Mortality In African Americans Research Articles

Exercise capacity and all-cause mortality in African American and Caucasian men with type 2 diabetes.

OBJECTIVEThe purpose of this study was to assess the association between exercise capacity and mortality in African Americans and Caucasians with type 2 diabetes and to explore racial differences regarding this relationship.RESEARCH DESIGN AND METHODSAfrican American (n = 1,703; aged 60 ± 10 years) and Caucasian (n = 1,445; aged 62 ± 10 years) men with type 2 diabetes completed a maximal exercise test between 1986 and 2007 at the Veterans Affairs Medical Centers in Washington, DC, and Palo Alto, California. Three fitness categories were established (low-, moderate-, and high-fit) based on peak METs achieved. Subjects were followed for all-cause mortality for 7.3 ± 4.7 years.RESULTSThe adjusted mortality risk was 23% higher in African Americans than in Caucasians (hazard ratio 1.23 [95% CI 1.1–1.4]). A graded reduction in mortality risk was noted with increased exercise capacity for both races. There was a significant interaction between race and METs (P < 0.001) and among race and fitness categories (P < 0.001). The association was stronger for Caucasians. Each 1-MET increase in exercise capacity yielded a 19% lower risk for Caucasians and 14% for African Americans (P < 0.001). Similarly, the risk was 43% lower (0.57 [0.44–0.73]) for moderate-fit and 67% lower (0.33 [0.22–0.48]) for high-fit Caucasians. The comparable reductions in African Americans were 34% (0.66 [0.55–0.80]) and 46% (0.54 [0.39–0.73]), respectively.CONCLUSIONSExercise capacity is a strong predictor of all-cause mortality in African American and Caucasian men with type 2 diabetes. The exercise capacity-related reduction in mortality appears to be stronger and more graded for Caucasians than for African Americans.

All-cause mortality after drug-eluting stent implantation in African–Americans

Recent studies have questioned the safety of drug-eluting stents because of a higher incidence of late stent thrombosis, raising the possibility that drug-eluting stents may be associated with an increased mortality. The effect of drug-eluting stents on mortality in African-Americans is unknown. We evaluated 628 African-American patients (354 patients treated with drug-eluting stents and 274 patients treated with bare metal stents) between January 2003 and August 2005, using data from our bolus-only platelet glycoprotein IIb/IIIa inhibitor database. The primary end point was all-cause mortality obtained using social security death index. After a mean follow-up of 3+/-0.9 years, the mortality rate in the bare metal stents group was 12.8% compared with 7.1% in the drug-eluting stents group [adjusted P value=0.19; hazard ratio (HR) for bare metal stents group compared with drug-eluting stents group for death=1.4; 95% confidence interval (CI): 0.8-2.4]. In a subgroup analysis, patients presenting with acute coronary syndrome had a higher mortality when treated with bare metal stents compared with drug-eluting stents (17.1 vs. 6.3%, P=0.022; HR=2.2; 95% CI: 1.1-4.4). Patients with chronic kidney disease (all patients with creatinine >1.5 mg/dl) also had a higher mortality with bare metal stents compared with drug-eluting stents (36.7 vs. 20.4%, P=0.044; HR=2.3; 95% CI: 1.02-5.2). Drug-eluting stents seem to be safe in African-Americans and may improve survival in certain subgroups such as patients with acute coronary syndromes and chronic kidney disease.

Abstract 5639: Persistent Depression Predicts Mortality among African Americans with Myocardial Infarction

Depression predicts adverse outcomes after myocardial infarction (MI), but the relative prognostic importance of new, past or current versus persistent depression among African Americans with MI is unknown. In a prospective MI registry in an inner-city hospital, we measured depressive symptoms in 397 African Americans hospitalized with MI using the Patient Health Questionnaire (PHQ). Patients were categorized as past (received depression treatment prior to MI), new (PHQ&gt;=10 at hospitalization and no past depression), persistent (new plus past depression) or never-depressed. We examined the association between depression categories and 3-yr mortality using multivariable models after adjusting for demographic, clinical, and quality of care variables. There were no differences in sociodemographics, comorbidities and clinical factors among the past (7%), new (23%), persistent (6%) or never-depressed (64%) groups except a younger age in persistent depression group. Patients with persistent depression but not new or past depression had a higher mortality compared with the never-depressed (52% vs. 31%; P=0.02; 36% vs. 31%, P=0.90 and 28% vs. 31%, P=0.7 respectively). Patients with persistent depression were almost three times as likely to die at 3 yrs post-MI (adjusted HR 2.9; 95% CI 1.5, 5.5) as those who were never-depressed (Figure ). Previously treated depression that persists at MI hospitalization, but not new or past depression, strongly predicts post-MI mortality in African Americans. These findings suggest the need to screen MI patients for persistent depression. This research has received full or partial funding support from the American Heart Association, AHA Greater Southeast Affiliate (Alabama, Florida, Georgia, Louisiana, Mississippi, Puerto Rico &amp; Tennessee). Figure 1. Differences in the influence of symptom cluster on event-free survival in HF patients with depressive symptoms

Ethnic differences in the treatment of depression in patients with ischemic heart disease

The aim of this study is to examine ethnic differences in depressive symptoms and antidepressant treatment in a cohort of patients undergoing diagnostic coronary angiography. Coronary heart disease (CHD) is the leading cause of mortality in the United States, with an excess of mortality in African Americans. Traditional risk factors occur more frequently among African Americans but do not fully account for this increased risk. Elevated depressive symptoms have been shown to be associated with higher morbidity and mortality in patients with CHD. A consecutive series of 864 patients (727 whites, 137 African Americans) completed the Beck Depression Inventory to assess depressive symptoms. Data describing cardiovascular risk factors and type of medications including antidepressants were obtained from chart review at the time of study enrollment. There was no difference in the severity of depressive symptoms between whites (P = .50); the prevalence of elevated depressive symptoms also was similar for African Americans (35%) and whites (27%) (P = .20). However, the rate of antidepressant use was 21% for whites but only 11.7% for African Americans (P = .016). The odds ratio for ethnicity (African American vs whites) in predicting antidepressant use was 0.43 (95% confidence interval 0.24-0.76, P = .004) after adjustment for Beck Depression Inventory scores. African Americans with CHD are less likely to be treated with antidepressant medications compared with whites despite having similar levels of depression. The ethnic differences in the psychopharmacological management of depression suggests that more careful assessment of depression, especially in African Americans, is necessary to optimize care of patients with CHD.

Left Ventricular Hypertrophy and Cardiovascular Mortality by Race and Ethnicity

Background Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood. Methods We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors. Results ECG left ventricular hypertrophy was significantly associated with 10-year cardiovascular mortality in all 3 racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31; 95% confidence interval [CI], 1.55-3.42) than for whites and Latinos (1.32; 95% CI, 1.14-1.76 and 2.11; 95% CI, 1.35-3.30, respectively), independent of systolic blood pressure. Conclusions ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.

Conceptual Model of Symptom‐Focused Diabetes Care for African Americans

Development of a conceptual model and description of its use to guide the content and format of a community-based intervention. CONCEPTUAL MODEL: We developed a symptom-focused model for type 2 diabetes for older African American women based on the UCSF symptom management model. Key concepts in this model are symptom experience, symptom management, and health outcomes. Review of literature, intervention protocol. The symptom-focused conceptual model is an innovative approach to tailoring care to a distinct population and to engaging participants in their own self-care. Diabetes is a major cause of morbidity and mortality in African Americans; and diabetes self-management is the cornerstone of care. To better meet the distinct needs of diverse populations and positively affect health outcomes, new tailored approaches should be developed that are culturally sensitive and acceptable.

The Predictive Value of Left Atrial Size for Incident Ischemic Stroke and All-Cause Mortality in African Americans

The association between left atrial (LA) size, ischemic stroke, and death has not been well established in African Americans despite their disproportionately higher rates of stroke and cardiovascular mortality compared to non-Hispanic whites. For the analysis, participants in the Jackson cohort of the Atherosclerosis Risk in Communities Study were followed from the date of the echocardiogram in cycle three to the date of the first ischemic stroke event (or death) or to December 31, 2004 if no ischemic stroke event (or death) was detected. There were 1886 participants in the study population (mean age 58.9 years, 65% women). Participants in the top quintile of LA diameter indexed to height (LA diameter/height; 2.57 to 3.55 cm/m) were more likely women, hypertensive, diabetic, and obese compared to those not in the top quintile. Over a median follow-up of 9.8 years for ischemic stroke and 9.9 years for all-cause mortality, there were 106 strokes and 242 deaths. In a multivariable model adjusting for traditional clinical risk factors, the top quintile of LA diameter/height was significantly related to ischemic stroke (HR 1.7; 95% CI: 1.1, 2.7) and all-cause mortality (HR 2.0; 95% CI: 1.5, 2.7). After further adjustment for left ventricular (LV) hypertrophy and low LV ejection fraction, the top quintile remained significantly related to all-cause mortality (HR 1.8; 95% CI: 1.3, 2.5). In this population-based cohort of African Americans, LA size was a predictor of all-cause mortality after adjusting for traditional cardiovascular risk factors, LV hypertrophy, and low LV ejection fraction.

Ethnic differences in socioeconomic status, diagnosis, treatment, and survival among older women with epithelial ovarian cancer

The purpose of the study was to determine the ethnic disparities in socioeconomic status (SES) and in receiving definitive surgical treatment and adjuvant chemotherapy and to examine if these differences contribute to ethnic disparities in survival. We studied a population-based cohort of 5131 women diagnosed with epithelial ovarian cancer at age ≥ 65 between 1992 and 1999, identified from the Surveillance, Epidemiology and End Results-Medicare linked databases with up to 11 years of follow-up. The percentage of women diagnosed with epithelial ovarian cancer at advanced stage (stage III or IV) was 71.6% in Caucasians and 69.7% in African-Americans. Of these 4264 with stage IC–IV disease who are recommended for chemotherapy, fewer African-Americans received chemotherapy compared to Caucasians (50.2% versus 64.7%,P&lt; 0.001). The risk of all-cause mortality in African-Americans was not significantly different from Caucasians (hazard ratio [HR] = 1.00, 95% CI = 0.88–1.13) after controlling for patient demographics, tumor characteristics, and comorbidity. The HR remained not significant in African-Americans compared to Caucasians after additionally adjusting for treatments (0.93, 0.82–1.06) or SES (0.94, 0.82–1.08) or both (0.88, 0.77–1.01). Women who underwent cancer-directed surgery and received adjuvant chemotherapy were 50% less likely to die than those who did not. The survival benefits from these therapies were similar in Caucasian and African-American women with ovarian cancer. There was no significant difference in survival between African-American and Caucasian women with ovarian cancer after adjusting for tumor characteristics, treatment, and sociodemographic factors. Although adjuvant chemotherapy was effective in prolonging survival, substantial numbers of women with ovarian cancer still did not receive chemotherapy.

Racial Analysis of Patients With Myocardial Infarction Complicated by Heart Failure and/or Left Ventricular Dysfunction Treated With Valsartan, Captopril, or Both

African Americans have a high incidence of heart failure (HF). Limited retrospective observational subgroup analyses of patients with left ventricular systolic dysfunction (LVSD) suggest marginal benefit of angiotensin-converting enzyme inhibitors in the prevention of HF hospitalizations or total mortality in African Americans. Very few data exist concerning the effectiveness of angiotensin receptor blockers in this population. Baseline characteristics, treatments, and outcomes of patients from the U.S. (3,390 white and 340 African-American patients) in the VALIANT (VALsartan In Acute myocardial iNfarcTion) trial were compared. This trial included patients with an acute myocardial infarction (MI) after initial stabilization and documented LVSD and/or HF. Patients were randomly assigned to receive treatment with valsartan, captopril, or the combination; follow-up continued for up to 3 years (median 24.7 months). African Americans had more coronary risk factors, more markers of poor outcome after MI, and were less likely to be revascularized when compared with white patients. After adjusting for treatment assignment, baseline characteristics, and post-infarction parameters, no difference was found in the 3-year rate of all-cause mortality, cardiovascular mortality, rehospitalization for HF, recurrent MI, or stroke between the 2 groups. African Americans sustaining an acute MI with LVSD and/or HF had similar clinical outcomes compared with white Americans. Valsartan, captopril, or the combination had comparable effects on cardiovascular morbidity and mortality in African Americans and white Americans.

A GRK5 polymorphism that inhibits β-adrenergic receptor signaling is protective in heart failure

Beta-adrenergic receptor (betaAR) blockade is a standard therapy for cardiac failure and ischemia. G protein-coupled receptor kinases (GRKs) desensitize betaARs, suggesting that genetic GRK variants might modify outcomes in these syndromes. Re-sequencing of GRK2 and GRK5 revealed a nonsynonymous polymorphism of GRK5, common in African Americans, in which leucine is substituted for glutamine at position 41. GRK5-Leu41 uncoupled isoproterenol-stimulated responses more effectively than did GRK5-Gln41 in transfected cells and transgenic mice, and, like pharmacological betaAR blockade, GRK5-Leu41 protected against experimental catecholamine-induced cardiomyopathy. Human association studies showed a pharmacogenomic interaction between GRK5-Leu41 and beta-blocker treatment, in which the presence of the GRK5-Leu41 polymorphism was associated with decreased mortality in African Americans with heart failure or cardiac ischemia. In 375 prospectively followed African-American subjects with heart failure, GRK5-Leu41 protected against death or cardiac transplantation. Enhanced betaAR desensitization of excessive catecholamine signaling by GRK5-Leu41 provides a 'genetic beta-blockade' that improves survival in African Americans with heart failure, suggesting a reason for conflicting results of beta-blocker clinical trials in this population.

Determinants of Exhaled Nitric Oxide Levels in Healthy Non-Smoking African American Adults

Asthma is a significant cause of morbidity and mortality for African Americans. Exhaled nitric oxide (FeNO) levels are elevated in asthma and airway levels of NO metabolites regulate airway inflammation and airway diameter. More needs to be known about the factors that regulate FeNO. There is a need for FeNO reference values for African Americans. The objective of this study was to establish reference values and identify factors associated with FeNO levels in healthy African American adults. FeNO was measured in 895 healthy, non-smoking, African Americans between the ages of 18 and 40. FeNO measurements were repeated in 84 subjects. Factors potentially associated with FeNO were measured including blood pressure, height, weight, serum total IgE, ECP, CRP and nitrate. Data on respiratory symptoms including upper respiratory infection (URI) symptoms were collected. Univariate and multivariate analyses of the relationship between these variables and FeNO were performed. In healthy, non-smoking African Americans, FeNO was stable during repeated measurements (rI = 0.81). Gender (p < 0.0001), serum total IgE (p < 0.0001) and current URI symptoms (p = 0.0002) contributed significantly to FeNO variability but together accounted for less than 50% of the variation in FeNO. The high correlation between repeated measurements of FeNO and the low correlation coefficients of known factors associated with FeNO suggest that other factors may contribute substantially to FeNO variability in African Americans. Gender, elevated serum total IgE and current URI symptoms should be considered when evaluating FeNO levels in adults. Importantly, these studies provide FeNO reference values for healthy African American adults.

The impact of race on outcomes of autologous transplantation in patients with multiple myeloma

Multiple myeloma is the most common hematologic malignancy in African-Americans, with twice the mortality of Caucasians according to population based data. In the pretransplantation era, comparable conventional therapy has resulted in similar outcomes between African-Americans and Caucasians. However, there has been limited data on outcomes after high dose chemotherapy with autologous stem cell transplantation (ASCT). A retrospective analysis of Caucasian (n = 55) and African-American (n = 36) myeloma patients who underwent ASCT in an equal access health care system in the Department of Defense was performed. Presenting demographic variables, pre/post ASCT characteristics, overall mortality and relapse rates after ASCT were obtained. Progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier, and compared via log-rank testing. The median age at diagnosis for African-Americans = 52 years, Caucasians = 56 years (P = 0.009). There were no differences in presenting ISS stage, hemoglobin, calcium, or creatinine. African-Americans presented with higher CRP levels (P = 0.005), and a trend for less skeletal involvement (P = 0.10). Response to induction and ASCT was similar. Median PFS was 60.5 months (95% CI: 31.3-89.8 months) for African-Americans, 43.7 months (95% CI: 33.9-53.5 months) for Caucasians, HR of 1.3 (95% CI: 0.7-2.4), P = 0.46. Median OS was 95.2 months (95% CI: N/A) for African-Americans, 68.5 months (95% CI: 14.2-122.9 months) for Caucasians, HR of 1.4 (95% CI: 0.7-2.9), P = 0.41. In a cohort of myeloma patients who received autologous transplantation in an equal access health care system, there was comparable survival between African-Americans and Caucasians, suggesting that the historical increased mortality for African-Americans may be due to inequalities in access to care.

Increased Mortality in African Americans with Idiopathic Pulmonary Arterial Hypertension

Idiopathic pulmonary arterial hypertension (IPAH) is a progressive disorder that usually culminates in right ventricular failure and death without treatment. To assess mortality trends by race and gender for idiopathic pulmonary arterial hypertension in the United States from 1994-1998. The U.S. National Center for Health Statistics data for the years 1994-1998 was reviewed for deaths in which the underlying cause was primary pulmonary hypertension (ICD-9 code 416.0), now known as IPAH. The age, gender, race and state of residence of the deceased were abstracted from the Centers for Disease Control Wonder System (http://wonder.cdc.gov). Average annual age-adjusted region-, race- and gender-specific rates were then calculated. African-American women demonstrated the highest mortality rates for IPAH across all age groups compared to other racial and gender groups. No geographical differences in mortality rates were noted. An increase in mortality rates with advancing age was observed in all racial and gender groups, with the highest mortality rates for IPAH noted in the elderly. African Americans with IPAH exhibit a substantially increased mortality compared with Caucasians, particularly African-American women.

New Developments in Understanding Cardiovascular Disease and the Implications for Social Work

ABSTRACT Cardiovascular disease is now viewed as an inflammatory disease. An index of chronic inflammation (viz., C-Reactive Protein) is as good a predictor of heart attacks as are fats in blood. The data suggest that stressful events are so closely associated with chronic inflammatory states, that the body's stress response can be viewed as an inflammatory state. This paper summarizes and explains the link between stress and cardiovascular disease. Negative health outcomes, particularly for cardiovascular diseases, are higher among those of lower socio-economic status. Differential stress among socio-economic tiers is considered as an explanation for the disparities. The literature linking cardiovascular risk factors to the Stressors of workplace unfairness and lack of control over working conditions is reviewed. The role of the Stressor of racism in explaining the higher rates of cardiovascular mortality in African Americans is discussed. Finally, for societies with wider gaps in income between the rich and the poor, increased stress is explored as a possible explanation for the diminished health outcomes found across all socio-economic tiers. The implications for social work direct practice and macro-practice are considered.

Determinants of exhaled nitric oxide levels in healthy, nonsmoking African American adults

Asthma is a significant cause of morbidity and mortality for African Americans. Fraction of exhaled nitric oxide (FeNO) levels are increased in patients with asthma, and airway levels of nitric oxide metabolites regulate airway inflammation and airway diameter. More needs to be known about the factors that regulate FeNO. There is a need for FeNO reference values for African Americans. We sought to establish reference values and identify factors associated with FeNO levels in healthy African American adults. FeNO levels were measured in 895 healthy, nonsmoking African Americans between the ages of 18 and 40 years. FeNO measurements were repeated in 84 subjects. Factors potentially associated with FeNO were measured, including blood pressure, height, weight, and serum total IgE, eosinophil cationic protein, C-reactive protein, and nitrate levels. Data on respiratory symptoms, including upper respiratory tract infection (URI) symptoms, were collected. Univariate and multivariate analyses of the relationship between these variables and FeNO levels were performed. In healthy, nonsmoking African Americans FeNO levels were stable during repeated measurements (intraclass correlation coefficient, 0.81). Sex (P < .0001), serum total IgE levels (P < .0001), and current URI symptoms (P = .0002) contributed significantly to FeNO variability but together accounted for less than 50% of the variation in FeNO levels. The high correlation between repeated measurements of FeNO and the low correlation coefficients of known factors associated with FeNO suggest that other factors might contribute substantially to variability of FeNO levels in African Americans.

Abstract 3616: Left Atrial Size Association with Incident Ischemic Stroke and All-Cause Mortality in African Americans: the Atherosclerosis Risks in Communities (ARIC) Study

Background: The association between left atrial (LA) size, ischemic stroke and mortality has been investigated in non-Hispanic whites but not in African Americans despite their disproportionately higher rates of stroke and cardiovascular mortality. Purpose: We examined the association of LA size assessed by echocardiogram with the incidence of ischemic stroke and all-cause mortality in a large population-based cohort of African Americans. Methods: Participants in the Jackson cohort of the ARIC study have been extensively evaluated including echocardiograms during the third examination (1993–1995) and have been followed for incident cardiovascular events including stroke. Results: The study population consisted of 1,887 participants of which 660 (35%) were men with a mean age of 58.9 ± 5.7 years. LA diameter by tertile was significantly related to hypertension, diabetes and body mass index (BMI) (p&lt;0.0001 for each). Over a median follow-up period of 8.8 years, there were 103 incident strokes (6.47 per 1,000 person-years) and 206 deaths (13.3 per 1,000 person-years). Adjusting for age, sex, hypertension, smoking, diabetes, total cholesterol:HDL ratio, and BMI, LA size was associated with stroke (HR per 10 mm increment of LA diameter 1.44; 95% CI: 0.99, 2.08, p = 0.05) and significantly associated with mortality (HR 1.38; 95% CI: 1.06,1.79 p &lt; 0.02). After further adjustment for prevalent CHD and congestive heart failure, only the association with mortality remained statistically significant (p &lt; 0.03). Conclusions: In this middle-aged population based cohort of African Americans, LA size was significantly associated with all-cause mortality independent of traditional cardiovascular risk factors.

Ethnic differences in socioeconomic status, diagnosis, treatment, and survival among older women with epithelial ovarian cancer

The purpose of the study was to determine the ethnic disparities in socioeconomic status (SES) and in receiving definitive surgical treatment and adjuvant chemotherapy and to examine if these differences contribute to ethnic disparities in survival. We studied a population-based cohort of 5131 women diagnosed with epithelial ovarian cancer at age >or=65 between 1992 and 1999, identified from the Surveillance, Epidemiology and End Results-Medicare linked databases with up to 11 years of follow-up. The percentage of women diagnosed with epithelial ovarian cancer at advanced stage (stage III or IV) was 71.6% in Caucasians and 69.7% in African-Americans. Of these 4264 with stage IC-IV disease who are recommended for chemotherapy, fewer African-Americans received chemotherapy compared to Caucasians (50.2% versus 64.7%, P < 0.001). The risk of all-cause mortality in African-Americans was not significantly different from Caucasians (hazard ratio [HR] = 1.00, 95% CI = 0.88-1.13) after controlling for patient demographics, tumor characteristics, and comorbidity. The HR remained not significant in African-Americans compared to Caucasians after additionally adjusting for treatments (0.93, 0.82-1.06) or SES (0.94, 0.82-1.08) or both (0.88, 0.77-1.01). Women who underwent cancer-directed surgery and received adjuvant chemotherapy were 50% less likely to die than those who did not. The survival benefits from these therapies were similar in Caucasian and African-American women with ovarian cancer. There was no significant difference in survival between African-American and Caucasian women with ovarian cancer after adjusting for tumor characteristics, treatment, and sociodemographic factors. Although adjuvant chemotherapy was effective in prolonging survival, substantial numbers of women with ovarian cancer still did not receive chemotherapy.

Differences in the Association Between Apolipoprotein E Genotype and Mortality Across Populations

The gene for apolipoprotein-E (APOE) has three common alleles (epsilon2, epsilon3, and epsilon4) that have been shown to be associated with differences in the risk of death in persons older than 60 years in European populations. However, previous research suggests that they may not be associated with mortality in African Americans, and the evidence in Asians is mixed. It is now possible to examine the effects of these genotypes on mortality in African American, Chinese, Japanese, and Korean populations. The analysis is based on two types of published data: genotype by age and mortality by genotype. Demographic synthesis uses a multistate model to combine data from these case-control and cohort studies to provide maximum likelihood estimates of the relative risks of death. In general, the APOE epsilon2 allele is associated with 5%-10% lower mortality than the epsilon3/3 genotype. The epsilon4/4 allele is generally associated with a moderately high relative risk of death. The epsilon3/4 genotype is associated with 22% excess risk in Europeans and U.S. whites and with about 35% in Chinese. However, there is no evidence of excess risk with epsilon3/4 among African Americans and little excess risk among Japanese and Koreans. The relationship between genotype and mortality is consistent within these ethnic groups. For example, the estimates of R(3/4) for Japanese in Japan and Hawaii are both low, and the estimates for Chinese in Taiwan and Shanghai are relatively high. . The relationship between APOE genotype and mortality differs across population groups but shows little evidence of variation within groups.

Enhanced surgery-induced angiogenesis among premenopausal women might partially explain excess breast cancer mortality of blacks compared to whites: An hypothesis

There is excess breast cancer mortality for African-Americans (AA) compared to European-Americans (EA) of 1.5–2.2 fold that first appeared in 1970s and has been worsening since. This disparity may not be explained solely by reduced access to medical care. We proposed that surgery to remove a primary tumor induces angiogenesis of distant dormant micrometastases in 20% of premenopausal node-positive patients. This hypothesis helps explain the reduced benefit of mammography for women aged 40–49. Interestingly, for AA the average age at diagnosis is 46 while for EA it is 57. The resultant increased proportion of AA premenopausal breast cancer suggests a possible explanation for the AA/EA excess mortality. Early detection, which began in the 1970s, is more effective in postmenopausal women than in premenopausal women. Since AA breast cancer is mostly premenopausal and EA breast cancer is mostly postmenopausal, it might be anticipated that starting in the 1970s because of surgery-induced early mortality, outcome would be superior for EA compared to AA.

The prognostic value of the mitral diastolic filling velocity ratio for all-cause mortality and cardiovascular morbidity in African Americans: the atherosclerotic Risks in Communities (ARIC) study

Although recent data suggest that the mitral diastolic early-to-late (E/A) ratio may be prognostic in selected population-based cohorts, its predictive value for morbidity and mortality in African Americans has not yet been well studied. The study population consisted of African American participants from the Jackson cohort of the Atherosclerotic Risks in Community Study. Three subgroups of E/A ratios were defined: E/A <0.7, E/A 0.7-1.5, and E/A >1.5, using the middle group as reference. Cox proportional hazard models were used to assess the association between the E/A ratio and both all-cause mortality and incident cardiovascular disease (CVD). The mean follow-up period was 6.8 +/- 1.3 years. Of the 2211 participants in the study population (mean age 62 years, 65.1% women), 8.2% had an E/A ratio <0.7, 84.7% had an E/A 0.7-1.5, and 7.1% had an E/A >1.5. An E/A >1.5 was independently associated with all-cause mortality (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.20-4.03) in the multivariable model. An E/A <0.7 was associated with higher all-cause mortality (HR 1.79, 95% CI 1.17-2.73) and incident CVD (HR 1.91, 95% CI 1.29-2.83) compared with a normal E/A in the age and sex adjusted model but was not independently predictive in the multivariable model (P > .05). In a population-based cohort of middle-aged African Americans, an E/A >1.5 independently predicts all-cause mortality. An E/A >1.5 and an E/A <0.7 were both associated with incident CVD when adjusted for age and sex alone but were not independently predictive in the multivariable analysis.