Discovering the full spectrum of cardiovascular disease: Minority Health Summit 2003: executive summary

Cardiovascular Risk and Diseases in Patients With and Without Leptin-Melanocortin Pathway Variants

OBJECTIVE

To study differences in cardiovascular risk factors and diseases between patients with and without genetic variants in the leptin-melanocortin pathway.

METHODS

A cross-sectional study of patients with a history of severe obesity genotyped in June 2019 as participants of the Mayo Clinic Biobank was conducted in March 2022 to assess differences in cardiovascular risk and diseases between carriers of a heterozygous variant in the leptin-melanocortin pathway and noncarriers. Cardiovascular risk factors included hypertension, diabetes, dyslipidemia, and smoking. Cardiovascular disease includes coronary artery disease, peripheral artery disease, and cerebrovascular accidents. Patients with a history of bariatric surgery were excluded. We used logistic regression models to estimate the odds ratio and 95% CI, adjusting for age, body mass index (BMI), and sex.

RESULTS

Among a total of 168 carriers (8%; 121 [72%] female; mean [SD] age, 65.1 [14.9] years; BMI, 44.0 [7.4] kg/m2) and 2039 noncarriers (92%; 1446 [71%] female; mean [SD] age, 64.9 [14.4] years; BMI, 42.9 [6.6] kg/m2), carriers had higher prevalence odds of hypertension (odds ratio, 3.26; 95% CI, 2.31 to 4.61; P<.001) and reported higher number of cardiovascular risk factors compared with noncarriers (2.4 [1.1] vs 2.0 [1.1]; P<.001). There were no significant differences in the adjusted odds associated with diabetes, dyslipidemia, smoking, or cardiovascular disease.

CONCLUSION

Despite having similar body weight and BMI, carriers of heterozygous variants in the leptin-melanocortin pathway had higher rates of hypertension than noncarriers. These findings point to an association between hypertension and leptin-melanocortin pathway variants.

Atrial fibrillation/atrial flutter related mortality trends in the US population 2010-2020: Regional, racial, sex variations

BACKGROUND

There is an evolving need to evaluate atrial fibrillation/atrial flutter (AF/AFL) mortality trends across races, sexes, geographic regions and urbanization statuses to better understand management inequalities.

METHODS

This observational study utilized the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Mortality rates due to AF/AFL as underlying and contributing causes of death between 2010 and 2020 were investigated. Mortality trends due to AF/AFL as contributing causes of death for different races, sexes, census regions and urbanization statuses were analyzed using annual percentage change (APC), and Joinpoint regression analysis.

RESULTS

Mortality from AF/AFL as the underlying cause was increasing across the US until 2016 (APC 4.8%), followed by a plateau 2016-2020 (APC 0.0 %). Conversely, the mortality rate due to AF/AFL as a contributing cause increases 2010-2020 (APC 3.3%). The mortality rate in both sexes significantly increased in almost all groups, with the largest increase seen in Non-Hispanic Black males. Rural areas had a higher mortality rate (36.9 and 22.9 per 100,000 for males and females in 2020, respectively) and higher slope of increase than urban areas in total US population. Non-Hispanic White people had greater mortality than Non-Hispanic Black people; however, Non-Hispanic Black mortality rates are increasing at a faster rate in urban areas.

CONCLUSION

AF/AFL as the underlying cause of death has plateaued from 2016 across the US 2010-2020; whilst AF/AFL as contributing cause of death is increasing. Significant discrepancies in mortality rates are identified between races and urbanization status.

Antihypertensive medication adherence and persistence among Black women: A qualitative study

ABSTRACT

The prevalence of hypertension in Black women (57.6%) is among the highest in the world. Many of those who identify as Black do not readily adhere to prescribed antihypertensive medications nor persist with long-term therapy. This qualitative study describes self-reported approaches used by Black women with consistent adherence and persistence to medication-taking for BP control.

OMICS approaches in cardiovascular diseases: a mini review

Ranked in the topmost position among the deadliest diseases in the world, cardiovascular diseases (CVDs) are a global burden with alterations in heart and blood vessels. Early diagnostics and prognostics could be the best possible solution in CVD management. OMICS (genomics, proteomics, transcriptomics, and metabolomics) approaches could be able to tackle the challenges against CVDs. Genome-wide association studies along with next-generation sequencing with various computational biology tools could lead a new sight in early detection and possible therapeutics of CVDs. Human cardiac proteins are also characterized by mass spectrophotometry which could open the scope of proteomics approaches in CVD. Besides this, regulation of gene expression by transcriptomics approaches exhibits a new insight while metabolomics is the endpoint on the downstream of multi-omics approaches to confront CVDs from the early onset. Although a lot of challenges needed to overcome in CVD management, OMICS approaches are certainly a new prospect.

Exploring Armenian Ethnicity as an Independent Risk Factor for Cardiovascular Disease: Findings from a Prospective Cohort of Patients in a County Hospital

OBJECTIVES

While several studies have examined the risk of cardiovascular disease (CVD) in larger racial and ethnic groups within the United States, limited information is available on smaller sub-populations, such as Armenians, with high rates of CVD in their home country. This study examined the association between Armenian ethnicity and a positive exercise treadmill test (ETT).

DESIGN

Prospective cohort study of patients at a 377-bed county hospital in Los Angeles, California from 2008-2011.

SETTING

All patients were interviewed at the time of ETT to assess their cardiovascular risk factors at the cardiac laboratory of the hospital.

PARTICIPANTS

5,006 patients between 18-89 years of age, of whom 12.6% were of Armenian ethnicity and 54.4% were female.Main Outcome Measure: ETT results as a proxy for CVD risk.

RESULTS

After adjusting for cardiovascular risk factors, Armenian ethnicity was significantly associated with higher odds of positive ETT (OR = 1.40, p = 0.01). Known coronary artery disease CAD (OR = 2.28, p < 0.01), hyperlipidemia (OR = 1.37, p < 0.01), and hypertension (OR = 1.24, p = 0.05) were significantly associated with higher odds of a positive ETT. In subgroup analyses, hyperlipidemia was the only significant predictor of positive ETT (OR = 1.92, p = 0.02) among Armenians, while patient history of CAD (OR = 2.49, p < 0.01), hyperlipidemia (OR = 1.29, p = 0.03), and age (OR = 1.04, p < 0.01) were significant predictors among non-Armenians. Armenian ethnicity remained associated with higher odds of positive ETT (OR = 1.40, p < 0.01) when patients with CAD were excluded.

CONCLUSION

Armenian ethnicity may be an independent risk factor for CVD, influenced by the uniformity of the genetic pool and cultural and dietary exposures.

Racial and ethnic differences in cardiovascular disease and outcome in type 1 diabetes patients

INTRODUCTION

Type 1 diabetes mellitus (T1DM) has increased dramatically over the last two decades with global variation greater than 350-fold difference reflecting the ethnic, racial, and geographical variation. Diabetic patients remain at a higher risk of cardiovascular mortality than those without diabetes. Therefore, it is vital for clinicians to have in-depth knowledge of T1DM statistics and their impact on people health and health resources.

AREAS COVERED

This review will cover the epidemiologic characteristics of T1DM and the influence of race, ethnicity, and geographical variation on the incidence and the outcome. The minority populations health disparities in the clinical presentation and outcomes among youth with T1DM, the long-term glycemic control patterns in racially and ethnically diverse youth, and the long-term influence of these factors on cardiovascular outcomes will be elucidated. The PubMed database was searched using the terms: T1DM ± incidence, Race, ethnicity, and Genetic.

EXPERT OPINION

Understanding the epidemiological characteristics of T1DM including race, ethnicity and the genetic predisposition will help to develop guidelines target these higher risk patients of an unfavorable outcome. Further research and interventional strategies to identify infants at genetic risk of T1DM may help to prevent, stop or retard the destructive autoimmune process leading to T1DM.

Racial Differences in Atrial Fibrillation-Related Cardiovascular Disease and Mortality: The Atherosclerosis Risk in Communities (ARIC) Study

IMPORTANCE

The adverse outcomes associated with atrial fibrillation (AF) have been studied in predominantly white cohorts. Racial differences in outcomes associated with AF merit continued investigation.

OBJECTIVE

To evaluate the race-specific associations of AF with stroke, heart failure, coronary heart disease (CHD), and all-cause mortality in a community-based cohort.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) Study is a prospective, observational cohort. From 1987 through 1989, the ARIC Study enrolled 15 792 men and women and conducted 4 follow-up examinations (2011-2013) with active surveillance for vital status and hospitalizations. Race was determined by self-report and categorized as white, black, or other.

MAIN OUTCOMES AND MEASURES

Atrial fibrillation (adjudicated using electrocardiograms, hospital discharge codes, and death certificates), stroke, heart failure, CHD, and mortality.

RESULTS

After exclusions, 15 080 participants (mean [SD] age, 54.2 [5.8] years; 8290 women [55.5%]; 3831 black individuals [25.4%]) were included in this analysis. During a mean (SD) follow-up of 20.6 (6.2) years, there were 2348 cases of incident AF. The incident rates of AF per 1000 person-years were 8.1 (95% CI, 7.7-8.5) in white individuals and 5.8 (95% CI, 5.2-6.3) in black individuals. The rates of stroke, heart failure, CHD, and mortality were higher in black individuals with AF than white individuals with AF. The association of AF with these outcomes, estimated with rate differences (rate of the end point in those with AF minus the rate in those without AF per 1000 person-years), also differed by race. The rate difference for stroke in individuals with AF was 10.2 (95% CI, 6.6-13.9) in white individuals and 21.4 (95% CI, 10.2-32.6) in black individuals. For heart failure and CHD, the rate differences were 1.5- to 2.0-fold higher in black individuals than white individuals. White individuals with AF had a rate difference of 55.9 (95% CI, 48.1-63.7) for mortality compared with black individuals, who had a rate difference of 106.0 (95% CI, 86.0-125.9).

CONCLUSIONS AND RELEVANCE

In the prospective ARIC Study, the outcome of AF on the rates of stroke, heart failure, CHD, and mortality was considerably larger in black individuals than white individuals. These results indicate the vulnerability and increased risk in black individuals with AF. Continued investigation of racial differences in AF and its related adverse outcomes are essential to identify and mitigate racial disparities in the treatment of AF.

Prevalence of chronic kidney disease and comorbidities in isolated African descent communities (PREVRENAL): methodological design of a cohort study

BACKGROUND

Chronic kidney disease (CKD) is considered a serious public health problem, both in Brazil and worldwide, with an increasing number of cases observed inrecent years. Especially, CKD has been reported to be highly prevalent in those of African descent. However, Brazil lacks data from early-stage CKD population studies, and the prevalence of CKD is unknown for both the overall and African descent populations. Hence, the present study aimsto estimate the prevalence of early-stage CKD and its associated risk factors in African-Brazilians from isolated African-descent communities. Herein, the detailed methodology design of the study is described.

METHODS

This population-based, prospective, longitudinal, cohort study (PREVRENAL) is performed in three stages: first, clinical, nutritional, and anthropometric evaluations; measurements of serum and urinary markers; and examinations of comorbiditieswere performed. Second, repeated examinations of individuals with CKD, systemic arterial hypertension, and/or diabetes mellitus; image screening; and cardiac risk assessment were performed. Third, long-term monitoring of all selected individuals will be conducted (ongoing). Using probability sampling, 1539 individuals from 32 communities were selected. CKD was defined asaglomerular filtration rate (GFR) ≤60 mL/min/1.73m2 and albuminuria > 30 mg/day.

DISCUSSION

This study proposes to identify and monitor individuals with and without reduced GFR and high albuminuria in isolated populations of African descendants in Brazil. As there are currently no specific recommendations for detecting CKD in African descendants, four equations for estimating the GFR based on serum creatinine and cystatin C were used and will be retrospectively compared. The present report describes the characteristics of the target population, selection of individuals, and detection of a population at risk, along with the imaging, clinical, and laboratory methodologies used. The first and second stages have been concluded and the results will be published in the near future. The subsequent (third) stage is the long-term, continuous monitoring of individuals diagnosed with renal abnormalities or with CKD risk factors. The entire study population will be re-evaluated five years after the study initiation. The expectation is to obtain information about CKD evolution among this population, including the progression rate, complication development, and cardiovascular events.

Peripheral Arterial Disease and Its Association With Arsenic Exposure and Metabolism in the Strong Heart Study

At high levels, inorganic arsenic exposure is linked to peripheral arterial disease (PAD) and cardiovascular disease. To our knowledge, no prior study has evaluated the association between low-to-moderate arsenic exposure and incident PAD by ankle brachial index (ABI). We evaluated this relationship in the Strong Heart Study, a large population-based cohort study of American Indian communities. A total of 2,977 and 2,966 PAD-free participants who were aged 45-74 years in 1989-1991 were reexamined in 1993-1995 and 1997-1999, respectively, for incident PAD defined as either ABI <0.9 or ABI >1.4. A total of 286 and 206 incident PAD cases were identified for ABI <0.9 and ABI >1.4, respectively. The sum of inorganic and methylated urinary arsenic species (∑As) at baseline was used as a biomarker of long-term exposure. Comparing the highest tertile of ∑As with the lowest, the adjusted hazard ratios were 0.57 (95% confidence interval (CI): 0.32, 1.01) for ABI <0.9 and 2.24 (95% CI: 1.01, 4.32) for ABI >1.4. Increased arsenic methylation (as percent dimethylarsinate) was associated with a 2-fold increased risk of ABI >1.4 (hazard ratio = 2.04, 95% CI: 1.02, 3.41). Long-term low-to-moderate ∑As and increased arsenic methylation were associated with ABI >1.4 but not with ABI <0.9. Further studies are needed to clarify whether diabetes and enhanced arsenic metabolism increase susceptibility to the vasculotoxic effects of arsenic exposure.

The Association between Trust in Health Care Providers and Medication Adherence among Black Women with Hypertension

BACKGROUND

Black women have the highest prevalence of hypertension in the world. Reasons for this disparity are poorly understood. The historical legacy of medical maltreatment of Blacks in the U.S. provides some insight into distrust in the medical profession, refusal of treatment, and poor adherence to treatment regimens.

METHODS

Black women (N = 80) who were prescribed antihypertensive medications were recruited from urban communities in North Carolina. Study participants completed the Trust in Physician and Hill-Bone Compliance to High Blood Pressure Therapy questionnaires. An exact discrete-event model was used to examine the relationship between trust and medication adherence.

RESULTS

Mean age of study participants was 48 ± 9.2 years. The majority of participants (67%) were actively employed and 30% had incomes at or below the federal poverty level. Increasing levels of trust in the health care provider was independently associated with greater medication adherence (P Trend = 0.015).

CONCLUSION

Black women with hypertension who trusted their health care providers were more likely to be adherent with their prescribed antihypertensive medications than those who did not trust their health care providers. Findings suggest that trusting relationships between Black women and health care providers are important to decreasing disparate rates of hypertension.

Progression of coronary atherosclerosis in African-American patients

BACKGROUND

African-Americans with coronary artery disease (CAD) demonstrate worse clinical outcomes than Caucasians. While this is partly due to a lack of accessibility to established therapies, the mechanisms underlying this difference remain to be elucidated. We aimed to characterize the progression of coronary atherosclerosis in African-Americans with CAD.

METHODS

3,479 patients with CAD underwent serial intravascular ultrasound (IVUS) imaging to evaluate atheroma progression in 7 clinical trials of anti-atherosclerotic therapies. Risk factor control and atheroma progression were compared between African-Americans (n=170) and Caucasians (n=3,309).

RESULTS

African-Americans were more likely to be female (51.8% vs. 28.1%, P<0.001), have a higher body mass index (32.8±6.0 vs. 31.3±5.8 kg/m(2), P=0.002) and greater history of hypertension (85.9% vs. 78.8%, P=0.02), diabetes (41.8% vs. 30.6%, P=0.002) and stroke (12.9% vs. 3.0%, P<0.001). Despite a high use of anti-atherosclerotic medications (93% statin, 89% aspirin, 79% β-blocker, 52% ACE inhibitor), African-Americans demonstrated higher levels of LDL-C (2.4±0.7 vs. 2.2±0.7 mmol/L, P=0.006), CRP (2.9 vs. 2.0 mg/dL, P<0.001) and systolic blood pressure (133±15 vs. 129±13 mmHg, P<0.001) at follow-up. There was no significant difference in atheroma volume at baseline (189.0±82.2 vs. 191.6±83.3 mm(3), P=0.82) between two groups. Serial evaluation demonstrated a greater increase in atheroma volume in African-Americans (0.51±2.1 vs. -3.1±1.7 mm(3), P=0.01). This difference persisted with propensity matching accounting for differences in risk factor control (0.1±2.1 vs. -3.7±1.7 mm(3), P=0.02).

CONCLUSIONS

African-Americans with CAD achieve less optimal risk factor control and greater atheroma progression. These findings support the need for more intensive risk factor modification in African-Americans.

No Racial Disparities in the Treatment of ST Elevation Myocardial Infarction - A Community-based Experience

Whether racial disparities exist in the treatment of ST elevation myocardial infarction (STEMI) is not exactly known. We report a retrospective chart review of patients with first event of STEMI, in two groups separated by one decade. Results revealed that hospital mortality in the 2007 and 1997 groups for African Americans versus Caucasians was one of 22 versus 21 of 170, 95 % confidence interval (CI) -0.178 to 0.022, p=0.48 and four of 41 versus 39 of 402, 95 % CI -0.095 to 0.096, p=1.00, respectively. The mean length of stay (LOS) for African Americans and Caucasians in the 2007 and 1997 groups was 5.7 versus 4.1 days (p=0.09) and 7.3 versus 6.6 days (p=0.42), respectively. During follow-up, a total of 40 patients needed re-intervention in the 2007 group. The re-intervention rate in African American patients being 13.6 % (three of 22) versus 21.2 % (36 of 170) in Caucasians, 95 % CI -0.231 to 0.081, with p=0.57. In conclusion, there was no evidence of racial disparity in the treatment of STEMI in terms of hospital mortality, length of hospital stay and re-intervention rate.

High prevalence of metabolic syndrome in young Hispanic women: findings from the national Sister to Sister campaign

BACKGROUND

Hispanics are the fastest growing segment of the U.S. population and have a higher prevalence of cardiometabolic risk factors as compared with non-Hispanic whites. Further data suggests that Hispanics have undiagnosed complications of metabolic syndrome, namely diabetes mellitus, at an earlier age. We sought to better understand the epidemiology of metabolic syndrome in Hispanic women using data from a large, community-based health screening program.

METHODS

Using data from the Sister to Sister: The Women's Heart Health Foundation community health fairs from 2008 to 2009 held in 17 U.S. cities, we sought to characterize how cardiometabolic risk profiles vary across age for women by race and ethnicity. Metabolic syndrome was defined using the updated National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, which included three or more of the following: Waist circumference ≥35 inches, triglycerides ≥150 mg/dL, high-density lipoprotein (HDL) <50 mg/dL, systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg, or a fasting glucose ≥100 mg/dL.

RESULTS

A total of 6843 community women were included in the analyses. Metabolic syndrome had a prevalence of 35%. The risk-adjusted odds ratio for metabolic syndrome in Hispanic women versus white women was 1.7 (95% confidence interval, 1.4, 2.0). Dyslipidemia was the strongest predictor of metabolic syndrome among Hispanic women. This disparity appeared most pronounced for younger women. Additional predictors of metabolic syndrome included black race, increasing age, and smoking.

CONCLUSIONS

In a large, nationally representative sample of women, we found that metabolic syndrome was highly prevalent among young Hispanic women. Efforts specifically targeted to identifying these high-risk women are necessary to prevent the cardiovascular morbidity and mortality associated with metabolic syndrome.

Freedom of choice and adherence to the health regimen for African Americans with hypertension

The prevalence of hypertension in African Americans exceeds that of all other racial/ethnic groups in the world. Hypertension in African Americans is less likely to be controlled and this problem is further complicated by failure to adhere to prescribed hypertension management regimens. Oftentimes, health care providers give African American patients with hypertension multiple health "rules" to follow that may arouse reactance behaviors: that is, patients may choose to do the opposite of what they are told to do. The theory of psychological reactance offers a framework for understanding the relationship between freedom of choice and adherence to hypertension regimens in African Americans.

Racial/ethnic discrepancies in the metabolic syndrome begin in childhood and persist after adjustment for environmental factors

BACKGROUND AND AIMS

Evaluation of metabolic syndrome (MetS) characteristics across an age spectrum from childhood to adulthood has been limited by a lack of consistent MetS criteria for children and adults and by a lack of adjustment for environmental factors. We used the pediatric and adult International Diabetes Federation (IDF) criteria to determine whether gender-specific and race-specific differences in MetS and its components are present in adolescents as in adults after adjustment for socio-economic status (SES) and lifestyle factors.

METHODS AND RESULTS

Waist circumference, blood pressure, triglycerides, HDL cholesterol, and fasting glucose measures were obtained from 3100 adolescent (12-19 years) and 3419 adult (20-69 years) non-Hispanic white, non-Hispanic black, and Mexican-American participants of the 1999-2006 National Health and Nutrition Examination Surveys. We compared odds of having MetS and its components across racial/ethnic groups by age group, while adjusting for income, education, physical activity and diet quality. After adjusting for possible confounding influences of SES and lifestyle, non-Hispanic-black adolescent males exhibited a lower odds of MetS and multiple components (abdominal obesity, hypertriglyceridemia, low HDL, hyperglycemia) compared to non-Hispanic-white and Mexican-American adolescents. Compared to non-Hispanic-white adolescent males, Mexican-American adolescent males had less hypertension. There were no differences in MetS prevalence among adolescent females, though non-Hispanic-black girls exhibited less hypertriglyceridemia.

CONCLUSION

Racial/ethnicity-specific differences in MetS and its components are present in both adolescence and adulthood, even after adjusting for environmental factors. These data help strengthen arguments for developing racial/ethnic-specific MetS criteria to better identify individuals at risk for future cardiovascular disease.

Care and outcomes of Asian-American acute myocardial infarction patients: findings from the American Heart Association Get With The Guidelines-Coronary Artery Disease program

BACKGROUND

Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients.

METHODS AND RESULTS

We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04).

CONCLUSIONS

Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.

Cardiovascular disease and risk factors in an indigenous minority population. The All-Ireland Traveller Health Study

BACKGROUND

The Traveller community are an indigenous minority group in Great Britain and Ireland who experience premature mortality. While minority populations worldwide are known to have high rates of risk factors for cardiovascular disease (CVD), Traveller CVD risk has not previously been defined.

DESIGN

All-Ireland cross-sectional census survey of the Traveller minority population (n = 10,615 families).

METHODS

A subsample of adult respondents completed a health survey (n = 2023). CVD was defined as self-report of doctor-diagnosed heart attack, angina, or stroke. CVD risk factors and measures of social position were examined in the Traveller group using age-adjusted prevalence and prevalence ratios (PR). Comparisons were made with a general population sample of low socioeconomic status.

RESULTS

Age-adjusted prevalence of CVD in the Traveller population was 5.6% (95% CI 4.6-6.8), similar to that in the comparator population. Compared to those without CVD, Travellers with CVD had a higher prevalence of self-report of diabetes, hypertension, hypercholesterolaemia, current smoking, and a measure of distrust. Compared with the general population sample, Travellers had a higher prevalence of diabetes (adjusted PR 2.8, 95% CI 2.1-3.8) and lifestyle-related risk factors such as smoking (PR 1.3, 95% CI 1.2-1.4), fried food consumption (PR 2.8, 95% CI 2.4-3.2), and physical inactivity (PR 1.3, 95% CI 1.2-1.4).

CONCLUSIONS

This comprehensive census survey confirms CVD as an important health risk in the economically disadvantaged Irish Traveller community. Our findings add to the international knowledge base on minority populations and CVD risk.

Evaluating clinic and community-based lifestyle interventions for obesity reduction in a low-income Latino neighborhood: Vivamos Activos Fair Oaks Program

Background

Obesity exerts an enormous health impact through its effect on coronary heart disease and its risk factors. Primary care-based and community-based intensive lifestyle counseling may effectively promote weight loss. There has been limited implementation and evaluation of these strategies, particularly the added benefit of community-based intervention, in low-income Latino populations.

Design

The Vivamos Activos Fair Oaks project is a randomized clinical trial designed to evaluate the clinical and cost-effectiveness of two obesity reduction lifestyle interventions: clinic-based intensive lifestyle counseling, either alone (n = 80) or combined with community health worker support (n = 80), in comparison to usual primary care (n = 40). Clinic-based counseling consists of 15 group and four individual lifestyle counseling sessions provided by health educators targeting behavior change in physical activity and dietary practices. Community health worker support includes seven home visits aimed at practical implementation of weight loss strategies within the person's home and neighborhood. The interventions use a framework based on Social Cognitive Theory, the Transtheoretical Model of behavior change, and techniques from previously tested lifestyle interventions. Application of the framework was culturally tailored based on past interventions in the same community and elsewhere, as well as a community needs and assets assessment. The interventions include a 12-month intensive phase followed by a 12-month maintenance phase. Participants are obese Spanish-speaking adults with at least one cardiovascular risk factor recruited from a community health center in a low-income neighborhood of San Mateo County, California. Follow-up assessments occur at 6, 12, and 24 months for the primary outcome of percent change in body mass index at 24 months. Secondary outcomes include specific cardiovascular risk factors, particularly blood pressure and fasting glucose levels.

Discussion and Conclusions

If successful, this study will provide evidence for broad implementation of obesity interventions in minority populations and guidance about the selection of strategies involving clinic-based case management and community-based community health worker support.

Clinical Trial Registration

ClinicalTrials.gov: NCT01242683

Higher cardiovascular disease prevalence and mortality among younger blacks compared to whites

BACKGROUND

Blacks have higher rates of cardiovascular disease than whites. The age at which these differential rates emerge has not been fully examined.

OBJECTIVE

We examined cardiovascular disease prevalence and mortality among black and white adults across the adult age spectrum and explored potential mediators of these differential disease prevalence rates.

METHODS

We conducted a cross-sectional analysis of National Health and Nutrition Examination Survey data from 1999-2006. We estimated age-adjusted and age-specific prevalence ratios (PR) for cardiovascular disease (heart failure, stroke, or myocardial infarction) for blacks versus whites in adults aged 35 years and older and examined potential explanatory factors. From the National Compressed Mortality File 5-year aggregate file of 1999-2003, we determined age-specific cardiovascular disease mortality rates.

RESULTS

In young adulthood, cardiovascular disease prevalence was higher in blacks than whites (35-44 years PR 1.9; 95% confidence interval [CI], 1.1-3.4). The black-white PR decreased with each decade of advancing age (P for trend=.04), leading to a narrowing of the racial gap at older ages (65-74 years PR 1.2; 95% CI, 0.8-1.6; > or =75 years PR 1.0; 95% CI, 0.7-1.4). Clinical and socioeconomic factors mediated some, but not all, of the excess cardiovascular disease prevalence among young to middle-aged blacks. Over a quarter (28%) of all cardiovascular disease deaths among blacks occurred in those aged <65 years, compared with 13% among whites.

CONCLUSIONS

Reducing black/white disparities in cardiovascular disease will require a focus on young and middle-aged blacks.

Knowledge, preventive action, and barriers to cardiovascular disease prevention by race and ethnicity in women: an American Heart Association national survey

BACKGROUND

Racial and ethnic disparities in cardiovascular disease (CVD) outcomes and risk factors are well documented, but few data have evaluated population differences in CVD knowledge, preventive action, and barriers to prevention.

METHODS

A nationally representative sample of 1008 women (17% Hispanic, 22% black, 61% white/other) selected through random digit dialing were given a standardized questionnaire about knowledge of healthy risk factor levels, recent preventive actions, and barriers to prevention. Analysis focused on predictors of knowledge and preventive action in the past year and proportion reporting select barriers to prevention. Logistic regression was used to determine if race/ethnicity was independently associated with knowledge and preventive action after adjustment.

RESULTS

No racial/ethnic differences in risk factor knowledge were identified except Hispanic women were 44% less likely than white/others to know the optimal high-density lipoprotein cholesterol (HDL-C) level (odds ratio [OR] 0.56,95% confidence interval [CI] 0.35-0.91). Knowledge of blood pressure goal was lower among those with less than a college education (OR 0.59,95% CI 0.44-0.79). Hispanics were twice as likely as white/others to help someone else lose weight (OR 1.78,95% CI 1.17-2.71) or add physical activity (OR 1.95,95% CI 1.18-3.22) in the past year. Blacks were more likely than whites/others to report decreased unhealthy food consumption (OR 1.77,95% CI 1.08-2.93), trying to lose weight (OR 1.62,95% CI 1.06-2.47), and taking action when they experienced CVD symptoms (30% vs. 23%,p = 0.03). Physician encouragement was cited as the reason for taking preventive action more often by black (59%,p = 0.002) and Hispanic (54%,p = 0.03) women than whites/others (43%).

CONCLUSIONS

Continued initiatives to improve and translate knowledge into preventive action are needed, especially among less educated and Hispanic women who may activate others to reduce risk.

Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease program

BACKGROUND

Racial/ethnic differences in cardiovascular care have been well documented. We sought to determine whether racial/ethnic differences in evidence-based acute myocardial infarction care persist among hospitals participating in a national quality improvement program.

METHODS AND RESULTS

We analyzed 142 593 acute myocardial infarction patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) at 443 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program between January 2002 and June 2007. We examined individual and overall composite rates of defect-free care, defined as the proportion of patients receiving all eligible performance measures. In addition, we examined temporal trends in use of performance measures according to race/ethnicity by calendar quarter. Overall, individual performance measure use was high, ranging from 78% for use of angiotensin-converting enzyme inhibitors to 96% for use of aspirin at discharge. Use of each of these improved significantly over the 5 years of study. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics (adjusted odds ratio versus whites 1.00, 95% confidence interval 0.94 to 1.06, P=0.94), and 77.7% for blacks (adjusted odds ratio versus whites 0.93, 95% confidence interval 0.87 to 0.98, P=0.01). A significant gap in defect-free care was observed for blacks mostly during the first half of the study, which was no longer present during the remainder of the study. Overall, progressive improvements in defect-free care were observed regardless of race/ethnic groups.

CONCLUSIONS

Among hospitals engaged in a national quality monitoring and improvement program, evidence-based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity, and differences in care by race/ethnicity care were reduced or eliminated.

Underdiagnosis of Metabolic Syndrome in Non-Hispanic Black Adolescents: A Call for Ethnic-Specific Criteria

Childhood obesity is a risk factor for the development of both type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). One marker that can be used to predict T2DM is the metabolic syndrome (MetS). MetS, a cluster of cardiovascular factors associated with insulin resistance, is defined by central obesity, impaired fasting glucose, hypertension, elevated triglycerides (TG), and low levels of high-density lipoprotein cholesterol. Some have advocated using a diagnosis of MetS to trigger increased intervention in children. However, ethnic differences in MetS may hamper identification of at-risk children. For example, non-Hispanic blacks are diagnosed with MetS less frequently than non-Hispanic whites, despite having higher rates of T2DM and CVD. These differences in MetS are predominantly due to a low frequency of hypertriglyceridemia in non-Hispanic blacks. Compared with non-Hispanic whites and Mexican Americans, non-Hispanic blacks have lower TG levels at baseline but exhibit worsening insulin resistance with increasing TG. Therefore "normal" TG levels appear to be falsely reassuring among insulin-resistant non-Hispanic blacks. Ethnic-specific tools may be needed to more accurately predict risk for T2DM and CVD in minorities.

Case management to reduce risk of cardiovascular disease in a county health care system

BACKGROUND

Case management (CM) is a systematic approach to supplement physician-centered efforts to prevent cardiovascular disease (CVD). Research is limited on its implementation and efficacy in low-income, ethnic minority populations.

METHODS

We conducted a randomized clinical trial to evaluate a nurse- and dietitian-led CM program for reducing major CVD risk factors in low-income, primarily ethnic minority patients in a county health care system, 63.0% of whom had type 2 diabetes mellitus. The primary outcome was the Framingham risk score (FRS).

RESULTS

A total of 419 patients at elevated risk of CVD events were randomized and followed up for a mean of 16 months (81.4% retention). The mean FRS was significantly lower for the CM vs usual care group at follow-up (7.80 [95% confidence interval, 7.21-8.38] vs 8.93 [8.36-9.49]; P = .001) after adjusting for baseline FRS. This is equivalent to 5 fewer heart disease events per 1000 individuals per year attributable to the intervention or to 200 individuals receiving the intervention to prevent 1 event per year. The pattern of group differences in the FRS was similar in subgroups defined a priori by sex and ethnicity. The main driver of these differences was lowering the mean (SD) systolic (-4.2 [18.5] vs 2.6 [22.7] mm Hg; P = .003) and diastolic (-6.0 [11.6] vs -3.0 [11.7] mm Hg; P = .02) blood pressures for the CM vs usual care group.

CONCLUSION

Nurse and dietitian CM targeting multifactor risk reduction can lead to modest improvements in CVD risk factors among high-risk patients in low-income, ethnic minority populations receiving care in county health clinics.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00128687.

Venous thromboembolism in African-Americans: a literature-based commentary

Among the cardiovascular diseases and after ischemic heart disease and stroke, venous thromboembolism (VTE) is the third leading cause of death in the U.S. (3). Although VTE is seen across most ethnic groups in the U.S. as well as throughout the world, the rate varies. In the U.S., American Indians/Alaskan Natives as well as Asians have been reported to have a significantly lower rate of deep vein thrombosis (DVT) and pulmonary embolism (PE) as compared to blacks and whites. In sharp conrast blacks appear to have much higher rates than whites. Although these rate differences are thought in part by some to be attributable to disparities in diagnosis and care as well as genetics, it nevertheless is important to define as well as to understand the true incidence and impact so that both public health and clinical resources can be maximally utilized. The purpose of this commentary is to review the VTE burden in the U.S. with respect to ethnicity in terms of clinical demographics and genetics with particular emphasis on blacks.

Multiple health disparities among minority adults with mobility limitations: san application of the ICF framework and codes

PURPOSE

To examine the interface between mobility limitations and minority status and its effect on multiple health and health-related domains among adults, using the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

We combined 8 years of data from the 1997-2004 US National Health Interview Survey to investigate health disparities among minorities with mobility limitations as defined by the ICF. A total of 79,739 adults surveyed met these criteria.

RESULTS

Adults with both mobility limitations and minority status experienced the greatest disparities (p<0.001) in worsening health (adjusted odds ratio [AOR]=8.5), depressive symptoms (AOR=17.2), diabetes (AOR=5.5), hypertension (AOR=3.4), stroke (AOR=7.2), visual impairment (AOR=4.6), difficulty with activities of daily living (AOR=42.7) and instrumental activities of daily living (AOR=27.7), use of special equipment (AOR = 28.1), obesity (AOR=3.3), physical inactivity (AOR=2.7), and low workforce participation (AOR=0.35).

CONCLUSIONS

For most outcome measures, findings supported our hypothesis that persons with both mobility limitations and minority status experience greater health disparities than do adults with minority status or mobility limitations alone.

Cardiology clinical trial participation in community-based healthcare systems: obstacles and opportunities

BACKGROUND

The objective of our study was to examine cardiologists' and organizational leaders' interest in clinical trial participation and perceived barriers and facilitators to participation within ten diverse non-profit healthcare delivery systems. Trials play a pivotal role in advancing knowledge about the safety and efficacy of cardiovascular interventions and tests. Although cardiovascular trials successfully enroll patients, recruitment challenges persist. Community-based health systems could be an important source of participants and investigators, but little is known about community cardiologists' experiences with trials.

METHODS

We interviewed 25 cardiology and administrative leaders and mailed questionnaires to all 280 cardiologists at 10 U.S. healthcare organizations.

RESULTS

The survey received a 73% response rate. While 60% of respondents had not participated in any trials in the past year, nearly 75% wanted greater participation. Cardiologists reported positive attitudes toward trial participation; more than half agreed that trials were their first choice of therapy for patients, if available. Almost all leaders described their organizations as valuing research but not necessarily trials. Major barriers to participation were lack of physician time and insufficient skilled research nurses.

CONCLUSIONS

Cardiologists have considerable interest in trial participation. Major obstacles to increased participation are lack of time and effective infrastructure to support trials. These results suggest that community-based health systems are a rich source for cardiovascular research but additional funding and infrastructure are needed to leverage this resource.

Translating Research Into Practice for Healthcare Providers

The American Heart Association’s (AHA’s) mission is “to build healthier lives, free of cardiovascular diseases and stroke.” This first article in a 2-part series will serve to present an overview of the work the AHA has undertaken to translate evidence into practice for healthcare professionals. It describes the extensive work of the AHA to support and further the delivery of evidence-based medicine, which includes the following: (1) supporting scientific discovery and the next generation of healthcare professionals and researchers; (2) disseminating scientific information; (3) developing evidence-based guidelines and statements; (4) creating and advocating for the implementation of performance indicators/measures; (5) developing clinical decision support and quality improvement tools; and (6) developing directed-cause campaigns, all of which can lead to improved patient care. This article also discusses the need for novel approaches and some of the AHA’s evolving strategies to help address gaps in care. The second article, which will be published shortly after this one, will examine the AHA’s efforts to engage and empower healthcare consumers to become more involved with their own health and health care.

Racial analysis of patients with myocardial infarction complicated by heart failure and/or left ventricular dysfunction treated with valsartan, captopril, or both

OBJECTIVES

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.

BACKGROUND

Very few data exist concerning the effectiveness of angiotensin receptor blockers in this population.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Blacks and whites have a similar prevalence of reduced left ventricular ejection fraction in the general population: the Dallas Heart Study (DHS)

BACKGROUND

The objective of the study was to evaluate racial differences in the prevalence of left ventricular (LV) dysfunction. Few data compare the relative frequency of reduced LV ejection fraction (EF) (LVEF) in blacks and whites. Because of the higher prevalence of risk factors for heart failure in blacks, including hypertension, obesity, and LV hypertrophy, we hypothesized that LV dysfunction would also be more common in this ethnic group.

METHODS

In the DHS, a probability-based sample of Dallas County, we performed cardiac magnetic resonance imaging on 1335 black and 858 white participants aged 30 to 67 years to measure LVEF and volumes. We compared the prevalence of reduced LV EF and distribution of ventricular volumes in the 2 ethnic groups.

RESULTS

The prevalence of a reduced LVEF, whether defined as < 50%, < 55%, or < 60%, did not appear to be different between black versus white women (P > or = .7 for each) or men (P > or = .4 for each). Similar findings were seen using a recently defined sex-specific threshold (men < 55% and women < 61%) for low EF (P = .1). Mean LV end-diastolic and end-systolic volumes indexed to body surface area were also comparable in black and white men (P > or = .3) and women (P > or = .1).

CONCLUSIONS

Despite having a higher prevalence of risk factors for heart failure, blacks as compared with whites did not have a higher prevalence of reduced LVEF in the general population.

Racial disparity in the utilization of implantable-cardioverter defibrillators among patients with prior myocardial infarction and an ejection fraction of <or=35%

Age-adjusted sudden cardiac death rates are highest for black patients compared with other racial groups. The prophylactic implantation of an implantable cardioverter-defibrillator (ICD) provides a significant reduction in sudden cardiac death and overall mortality in patients after myocardial infarctions with significant left ventricular systolic dysfunction. The purpose of this study was to determine whether black patients with left ventricular systolic dysfunction were less likely than white patients to receive ICDs for the primary prevention of sudden cardiac death. Data from the National Registry to Advance Heart Health (ADVANCENT) were analyzed to determine which patients with histories of myocardial infarctions and ejection fractions<or=35% received ICDs for the primary prevention of sudden cardiac death. Multivariate logistic regression was used to evaluate the association of patients' race with ICD implantation. Overall, 7,830 patients were identified as eligible candidates for ICDs. Black patients (n=660) were younger, more often women, had less education, had more co-morbidities, and had a lower mean ejection fraction compared with white patients (n=7,170). More than 90% of the study population were insured, and approximately 88% of participants in the registry were enrolled by cardiologists. Blacks were significantly less likely than whites to receive ICDs (30% vs 41%, p<0.001). This difference in ICD use persisted after adjusting for demographics, clinical characteristics, and socioeconomic factors (odds ratio 0.62, 95% confidence interval 0.50 to 0.75, p<0.001). In conclusion, among patients at an increased risk for sudden cardiac death, blacks were significantly less likely to receive ICDs than whites.

Ethnic Differences in the Prognostic Value of Coronary Artery Calcification for All-Cause Mortality

OBJECTIVES

The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large, ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality.

BACKGROUND

Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than non-Hispanic whites (NHW). Some of this variability may be due to differing pathophysiological mechanisms and effects of underlying atherosclerosis.

METHODS

Ten-year death rates from all causes (total deaths = 505) were compared using risk-adjusted Cox proportional hazards models in AA (n = 637), Hispanic (HS, n = 1,334), Asian (AS, n = 1,065), and NHW (n = 11,776) populations.

RESULTS

Ethnic minority patients were generally younger (0.3 to 4 years), more often persons with diabetes (p < 0.0001), hypertensive (p < 0.0001), and female (p < 0.0001). The prevalence of CAC scores > or =100 was highest in NHW (31%) and lowest for HS (18%) (p < 0.0001). Overall survival was 96%, 93%, and 92% for AS, NHW, and HS, respectively, as compared with 83% for AA (p < 0.0001). When comparing prognosis by CAC scores in ethnic minorities as compared with NHW, relative risk ratios were highest for AA with CAC scores > or =400 exceeding 16.1 (p < 0.0001). Hispanics with CAC scores > or =400 had relative risk ratios from 7.9 to 9.0, whereas AS with CAC scores > or =1,000 had relative risk ratios 6.6-fold higher than NHW (p < 0.0001).

CONCLUSIONS

Consistent with population evidence, AA with increasing burden of subclinical coronary artery disease were the highest-risk ethnic minority population. These data support a growing body of evidence noting substantial differences in cardiovascular risk by ethnicity.

Secondary prevention outcomes among black and white cardiac rehabilitation patients

BACKGROUND

Disparities in coronary heart disease and related risk factors persist. It is unknown if cardiac rehabilitation (CR) narrows the gap in risk factor control between black and white patients. Thus, we compared baseline characteristics and secondary prevention outcomes between black and white CR patients.

METHODS

Data from patient records (n = 616, mean age 62 +/- 10 years, 29% women, 25% black) collected between January 1996 and June 2006 were examined. Comparisons were made between Blacks and Whites for baseline characteristics, changes in secondary prevention measures during CR, and the proportion of patients at treatment goals before and after CR. General linear regression modeling was used to determine the effect of race/ethnicity on outcomes.

RESULTS

At baseline, Blacks had more hypertension and diabetes and more adverse measures for blood pressure, low-density lipoprotein and non-high-density lipoprotein cholesterol (non-HDL-C), hemoglobin A1c, 6-minute walk distance, and Short-Form Health Survey (SF-36) physical component score. At CR completion, improvement (P < .05) was achieved among whites in all measures except for HDL-C and systolic blood pressure. Among Blacks, improvement did not reach significance for HDL-C, body mass index, waist circumference, and hemoglobin A1c (when diabetes was present). When adjusting for age, gender, number of sessions attended, and baseline measure, Whites improved more than Blacks in 6-minute walk distance, self-reported physical activity, body mass index, waist circumference, low-density lipoprotein cholesterol, and hemoglobin A1c (all P < .05).

CONCLUSION

Blacks entered CR with more adverse risk factor measures compared with Whites. Although both groups gained secondary prevention benefits, the degree of improvement was less for Blacks than Whites, and this was especially evident among black women.

Implementation of case management to reduce cardiovascular disease risk in the Stanford and San Mateo Heart to Heart randomized controlled trial: study protocol and baseline characteristics

Background

Case management has emerged as a promising alternative approach to supplement traditional one-on-one sessions between patients and doctors for improving the quality of care in chronic diseases such as coronary heart disease (CHD). However, data are lacking in terms of its efficacy and cost-effectiveness when implemented in ethnic and low-income populations.

Methods

The Stanford and San Mateo Heart to Heart (HTH) project is a randomized controlled clinical trial designed to rigorously evaluate the efficacy and cost-effectiveness of a multi-risk cardiovascular case management program in low-income, primarily ethnic minority patients served by a local county health care system in California. Randomization occurred at the patient level. The primary outcome measure is the absolute CHD risk over 10 years. Secondary outcome measures include adherence to guidelines on CHD prevention practice. We documented the study design, methodology, and baseline sociodemographic, clinical and lifestyle characteristics of 419 participants.

Results

We achieved equal distributions of the sociodemographic, biophysical and lifestyle characteristics between the two randomization groups. HTH participants had a mean age of 56 years, 63% were Latinos/Hispanics, 65% female, 61% less educated, and 62% were not employed. Twenty percent of participants reported having a prior cardiovascular event. 10-year CHD risk averaged 18% in men and 13% in women despite a modest low-density lipoprotein cholesterol level and a high on-treatment percentage at baseline. Sixty-three percent of participants were diagnosed with diabetes and an additional 22% had metabolic syndrome. In addition, many participants had depressed high-density lipoprotein (HDL) cholesterol levels and elevated values of total cholesterol-to-HDL ratio, triglycerides, triglyceride-to-HDL ratio, and blood pressure. Furthermore, nearly 70% of participants were obese, 45% had a family history of CHD or stroke, and 16% were current smokers.

Conclusion

We have recruited an ethnically diverse, low-income cohort in which to implement a case management approach and test its efficacy and cost-effectiveness. HTH will advance the scientific understanding of better strategies for CHD prevention among these priority subpopulations and aid in guiding future practice that will reduce health disparities.

EFFECTIVE RECRUITMENT AND RETENTION OF MINORITY RESEARCH PARTICIPANTS

Our ability, as leaders in public health scholarship and practice, to achieve and measure progress in addressing racial/ethnic disparities in health status and health care is severely constrained by low levels of participation of racial/ethnic minority populations in health-related research. Confining our review to those minority groups federally defined as underrepresented (African Americans/blacks, Latinos/Hispanics, and Native Americans/American Indians), we identified 95 studies published between January 1999 and April 2005 describing methods of increasing minority enrollment and retention in research studies, more than three times the average annual output of scholarly work in this area during the prior 15-year period. Ten themes emerged from the 75 studies that were primarily descriptive. The remaining 20 studies, which directly analyzed the efficacy or effectiveness of recruitment/retention strategies, were examined in detail and provided useful insights related to four of the ten factors: sampling approach/identification of targeted participants, community involvement/nature and timing of contact with prospective participants, incentives and logistical issues, and cultural adaptations. We then characterized the current state of this literature, discussing implications for future research needs and directions.