| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2001;71:405-406
© 2001 The Society of Thoracic Surgeons
a Department of Surgery, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
Address reprint requests to Dr Scott, Department of Surgery, Charles R. Drew University of Medicine and Science, 1621 E 120th St, Los Angeles, CA 90059
e-mail: rozscott{at}gte.net
Risk and operative mortality after coronary artery bypass grafting (CABG) have traditionally been characterized in terms of nondemographic, nonsocioeconomic, biological variables. More recently, increasing attention has been directed to the impact of sex on the pathology, clinical presentation, diagnosis, and treatment of coronary artery disease. As a result, sex has been definitively identified as an important predictor of cardiovascular surgical outcomes, including operative mortality after CABG.
In this issue, Hartz and associates have extended previous analyses of The Society of Thoracic Surgeons National Database records for 1994 through 1996 to delineate the influence of race alone and in combination with sex on the 30-day operative mortality after CABG. In their study, both race and sex were independent predictors of adverse outcome. However, because of the relatively small number of records within each nonwhite (to use the terminology of Hartz and coworkers) racial group, all these groups were classified as nonwhite for the purpose of risk modeling. Among the nonwhite patients studied, more than 50% were African-American. The study also demonstrated that proportionally more nonwhite women than white women underwent CABG and that the nonwhite patients were younger, had more advanced disease, and were diabetic and in renal failure more often than white patients at the time of operation.
The critical inference made in this study, that all nonwhite populations are the same, may have statistical convenience, but it is not substantiated by what is known about health outcomes. All nonwhite racial groups—Black, Asian/Pacific Islander, American Indian/Alaskan Native, and ethnic groups such as Hispanic—are considered together in one racial categorization by Hartz and coauthors. These categories correspond to the race and ethnic standards for federal statistics and administrative reporting.
The current notions of "race" and "ethnicity" have evolved in the United States as mainly social and cultural constructs to distinguish observed biological (physical appearance), behavioral, and cultural differences. Race is used to identify presumed biological differences, and ethnicity is used to identify population groups characterized by common ancestry, language, and custom [1]. It can be argued that it is not the individual’s association with a particular racial or ethnic group that predicts health and other outcomes but the attribution of that relationship by others that underlies the inevitability of these outcomes.
Specifically considering the epidemiology of ischemic heart disease and the associated outcomes, we know that there are significant differences in risk factor profiles and mortality across racial groups. The most recent national mortality data show that the death rate associated with ischemic heart disease is highest for African-Americans followed by whites [2]. Among other nonwhite groups, the rate is lower than the rate for whites.
Most importantly, despite the reductions in mortality caused by heart disease as well as in mortality overall, during the past 50 years, the racial gap between African-Americans and whites in the leading causes of death, including heart disease, is actually wider today than it was in 1950. These differences persist at every socioeconomic level. For example, a cohort of African-American medical students from the 1958–1965 classes of Meharry Medical College and white medical students from the 1957–1964 classes of The Johns Hopkins University have been followed for more than 30 years. At follow-up, the African-American physicians had a 1.4 times higher incidence of coronary artery disease and a much higher fatality rate (51.5% versus 9.4%) [3].
As alluded to by Hartz and coauthors in their discussion, African-Americans are less likely than whites to undergo important cardiac diagnostic and therapeutic interventions. How do we resolve this finding with the greater prevalence of angina and the higher mortality relating to ischemic heart disease among African-Americans? Williams [4] recently suggested that these differences in health and their persistence through time reflect, in large part, policies and practices that are linked to the historic legacy of racism and that have created adverse living conditions that are pathogenic for nonwhite populations.
Studies published in the 1930s suggested that angina pectoris is exceedingly rare in "Negroes" because of their poorly developed nervous systems and their inability to perceive anginal symptoms should they occur. Weiss [5] reported that "a lack of ability to fully describe and interpret the sensation of cardiac pain can entirely explain the infrequency with which the syndrome is encountered." In his treatise read at the annual meeting of the American Heart Association in 1931, Roberts [6] emphasized the importance of nervous and mental influences in angina. He postulated that "the psychology of stress and strain and struggle in white races is in sharp contrast to the humorous carelessness of the musical Negro or the placid acceptance of the Chinaman."
More recent data have refuted these opinions and generated a number of other hypotheses based on genetic, biological, environmental, and socioeconomic differences among the races. Even at the very high socioeconomic-status strata, where racial differences in access to care and in attitudes should be at a minimum, marked racial differences exist in heart disease risk and outcome. This suggests that other factors such as stress, residual socioeconomic-status differences, or biological differences may be responsible. Nevertheless, after adjusting for differences in several major risk factors and for divergent socioeconomic levels, researchers have not been able to account for a major portion of the observed disparities.
Earlier surgical studies from single institutions dating back to 1983 have examined outcome after CABG according to race. The study by Watkins and coauthors [7] of urban African-Americans who underwent CABG at The Johns Hopkins Hospital between 1972 and 1980 showed a higher mortality and a higher proportion of patients with unstable angina and diffusely diseased arteries among the African American participants than the white patients. By contrast, the study by Sterling and colleagues [8] of patients undergoing myocardial revascularization between 1970 and 1983 at Walter Reed Army Medical Center found no racial differences in outcome. In the recent Bypass Angioplasty Revascularization Investigation [9], there was a higher proportion of women among the African-American patients. The African-American patients also had a lower educational level, more diabetes, and a higher incidence of congestive heart failure. Being African-American was an independent risk factor for not receiving an internal mammary artery and for death. The quality of the data analyzed by Hartz and coworkers precluded analysis of internal mammary artery use. These studies raise this question: If being African-American in today’s society affects health, do the career soldiers treated at Walter Reed Army Medical Center represent an important subset of African-Americans who live and work in a more egalitarian environment where they are judged by the content of their individual characters and not prejudged by society’s assumptions about their collective character?
Although the present study is a valuable addition to the important analyses derived from The Society of Thoracic Surgeons National Database, we must wonder if the database in its current form can properly characterize all patients. Although the database does not include a measure of diffuseness of disease, it may be possible to determine geographic patterns of mortality, geographic distribution of African-American patients relative to the population distribution and death rates, or proxies for socioeconomic status.
The importance of the study by Hartz and associates is best appreciated within the larger context of the disparate status of cardiovascular health among racial groups. The high risk of cardiac disease among African-Americans and the increased operative mortality observed most likely have unique contributing factors that have not been measured or identified. Because of the complex interactions of environment, biology, and genetics operational in the outcomes of coronary artery disease, novel approaches will be needed to fully account for differences and to determine opportunities to improve the operative and overall mortality associated with coronary artery disease.
The National Heart, Lung, and Blood Institute and the Office of Research on Minority Health have established the Jackson Heart Study as a long-term prospective epidemiological study of the African-American population of Jackson, MS. This community was chosen as the site for study because Mississippi’s death rates for cardiovascular disease are the highest in the United States. For example, among women in Mississippi, the mortality rate for cardiovascular disease is 75% higher for African-Americans than for whites. The Society of Thoracic Surgeons National Database Committee must consider whether the data currently being collected reflect the complex interactions of environment and biology and whether these data will be adequate to inform future discussions about cardiovascular disease, in general, and coronary revascularization, in particular. The thoracic surgical community as a whole, indeed our entire profession, must consider to what extent we have overcome the "legacy" and can ensure that all members of the communities we serve as physicians and surgeons benefit from the full spectrum of our achievements. The study by Hartz and coauthors should be the background for that discussion.
References
This article has been cited by other articles:
|
|
 |
|
  R. P. Scott and K. C. Heslin Historical perspectives on the care of african americans with cardiovascular disease Ann. Thorac. Surg., October 1, 2003; 76(4): S1348 - 1355. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
