1. McGraw, Mark

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New research finds that, while Black patients demonstrate a higher risk of coronary artery disease (CAD) in comparison to White patients, they don't necessarily experience a higher occurrence of serious adverse cardiac events. Published in JAMA Cardiology, the study's findings suggest that, "despite a higher risk burden in Black individuals, rates of epicardial coronary artery disease in Black persons were lower than in White persons, with a similarly low event rate," according to the authors (2021; doi: 10.1001/jamacardio.2021.5340).

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As the investigators noted, "race and ethnicity have been studied as risk factors in cardiovascular disease. How risk factors, epicardial coronary artery disease, and cardiac events differ between Black and White individuals undergoing non-invasive testing for coronary artery disease is not known."


In an effort to determine if there were differences in risk burden, plaque, and adverse cardiac events between Black and White individuals with stable chest pain, the researchers studied 8,674 patients assigned to receive coronary computed tomography angiography (CCTA) or functional testing for the chest pain they were experiencing, and were included in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial.


Among participants, self-identified Black individuals had a higher cardiovascular risk burden than White individuals, yet there were similarly few major adverse cardiovascular events over the course of a 24.4-month follow-up period, the authors noted. The primary endpoint was the composite of death, myocardial infarction, or hospitalization for unstable angina over the median follow-up period.


Among the more than 1,000 Black patients and more than 7,600 White patients taking part in the study, Black participants showed a higher cardiovascular risk burden, i.e., more hypertension and diabetes, but the two groups demonstrated a "similarly low major adverse cardiovascular events rate" (3% vs. 3.2%), according to the authors.


In addition, 45.1 percent of Black individuals demonstrated a coronary artery calcium score greater than zero, compared to 63.2 percent of White study participants with a coronary artery calcium score in the same range. Among Black patients taking part in the study, 8.7 percent showed coronary artery stenosis greater than or equal to 50 percent, compared to 14.6 percent of White individuals.


Overall, the findings of the study suggest differences in cardiovascular risk burden and coronary plaque in Black and White individuals with stable chest pain, with Black participants having a higher cardiovascular risk burden but less epicardial coronary artery disease on coronary CT angiography compared to White participants.


The underlying reasons for such differences are unclear, noted lead study author Lili Zhang, MD, Assistant Professor of Medicine, internist, and cardiovascular specialist at the Albert Einstein College of Medicine and Montefiore Health System.


"We think perhaps the higher cardiovascular risk burden in Black participants may manifest as other forms of cardiovascular disease, such as coronary microvascular disease or cardiomyopathy, other than the epicardial coronary artery disease assessed by CCTA in the PROMISE trial," Zhang stated.


Ultimately, the findings underscore how much remains to be learned about the relationship between risk factors and disease, said Zhang, noting that the research can still inform how providers, including those in radiology, can help higher-risk patients mitigate cardiovascular risk factors.


"This study tells us that, in patients with stable chest pain requiring non-invasive testing, Black and White individuals have a similar rate of major adverse cardiac events in 2-year follow-up, despite Black individuals having a higher cardiovascular risk burden," she said.


CCTA will be increasingly utilized, with 2021 American College of Cardiology and American Heart Association guidelines for the evaluation and diagnosis of chest pain providing a Class 1 recommendation for CCTA to evaluate stable chest pain in patients with intermediate-to-high risk for CAD and without known CAD, Zhang added.


"Although Black individuals may have less coronary artery calcium or less coronary stenosis based on CCTA, their risk of major adverse cardiac events can be similar to White individuals. I think this is important for clinicians who interpret CCTA results," she concluded. "We did not test any interventions to mitigate cardiovascular risk factors in this study."


Mark McGraw is a contributing writer.


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