Association of Race and Ethnicity With Obstructive Coronary Artery Disease

Variations of the Extent of Obstructive Coronary Artery Disease Among Canadian Immigrants

BACKGROUND

An increasing proportion of immigrants are residing in developed countries, but little is known about the extent of their obstructive coronary artery disease (CAD). Our objective was to evaluate the association between immigrant status and CAD among immigrants.

METHODS AND RESULTS

Initial coronary angiography performed for stable CAD from 2012 to 2021 in Ontario, Canada was examined. Immigrants were categorized by their country of birth into 7 world regions. The primary outcome was the rate of obstructive CAD, defined as the presence of left main stenosis ≥50% or major epicardial vessel stenosis ≥70%. Multivariable logistic regression analyses were conducted to compare the adjusted odds of obstructive CAD among long-term residents and immigrants, and then within immigrant groups. Our cohort included 208 363 long-term residents and 36 139 immigrants; the immigrants were substantially younger than the long-term residents (61.3 versus 66.6 years). Male immigrants had 12.0% higher adjusted odds (95% CI, 1.17-1.24) of having obstructive CAD than long-term residents, whereas no significant difference was observed among female immigrants and long-term residents. There was also substantial variation in CAD among immigrants based on their country of origin. For example, male immigrants from South Asia had 49.0% higher adjusted odds of having CAD, whereas patients from Africa (0.75) and the Caribbean (0.63) had lower adjusted odds.

CONCLUSIONS

We observed earlier presentations for cardiac catheterization among immigrants with stable CAD and higher adjusted odds of having obstructive CAD among male immigrants compared with long-term residents of Canada. Rates of obstructive CAD varied significantly by their region of birth.

Evaluating the American Heart Association/American College of Cardiology Guideline-Recommended and Contemporary Pretest Probability Models in a Mixed Asian Cohort: The Contribution of Coronary Artery Calcium

BACKGROUND

Most pretest probability (PTP) tools for obstructive coronary artery disease (CAD) were Western -developed. The most appropriate PTP models and the contribution of coronary artery calcium score (CACS) in Asian populations remain unknown. In a mixed Asian cohort, we compare 5 PTP models: local assessment of the heart (LAH), CAD Consortium (CAD2), risk factor-weighted clinical likelihood, the American Heart Association/American College of Cardiology and the European Society of Cardiology PTP and 3 extended versions of these models that incorporated CACS: LAH(CACS), CAD2(CACS), and the CACS-clinical likelihood.

METHODS AND RESULTS

The study cohort included 771 patients referred for stable chest pain. Obstructive CAD prevalence was 27.5%. Calibration, area under the receiver-operating characteristic curves (AUC) and net reclassification index were evaluated. LAH clinical had the best calibration (χ2 5.8; P=0.12). For CACS models, LAH(CACS) showed least deviation between observed and expected cases (χ2 37.5; P<0.001). There was no difference in AUCs between the LAH clinical (AUC, 0.73 [95% CI, 0.69-0.77]), CAD2 clinical (AUC, 0.72 [95% CI, 0.68-0.76]), risk factor-weighted clinical likelihood (AUC, 0.73 [95% CI: 0.69-0.76) and European Society of Cardiology PTP (AUC, 0.71 [95% CI, 0.67-0.75]). CACS improved discrimination and reclassification of the LAH(CACS) (AUC, 0.88; net reclassification index, 0.46), CAD2(CACS) (AUC, 0.87; net reclassification index, 0.29) and CACS-CL (AUC, 0.87; net reclassification index, 0.25).

CONCLUSIONS

In a mixed Asian cohort, Asian-derived LAH models had similar discriminatory performance but better calibration and risk categorization for clinically relevant PTP cutoffs. Incorporating CACS improved discrimination and reclassification. These results support the use of population-matched, CACS-inclusive PTP tools for the prediction of obstructive CAD.