High CV Burden in Black Patients May Not Mean Higher Event Rates

Megan Brooks

December 28, 2021

Black adults with chest pain have a higher burden of cardiovascular disease (CVD) risk factors compared with White adults, but they have a similarly low incidence of major adverse cardiac events (MACE) over 2 years, new data from the PROMISE trial suggest.

Black adults tend to have a higher incidence of long-term coronary artery disease (CAD) morbidity and mortality compared with White adults — differences that may be a result of a higher burden of CVD risk factors as well as disparities in socioeconomic status and access to healthcare.

Yet, how CVD risk factors, epicardial CAD, and cardiac events differ between Black and White adults undergoing noninvasive testing for CAD is unclear.

To investigate, researchers did a post-hoc analysis of 1071 Black adults (mean age 59, 60% women) and 7693 non-Hispanic White adults (mean age 61, 52% women) with stable chest pain who underwent coronary computed tomography angiography (CCTA) for suspected CAD as part of the previously reported PROMISE trial.

The study, by Lili Zhang, MD, Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston and colleagues, was published online December 22 in JAMA Cardiology.

Black adults had a higher CV risk burden than White adults, including significantly higher BMI (32.3 vs 30.4 kg/m2; P < .001), more hypertension (82.6% vs 62.6%, P < .001), diabetes (32.2% vs 18.4%; P < .001), CAD risk equivalent (36.2% vs 22.4%; P < .001), metabolic syndrome (43.5% vs 36.4%; P < .001) and a sedentary lifestyle (58.4% vs 47.5%; P < .001).

Overall, the average number of reported CV risk factors per patient was significantly higher in Black individuals compared with White patients (2.47 vs 2.35; P < .001).

Yet, despite the significantly higher CV risk burden, Black and White persons had a "similarly low" rate of MACE over a median follow-up of 24.4 months (3.0% vs 3.2%; P = .84), Zhang and colleagues report.

Sensitivity analyses restricted to the 79.8% of participants with a normal or mildly abnormal noninvasive CCTA result and the 54.3% not on statin therapy yielded similar findings.

Significant coronary stenosis and high-risk plaque were associated with MACE in both Black and White patients.

However, with respect to epicardial CAD burden, Black patients had a less-prevalent coronary artery calcium score > 0 (45.1% vs 63.2%; P < .001), coronary stenosis ≥ 50% (8.7% vs 14.6%; P = .001), and high-risk plaque (37.6% vs 52.4%; P < .001).

The finding that Black individuals had more CV risk factors, yet less coronary plaque on CCTA and similar MACE at 2 years, "underscores the limits of our understanding of the relationship between risk factors and plaque in Black and White persons," write Zhang and colleagues.

They caution that while the PROMISE trial included a diverse pool of patients with suspected CAD, it may not reflect the broader population in whom CAD is not suspected.

Also, the number of Black participants included was modest and follow-up was limited to 24 months. Therefore, the results should be interpreted in the context of 2-year MACE and may not capture differences that would emerge over 10 years, the study team says.

Finally, they say the study may be underpowered to detect the differences in MACE between Black and White individuals owing to the low rate of MACE.

The PROMISE study was funded by National Heart, Lung, and Blood Institute (NHLBI). Zhang has disclosed no relevant financial relationships. A complete list of author disclosures is available with the original article.

JAMA Cardiol. Published online December 22, 2021. Abstract

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