Ethnic Differences in Myocardial Perfusion Imaging-Identifying Patients at Higher Risk

Ethnic Differences in Myocardial Perfusion Imaging-Identifying Patients at Higher Risk

Heller Gary, Noble Gavin
US Cardiology 2004
Published: August 2004
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Introduction
Coronary artery disease (CAD) is the leading cause of death in the US in both men and women, and in all ethnic groups that have been evaluated.1 The American College of Cardiology estimated the 1998 annual costs (direct and indirect) of CAD in the US to be US$368.4 billion, compared with cumulative cancer costs of US$189 billion.2 The scope of this problem is expanding as the population ages. The national focus on cardiovascular research, diagnosis and therapeutics has led to a recent trend toward decreased CAD-related mortality1 (see Figure 1). However, this trend may not benefit all groups equally, as African-Americans have experienced a slower decline in mortality than non- Hispanic whites, and women have a smaller decrease than men 3 (see Figure 2).

This has led to increased disparity between certain subgroups, a challenge recognized in the Healthy People 2010 Objectives. 4 Early detection of CAD may be able to address this disparity by providing accurate, cost-effective diagnosis, risk stratification, and guides for treatment strategies to potentially reduce cardiac risk.The identification of ethnic minority patients at higher risk of cardiac events could provide more appropriate treatment- and therapy-impacting outcomes. In addition to primary and secondary risk factor management,myocardial perfusion imaging represents an effective strategy to achieve such a goal.

Ethnic Differences in Cardiovascular Mortality
Epidemiologic data show wide variability between ethnic groups with respect to cardiovascular disease.White males, with historically the highest coronary disease death rates, have experienced the sharpest decline in mortality. The decline has been less dramatic in black males, to the point that in 2001 African-American males had a higher overall CAD mortality rate than Caucasian males, 262.0 versus 228.4 (per 100,000), representing a reversal from the historical relationship.An even greater relative disparity is seen between African-American and Caucasian women1 (see Table 1). Excess cardiovascular mortality has not been demonstrated in all ethnic minorities. From 1999 CDC data, the overall death rate in Hispanics (138 per 100,000), Native Americans (123.9 per 100,000), and Asian/Pacific Islanders (115.5 per 100,000) is much lower than the overall rate in the US (177.8 per 100,000). Research into the importance of the biologic, social, and behavioral issues underlying these differences is on-going.

Traditional Cardiovascular Risk Factors in Ethnic Minorities

Familiar cardiovascular disease risk factors are present in varying percentages of different populations. 3 The Third National Health and Nutrition Examination Survey (NHANES III) data show increased rates of obesity, hypertension, smoking, and diabetes among blacks and Hispanics.5 Furthermore, these risk factors may have differing effects in ethnic groups, with hypertension exerting a particularly deleterious effect among Blacks while diabetes disproportionately affects Hispanics.6 The impact of these risk factors is complex – increased cardiovascular mortality has been demonstrated in some ethnic minorities in the presence of less obstructive coronary disease.7 The disparity in cardiovascular mortality is not explained by differences in traditional risk factors.8 Strategies focusing on broad issues, such as socioeconomic status (SES), or individual risk stratification, such as that offered with myocardial perfusion imaging may help clarify the issue in a clinically relevant manner.

SES and Mortality
Indicators of SES have consistently been found to have an inverse relationship to cardiovascular death and all causes of mortality.9 Several studies have supported the concept that SES may have a greater impact on mortality than traditional risk factors.10 The interaction between ethnicity and SES is difficult to untangle. In the US, Blacks and Hispanics have lower mean incomes and a greater percentage of their populations are at or near the poverty level.11 Mortality differences may be explained by differences in risk factors, access to healthcare, environmental factors, psychological stressors, behavioral factors, and other yet to be understood factors.

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