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CLINICAL RESEARCH: ATHEROMA MORPHOLOGY

Ethnic Differences in the Prognostic Value of Coronary Artery Calcification for All-Cause Mortality

Khurram Nasir, MD, MPH^_*,1, Leslee J. Shaw, PhD, Sandy T. Liu, MD, Steven R. Weinstein, MD, Tristen R. Mosler, MD, Phillip R. Flores, MD, Ferdinand R. Flores, MD, Paolo Raggi, MD, Daniel S. Berman, MD, Roger S. Blumenthal, MD^|| and Matthew J. Budoff, MD^,2,_*

^_* Cardiac MRI PET CT Program, Massachusetts General Hospital Boston, Harvard School of Medicine, Boston, Massachusetts
Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
Division of Cardiology, Harbor-UCLA Medical Center Research and Education Institute, Torrance, California
Department of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
^|| Ciccarone Preventive Cardiology Center, Johns Hopkins University, School of Medicine, Baltimore, Maryland.

Manuscript received January 23, 2007; revised manuscript received March 8, 2007, accepted March 12, 2007.

^_* Reprints requests and correspondence: Dr. Matthew J. Budoff, Harbor-UCLA Research and Education Institute, 1124 West Carson Street, RB2, Torrance, California 90502. (Email: Budoff{at}ucla.edu).

Objectives: The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large, ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality.

Background: Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than non-Hispanic whites (NHW). Some of this variability may be due to differing pathophysiological mechanisms and effects of underlying atherosclerosis.

Methods: Ten-year death rates from all causes (total deaths = 505) were compared using risk-adjusted Cox proportional hazards models in AA (n = 637), Hispanic (HS, n = 1,334), Asian (AS, n = 1,065), and NHW (n = 11,776) populations.

Results: Ethnic minority patients were generally younger (0.3 to 4 years), more often persons with diabetes (p < 0.0001), hypertensive (p < 0.0001), and female (p < 0.0001). The prevalence of CAC scores 100 was highest in NHW (31%) and lowest for HS (18%) (p < 0.0001). Overall survival was 96%, 93%, and 92% for AS, NHW, and HS, respectively, as compared with 83% for AA (p < 0.0001). When comparing prognosis by CAC scores in ethnic minorities as compared with NHW, relative risk ratios were highest for AA with CAC scores 400 exceeding 16.1 (p < 0.0001). Hispanics with CAC scores 400 had relative risk ratios from 7.9 to 9.0, whereas AS with CAC scores 1,000 had relative risk ratios 6.6-fold higher than NHW (p < 0.0001).

Conclusions: Consistent with population evidence, AA with increasing burden of subclinical coronary artery disease were the highest-risk ethnic minority population. These data support a growing body of evidence noting substantial differences in cardiovascular risk by ethnicity.

Abbreviations and Acronyms   AA = African American(s)   AS = Asian(s)   CAC = coronary artery calcium   CI = confidence interval   CVD = cardiovascular disease   EBT = electron beam tomography   HS = Hispanic(s)   NHW = non-Hispanic white(s)   RR = relative risk

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