Race/ethnic inequalities in cardiovascular disease: Examining burden mitigation in low-risk black Americans (multi-cohort study)
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Background
While the greater burden of cardiovascular disease (CVD) in black Americans relative to white is well-documented, whether standard care targeting conventional risk factors (e.g., blood pressure, cigarette smoking) or social determinants of health (e.g., education, income) mitigate this inequality is largely untested.
Methods
In this multicohort study, we used baseline ethnicity and risk factor data from the US National Health and Nutrition Examination Survey (NHANES, 10 cohorts initiated 1999-2018) with study member linkage to national registries for cause-specific mortality. Low risk was denoted by favourable levels of five biological, three behavioural, and five social determinants of CVD, separately and collectively. Cox proportional hazard regression models were used to summarise the association of ethnicity with CVD mortality.
Results
The analytical sample of 50,065 individuals (25934 women; mean baseline age 53) contributed 473,949 person-years at risk during a mean follow-up of 9.5 yr. This surveillance period gave rise to 9118 deaths, 2908 of which were ascribed to CVD. In age- and sex-adjusted analyses, as anticipated, black American had a markedly higher burden of CVD deaths (hazard ratio; 95% confidence interval: 1.51; 1.30, 1.77) and other major cause of death relative to whites. These elevated CVD rates in black Americans persisted in low-risk strata of biological and behavioural risk factors whether these groups were based on individual characteristics or aggregated using the Framingham algorithm. Similar observations of raised CVD rates in black study members were also made for social determinants of health when separate indices were considered, however, collectively, a marked reduction in the risk of CVD was apparent in black Americans relative to white for one (1.09; 0.78, 1.51), two (0.99; 0.67, 1.48), or three or more (1.31; 0.81, 2.12) favourable social determinants.
Conclusions
Black Americans in favourable social circumstances appear to have similar CVD mortality relative to whites with the same characteristics.
