Racial Differences in Long-term Survival among Patients with Coronary Artery Disease

Kevin L. Thomas, MD, FACC; Emily Honeycutt, MBI; Linda K. Shaw, MS; Eric D. Peterson, MD, MPH, FACC

Disclosures

Am Heart J. 2010;160(4):744-751. 

In This Article

Abstract and Introduction

Abstract

Background Cardiovascular disease is the leading cause of death among blacks and whites in the United States. Despite this, there are insufficient data on the long-term prognosis of black patients with coronary artery disease (CAD) as well as the major clinical related determinants of outcome.
Methods We studied 22,618 patients (3,314 black) having significant CAD findings at cardiac catheterization performed at Duke from January 1986 to December 2004 with follow-up through June 2006. Using Kaplan-Meier and Cox modeling, we compared unadjusted and adjusted long-term survival by patient race and gender (median follow-up 7.6 years, interquartile range 3.5–13.0) as well as identified major patient characteristics associated with survival.
Results Blacks with CAD were younger; were more often female; had lower median household incomes; and had more hypertension, diabetes mellitus, and heart failure. The number of coronary vessels with significant disease was similar by race. At 15-year follow-up, black women had the lowest survival and white men had the highest (41.5% vs 45.8%, P < .0001). Blacks were less likely to receive initial therapy with coronary revascularization (odds ratio 0.66, 95% CI 0.60–0.72, P < .0001). After adjusting for baseline clinical and demographic characteristics and initial treatment selection, black race remained an independent predictor of lower survival (hazard ratio 2.54, 95% CI 1.60–4.04, P < .0001).
Conclusions Among patients with CAD, blacks have lower long-term survival compared with whites. The difference may be partially, but not fully, explained by differences in cardiovascular risk factors and 30-day revascularization rates.

Introduction

Thirteen million Americans have coronary artery disease (CAD), and >7 million have had myocardial infarctions (MIs).[1,2] Cardiovascular disease accounts for >900,000 deaths per year and remains the leading cause of death among whites and blacks.[3] Although advances in medical therapy and technology for the prevention and treatment of cardiovascular disease are reducing mortality rates, recent evidence suggests that black patients may not be benefiting as much as their white peers.[3,4]

To date, there has been limited information available on the long-term comparative outcomes among blacks and whites with CAD. Prior data in this area have been derived from cross-sectional census data or small randomized trial populations.[3,5–11] Such data are limited in their reflection of contemporary treatment, have relatively short longitudinal follow-up, and contain limited information on coronary anatomy or disease severity. We used information from the Duke Databank for Cardiovascular Disease (DDCD), the nation's oldest and largest longitudinal cardiovascular database, to (1) compare survival rates by race among CAD patients for up to 15 years; (2) determine whether the baseline clinical risk factors and initial treatment selection for coronary revascularization varied as a function of race; and (3) evaluate whether race, both overall and among important patient subgroups, was an independent predictor of lower long-term survival after adjusting for baseline demographic, clinical, and initial treatment factors.

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