Prevalence of cardiovascular disease risk factors in blacks and whites: the Minnesota Heart Survey

Validation of the Korean Genome Epidemiology Study Risk Score to Predict Incident Hypertension in a Large Nationwide Korean Cohort

BACKGROUND

This study aimed to validate the Korean Genome Epidemiology Study (KoGES) risk score to predict the 4-year risk of hypertension (HT) in a large nationwide sample, and compare its discrimination and calibration with the Framingham and blood pressure (BP)-only models.

METHODS AND RESULTS

This study analyzed 69,918 subjects without HT at baseline from the National Sample Cohort in the National Health Insurance Service database. We compared the Framingham, KoGES, and BP-only models for discrimination using area under the receiver-operating characteristic curves (AROC), calibration using goodness-of-fit tests, and reclassification ability using the continuous net reclassification improvement (NRI) and integrated discrimination improvement. Of 69,918 subjects, 18.6% developed HT during the follow-up. AROC was significantly higher for the KoGES (0.733) than for the Framingham (0.729) or BP-only (0.707) model. Recalibrated Framingham model underestimated HT incidence in all deciles (P<0.001). BP-only model overestimated risk in the lower deciles (P<0.001). KoGES model accurately predicted risk in all except the highest decile (χ(2)=14.85, P=0.062). The KoGES model led to a significant improvement in risk reclassification compared with the Framingham and BP-only models (NRI, 0.354; 95% confidence interval [CI], 0.343-0.365 and 0.542; 95% CI, 0.523-0.561, respectively).

CONCLUSIONS

In this validation study, the KoGES model demonstrated better discrimination, calibration, and reclassification ability than either the Framingham or BP-only model. The KoGES model may help identify Korean individuals at high risk for HT. (Circ J 2016; 80: 1578-1582).

Comparison of Cardiovascular Risk Factors in Obese Blacks and Whites

Blacks are known to have higher blood pressure levels, a higher prevalence of hypertension, and higher body weights than whites. However, the interrelationships of these and other cardiac risk factors have not been analyzed in an obese population. We compared blood pressure (BP) and lipid levels in 174 obese blacks and 939 obese white patients who were entering a weight loss program; we also assessed the effects of weight loss on these factors. Prevalence of treated hypertension was similar in blacks and whites (28% vs. 25%, respectively). In patients not taking BP medication, black women weighed more (108 kg) than white women (102 kg) and black and white males' weights were similar (135 kg vs. 131 kg). Systolic and diastolic BP were similar in black and white women; black males had similar SBP but a significantly lower DBP than white males (83 mmHg vs. 89 mmHg, respectively). Lipid levels were similar in black and white women except black women had lower triglycerides (1.30 mmol/L) than white women (1.58 mmol/L, p < 0.05); and black males compared to white males had significantly lower total cholesterol (4.76 mmol/L vs. 5.56 mmol/L), LDL-cholesterol (3.15 mmol/L vs. 3.52 mmol/L) and triglycerides (1.31 mmol/L vs. 2.17 mmol/L, p < 0.05). Adult-onset obesity adversely affected a number of cardiovascular risk factors in whites, but not in blacks. Blacks lost significantly less weight (-13 kg) than whites (-19 kg). However, controlling for the difference in weight loss, blacks sustained comparable improvement in lipids and blood pressure, except for TC/HDL-C (whites improved significantly more, -0.36 kg/m2, than blacks, 0.03 kg/m2). Thus, the impact of obesity on cardiovascular risk factors seems ameliorated in blacks compared to whites.

Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis

The prevalence of hypertension is higher among blacks than whites. However, inconsistent findings have been reported on the incidence of hypertension among middle-aged and older blacks and whites, and limited data are available on the incidence of hypertension among Hispanics and Asians in the United States. Therefore, this study investigated the age-specific incidence of hypertension by ethnicity for 3146 participants from the Multi-Ethnic Study of Atherosclerosis. Participants, age 45 to 84 years at baseline, were followed for a median of 4.8 years for incident hypertension, defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or the initiation of antihypertensive medications. The crude incidence rate of hypertension, per 1000 person-years, was 56.8 for whites, 84.9 for blacks, 65.7 for Hispanics, and 52.2 for Chinese. After adjustment for age, sex, and study site, the incidence rate ratio (IRR) for hypertension was increased for blacks age 45 to 54 (IRR: 2.05 [95%CI: 1.47 to 2.85]), 55 to 64 (IRR: 1.63 [95% CI: 1.20 to 2.23]), and 65 to 74 years (IRR: 1.67 [95% CI: 1.21 to 2.30]) compared with whites but not for those 75 to 84 years of age (IRR: 0.97 [95% CI: 0.56 to 1.66]). Additional adjustment for health characteristics attenuated these associations. Hispanic participants also had a higher incidence of hypertension compared with whites; however, hypertension incidence did not differ for Chinese and white participants. In summary, hypertension incidence was higher for blacks compared with whites between 45 and 74 years of age but not after age 75 years. Public health prevention programs tailored to middle-aged and older adults are needed to eliminate ethnic disparities in incident hypertension.

Blood pressure and the risk of developing diabetes in african americans and whites: ARIC, CARDIA, and the framingham heart study

OBJECTIVE

We examined the association between high blood pressure and incident type 2 diabetes in African Americans and whites aged 35-54 years at baseline.

RESEARCH DESIGN AND METHODS

We combined data from the Atherosclerosis Risk in Communities (ARIC) study, the Coronary Artery Risk Development in Young Adults (CARDIA) study, and the Framingham Heart Study offspring cohort. Overall, 10,893 participants (57% women; 23% African American) were categorized by baseline blood pressure (normal, prehypertension, hypertension) and examined for incident diabetes (median follow-up 8.9 years).

RESULTS

Overall, 14.6% of African Americans and 7.9% of whites developed diabetes. Age-adjusted incidence was increasingly higher across increasing blood pressure groups (P values for trend: <0.05 for African American men; <0.001 for other race-sex groups). After adjustment for age, sex, BMI, fasting glucose, HDL cholesterol, and triglycerides, prehypertension or hypertension (compared with normal blood pressure) was associated with greater risks of diabetes in whites (hazard ratio [HR] for prehypertension: 1.32 [95% CI 1.09-1.61]; for hypertension: 1.25 [1.03-1.53]), but not African Americans (HR for prehypertension: 0.86 [0.63-1.17]; for hypertension: 0.92 [0.70-1.21]). HRs for developing diabetes among normotensive, prehypertensive, and hypertensive African Americans versus normotensive whites were: 2.75, 2.28, and 2.36, respectively (P values <0.001).

CONCLUSIONS

In African Americans, higher diabetes incidence among hypertensive individuals may be explained by BMI, fasting glucose, triglyceride, and HDL cholesterol. In whites, prehypertension and hypertension are associated with greater risk of diabetes, beyond that explained by other risk factors. African Americans, regardless of blood pressure, have greater risks of developing diabetes than whites.

The effects of ethnic discrimination and socioeconomic status on endothelin-1 among blacks and whites

BACKGROUND

Ethnic disparities in cardiovascular disease (CVD) may partially reflect differences in chronic stress burden that vary by social class and exposure to ethnic discrimination. Stress is associated with increased endothelin-1 (ET-1). This study examined the relationship of ET-1 to socioeconomic status (SES) and to perceived ethnic discrimination among black (n = 51) and white (n = 65) adults (mean age 36.5).

METHODS

The Perceived Discrimination subscale of the Scale of Ethnic Experience measured exposure to discrimination and the Hollingshead Two-Factor Index of Social Position assessed SES. Plasma ET-1 was sampled upon awakening after an overnight admission.

RESULTS

SES and ET-1 levels were similar across ethnic groups, but mean discrimination scores were higher among blacks than whites (P < 0.001). Multiple regressions found that the SES x ethnicity interaction was associated with ET-1 (P < 0.05), after adjustment for gender, resting mean arterial pressure (MAP), body mass index (BMI), and exercise frequency. Regressions stratified by ethnicity revealed that lower SES correlated with higher ET-1 in whites (P < 0.001), but not blacks, and accounted for 21% of the variance. Another series of regressions revealed an interaction effect of ethnicity by discrimination on ET-1 (P < 0.05). Increased discrimination correlated with increased ET-1 among blacks (P < 0.05), but not whites, and explained 11% of the variance after adjustment for SES, gender, exercise frequency, and socially desirable response bias.

CONCLUSIONS

Thus, ET-1 levels increased in association with different psychosocial burdens in blacks and whites. Plasma ET-1 was higher among whites with lower SES and among blacks with higher levels of perceived ethnic discrimination, regardless of SES.

Combating the epidemic of obesity and cardiovascular disease: perspectives from school-aged children

This study was designed to assess students' perceptions of the obstacles to positive dietary practices and increased physical activity and to solicit the students' recommendations for addressing and possibly reducing the negative practices that are associated with the rise in obesity and the development of cardiovascular diseases. Data for the study were obtained from the administration of the 2005 Project Health High School Survey (PHHSS) which measured the students' perceptions regarding obstacles to eating more nutritious, healthier foods and obstacles to participating in daily physical activity. The reasons for students' lack of interest in practicing more life-healthy behaviors are ranked and recorded. Some of the students indicated that they usually ate what they liked to eat, and the decision about what to eat was made because of the taste of the food without regard for any health consequence or negative health outcomes. Finding ways to reach these students at their young ages is the key to successfully combating the high prevalence of obesity and the development of other chronic diseases in childhood, as well as in adulthood.

Multiple Polymorphisms in the renin- angiotensin-aldosterone system (ACE, CYP11B2, AGTR1) and their contribution to hypertension in African Americans and Latinos in the multiethnic cohort

OBJECTIVE

When compared with other U.S. populations, African Americans have excess hypertension. Genetic variants in elements of the renin-angiotensin-aldosterone system (RAAS), namely the angiotensin-converting enzyme (ACE), aldosterone synthase (CYP11B2), and angiotensin II type 1 receptor (AGTR1) genes, have been associated with risk of hypertension in some populations.

METHODS

We genotyped the D/I polymorphism in the ACE gene, the C(-344)T polymorphism in the CYP11B2 gene, and the C(-535)T polymorphism in the AGTR1 gene among African American and Latino members of the Multiethnic Cohort Study (MEC) to determine their association with hypertension.

RESULTS

We observed no significant increase in the risk of hypertension for either African Americans or Latinos homozygous or heterozygous for the D allele of the ACE gene. Among African Americans we observed carriers of the (-344)T allele of CYP11B2 to be at increased risk of hypertension (versus CC genotype: TC genotype, OR = 1.66 [95% CI: 1.01-2.72]; TT genotype, OR = 1.74 [95% CI: 1.07-2.82]). There was also an increase in risk of hypertension associated with the AGTR1 T allele for African Americans (versus CC genotype: TC genotype, OR = 2.62 [95% CI: 1.46-4.72]; TT genotype, OR = 2.67 [95% CI: 1.51-4.74]). The associations observed with CYP11B2 and AGTR1 genotypes were not observed among Latinos.

CONCLUSION

These data suggest that the (-535)T allele of AGTR1 and (-344)T allele of CYP11B2 may increase hypertension risk among African Americans but not among Latinos. Characterization of the linkage disequilibrium and haplotype patterns in the RAAS pathway genes will be crucial to understanding differences in hypertension susceptibility in these ethnic populations.

Hostility differentially predicts cardiovascular risk factors in African American and White young adults

OBJECTIVE

Hostility may influence racial disparities in cardiovascular disease through differential associations with cardiovascular risk factors. This study explored racial variations in relations between hostility and selected cardiovascular risk factors.

METHODS

Cook-Medley Hostility (Ho) scores and 11 risk factors were examined among 66 healthy, White and African American young adults.

RESULTS

Controlling for age, gender, and body mass index, the interaction of hostility and race yielded significant (or marginal) associations with resting systolic and diastolic blood pressure (SBP, DBP), cardiac index (CI; i.e. cardiac output adjusted for body size), total peripheral resistance (TPR), insulin (INS), triglycerides (TG) and percent body fat (PBF). Contributing substantial variance, hostility was positively associated with SBP, DBP, TPR, TG and INS, and negatively associated with CI among African Americans. Conversely, hostility was negatively associated with TPR and PBF among Whites.

CONCLUSION

Hostility may confer greater cardiovascular risk among young African Americans than Whites.

Cardiovascular disease mortality

Although mortality from cardiovascular diseases (CVDs) has been declining, it remains the leading cause of death among urban U.S. blacks. McCord and Freeman reported CVD as the major contributor to excess mortality in Central Harlem. However the disease-specific CVD mortality was not assessed. Thus, it was unclear what the distribution of specific CVDs was in Central Harlem and their contribution to excess mortality. We reviewed the vital statistics records of New York City (NYC) Department of Health for 1990 and identified all cases in which the cause of death was coded as cardiovascular (International Classification of Diseases-ICD, 9th Revision, codes 391, 393-398, 401-404, 410, 411, 414-417, 420-438 and 440-444). The total and disease-specific CVD mortality for NYC and Central Harlem were calculated using the appropriate 1990 census data as the denominator. Central Harlem residents aged between 25-64 years were at least twice as likely to die from cardiovascular causes, compared to NYC residents. Hypertension-related deaths, ICD codes 401 (essential hypertension), 402 (hypertensive heart disease), 403 (hypertensive renal disease), and 404 (hypertensive heart and renal disease), were the major cause of excess death for men and women in Central Harlem. These findings show the importance of hypertension as the main determinant of the excess cardiovascular mortality in urban blacks and suggest an increased risk of cardiovascular death in blacks residing in Central Harlem.

Baseline fat-related dietary behaviors of white, Hispanic, and black participants in a cholesterol screening and education project in New England

OBJECTIVE

To examine baseline fat-related dietary behaviors of white, Hispanic, and black participants in Minimal Contact Education for Cholesterol Change, a National Institutes for Health-funded cholesterol screening and education project conducted in New England.

SUBJECTS

A sample of 9,803 participants who joined the study at baseline (n=7,817 white; n=1,425 Hispanic; and n=561 black).

METHODS

Participants completed baseline questionnaires that included demographic and psychosocial items as well as the Food Habits Questionnaire, a dietary assessment tool measuring fat-related dietary behaviors. They also had their blood cholesterol level and height and weight measured.

STATISTICAL ANALYSES

Analysis of variance (ANOVA) was used to compare racial/ethnic groups on continuous demographic variables, and the chi(2) test of association was used to compare groups on demographic categorical variables. Multivariate analysis of variance (MANOVA) was used to compare mean differences between racial/ethnic groups on six behavioral subscales (Fat Factors) differentiating domains of behavior related to fat intake and to compare 27 individual fat-related dietary behaviors.

RESULTS

After adjusting for sex, age, marital status, education, employment status, and percent time lived in the United States, white participants had the lowest Food Habits Questionnaire summary score (2.44) (indicating a lower fat diet), followed by Hispanic (2.61) and black (2.68) participants. The three ethnic groups also differed on the prevalence of Fat Factors and specific fat-related dietary behaviors. White participants were more likely to use lower-fat alternatives, to avoid frying, to replace meat, and to modify meat to make it lower in fat. However, they were least likely to eat fruits and vegetables for snacks and desserts. Hispanic participants were more likely to engage in fat-avoidance behaviors and to eat fruits and vegetables for snacks and desserts. Black participants were less likely to eat meatless meals and modify meats to make them lower in fat. Black and Hispanic participants were more likely than white participants to fry foods. Hispanics were less likely to read food labels for nutrition information. The most and least prevalent fat-related behaviors also differed by each ethnic group, showing that different behaviors were more and less easily implemented by each ethnic group.

CONCLUSIONS/APPLICATIONS

The results of this study suggest that there is a need for improvement in dietary behaviors related to fat intake, especially for blacks and Hispanics, and that the specific dietary behavior issues differ widely by ethnicity. These results can be used by nutrition educators and researchers to help them decide what messages to emphasize in dietary counseling, nutrition education programs, and materials. The results can also be used to help design better dietary assessment tools and more effective interventions for culturally diverse populations.

Comparison of perceived health to physiological measures of health in Black and White women

BACKGROUND

Obesity and sedentary lifestyles are prevalent among minority women. This study compared perceived and physiological measures of health in 35 non-Hispanic Black (NHB) and 155 non-Hispanic White (NHW) sedentary women.

METHODS

Self-perception of body weight, physical shape and appearance, physical fitness, and eating habits were assessed via questionnaire using 10-point scales (1 = poor, 10 = excellent), and height, weight, aerobic capacity (V(O(2))(max)), and 4-day food records were directly measured.

RESULTS

Although body mass index (BMI, 30.3 +/- 5.3 vs 27.2 +/- 4.5 kg/m(2)) and weight (82.7 +/- 16.5 vs 73.1 +/- 12.9 kg) were greater (both P = 0.0001) in NHB, groups were similar in self-perception of physical shape and appearance and weight. V(O(2))(max) was lower in NHB compared to NHW (20.7 +/- 4.5 vs 23.5 +/- 4.6 ml x kg(-1) x min(-1), P = 0.002), despite no difference between groups in self-perception of physical fitness. Finally, there was no difference between groups for self-perception of eating habits and percentage of calories derived from fat (%fat). The results were unchanged after adjusting for age, education, and income, except that %fat was greater in NHB compared to NHW (35.7 +/- 6.3 vs 33.8 +/- 6.9%, P = 0.03).

CONCLUSIONS

Although NHB were heavier, more obese, less fit, and consumed a greater %fat than NHW, they perceived their weight, physical shape and appearance, physical fitness, and eating habits to be no worse than those of their White counterparts. The perceptions of NHB regarding their weight, fitness, and eating habits may represent barriers to change.

Premenopausal black women are uniquely at risk for coronary heart disease compared to white women

Premenopausal black women have a two to threefold greater rate of coronary heart disease than premenopausal white women. This study was designed to provide greater insight into the reasons for this difference which is currently unclear. Coronary heart disease risk factors were compared in 100 black and 100 white, healthy premenopausal women, ages 18-45 years, and of relatively advantaged socioeconomic status. Compared to white women, black women had a higher body mass index (32.0±9.2 vs. 29.0±9.4 kg/m2, p=0.021), and higher systolic (124±17 vs. 115±14 mm Hg, p<0.0001) and diastolic (79±14 vs. 75±11 mm Hg, p=0.048) blood pressures. The mean plasma lipoprotein(a) concentration was markedly higher in the black women (40.2±31.3 mg/dL) than in the white women (19.2±23.7 mg/dL, p<0.0001). The plasma total homocysteine level was also higher in the black women (8.80±3.38 vs. 7.81±2.58 mmol/L, p=0.013). The black women, however, had lower plasma triglyceride levels (0.91±0.46 vs. 1.22±0.60 mmol/L, p<0.0001) and a trend toward higher high-density lipoprotein cholesterol levels (1.37±0.34 vs. 1.29±0.31 mmol/L, p=0.064) than the white women. Plasma total and low-density lipoprotein cholesterol levels were similar. Black women consumed more saturated fat and cholesterol. Rates of cigarette smoking and alcohol intake were low and similar between the races. In summary, compared to white women, black women had a higher mean body mass index, higher blood pressures, higher lipoprotein(a) and plasma total homocysteine levels, and greater consumption of saturated fat and cholesterol. The differences in coronary risk factors between these two premenopausal groups may explain the higher incidence of coronary heart disease in black women. (c) 2000 by CHF, Inc.

Risk factors for cardiovascular and cerebrovascular death among African Americans and Hispanics in Los Angeles, California

OBJECTIVE

To describe the risk factors associated with cardiovascular mortality in the African American (AA) and Hispanic populations in Los Angeles County in an effort to define causes for the excess mortality seen in AAs.

METHODS

This was a longitudinal analysis of all-cause, cardiovascular, and cerebrovascular mortality in a large, prospective multiethnic cohort of individuals aged 45-74 years. Death rates between AA and Hispanic men and women during the six-year period from 1993 to 1998 due to hypertension, cardiomyopathy, acute myocardial infarction (AMI), ischemic heart disease, and stroke were compared.

RESULTS

There were 1,157 deaths due to cardiovascular disease (CVD) or cerebrovascular disease among the 71,798 eligible members of the cohort included in these analyses. Age-adjusted mortality rates were two to five times higher in AAs as compared with Hispanics (e.g., 373.15 in AAs for hypertensive disease vs 50.37 in Hispanics). A history of hypertension was the most common significant risk factor for CVD; other risk factors significantly associated with CVD mortality included cigarette smoking and a past history of diabetes and stroke. Adjusting for these factors did not remove the significance of AA ethnicity as a risk factor for CVD mortality in either subjects reporting or subjects not reporting hypertension at baseline.

CONCLUSIONS

The evidence for both higher relative severity and higher incidence of hypertensive disease among AAs, and the consistency of the effect across gender, suggests that a major determinant of risk may be a gene environment interaction.

Changing trends in angioedema

Angioedema can be a life-threatening event presenting to otolaryngologists, emergency medicine physicians, and other physicians. Recent reports suggest an increasing role of angiotensin-converting enzyme inhibitors (ACEIs) in the causation of angioedema. Sixty-four cases occurring between 1994 and 1998 were identified and examined retrospectively. Fifty-eight percent of patients presenting with angioedema were using ACEIs. Ninety-four percent of patients overall, and 92% of patients with ACEI-associated angioedema, were African-American. Tongue, lip, facial, and supraglottic edema were most common. Treatment included intubation in 13% and intensive care unit monitoring in 20%. Nearly all patients were treated with corticosteroids and antihistamines. There were no deaths. Angioedema associated with ACEI use appears to be much more common than previously reported. African-American patients may be at higher risk for angioedema with ACEI use. Successful management was achieved with observation, expectant airway management, corticosteroids, and discontinuation of ACEIs. Patients without airway obstruction or pharyngeal or laryngeal edema who improved with treatment and observation were successfully treated as outpatients.

Obesity intervention among African-American children and adolescents

Often, researchers and clinicians approach the African-American community from a deficit model with African Americans viewed as having less desirable health practices and higher disease risk; however, in developing interventions for African Americans, it is important to keep in mind positive aspects of black culture as they relate to obesity. For example, the cultural acceptance of a larger body type and less negative views toward overweight individuals need not be viewed as problematic or abnormal. In fact, it could be argued that majority culture has a dysfunctional view of body image and obesity. The fact that whites are less likely to be overweight than African Americans may stem from a value system that places undue emphasis on thinness, youth, and external beauty and a culture that imbues women with shame about how they look and what they eat. Thus, rather than holding whites and majority culture as the ideal, it may be important to incorporate the positive elements of black culture regarding body image and food rather than attempting to shift their values toward those of European Americans. How best to achieve a reduction in obesity and its medical consequences, without inducing undesirable shifts in body image and attitudes toward food, is a formidable but important challenge.

Risk factor distribution among sociodemographically diverse African American adults

Because African Americans tend to have lower socioeconomic status (SES) than whites and numerous health indicators are related to SES variables, it is important when examining between-group differences in health indices to account for SES differences. This study examined the effects of income and education on several biologic and behavioral risk factors in a sample of sociodemographically diverse African American adults. Approximately 1,000 African American adults (aged 18-87) were recruited from 14 churches with predominantly black membership to participate in a nutrition education intervention. Demographics, height, weight, blood pressure, self-reported cigarette and alcohol use, self-reported diet by food frequency questionnaire, serum carotenoids, serum total cholesterol, and nutrition knowledge were assessed. The association of these risk factors were examined by four levels of education and income. For men, body mass index, blood pressure, total cholesterol, daily intake of fruits and vegetables, serum carotenoids, heavy alcohol use, or exercise were not associated significantly with income or education using analysis of variance (ANOVA). Past month alcohol use and nutrition knowledge were associated positively with education, but not income. For women, body mass index and smoking were associated inversely with income, but not with education. Blood pressure, total cholesterol, intake of fruits and vegetables, heavy alcohol use, and exercise were not associated with either income or education using ANOVA. Serum carotenoids, any 30-day alcohol use, and nutrition knowledge were associated positively with both income and education. Results using linear regression generally were similar for men and women, although a few more variables were associated significantly with SES compared to ANOVA analyses. Several health indicators that have been associated with socioeconomic variables in whites were not associated or only weakly associated in this diverse sample of African Americans. One interpretation of these findings is that SES factors may function differently among blacks and whites.

The low-density lipoprotein cholesterol-lowering effect of pravastatin and factors associated with achieving targeted low-density lipoprotein levels in an African-American population

STUDY OBJECTIVES

To describe the low-density lipoprotein cholesterol (LDL)-lowering effect of pravastatin in African-American patients and to identify factors associated with achieving National Cholesterol Education Program (NCEP)-defined target levels.

DESIGN

Retrospectively defined cohort study.

SETTING

Large, government-owned, teaching hospital.

PATIENTS

Eighty-four African-American patients starting therapy with pravastatin in October-November 1997.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Whether or not target LDL concentrations were achieved was used to measure efficacy. Stepwise logistic regression identified the target LDL, baseline LDL, and baseline high-density lipoprotein cholesterol (HDL) as significant predictors of achieving the target. The proportion of patients achieving their target LDL when that target was below 160, below 130, and 100 mg/dl or below was 64%, 32%, and 13% (p=0.004), respectively. Medical record review identified the reasons for not achieving target as incorrect drug regimen, inadequate lipid monitoring, and noncompliance.

CONCLUSION

These results indicate that substantial numbers of patients receiving lipid-lowering therapy are not meeting NCEP-defined targets and that with increased drug monitoring and compliance, improvements in achieving NCEP target LDL levels could be realized.

Brachial vascular reactivity in blacks

Endothelial function was studied ultrasonographically in a healthy subset of African Americans (blacks) because they have an increased risk of hypertension and vascular disease. Twenty-four healthy black and 28 well-matched white subjects were investigated. Ischemia was induced by inflating a cuff over the forearm to 40 mm Hg higher than systolic pressure for 5 minutes. Brachial artery diameter and blood flow velocity were measured at baseline and at 15, 45, and 60 seconds after deflation by use of an Acuson 128XP10 ultrasonograph with a 7.5 MHz transducer. Mean postischemic dilatation, an index of endothelial function, was 1.76+/-0.56% in blacks and 8.79+/-1.22% in whites (P<0.001). Median postischemic vasodilatation in black men [0% (0% to 2.86%)] was not significantly different to that in black women [0.82% (0% to 3.14%)], whereas white women [11.48% (8.70% to 14.29%)] dilated significantly more than white men [4.20% (2.13% to 5.56%)] (P<0.05). Both groups dilated significantly over baseline diameter to sublingual nitroglycerin administration 18.7+/-2.5% (blacks) and 20.2+/-3.2% (whites; P=NS). Mean hyperemic responses did not differ significantly between the 2 subject groups, nor did they differ between men and women of both ethnic groups. We conclude that endothelium-dependent vasodilatation is significantly impaired in healthy, young blacks compared with whites and that gender differences are not seen in blacks with regard to this phenomenon. An impairment in endothelium-dependent NO generation may be a contributing factor to future hypertension and vascular disease in healthy blacks.

Elevated mortality rates from circulatory disease in African American men and women of Los Angeles County, California--a possible genetic susceptibility?

OBJECTIVE

Reports of higher mortality in African Americans have often focused on socioeconomic differences. Such differences do not explain the excess mortality in African Americans compared with Hispanics in Los Angeles County. We suggest the existence of genetic factors to explain at least some of the differences in mortality risk.

METHODS

We compared the mortality rates from circulatory diseases in African American and Hispanic adults of Los Angeles County for 1988 to 1992 with the frequency of the angiotensin-converting enzyme (ACE) genotype.

RESULTS

African American adults 45 to 74 years old had a 2-fold higher overall mortality rate than Hispanics. The largest differences were seen for hypertensive disease and cardiomyopathy in men; the most striking differences were seen in the youngest age group. Rates were lower in women than in men, but African American women also showed substantial excess compared with Hispanics. ACE genotype also showed a significant difference between the Hispanic and African American population; the latter had a significantly higher prevalence of the DD genotype, which is associated with a higher level of circulating enzyme, and lower prevalence of the II genotype, which is associated with a lower enzyme level.

CONCLUSION

African American adults aged 45 to 74 years in Los Angeles County have a substantial excess mortality from hypertensive diseases compared with a similar Hispanic population. The frequency of the ACE DD genotype was higher in African Americans than in Hispanics. These studies may indirectly support the possibility of a genetic contribution to the excess hypertensive disease mortality in African Americans.

Low awareness of cardiovascular disease risk among low-income African-American women

Focus groups were conducted with low-income African-American women in six different community settings in Northern California to assess their awareness of and concern for cardiovascular disease (CVD). These women had low awareness of the prevalence of CVD, attributed CVD to stress and low socioeconomic status, saw the media as an important source of health-related knowledge, and saw a need for more community awareness on CVD among African-American people.

Insights into the pathophysiology of atherosclerosis and prognosis of black Americans with acute coronary syndromes

BACKGROUND

Disparities in prognosis for black and white patients with coronary heart disease have been widely reported. For several reasons it is unclear to what extent biologic factors contribute to these differences.

METHODS

The current medical literature regarding the pathophysiologic characteristics of cardiovascular disease is reviewed with emphasis on how racially mediated biologic differences may affect the manifestation, treatment, and prognosis of patients with coronary heart disease, particularly patients with acute coronary syndromes.

RESULTS

Black patients with coronary heart disease have a higher prevalence of ischemic heart disease risk factors, including hypertension, left ventricular hypertrophy, diabetes, and tobacco use. Other factors related to atherosclerosis, vascular reactivity, and thrombolysis that quantitatively and functionally differ among racial groups are identified. Prospective, randomized trials comparing outcomes among patients with acute coronary syndromes have included only a fraction of the available black population, although they reveal a similar short-term mortality rate for black and white patients. Several factors, including enhanced fibrinolysis among black patients with acute myocardial infarction, may in part counterbalance better understood and more prevalent comorbidities to equalize short-term (30-day) survival. All-cause, long-term (1-year) mortality appears worse for black patients compared with white patients with similar cardiovascular risk profiles.

CONCLUSION

As racially mediated biologic differences between black and white patients become better understood, targeted interventions to prevent coronary heart disease and treat acute coronary syndromes in black patients can be developed.

Seven-year incidence of hypertension in a cohort of middle-aged African Americans and whites

Many studies have suggested that African Americans have a higher prevalence of hypertension than whites. The authors conducted a prospective study of hypertension incidence from 1987-1988 to 1994-1995 in 140 African American and 237 white adults aged 30 to 54 years at baseline. The study participants were screened for participation in the Trials of Hypertension Prevention, phase 1, an 18-month lifestyle modification intervention trial aimed at lowering blood pressure, at the Baltimore Clinical Center. Baseline age, blood pressure, body mass index, and heart rate were similar in the two groups. Compared with whites, however, African Americans had a lower percentage of men, college graduates, and households with an income > or = $40,000 per year. African Americans also had lower mean urinary sodium to creatinine ratio and potassium to creatinine ratio, but a similar sodium to potassium ratio. The incidence of hypertension (blood pressure > or = 160/95 mm Hg and/or taking antihypertensive medication) over 7 years of follow-up was nearly identical: 25.7% in African Americans and 25.3% in whites. Baseline age, gender, blood pressure, and heart rate were all associated with the incidence of hypertension. Even after adjustment for these covariables, the risk of hypertension was not higher in African Americans compared with whites. These results indicate that middle-aged African Americans and whites have a similar risk of developing hypertension given the same age, initial blood pressure, and body mass index at baseline.

Subclinical atherosclerosis in relation to hysterectomy status in black women

BACKGROUND AND PURPOSE

This study was designed to investigate whether black women who underwent hysterectomy only (n = 59) or hysterectomy plus bilateral oophorectomy (n=25) were at increased risk of subclinical carotid atherosclerosis compared with black women who underwent natural menopause (n = 54). The effects of both surgery and menopausal status were evaluated.

METHODS

Women aged 34 to 58 years were recruited from the Pittsburgh, Pa, area. Postmenopausal status was defined as a serum follicle-stimulating hormone level of >30 mIU/mL. Carotid duplex scans were performed to assess the degree of focal plaque.

RESULTS

Among premenopausal women, focal plaque was present in 20% of nonhysterectomized versus 49% of hysterectomized-only women (P=.004). Among postmenopausal women, plaque was present in 69% of nonhysterectomized women, 86% of women with hysterectomy only, and 48% of women with oophorectomy and hysterectomy (P=.056). Among postmenopausal women, hormone replacement therapy was used by 23% of women who had undergone natural menopause, 0% of women with hysterectomy only, and 36% of women with oophorectomy and hysterectomy. The prevalence of plaque was 33% among hormone replacement therapy users versus 73% among nonusers (P=.014). In multivariate analysis, independent associations with the presence of at least 1 plaque were postmenopausal status and hysterectomy only.

CONCLUSIONS

These data suggest that black women who undergo hysterectomy without oophorectomy may be at higher risk of subclinical carotid atherosclerosis than black women who undergo natural menopause or hysterectomy plus oophorectomy.

A review on ethnic differences in plasma triglycerides and high-density-lipoprotein cholesterol: is the lipid pattern the key factor for the low coronary heart disease rate in people of African origin?

Black people in the UK, in the Caribbean, and to a lesser extent in the USA, experience coronary heart disease events at different rates than white people. Despite having higher prevalence of hypertension, cigarette smoking and diabetes, black males have significantly lower coronary heart disease rates than white males, whereas no significant differences have been detected in females. The only known risk factor differences that could account for the difference in CHD rates are higher HDL cholesterol and lower triglycerides that are seen in blacks compared with whites. Obesity and, in particular abdominal obesity, seems to determine TG and HDL cholesterol levels: black males are less centrally obese than whites, while total adiposity and central distribution of fat is more predominant in black females compared with white females. We propose that the less degree of abdominal adiposity observed in black males is related with an increased anti-lipolytic effect of insulin, which could account for low triglycerides and high HDL cholesterol levels, and consequently explain the higher protection from coronary heart disease experienced by black males compared with whites and black females.

Awareness, treatment and control of hyperlipidaemia, hypertension and diabetes mellitus in a selected population of southern Italy

The purpose of the present study was to assess the degree of awareness, treatment and control of hyperlipidaemia compared with hypertension and diabetes mellitus in a selected population of southern Italy. All participants to a cardiovascular disease prevention campaign examined between April 1994 and July 1995 were screened for hyperlipidaemia, hypertension and diabetes mellitus. Subjects received also ECG, echo-Doppler of carotid arteries and filled in a questionnaire concerning personal and familial cardiovascular diseases, smoking habit and drug consumption. Of the 742 participants, 327 were found to have hypertension, 73 to have diabetes mellitus, 287 to have mild hyperlipidaemia and 322 to have moderate-severe hyperlipidaemia. Among hypertensive subjects, 60.2% were aware of their condition, 53.5% were treated and 15.6% had their blood pressure controlled at the recommended level (< 140/90 mmHg). Among diabetic subjects, 76.7% were aware, 64.4% treated and 19.2% reached fasting blood glucose level of less than 7.77 mmol/l (140 mg/dl). Only 24.0% of subjects with mild hyperlipidaemia were aware of their condition. Of the subjects found to have moderate-severe hyperlipidaemia, 64.9% were aware, 32.3% were treated and 9.0% had plasma cholesterol and triglycerides concentration of less than 6.45 and 5.65 mmol/l (250 and 500 mg/dl), respectively (cutoffs chosen to separate mild from moderate-severe hyperlipidaemia). These results show that mild hyperlipidaemia is almost neglected whereas awareness of moderave-severe hyperlipidaemia is quite widespread and comparable to that of hypertension and diabetes mellitus. Prevalence of treatment and control of moderate-severe hyperlipidaemia is, however, much lower than that of hypertension and diabetes.

African-American mothers' perceptions of cholesterol and its effects on their children

This study examined African-American mothers' perceptions of cholesterol and its effects on their children. A random sample of middle- and upper-class women, Alpha Kappa Alpha sorority members, 26 to 53 years of age, responded to a 42-item questionnaire. Fifty-nine percent knew their cholesterol level and 13% knew the cholesterol level of their children. Two thirds of the parents believed that all elementary school children should have their cholesterol levels checked. A total of 79% had made lifestyle changes to reduce their child's risk of hypercholesterolemia, including 22% of this group who had purchased food supplements for this activity. Parents were more likely to receive most of their cholesterol information from the mass media, magazines (74%), newspapers (64%), and television (52%). The results of this study imply that these parents may be in need of further nutritional guidance from physicians to help them establish a safe and nutritious approach to maintaining normal cholesterol levels for their children.

Response rates to random digit dialing for recruiting participants to an onsite health study

OBJECTIVE

To evaluate the response rates when random digit dialing was used as a substitute for geographic area sampling and household interviews to recruit 2100 African Americans for a blood pressure measurement and hypertension-related knowledge and attitudes survey.

METHODS

Random digit dialing was used to identify African American adults living in 12 low-income ZIP code areas of Houston, Texas. A brief survey of hypertension awareness and treatment was administered to all respondents. Those who self-identified as African American were invited to a community location for blood pressure measurement and an extended personal interview. An incentive of $10 was offered for the completed clinic visit. A substudy of nonrespondents was carried out to test the effectiveness of a $25 incentive in increasing the response rate. Data from the initial random telephone interview were used to identify differences between those who did and did not attend the measurement session.

RESULTS

Ninety-four percent of eligible persons contacted completed the telephone survey, and 65% agreed to visit a central community site for blood pressure measurement. In spite of the financial incentive and multiple attempts to reschedule missed appointments, only 26% of the 65% who agreed to attend completed the scheduled visit. In the substudy of the higher financial incentive, all of those who missed the original appointment agreed to another appointment, and 85% of this subgroup kept it. Not being employed full-time and a history of hypertension were consistently associated with agreement to be measured and keeping an appointment. In spite of the low response rate for scheduled appointments, differences--other than in employment status and a history of hypertension--between responders and nonresponders were small and consistent with what is usually observed in health surveys.

CONCLUSIONS

The use of random digit dialing as a substitute for area sampling and household screening resulted in unacceptably low response rates in the study population and should not be undertaken without further research on ways to increase response rates.

Black-white differences in subclinical cardiovascular disease among older adults: the Cardiovascular Health Study. CHS Collaborative Research Group

Cardiovascular and all-cause mortality are higher in black than white Americans, but racial differences in clinical and subclinical cardiovascular disease (CVD) have not been examined in older adults. Clinical and subclinical CVD and its risk factors were compared in 4926 white and 244 black men and women aged 65 years and older. Black participants had lower socioeconomic status and generally higher prevalences of CVD and its risk factors, except for adverse lipid profiles. Common carotid wall thickness was greater in black than white women, and ankle-arm blood pressure ratios were lower in black women and men (p < 0.01). After adjustment for CVD risk factors, common carotid walls were significantly thicker and ankle-arm ratios were lower in blacks than whites of both sexes, while internal carotid walls were significantly thinner in black women. Racial differences in clinical and subclinical CVD in older adults are similar to those reported in younger populations and do not appear to be explained by CVD risk factors.

Cholesterol screening in a community health promotion program: epidemiologic results from a biracial population

The prevalence and interrelationship of high blood cholesterol levels with other cardiovascular disease risk factors were studied in a biracial suburb of New York City. Participants in community-based screenings to determine blood cholesterol levels have been predominantly white women in older age groups, highly educated and nonsmokers. To reach a more representative segment of a local population and promote healthy lifestyle behaviors, cholesterol screenings were conducted within an ongoing health promotion program in Mount Vernon, NY. Plasma cholesterol levels were determined for 5,011 participants, including 2,308 whites and 1,778 blacks. Of the men, 29 percent had high cholesterol levels; among women, it was 27 percent. Of the men with high levels, half had levels greater than 200 milligrams per deciliter, as did 55 percent of the women. After statistical adjustments were made for age and other risk factors for high blood cholesterol, mean cholesterol levels were higher for whites than blacks. The level for white men was 204 milligrams per deciliter; for women, 212. For black men, the level was 199 milligrams per deciliter; for women, 208, P < .10. Hispanic men had levels of 199, P < .10. The levels for Hispanic women (203 milligrams per deciliter) were significantly lower than that of white women. Among whites who smoked more than 1 pack of cigarettes per day, mean cholesterol levels were 11 milligrams per deciliter higher than for those who never smoked or were light smokers (0, 1-20 cigarettes per day, P < .10). There were too few who smoked more than 1 pack to test this association adequately among blacks. The mean cholesterol levels for hypertensive black men were 10 milligrams per deciliter greater than for black men with normal blood pressure (P<.10).

Race: an explanation of patient compliance--fact or fiction?

This article describes a retrospective study that examines the relationship between patient compliance and race among diagnosed hypertensives in the National Health and Nutrition Examination Survey (NHANES II). The study reviewed and analyzed the compliance of 403 blacks diagnosed with hypertension. Patient compliance was measured using the frequency that patients took their hypertensive medicine. Bivariate analysis revealed a statistically significant relationship with patient compliance (dependent) and the independent variables (age, education, gender, and smoking). Multiple regression for the black population revealed that the age of the person accounted for the most explained variance. As age increased among blacks, so did compliance. The results may suggest the need to target school-aged blacks early in order to increase the awareness and importance of monitoring one's blood pressure. The results also may indicate that race is not a marker for other characteristics (income, education, etc) that might be used to explain the difference in the prevalence of hypertension among blacks compared with whites.

Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project

BACKGROUND

Differences between blacks and whites have been reported in the incidence of several forms of cardiovascular disease, including hypertension and stroke. We examined racial differences in the incidence of cardiac arrest in a large urban population and in subsequent survival.

METHODS

We collected data on all nontraumatic, out-of-hospital cardiac arrests in Chicago from January 1, 1987, through December 31, 1988, and compared the incidence and survival rates for blacks and whites. We examined the association between survival and race and seven other known risk factors by logistic-regression analysis. We computed incidence rates by coupling our data with U.S. Census population data.

RESULTS

Our study population comprised 6451 patients: 3207 whites, 2910 blacks, and 334 persons of other races. The incidence of cardiac arrest was significantly higher for blacks than for whites in every age group. The survival rate after cardiac arrest was 2.6 percent in whites, as compared with 0.8 percent in blacks (P < 0.001). Blacks were significantly less likely to have a witnessed cardiac arrest, bystander-initiated cardiopulmonary resuscitation, or a "favorable" initial rhythm or to be admitted to the hospital. When they were admitted, blacks were half as likely to survive. The association between race and survival persisted even when other recognized risk factors were taken into account. We did not find important differences between blacks and whites in the response times of the emergency medical services.

CONCLUSIONS

The black community in our study was at higher risk for cardiac arrest and subsequent death than the white community, even after we controlled for other variables.

Antibiotic use in urban whites and blacks: the Minnesota Heart Survey

OBJECTIVE

To assess racial differences in the use of antibiotics, including penicillins, erythromycins, tetracyclines, sulfas, and cephalosporins.

DESIGN

Population-based surveys, conducted from 1985 to 1987.

SETTING

The seven-county metropolitan area of Minneapolis-St. Paul, MN.

PARTICIPANTS

3127 whites (response rate 68 percent) and 1047 blacks (response rate 65 percent), aged 35-74 years.

RESULTS

White women (26 percent of 1625) were more likely to report having taken an antibiotic in the past year than were white men (18 percent of 1502), black women (18 percent of 590), or black men (15 percent of 457). Reported antibiotic usage decreased with increasing age. Black men were more likely than white men to report the use of tetracyclines or sulfas; otherwise, white men reported higher usage prevalences. White women reported higher usage prevalences of all drug classes than black women.

CONCLUSIONS

Significant independent predictors of antibiotic use were younger age, white race, and female gender. Potential explanations for these differences include differences in patient access, physician-prescribing behaviors, or both.

Education, race, and high-density lipoprotein cholesterol among US adults

OBJECTIVES

Although educational achievement is positively related to levels of high-density lipoprotein cholesterol (HDL-C) among White adults, there is an inverse association among Blacks. We assessed whether this interaction could be attributed to differences in the relation of education to correlates of HDL-C.

METHODS

Cross-sectional analyses were based on data from 8391 White and 995 Black adults who participated in the Second National Health and Nutrition Examination Survey.

RESULTS

Associations between education and HDL-C levels varied from negative (Black men), to nearly nonexistent (White men and Black women), to positive (White women). Mean HDL-C levels were higher among Blacks than among Whites, but differences varied according to educational achievement. Among adults with less than 9 years of education, mean levels were 6 to 10 mg/dL higher among Blacks, but the radical difference was less than 1 mg/dL among adults with at least 16 years of education. About 20% to 40% of these differences could be accounted for by obesity, alcohol consumption, and other characteristics.

CONCLUSIONS

Because of the implications for coronary heart disease risk, consideration should be given to behavioral characteristics associated with the interaction between race and educational achievement.

Community trends in CPR training and use: the Minnesota Heart Survey

STUDY OBJECTIVE

To examine community changes in self-reported CPR training and use from 1980-82 to 1985-87 using data obtained from the Minnesota Heart Survey. A comparative investigation of CPR training among blacks and whites in 1985-86 also was completed.

DESIGN

Data were obtained in 1980-81, 1981-82, 1985-86, and 1986-87 from four population-based samples drawn from the seven-county Minneapolis-St Paul metropolitan area. To increase sample sizes and to compare prevalences of CPR training and use in the early 1980s with prevalences in the mid-1980s, the four Minnesota Heart Survey surveys were combined into two time periods, 1980-82 and 1985-87. A separate survey of black individuals was conducted in 1985, and these data were used in the comparisons between blacks and whites in 1985-86.

RESULTS

The prevalence of whites trained in CPR increased significantly between 1980-82 and 1985-87 in both nonhealth professionals (18.5% vs 30.9%) and health professionals (71.9% vs 86.8%). No significant change was observed between the two periods in the percentage of nonhealth professionals who had ever used their CPR skills (9.7% vs 10.7%), whereas use among health professionals increased significantly (40.2% vs 53.4%). Training within the prior two or three years decreased from 1980-82 to 1985-87 among nonhealth professionals, but increases in recent training were observed among health professionals. There were no significant differences between black and white nonhealth professionals in the prevalence of CPR training. Black trainees, however, reported a higher percentage of ever using CPR skills than white trainees (15.4% vs 9.8%, respectively). Black trainees also had higher rates of recent CPR training than white trainees. No differences were observed between black and white health professionals regarding CPR training and use, or recency of certification.

CONCLUSION

These results suggest that the percentage of individuals trained in CPR is increasing. Improvement is needed, however, in the rates of recent certification among nonhealth professionals.

Prevalence, control and awareness of high blood pressure among Canadian adults. Canadian Heart Health Surveys Research Group

OBJECTIVE

To estimate the prevalence and distribution of elevated blood pressure (BP) among Canadian adults and to determine the level of control, treatment, awareness and prevalence of other risk factors among adults with high BP.

DESIGN

Population-based cross-sectional surveys.

SETTING

Nine Canadian provinces, from 1986 to 1990.

PARTICIPANTS

A probability sample of 26,293 men and women aged 18 to 74 years was selected from the health insurance registers in each province. For 20,582 subjects, BP was measured at least twice. Nurses administered a standard questionnaire and recorded two BP measurements using a standardized technique. Two further BP readings, anthropometric measurements and a blood specimen for lipid analysis were obtained from those subjects who attended a clinic.

OUTCOME MEASURES

Mean values of systolic and diastolic BP, prevalence of elevated BP using different criteria, and prevalence of smoking, elevated blood cholesterol, body mass index, physical activity and presence of diabetes by high BP status are reported.

MAIN RESULTS

Sixteen percent of men and 13% of women had diastolic BP of 90 mm Hg or greater or were on treatment (or both). About 26% of these subjects were unaware of their hypertension, 42% were being treated and their condition controlled, 16% were treated and not controlled, and 16% were neither treated nor controlled. Use of non-pharmacologic treatment of high BP with or without medication was low (22%). Hypertensive subjects showed a higher prevalence of elevated total cholesterol, high body mass index, diabetes and sedentary lifestyle than normotensive subjects. Most people with elevated BP were in the 90 to 95 mm Hg range for diastolic pressure and 140 to 160 mm Hg range for systolic pressure. Prevalence of high isolated systolic BP sharply increased in men (40%) and women (49%) 65 to 74 years old.

CONCLUSIONS

The relatively low level of control of elevated BP calls for population and individual strategies, stressing a non-pharmacologic approach and addressing isolated systolic hypertension in the elderly.

Genetic markers associated with high density lipoprotein cholesterol levels in a biracial population sample

An explanation for the consistently documented finding of higher levels of high density lipoprotein-cholesterol in black men relative to white men was sought by comparing the frequency of restriction fragment length polymorphism markers present in blacks and in whites at the gene loci coding for the two major apolipoprotein constituents of high density lipoprotein, apolipoproteins AI and AII. The measurements were made in population-based samples of 45 to 54-year-old black (n = 190) and white (n = 370) subjects from the Minnesota Heart Survey for whom lipoprotein levels were available. The mean high density lipoprotein-cholesterol level for black men in the sample (47 +/- 1.5 mg/dl) was higher (P less than 0.05) than that for white men (42 +/- 0.9 mg/dl), while levels in women were not different between races. While the SacI and MspI markers at the apolipoprotein AI-CIII-AIV gene locus showed similar frequencies in blacks compared to whites, the degree of the linkage disequilibrium previously noted between these markers in white subjects was altered in blacks and the minor allele of the PstI marker at this locus was virtually absent in the black subjects (P less than 0.005 vs whites). For black men, there were significant associations of the M2 allele and the S2M2 haplotype at the apolipoprotein AI locus with lower high density lipoprotein-cholesterol levels. The results are consistent with the hypothesis that DNA sequence variations in the vicinity of the apolipoprotein AI-CIII-AIV gene locus are associated with the difference in high density lipoprotein-cholesterol levels between blacks and whites.

Cigarette use among Arab Americans in the Detroit metropolitan area

Use of cigarette tobacco by large proportions of the population of Middle Eastern countries has been reported; however, little is known about smoking behavior in one of America's fastest growing minorities, the Arab Americans. The purpose of this study was to examine cigarette smoking behavior of 237 randomly selected Arab American adults from a telephone listing in the Detroit area. Participants lived in the geographic Arab American community and identified with a Middle Eastern cultural heritage. Nurses, who spoke both English and Arabic, interviewed one adult family member using the 59-item self-report from the Cardiovascular Risk Factor Survey developed by Rice. Mean age of respondents was 40.4 years, 97 percent had been born in the Middle East, and 67 percent had been living in the United States 15 years or less. Current smokers rate was 38.9 percent, former smokers rate was 11.1 percent, never smokers rate was 50 percent, and the quit ratio (proportion of ever smokers who are former smokers) was 22.2 percent. Fifty-four percent of the current smokers were between 25 and 34 years of age; fewer women than men were former smokers, and the highest proportion of current smokers were Lebanese. Subjects who had smoked for the longest time were the least well educated. Arab Americans in this sample had a higher smoking rate, a lower quitting rate, and a much lower quit ratio when compared with national and State of Michigan data. With the growing numbers of Middle Eastern immigrants, there is potential for a dramatic increase in smoking-related health problems.

Coronary artery disease risk factors in Yaqui Indians and Mexican Americans

The prevalence of coronary artery disease risk factors in adults was studied in Yaqui Indians and Mexican Americans. The risk factors studied included hypertension, diabetes, hypercholesterolemia, smoking, and sedentary life-style. Subjects included 94 Mexican Americans, 44 Yaqui Indians, and 12 of mixed or other ancestry. Mexican Americans had higher rates of smoking (21.3% versus 11.4%) and hypercholesterolemia (9.4% versus 4.8%) than did Yaqui Indians although neither comparison was statistically significant. Yaqui Indians had twice the risk of diabetes (40.5% versus 19.8%, P less than .05). When looking at both races combined, men smoked at six times the rate of women (36.4% versus 6.3%, P less than .05). Of all those tested, only 6% had no risk factors, and 88% were classified as having a sedentary life-style. Achieving increased levels of exercise in the population studied would appear to hold the most promise for reducing coronary artery disease risks.

Physical activity and hypertension in black adults: the Pitt County Study

The relation of physical activity to hypertension was examined in 1751 Black adults in Pitt County, NC. More women (65%) than men (44%) were classified as sedentary. Sedentary behavior was not associated with the prevalence of hypertension in men, but was associated with a 31% increase in prevalence for women (sedentary-26.2%; active-20.0%; P less than .01). The association in women was independent of other risk factors for hypertension.

Correlates of postural hypotension in a community sample of elderly blacks and whites

Postural hypotension is thought to be prevalent among the elderly, but few community-based studies of this condition have been conducted. In addition, little is known about postural hypotension in blacks despite well documented racial differences in hypertension and stroke. Data on 659 elderly (greater than or equal to 60 years of age) participants in a survey of two rural, biracial townships were analyzed to describe the frequency and correlates of postural hypotension. Twelve percent of the 659 adults experienced a drop of 10 mmHg or greater in systolic blood pressure on going from sitting to standing (supine measures were not available). This degree of postural hypotension was twice as common for whites as for blacks (14.5% vs 7.5%, P = 0.01). Postural hypotension was associated with elevated sitting blood pressure and showed positive but statistically non-significant relationships with anti-hypertensive medications and leanness. The association between race and postural hypotension persisted after adjusting for these and other risk factors (OR = 2.2, 95% CI:1.2,4.0).

Trends in serum cholesterol levels from 1980 to 1987. The Minnesota Heart Survey

BACKGROUND AND METHODS

We assessed community trends in the awareness, treatment, and control of hypercholesterolemia (defined as a serum cholesterol level greater than 6.21 mmol per liter [240 mg per deciliter]) during the 1980s in the Minneapolis-St. Paul (Twin Cities) metropolitan area. Twin Cities residents 25 to 74 years old participated in independent, cross-sectional, population-based surveys of risk factors for cardiovascular disease in 1980-1982 (n = 3365) and 1985-1987 (n = 4545).

RESULTS

Mean serum total cholesterol levels, as adjusted for age, decreased significantly (P less than 0.01) from 1980-1982 to 1985-1987 in men (from 5.30 mmol per liter [205 mg per deciliter] to 5.16 mmol per liter [200 mg per deciliter]) and women (from 5.19 mmol per liter [201 mg per deciliter] to 5.04 mmol per liter [195 mg per deciliter]). The prevalence of hypercholesterolemia as adjusted for age decreased significantly (P less than 0.05) in men (17.8 to 15.1 percent) and women (17.1 to 13.6 percent). The ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol was unchanged during this period, because of a concurrent decline in the level of HDL cholesterol. Participants with hypercholesterolemia in the 1985-1987 survey were more likely than those in the 1980-1982 survey to be aware of their condition (32.6 vs. 25.4 percent), to be treated with lipid-lowering agents (4.3 vs. 1.9 percent), and to have their condition controlled (1.9 vs. 0.3 percent). Among those who reported treatment by a physician for hyperlipidemia, changes were observed in the type of treatment recommended. A significant increase (P less than 0.05) was noted from 1980-1982 to 1985-1987 in the percentage of men being treated for hyperlipidemia with lipid-lowering medication (5.2 vs. 11.6 percent) and with exercise programs (10.3 vs. 20.1 percent). In women being treated for hyperlipidemia, a nonsignificant increase was noted in the use of lipid-lowering medication (8.2 vs. 13.9 percent), and a significant increase (P less than 0.05) was observed in the number of exercise prescriptions (4.1 vs. 12.0 percent).

CONCLUSIONS

We found a substantial decline in the prevalence of hypercholesterolemia in the Twin Cities between 1980-1982 and 1985-1987 that may be attributed to changes in lifestyle, such as diet and exercise, and to a lesser extent to more aggressive intervention with lipid-lowering drugs by physicians.

Differences in leisure-time physical activity levels between blacks and whites in population-based samples: the Minnesota Heart Survey

Energy expenditure in leisure-time physical activity (LTPA) was measured using the Minnesota LTPA Questionnaire in 35- to 74-year-old black and white residents of Minneapolis-St. Paul, Minnesota. Estimates of the geometric mean LTPA energy expenditure were 129 and 204 kcal per day for black and white men (p less than .05) and 91 and 123 kcal per day for black and white women (p less than .05). The percentage of individuals expending 2000 kcal or more per week in LTPA was significantly lower in black men than white men (25 vs. 35%; p = .01) but was not different in black versus white women (18 vs. 17%). Although black men and women reported greater occupational physical activity than their white counterparts, LTPA and job activity were unrelated in all race and sex groups. In both races, LTPA energy expenditure declined with age. LTPA increased with level of formal education, and the largest LTPA difference between blacks and whites was observed in those who had a high-school diploma or less. Blacks had lower participation rates than whites in most of the individually assessed physical activities. Additional research is needed on the determinants and promoters of LTPA in population subgroups.

Blood pressure and anthropometric differences in regularly exercising and nonexercising black adults

Few studies have examined the relationship between exercise and BP in Black adults, a population with substantial risk for hypertension. This pilot study was undertaken to examine BP, anthropometric characteristics, dietary intake, and resting pulse rate by level of exercise participation in a group of Black Seventh Day Adventists. Subjects were classified as regular exercisers (n = 54, age = 54.6 yrs) if they reported at least two exercise sessions per week (x = 4.0 times per week) lasting a minimum of 20 minutes each, in which they engaged in vigorous exercise. Nonexercisers (n = 60, age = 56.2 yrs) were those who reported participation in such exercise no more than once per week (x = 0.1 times per week). There were no group differences in dietary intake of any macro or micronutrients, but exercisers exhibited significantly lower body mass index, waist circumference, triceps skinfold thickness, and resting pulse rate. Forty-two percent of the nonexercisers were confirmed hypertensives compared to only 20 percent of the exercisers. Age and gender-adjusted BP was significantly lower in the exercisers (BP = 123.8/73.4 mm Hg) compared to the nonexercisers (BP = 133.5/77.1 mm Hg). After adjustment for anthropometric differences, the systolic BP of the exercisers remained approximately 8 mm Hg lower than their nonexercising counterparts. These data suggest that participation in vigorous exercise is favorably related to blood pressure and may attenuate the risk of hypertension in Black Seventh Day Adventists.

Validation of reported myocardial infarction mortality in blacks and whites. A report from the Community Cardiovascular Surveillance Program

It is widely believed that blacks experience a higher mortality due to coronary heart disease (CHD) than do whites. To determine whether this reported difference in mortality between blacks and whites is real, we studied the question in the context of the Community Cardiovascular Surveillance Program (CCSP). Fatal and nonfatal cases of CHD were reviewed in 12 US communities. Standardized criteria were applied to classify these cases as possible CHD, definite CHD, possible myocardial infarction (MI), or definite MI. The annual age-adjusted mortality rate per 100,000 ascribed to definite MI by the CCSP criteria was higher in blacks than in whites: 47 in white men (95% confidence interval, 36 to 58), 18 in white women (95% confidence interval, 8 to 28), 95 in black men (95% confidence interval, 10 to 180), and 41 for black women (95% confidence interval, 0 to 99). The proportion of definite MI to all fatal CHD events was higher in blacks (16%) than in whites (12%). For nonfatal events, however, the rate of definite MI was higher in whites than in blacks: 322 in white men (95% confidence interval, 293 to 351), 225 in black men (95% confidence interval, 160 to 290), 82 in black women (95% confidence interval, 43 to 121), and 103 in white women (95% confidence interval, 88 to 118). The proportion of definite MI to all nonfatal CHD events was lower in blacks (16%) than in whites (30%). Thus, the overall rate for fatal and nonfatal definite MI was lower in blacks (215/100,000) than in whites (244/100,000). These observations suggest that a combination of high case-fatality ratio and misclassification of cause and death may contribute to the reported higher rate of CHD mortality among blacks.

Changes in sodium-lithium countertransport correlate with changes in triglyceride levels and body mass index over 2 1/2 years of follow-up in Utah

We have previously reported from a cross-sectional study that plasma total cholesterol, triglycerides, and HDL-C were significantly and independently correlated with Na(+)-Li+ countertransport. These original participants were rescreened 2 1/2 years later (range of 20-58 months), with lipid, blood pressure, and Na(+)-Li+ countertransport measurements from both visits on 906 normotensive adults. The correlation found between age- and sex-adjusted triglyceride levels and Na(+)-Li+ countertransport at visit 1 (r = 0.34, p less than 0.0001) was reconfirmed at visit 2 (r = 0.32, p less than 0.0001). The Na(+)-Li+ countertransport correlations with HDL-C (r = -0.11, p less than 0.01) and body mass index (r = 0.24, p less than 0.0001) also remained at visit 2. After 30 months, there were significant increases of triglyceride, body mass index, blood pressure, and Na(+)-Li+ countertransport levels, and significant decreases of HDL-C and total cholesterol levels, after adjusting the changes in these variables between visit 2 and visit 1 for age, sex, time between the two visits, and the visit 1 level of the variable. Increases in triglycerides, cholesterol, and body mass index were significantly correlated with increases in Na(+)-Li+ countertransport (r = 0.23, r = 0.19, and r = 0.21, respectively). The correlations of the lipid and lipoprotein changes with Na(+)-Li+ countertransport changes were independent of body mass index and blood pressure changes. We conclude that increasing plasma triglyceride levels and body mass index are associated with increasing Na(+)-Li+ countertransport levels in both cross-sectional and longitudinal data.

Lipids and lipoproteins in a triethnic sample of 5- or 6-year-old Type A or Type B children

The Type A behavior pattern (TABP) has been proposed as a risk factor for coronary heart disease (CHD). Several studies have indicated an association between Type A behavior and serum cholesterol levels. If the effects of TABP are mediated by conventional CHD risk factors, evidence for a causal relationship between TABP and CHD would be strengthened if associations were detected among the young. This paper addresses the following: (1) Do levels of serum lipids and lipoproteins among young children vary by ethnicity, gender, or TABP? (2) Can obtained differences be accounted for by possible confounding factors, such as SES or body composition? ANCOVA revealed no significant ethnic, gender, or TABP effects for total serum cholesterol or HDLc. Analyses of LDLc and triglycerides disclosed significant main effects for gender and for ethnicity. A Competition subscale by ethnicity interaction was the only effect to approach statistical significance for TABP. The strongest findings were a replication of differences in lipid and lipoprotein risk factors by ethnicity.

Cigarette smoking and cessation behaviors among urban blacks and whites

Smoking behaviors among blacks and whites were studied in a population-based sample of 2,626 residents of Minneapolis-St. Paul, MN. More blacks than whites were found to be smokers, before and after adjusting for age and education differences. More whites than blacks were former smokers, but the prevalence of those who had never smoked was comparable for whites and blacks. Among smokers, the mean number of cigarettes smoked per day was lower among blacks than whites, but more blacks were found to smoke cigarettes with high "tar" (dry particulate matter) and nicotine content. Men smokers were found to smoke more than women smokers, young people smoked more than older people, and those with a high school education or less smoked more than those with more than a high school education. Smoking cessation behavior consisted mostly of a variety of strategies that began with reducing cigarette consumption, followed by changing to lower tar brands, attempting to quit, and actually quitting. In general, a higher percentage of whites than blacks reported smoking cessation behaviors. A greater percentage of white than black women had tried cigarette brands lower in tar and nicotine within the previous year. Among men, a lower percentage of black than white smokers had tried quitting, and fewer black men planned to quit in the future. Blacks appeared to lag behind whites in their efforts to quit smoking. Smoking behavior continues to be problematic for both blacks and whites. Studies are needed to explain better the racial differences in smoking and smoking cessation behaviors, and to facilitate programs to encourage cessation.