Surprising Ethnic Difference in Atherosclerosis Burden in Harlem, NY

Batya Swift Yasgur MA, LSW

July 14, 2022

Non-Hispanic Black young adults in a large, ethnically diverse underserved neighborhood in New York City have about twice the prevalence of subclinical atherosclerosis as Hispanic young adults, according to a new cross-sectional study. It was noteworthy for identifying subclinical cardiovascular (CV) disease in the cohorts using 3D intravascular ultrasound (3DIVUS).

The study's 436 Black and Hispanic adults, 82% of them women, completed questionnaires regarding nutrition, lifestyle, medical history, weight, blood pressure, cholesterol levels, and other metrics.

The Black participants, compared with the Hispanic cohort, showed almost triple the rate of hypertension (30.6% vs 11.1%) and more than twice the rate of current smoking (24.5% vs 9.3%). Overall Framingham scores for 10-year risk for CV events were not statistically different, at 4.6 and 3.6, respectively.

Overall, the presence of atherosclerosis in either the carotid or femoral arteries was identified with 3DVUS in 8.7% of participants. But its prevalence was about twofold greater in Black than in Hispanic participants (12.9% vs 6.6%), a finding that persisted after multivariable adjustment and appeared driven by a greater prevalence of carotid disease among Black participants (12.9% vs 4.8%).

"For the same predicted CV risk, non-Hispanic Black individuals appear to be more vulnerable than people of Hispanic origin to early subclinical atherosclerosis, particularly in the carotid arteries, potentially placing them at increased risk of clinical CV disease," concludes a report published in the July 19 issue of the Journal of the American College of Cardiology, with lead author Josep Iglesies-Grau, MD, Montreal Heart Institute.

International Program

The current analysis from the FAMILIA study is part of a large international project called Science, Health, and Education (SHE), which is designed to promote early intervention in the lives of children, their caretakers, and teachers so they can develop lifelong heart-healthy habits, senior author Valentin Fuster, MD, PhD, physician-in chief, Mount Sinai Hospital, New York City, told | Medscape Cardiology.

The SHE program has been presented to more than 50,000 children worldwide, and FAMILIA has delivered successful interventions to more than 500 preschoolers, caretakers, and educators at Head Start schools in the Harlem neighborhood of New York City, where the current study was conducted.

The analysis centered on the children's adult caregivers, of whom one-third were non-Hispanic Black and two-thirds were Hispanic. "We wanted to know if this young population of parents and caregivers [would show] development or initiation of atherosclerotic disease," Fuster said, "thinking that when we showed them that they had disease, it would further motivate them to change their lifestyle."

Participants were assessed for seven basic CV risk factors — hypertension, smoking, body mass index (BMI), diabetes, dyslipidemia, low physical activity levels, and poor-quality diet — as well as socioeconomic descriptors. All participants also underwent 3DVUS to evaluate the presence and extent of atherosclerosis in the carotid and femoral arteries.

"Expected and Unexpected" Findings

Black participants were considerably more likely than their Hispanic counterparts to be hypertensive, to be active smokers, and to have higher BMIs. The Black cohort reported higher consumption of fruits and vegetables (P < .001).

Differences in Risk Factors in a Multiethnic Cohort
Risk Factor Difference Value
Hypertension OR 3.54 (2.14–5.87) <.001
Active smoking OR 3.15 (1.83–5.41) <.001
Elevated BMI (mean difference) 1.45 kg/m2 .027
OR (95% CI), odds ratio with 95% confidence intervals for Black vs Hispanic participants.

There were no between-group differences in the prevalence of diabetes or in mean fasting glucose or total cholesterol levels.

The mean 10-year Framingham CV risk score across the entire study population was 4.0%, with no significant differences between the two groups. In fact, 89% of participants were classified as low-risk on the basis of the score.

The overall prevalence of subclinical atherosclerosis was 8.7%, with a mean global plaque burden of 5.0 mm3. But there were dramatic differences in atherosclerotic burden. Across all 10-year Framingham risk categories, Black participants had twice the odds of having subclinical atherosclerosis as Hispanic participants (odds ratio [OR], 2.11; 95% CI, 1.09 - 4.08; = .026).

Black participants also had a greater atherosclerotic disease burden (9.0 mm3 vs 2.9 mm3), mean total plaque volume (= .028), and a higher prevalence of disease in both the carotid and femoral arteries (8.2% vs 3.8%; = .026).

"Our findings were both expected and completely unexpected," Fuster commented. "It was expected that the non-Hispanic Black population would have more hypertension, obesity, and smoking, and might therefore have more [atherosclerotic] disease. But what was unexpected was when we adjusted for the seven risk factors and socioeconomic status, the Black population had three times the amount of disease," he said.

"We need to take better care of the risk factors already known in the Black population, which is critical." However, "our challenge today is to identify these new risk factors, which might be genetic or socioeconomic." Fuster said his group is "already working with artificial intelligence to identify risk factors beyond the traditional risk factors that are already established."

Socioeconomic Differences?

"The fact that we're uncovering and demonstrating that this is an issue — especially for African American women at a young age — and we could make a significant interdiction in terms of risk reduction if we have tools and invest the necessary time and effort, that is the important part of this paper," Keith Churchwell, MD, Yale New Haven Hospital, and Yale School of Medicine, New Haven, Connecticut, told | Medscape Cardiology.

"If you're going to evaluate African Americans in Harlem who are socially disadvantaged, I would want to know if there is a difference between them and other African Americans who have a different socioeconomic status, in terms of atherosclerotic disease," added Churchwell, who was not involved with the study.

The Framingham 10-year risk score is "inadequate in assessing CV disease risk in all populations and is not generalizable to non-Whites," contend Ramdas G. Pai, MD, and Vrinda Vyas, MBBS, University of California Riverside School of Medicine, in an accompanying editorial.

"New data are emerging in favor of imaging-based classification of CV disease risk and has been shown to improve patient adherence to and compliance with risk-modifying interventions," they write. "Subclinical atherosclerosis may help better stratify CV disease risk so that preventive measures can be instituted to reduce cardiovascular events at a population level."

Fuster and coauthors, Ramdas and Pai, and Churchwell report no relevant financial relationships.

J Am Coll Cardiol. 2022;80:219-229, 230-232. Abstract, Editorial


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