Association of plasma apolipoprotein CIII, high sensitivity C-reactive protein and tumor necrosis factor-α contributes to the clinical features of coronary heart disease in Li and Han ethnic groups in China.

BACKGROUND: Apolipoprotein CIII (apoCIII) is an independent risk for coronary heart disease (CHD). In this study, we investigated the associations among plasma apoCIII, hs-CRP and TNF-α levels and their roles in the clinical features of CHD in the Li and Han ethnic groups in China. METHODS: A cohort of 474 participants was recruited (238 atherosclerotic patients and 236 healthy controls) from the Li and Han ethnic groups. Blood samples were obtained to evaluate apoCIII, TNF-α, hs-CRP and lipid profiles. Chi-squared, t-tests, and Kruskal-Wallis or Wilcoxon-Mann-Whitney tests, Pearson or Spearman correlation tests and multiple unconditional logistic regression were employed to analyze lipid profiles and variations in plasma apoCIII, TNF-α, hs-CRP in subgroups of CHD and their contributions to CHD using SPSS version 20.0 software. RESULTS: Compared to healthy participants, unfavorable lipid profiles were identified in CHD patients with enhanced systolic pressure, diastolic pressure, fasting blood sugar (FBS), TG, TC, LDL-C, apoB, Lp(a) (P < 0.05, TC and Lp(a); P < 0.01, FBS, TG, LDL-C, apoB); and lower HDL-C and apoAI (P < 0.05). Plasma apoCIII, TNF-α and hs-CRP levels were higher in CHD individuals (16.77 ± 5.98 mg/dL vs. 10.91 ± 4.97 mg/dL; 17.23 ± 6.34 pg/mL vs. 9.49 ± 3.88 pg/mL; 9.55 ± 7.32 mg/L vs. 2.14 ± 1.56 mg/L; P < 0.01 vs. healthy participants). Identical patterns were obtained in the Li and Han groups (16.46 ± 6.08 mg/dL vs. 11.72 ± 5.16 mg/dL; 15.71 ± 5.52 pg/mL vs. 9.74 ± 4.31 pg/mL; 8.21 ± 7.09 mg/L vs. 2.15 ± 1.51 mg/L in Li people; 17.05 ± 5.90 mg/dL vs. 10.07 ± 4.63 mg/dL; 18.59 ± 6.73 pg/mL vs. 9.23 ± 3.38 pg/mL; 10.75 ± 7.44 mg/L vs. 2.12 ± 1.63 mg/L in Han people; P < 0.01). Paired comparisons of subgroups with stable angina, unstable angina, and acute myocardial infarction (AMI) revealed significant variation in plasma levels of apoCIII, TNF-α and hs-CRP (P < 0.01), but not among subgroups with mild, moderate and severe stenosis (P > 0.05). Plasma apoCIII, TNF-α and hs-CRP contributed to the development of CHD (OR = 2.554, 7.252, 6.035, P < 0.01) with paired correlations in CHD patients (apoCIII vs. TNF-α, r = 0.425; apoCIII vs. hs-CRP, r = 0.319; TNF-α vs. hs-CRP, r = 0.400, P < 0.01). CONCLUSIONS: Association among plasma apoCIII, hs-CRP and TNF-α interacts with unfavorable lipid profiles to contribute to the clinical features of CHD with stable angina, unstable angina, and AMI in the Li and Han ethnic groups in China.

Ethnicity of Symptomatic Coronary Artery Disease Referred for Coronary Angiography in the Galilee: Prevalence, Risk Factors, and a Case for Screening and Modification.

BACKGROUND: Coronary artery disease (CAD) has known risk factors. Individual risks related to specific ethnicities are complex and depend on genetic predisposition and lifestyle. OBJECTIVES: To compare the nature and prevalence of risk factors in Arab and non-Arab ethnic patients with symptomatic obstructive CAD referred for coronary angiography. METHODS: CAD, defined as coronary angiography with a ≥ 50% narrowing in ≥ 1 vessel, was diagnosed in 1029 patients admitted to a medical center between April 2014 and October 2015. Patients were divided into two groups according to ethnic origin: Arab vs. non-Arab. Demographics, clinical presentation, and coronary risk profiles were compared. RESULTS: The diagnosis of CAD was made during ST-elevation myocardial infarction (STEMI) in 198 patients (19%) who arrived at the clinic, 620 (60%) with unstable angina/non-STEMI, and 211 (21%) with stable angina. Patients with symptomatic CAD and Arab ethnicity were 47% more prevalent than non-Arab patients presenting with CAD. The Arab patients were appoximately 5 years younger, 50% more likely to be active smokers, 25% more likely to be obese, and more likely to have a family history of CAD. Other coronary risk factors were similar between the two groups. CONCLUSIONS: Smoking and obesity, which are potentially modifiable CAD risk factors, stood out as major risk factors, in addition to genetic disposition, among Arab and non-Arab patients with symptomatic CAD. Screening and educational interventions for smoking cessation, obesity control, and compliance to treatment of co-morbidities should be attempted in order to decrease CAD in the Arab population.

Ethnic differences in clinical outcome of patients presenting to the emergency department with chest pain.

BACKGROUND: Ethnicity, although known to influence cardiovascular outcome in assorted clinical settings, has not been investigated previously as a risk factor in patients presenting to the emergency department with suspected acute myocardial infarction. METHODS: In this multi-ethnic cohort study conducted in Singapore and The Netherlands, 2784 patients presenting to the emergency department with chest pain were enrolled (788 Caucasians, 1281 Chinese, 404 Indians and 311 Malays) and were followed up for 1 year. RESULTS: Although Caucasian patients on average were older and had incurred more cardiovascular adverse events, the Asian ethnic groups carried a greater burden of cardiovascular risk factors. Caucasian and Malay patients were most frequently diagnosed with acute myocardial infarction (Caucasians 11.2%, Chinese and Indians 6.4%, Malays 10.6%, P<0.001), also after correction for baseline differences. Chinese and Indian patients, however, more often had unstable angina. Asian patients had strikingly more extensive coronary artery disease than Caucasian patients (triple-vessel disease: Caucasians 6.5%, Chinese 22.8%, Indians 32.4%, Malays 32.8%, P<0.001) and Chinese patients with myocardial infarction more frequently underwent coronary revascularisation compared with Caucasian patients (Caucasians 41.4%, Chinese 67.5%, Indians 62.5%, Malay 46.7%, P=0.005). Ethnicity was not an independent predictor of major adverse cardiovascular events during 1-year follow-up in all chest pain patients. CONCLUSIONS: The prevalence of myocardial infarction and unstable angina, revascularisation rate and extent of coronary artery disease differ significantly among chest pain patients of different ethnic groups. These findings have important clinical implications and support consideration of ethnicity in risk stratification and determination of the patient management strategy in patients with symptoms suggestive of myocardial infarction.

Differences in short-term versus long-term outcomes of older black versus white patients with myocardial infarction: findings from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE).

BACKGROUND: Blacks are less likely than whites to receive coronary revascularization and evidence-based therapies after acute myocardial infarction, yet the impact of these differences on long-term outcomes is unknown. METHODS AND RESULTS: We linked Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry data to national Medicare claims, creating a longitudinal record of care and outcomes among 40 500 patients with non-ST-segment-elevation myocardial infarction treated at 446 hospitals to examine mortality and readmission rates (mean follow-up, 2.4 years) among black and white patients. Relative to whites (n=37 384), blacks (n=3116) were more often younger and female; more often had diabetes mellitus and renal failure; and received less aggressive interventions, including cardiac catheterization (60.7% versus 54.0%; P<0.001), percutaneous coronary intervention (32.1% versus 23.8%; P<0.001), and coronary bypass surgery (9.2% versus 5.7%; P<0.001). Although blacks had lower 30-day mortality (9.1% versus 9.9%; adjusted hazard ratio, 0.80; 95% confidence interval, 0.71-0.92), they had higher observed mortality at 1 year (27.9% versus 24.5%; P<0.001), although this was not significant after adjustment on long-term follow-up (hazard ratio, 1.00; 95% confidence interval, 0.94-1.07). Black patients also had higher 30-day (23.6% versus 20.0%; P<0.001) and 1-year (62.0% versus 54.6%; P<0.001) all-cause readmission, but these differences were no longer significant after risk adjustment on 30-day (hazard ratio, 1.02; 95% confidence interval, 0.92-1.13) and long-term (hazard ratio, 1.05; 95% confidence interval, 1.00-1.11) follow-up. CONCLUSIONS: Although older blacks with an acute myocardial infarction had lower initial mortality rates than whites, this early survival advantage did not persist during long-term follow-up. The reasons for this are multifactorial but may include differences in comorbidities and postdischarge care.

Study of C-reactive protein and C3 complement as acute phase reactants in unstable angina.

Prevalence rates of coronary artery disease are reported to be very high in Asian Indians. Traditional risk factors alone fail to explain the high rates of coronary artery disease in Indians. Acute phase reactants C-reactive protein and C3 in Indian subjects with unstable angina were evaluated and compared them with suitable controls to test the hypothesis that a relationship exists between acute phase reactants and unstable angina. Forty cases of unstable angina and forty suitable controls were enrolled for the study. Cases of unstable angina had significantly increased level of CRP as compared to control group (p = 0.01098). Statistically significant difference was found between case and control groups in TLC (p = 0.0037) and ESR (p = 0.0368), TLC and ESR being more in case group as compared to control group. C-reactive protein was significantly correlated with TLC, ESR and C3 in case group and TLC and ESR in control group. C3 was significantly correlated with all the other three inflammatory markers. C-reactive protein, TLC and ESR in case group while no correlation was observed with any variable in control group. The present study concludes that a relationship exists between acute phase reactants studied and unstable angina.

Adrenergic-pathway gene variants influence beta-blocker-related outcomes after acute coronary syndrome in a race-specific manner.

OBJECTIVES: Overcoming racial differences in acute coronary syndrome (ACS) outcomes is a strategic goal for U.S. health care. Genetic polymorphisms in the adrenergic pathway seem to explain some outcome differences by race in other cardiovascular diseases treated with ß-adrenergic receptor blockade (BB). Whether these genetic variants are associated with survival among ACS patients treated with BB, and if this differs by race, is unknown. BACKGROUND: ß-adrenergic receptor blockade after ACS is a measure of quality care, but the effectiveness across racial groups is less clear. METHODS: A prospective cohort of 2,673 ACS patients (2,072 Caucasian; 601 African-American) discharged on BB from 22 U.S. hospitals were followed for 2 years. Subjects were genotyped for polymorphisms in ADRB1, ADRB2, ADRA2C, and GRK5. We used proportional hazards regression to model the effect of genotype on mortality, stratified by race and adjusted for baseline factors. RESULTS: The overall 2-year mortality rate was 7.5% for Caucasians and 16.7% for African Americans. The prognosis associated with different genotypes in these BB-treated patients differed by race. In Caucasians, ADRA2C 322-325 deletion carriers had significantly lower mortality as compared with homozygous individuals lacking the deletion (hazard ratio: 0.46; confidence interval [CI]: 0.21 to 0.99; p = 0.047; race × genotype interaction p = 0.053). In African Americans, the ADRB2 16R allele was associated with significantly increased mortality (hazard ratio for RG vs. GG: 2.10; CI: 1.14 to 3.86; RR vs. GG: 2.65; CI: 1.38 to 5.08; p = 0.013; race × genotype interaction p = 0.096). CONCLUSIONS: Adrenergic pathway polymorphisms are associated with mortality in ACS patients receiving BB in a race-specific manner. Understanding the mechanism by which different genes impact post-ACS mortality differently in Caucasians and African Americans might illuminate opportunities to improve BB therapy in these groups.

Cross-cultural validation of the Cardiac Depression Scale in Iran.

BACKGROUND: The Cardiac Depression Scale (CDS) is a disease-specific instrument for measuring depression in cardiac patients. This study was designed to validate the CDS in an Iranian population. METHODS: Translation and back-translation of the 26-item CDS scale was performed using recommended procedures. The Iranian translation of the CDS (I-CDS) was administered to 261 individuals in Iran, concurrently with the Beck Depression Inventory. The factor structure of the I-CDS was examined using exploratory factor analysis procedures to enable comparison with previous psychometric evaluation of the CDS. Receiver operating characteristic curves were used to examine the ability of the I-CDS to discriminate between categories of depression. RESULTS: First-order exploratory factor analysis uncovered two robust factors, consistent with the second-order dimensions originally reported by the developers of this instrument. Cronbach's alpha was .88 for the total 26-item I-CDS, indicating satisfactory internal consistency of the I-CDS. Intercorrelation between the total scores for the I-CDS and BDI was .62 (p<.001). For the I-CDS cut-off of 90, the sensitivity was 85%, and specificity was 61% with a computed area under the curve (AUC) of 0.81 (95% CI, 0.76-0.87). For the I-CDS cut-off of 100, the sensitivity was 81%, and specificity was 63% with a computed AUC of 0.81 (95% CI, 0.76-0.87). CONCLUSION: This validation study of the Iranian version of the CDS demonstrated that it is an acceptable, reliable, and valid measure of depression in people with heart disease.

[Association between the -1031T/C polymorphism in tumor necrosis factor-alpha gene and unstable angina].

OBJECTIVE: To investigate the association between the -1031T/C polymorphism in the promoter of tumor necrosis factor-alpha (TNF- alpha) gene and unstable angina in Chinese Han population. METHODS: The genotype of -1031T/C locus was analyzed by MALDI-TOF in 299 patients with unstable angina and 202 healthy controls. The serum TNF-alpha level was measured by enzyme-linked immunosorbent assay(ELISA). RESULTS: There was no significant difference in the genotype distribution and allele frequencies of the -1031T/C locus between the two groups (P > 0.05). However, stratification by gender showed that the genotype distribution of this locus was obviously different between the two groups in men (P was 0.032). The risk of developing unstable angina in men carrying the CC+TC genotypes were 1.66-fold higher than that in men of TT genotype (95% CI: 1.040 to 2.659). There was no significant difference in the frequencies of the C and T alleles between the two subgroups (P > 0.05). Furthermore, serum TNF-alpha levels of the patients were significantly higher than those of controls (P = 0.028, P = 0.013 in men), but there was no significant difference in the TNF-alpha level among different genotypes. CONCLUSION: The -1031T/C polymorphism of the TNF-alpha gene might be associated with unstable angina in male Han population, especially the C allele carriers might be more likely to be affected by unstable angina than the rest of the population.

Gender differences in patients with coronary artery disease in Japan: the Japanese Coronary Artery Disease Study (the JCAD study).

BACKGROUND: Gender differences among patients with coronary artery disease vary from study to study. In one of the largest studies, the Japanese Coronary Artery Disease (JCAD) Study, gender differences in patients were investigated. METHODS AND RESULTS: Consecutive patients diagnosed with stenosis 75% or more in at least one branch of the coronary arteries were enrolled in the study. The endpoint is a composite of all-cause death and cardiovascular events. Data were collected over the internet. Out of 15,628 patients screened, 13,812 of them met the inclusion criteria and were followed up for a mean period of 2.7 years. The event rate was 62.8 per 1,000 patients-year, all-cause death 17.3 and total cardiac events 47.4. The incident rate of unstable angina was higher in females (27.1) than males (21.8) (P=0.0363). The incidence of all-cause death was lower in females than males (16.9 and 17.8, respectively; P=0.0148). Other than gender, hypertension and number of vessel disease contribute to the event of unstable angina, and age, family history, obesity, impaired fasting glycemia, hyperlipidemia, congestive heart failure and number of vessel disease contribute to the all-cause death. CONCLUSIONS: Gender is an independent contributing factor of unstable angina and of all-cause death.

Role of pro-/anti-inflammatory cytokines and their correlation with established risk factors in South Indians with coronary artery disease.

Cytokines are responsible for the modulation of immunological and inflammatory processes and play a significant role in the pathogenesis of coronary artery disease. We estimated the levels of pro-/anti-inflammatory cytokines in South Indian patients with coronary artery disease. The study population comprised of groups 1-3: 100 patients each with acute myocardial infarction, unstable angina, and stable angina, respectively, and group 4 (100 healthy controls). Cytokine levels (interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-alpha) were estimated by enzyme-linked immunosorbent assay (ELISA). Interleukin-6, interleukin-8, and tumor necrosis factor-alpha levels were significantly higher in patients from groups 1 and 2, than in group 3 and controls. Acute myocardial infarction patients exhibited higher serum levels of interleukin-10 compared with other groups and control subjects. Patients with unstable angina had significantly lower interleukin-10 concentrations than those with stable angina. The ratios of pro-/anti-inflammatory cytokines in all the study groups increased significantly when patients with unstable angina were compared to other groups. In patients with acute myocardial infarction, interleukin-10 and tumor necrosis factor-alpha levels showed significant correlation with established risk factors such as body mass index, blood pressure, and lipid levels. Acute myocardial infarction patients show elevation in proinflammatory and anti-inflammatory cytokines, while unstable angina is associated with low levels of serum interleukin-10. Higher levels of anti-inflammatory cytokine interleukin-10 may be needed to provide protection in unstable angina. These cytokines are markers of coronary artery disease and may be used for the identification of high-risk patients with unstable angina/acute myocardial infarction.

Comparison of baseline characteristics, treatment patterns, and in-hospital outcomes of Asian versus non-Asian white Americans with non-ST-segment elevation acute coronary syndromes from the CRUSADE quality improvement initiative.

It has been suggested that Asians may respond differently to antithrombotic therapy, but contemporary management and outcomes of non-ST-segment elevation (NSTE) acute coronary syndromes (ACSs) in Asian patients have not been well characterized. Using data from the CRUSADE initiative, we compared baseline characteristics, treatment patterns, and in-hospital outcomes between 1,071 Asian and 72,513 non-Asian white patients hospitalized with NSTE ACS. Asian patients were more likely to have hypertension, diabetes, and renal insufficiency compared with non-Asian whites. Body mass index was lower in Asian patients (24.9 vs 27.8 kg/m(2), p <0.0001). Use of acute medical therapies, cardiac catheterization, and percutaneous or surgical revascularization did not significantly differ between Asian and white groups after adjustment for patient and hospital characteristics. In-hospital mortality (5.0% vs 4.4%, adjusted odds ratio [OR] 1.24, 95% confidence interval [CI] 0.88 to 1.73) and reinfarction rates (2.0% vs 2.3%. adjusted OR 0.94, 95% CI 0.65 to 1.38) were also similar. In contrast, rates of major bleeding (13.4% vs 9.4%, p <0.0001) and red blood cell transfusion (9.6% vs 6.6%, p = 0.0005) were significantly higher in the Asian population and this higher bleeding risk persisted after adjustment for bleeding risk factors and body mass index; adjusted ORs were 1.32 (95% CI 1.08 to 1.62) and 1.32 (95% CI 1.01 to 1.72), respectively. In conclusion, despite similar treatment, Asian patients with NSTE ACS have significantly higher bleeding risk even after adjustment for risk factors and body mass index. Further investigation is needed to explore the potential for ethnic variability in antithrombotic susceptibility.

Disparities by insurance status in quality of care for elderly patients with unstable angina.

CONTEXT: Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities. OBJECTIVE: To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigate mediators for potential disparities. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, random chart review of 3122 African American or White Medicare patients >65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993-1999. MAIN OUTCOME MEASURES: Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, beta-blockers during hospitalization, and performance of appropriate coronary angiography. RESULTS: 182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, >85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P<.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44-.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50-.87), or heparin (OR .71, 95% CI .53-.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P=.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48-.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64-1.39). CONCLUSIONS: Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized.

Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE).

BACKGROUND: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce. METHODS: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative. RESULTS: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05). CONCLUSIONS: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

The influence of race on health status outcomes one year after an acute coronary syndrome.

OBJECTIVES: The goal of this study was to compare health status (symptoms, function, and quality of life) outcomes of whites and blacks one year after an acute coronary syndrome (ACS). BACKGROUND: Although racial differences in the use of angiography and revascularization after ACS are known to exist, differences in health status outcomes have not been described. METHODS: We conducted a prospective registry of 1,159 consecutive ACS patients treated between February 1, 2000 and October 31, 2001. One-year health status was quantified with the Seattle Angina Questionnaire (SAQ) and Short Form-12 Physical Component Score (SF-12 PCS). Multivariable models were used to adjust for racial differences in sociodemographic, clinical, and treatment characteristics. RESULTS: Mortality rates were similar among the 196 black and 963 white patients (7.1% vs. 7.0%, p = 0.93); 81 died during follow-up, and 199 (17%) could not be interviewed. At one year, blacks had a higher prevalence of angina (43.4% vs. 27.1%), worse quality of life (SAQ score = 70.6 +/- 28.3 vs. 83.9 +/- 20.8), and poorer physical function (SF-12 PCS = 36.8 +/- 12.3 vs. 43.2 +/- 11.4; p < 0.0001 for all). Multivariable models, including hospital treatments, revealed a trend for more angina (odds ratio 1.46 [95% confidence interval 0.91 to 2.34]) and significantly worse quality of life (mean difference = -7.7 +/- 2.4, p = 0.002) and physical function (-3.6 +/- 1.3, p = 0.005). CONCLUSIONS: Blacks have more angina, worse quality of life, and worse physical function one year after an ACS than do whites. Closer surveillance of black ACS patients is needed to determine whether additional treatment can improve their outcomes.

Acute coronary syndromes in black Americans: is treatment different? Should it be?

Black Americans with acute coronary syndromes (ACS) are at greater risk and have poorer outcomes than white Americans. The reasons for this appears, at least in part, to be due to a greater burden of baseline risk factors, longer delays prior to seeking medical care, and underutilization of aggressive treatment strategies in high-risk individuals. A guiding principle of treatment of ACS is that patients at highest risk should receive the most immediate and aggressive therapy. However, compared with whites, blacks with ACS paradoxically receive less aggressive medical therapy, and are less often referred for cardiac catheterization, percutaneous coronary interventions, and bypass surgery. Treatment is--but should not be--different in black Americans. Changing this and improving care for ACS in blacks requires better strategies for decreasing patient delays, earlier recognition and diagnosis of ACS, and more effective implementation of evidence-based treatment guidelines.

Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries.

OBJECTIVE: The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients. DESIGN: A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 2 years postdischarge. SETTING: The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care. PATIENTS/PARTICIPANTS: Participants included all 700,000 age 65+ Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997. MEASUREMENTS AND MAIN RESULTS: Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure. CONCLUSIONS: Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide "failures to refer" and patient "aversions to surgery" as explanations for lower black rates of surgical interventions.

Demographic data and outcome of acute coronary syndrome in the South African Asian Indian population.

Significant differences in the prevalence of coronary heart disease (CHD) exist with respect to gender, age and ethnicity. The disease has been reported to be higher in Indian populations that have emigrated from the Indian subcontinent. The aim of this study was to examine differences in major cardiovascular risk factors and clinical outcome in South African Asian Indians of different age groups and gender, who presented with acute coronary syndromes (ACS). The study cohort consisted of 2 290 consecutive patients, admitted between 1996 and 2002, who were divided into three age subgroups: young ( 45 to 65 years; 21%). All three age groups were predominantly male, but this was more evident in the younger (88%) and middle age groups (71%), and became less striking as the proportion of females increased with age. Smoking was more common in young men compared with young women (p < 0.01). Diabetes mellitus (21%) and hypertension (18%) were seen less frequently in young patients but this was confined to men only. Total cholesterol was elevated in 65 to 70% of all patients while high-density lipoprotein (HDL) levels were significantly lower in men compared with women for all age subsets. Hospital mortality was extremely low in young (1%) and middle-aged patients (2%), but was expectedly higher in older patients (8%; p < 0.0001). A family history of CHD was the most common familial vascular disease seen. Young patients were more often subjected to diagnostic and therapeutic interventions. They had more aggressive disease, with 48% of those subjected to angiographic studies having triple vessel disease (TVD), and 14% undergoing coronary artery bypass grafting (CABG). Triple vessel disease was also detected most commonly in middle-aged (64%) and old patients (75%). In conclusion, significant differences in risk factor status were found in South African Indians between genders and for different age groups. Also, young Indians in this study differed markedly from other young population groups with CHD, in that they frequently had premature atherosclerosis with diffuse and aggressive disease.

Association of genetic polymorphisms in the fibrinogen and platelet glycoprotein genes with unstable angina in Chinese patients.

BACKGROUND: Inherited predisposition has been associated with coronary artery disease (CAD) in the white population. HYPOTHESIS: The objective of this study was to investigate the association between the risk of unstable angina (UA) and genetic factors believed to be associated with an increased tendency toward thrombosis (the variable number of tandem repeats [VNTR] polymorphism of the platelet glycoprotein [GP] Ib alpha gene, Pl(A1/A2) of the platelet GP IIIa gene, 448G/A of the Bbeta fibrinogen gene and Thr312Ala of the Aalpha fibrinogen gene) in Chinese patients with UA. METHODS: We performed a case/control study evaluating 69 Chinese patients (43 men, 26 women) with UA and 69 control subjects without CAD, individually matched for age and gender. The restriction fragment length polymorphism (RFLP) method was used to determine the genetic polymorphisms. RESULTS: The frequencies of GP Ib alpha C/B genotype and Bbeta fibrinogen 448A allele were higher in patients with UA (46.4 vs. 30.4%, odds ratio [OR] 1.977, 95% confidence interval [CI] 0.98-3.97, p = 0.054, and 49.3 vs. 20.3%, OR 3.816, 95% CI 1.797-8.103, p = 0.000, respectively). Only four subjects (two cases, two controls) with GP IIIa Pl(A2) allele were found, and there was no association between Aalpha fibrinogen Thr312Ala polymorphism and UA. CONCLUSIONS: Chinese patients with UA had increased frequencies of GP Ib alpha C/B genotype and Bbeta fibrinogen 448A allele. These data suggest that some genetic factors may influence the development of UA.