to describe the influence of race and gender among blacks and whites on the likelihood of having a major therapeutic or major diagnostic procedure, controlling for patient age, disease severity, health insurance and hospital-level characteristics. The study found that blacks were less likely than whites to receive major therapeutic procedures in 37 of 77 (48%) conditions, and females were less likely than males to receive major therapeutic procedures for 32 of 62 (52%) conditions. The proportion of conditions in which blacks and females were less likely to receive a major diagnostic procedure (without a major therapeutic procedure) was 21% and 26%, respectively. This study identified a number of conditions with apparent variations in medical treatment by race or gender among blacks and whites that should be targeted for more detailed investigations.

Comments:

• Comment in: Ethn Dis 1999 Winter;9(1):145-6

PMID: 9386949, UI: 98048190

Stroke 1997 Oct;28(10):1908-12

Familial history of stroke and stroke risk. The Family Heart Study.

Liao D, Myers R, Hunt S, Shahar E, Paton C, Burke G, Province M, Heiss G

Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill 27514, USA. duanping_liao@unc.edu

BACKGROUND AND PURPOSE: Although familial history of stroke is generally perceived to be an important marker of stroke risk, very few epidemiological studies have been published to address this hypothesis. We sought to examine whether familial history of stroke is associated with the prevalence of stroke in the Family Heart Study, a National Heart, Lung, and Blood Institute-supported multicenter study of the familial, genetic, and nongenetic determinants of cardiovascular disease in populations. METHODS: The personal and familial histories of stroke were assessed in 3168 individuals (probands) who were at least 45 years old and 29,325 of their first-degree relatives with the use of a standardized questionnaire. RESULTS: The age-, ethnicity-, and sex-adjusted stroke prevalences were 4.8%, 4.9%, and 3.9% in probands with a positive familial, paternal, and maternal history of stroke, respectively, in comparison with 2.0% in probands without any positive familial history (P < .01). The age-, ethnicity-, and sex-adjusted odds ratios (95% confidence interval) of stroke were 2.00 (1.13, 3.54) for a positive paternal and 1.41 (0.80, 2.50) for a positive maternal history of stroke. Additional statistical adjustment for the proband's history of elevated cholesterol level, cigarette smoking status, history of coronary heart disease, hypertension, and diabetes did not alter the associations. A similar pattern was seen for African Americans and European Americans. CONCLUSIONS: The increased risk of stroke among persons with a positive familial history of stroke compared with those without a familial history of stroke is consistent with the expression of genetic susceptibility, a shared environment, or both in the etiology of stroke.

Publication Types:

• Multicenter study

PMID: 9341694, UI: 98000901

Med Care 1997 Oct;35(10):1031-43

The risk of hospitalization for congestive heart failure among older adults.

Wolinsky FD, Overhage JM, Stump TE, Lubitz RM, Smith DM

School of Public Health, Saint Louis University Health Sciences Center, MO 63108-3342, USA.

OBJECTIVES: The purpose of the study was to estimate the 8-year rate of hospitalization for congestive heart failure (CHF), to report the resources consumed, and to evaluate previously reported risk factors in a nationally representative sample of 7,286 older white and black adults. METHODS: Secondary analysis of baseline interview data was linked to Medicare hospitalization and death records for 1984 to 1991. Hospitalization for CHF was defined as having one or more episodes with an International Classification of Diseases (ninth revision, clinical modification) discharge code of 428. Combined and separate analyses of first-listed and second-through fifth-listed CHF discharge diagnoses were conducted. Multivariable proportional hazards models were used to evaluate the risks in pooled analyses of all white and black men and women and in separate stratified analyses of white men and white women. RESULTS: Over the 8-year period, 1,102 or 15.1% of the 7,286 older white and black adults were hospitalized for CHF (7.1% with first-listed and 8.1% with second- through fifth-listed diagnoses). The 1- and 5-year combined postdischarge mortality rates were 34.7% and 69.0%, respectively. In descending order, the major risk factors for being hospitalized for CHF in the combined, pooled analysis were age, being a white man, having lower body functional limitations, and having self-reported medical histories of coronary heart disease, heart attack, diabetes, and angina. The increased risk associated with age was not linear, and it diminished significantly over the course of life. Some significant differences were observed in the risk factors for hospitalization for first-listed versus second- through fifth-listed CHF and in the risk factors for white women versus white men. CONCLUSIONS: Hospitalization for CHF among older adults is a common, costly event with a poor prognosis. The differential risk for white men remains unexplained and warrants further study.

Publication Types:

• Meta-analysis

PMID: 9338529, UI: 97478234

Am J Public Health 1997 Sep;87(9):1461-6

Sudden cardiac death in Hispanic Americans and African Americans.

Gillum RF

National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Md 20782, USA.

OBJECTIVES: The goal of this study was to estimate rates of sudden cardiac death in US Hispanics and African Americans. METHODS: Data on coronary deaths occurring outside of the hospital or in emergency rooms were examined for 1992. RESULTS: In 1992, 53% (8194) of coronary heart disease deaths among Hispanic Americans 25 years of age and older occurred outside of the hospital or in emergency rooms. The percentage was lower among Hispanics than among non-Hispanic Whites and Blacks. Age-adjusted rates per 100,000 were lower in Hispanics than in non-Hispanic Whites or Blacks (Hispanic men, 75; White men, 166; Black men, 209; Hispanic women, 35; White women, 74; Black women, 108). The percentages dying outside of the hospital or in emergency rooms were higher in young persons, those living in nonurban areas, and those who were single. CONCLUSIONS: The percentage and rate of coronary deaths occurring outside of the hospital or in emergency rooms were lower in Hispanics than in non-Hispanics; African Americans had the highest rates. Further research is needed on sudden coronary death in Hispanic Americans and African Americans.

PMID: 9314797, UI: 97460415

Arch Intern Med 1997 Sep 22;157(17):1953-9

Lack of relations of hostility, negative affect, and high-risk behavior with low plasma lipid levels in the Coronary Artery Risk Development in Young Adults Study.

Markovitz JH, Smith D, Raczynski JM, Oberman A, Williams OD, Knox S, Jacobs DR Jr

Division of Preventive Medicine, University of Alabama at Birmingham, USA.

BACKGROUND: Previous studies have suggested that low plasma cholesterol levels or cholesterol lowering may increase the risk of suicide and violent death. Increased aggression, risk-taking behavior, or depression has been associated with low cholesterol levels in some studies. METHODS: A total of 4240 subjects of the Coronary Artery Risk Development in Young Adults study, aged 23 to 35 years, were included in the study. Analyses were stratified by race (black or white) and sex. Persons in the lowest 10% of plasma total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride levels were compared with the other participants in each race/sex group, using standardized measures of hostility, anger suppression, depressive symptoms, and anxiety. The relations between 5-year change in hostility and 5-year change in lipid levels also were examined. The relations between lipid levels and high-risk behavior (e.g., violent arguments or having a gun at home) were examined in a subset of subjects. All analyses were adjusted for relevant covariates. RESULTS: In cross-sectional analyses, low total cholesterol levels were not related to any of the psychological measures in any race/sex group. Among black women only, low low-density lipoprotein cholesterol was related to greater anxiety, and low triglycerides were related to lower anger suppression (P < or = .002). Among white men only, increases in hostility during the 5-year follow-up were related to increases in triglycerides (P < .01), but changes in hostility were unrelated to changes in cholesterol levels. Among a subset of 371 subjects with initially elevated total cholesterol (> or = 5.17 mmol/L [> or = 200 mg/dL]) and a non-medicated decrease of 0.52 mmol/L (> or = 20 mg/dL) or more during 5 years, hostility decreased in a univariate analysis (P < .001). High-risk behaviors also were not associated with low lipid levels. CONCLUSION: The results do not support a consistent relation between hostility, negative affect, or high-risk behaviors with low lipid levels or lipid-lowering among young adults.

Publication Types:

• Multicenter study

PMID: 9308507, UI: 97453887

J Natl Med Assoc 1997 Sep;89(9):594-600

Sociodemographic factors and obesity in preadolescent black and white girls: NHLBI's Growth and Health Study.

Patterson ML, Stern S, Crawford PB, McMahon RP, Similo SL, Schreiber GB, Morrison JA, Waclawiw MA

Kaiser Permanente Medical Center, Riverside, USA.

The association of sociodemographic and family composition data with obesity was studied in 1213 black and 1166 white girls, ages 9 and 10, enrolled in the National Heart, Lung, and Blood Institute's Growth and Health Study. Obesity was defined as body mass index at or greater than age- and sex-specific 85th percentile as outlined in the Second National Health and Nutrition Examination Survey. The prevalence of obesity was higher for pubertal girls than for prepubertal girls and for girls with older mothers/female guardians. As odds ratio of 1.14 was observed for each 5-year increase in maternal age. Obesity was less common for girls with more siblings; the odds for obesity decreased by 14% for each additional sibling in the household. In blacks, the prevalence of obesity was not related to parental employment or to parental education. In whites, the odds of obesity were higher for girls with no employed parent/guardian in the household and for girls with parents or guardians with lower levels of educational attainment. Examining the associations between sociodemographic factors and risk of childhood obesity provides important clues for understanding racial differences in obesity, a major risk factor for coronary heart disease.

PMID: 9302856, UI: 97448448

Br J Clin Pract 1997 Apr-May;51(3):157-9

Report from the 46th annual scientific session of the American College of Cardiology, Anaheim, California, 16-19 March 1997.

Wroe CD

Publication Types:

• Congresses

Comments:

• Comment in: Br J Clin Pract 1997 Apr-May;51(3):131-2