Black-White Differences in Incident Fatal, Nonfatal, and Total Coronary Heart Disease

Background: Blacks have higher coronary heart disease (CHD) mortality compared with whites. However, a previous study suggests that nonfatal CHD risk may be lower for black versus white men. Methods: We compared fatal and nonfatal CHD incidence and CHD case-fatality among blacks and whites in the Atherosclerosis Risk in Communities study (ARIC), the Cardiovascular Health Study (CHS), and the Reasons for Geographic and Racial Differences in Stroke study (REGARDS) by sex. Participants 45 to 64 years of age in ARIC (men=6479, women=8488) and REGARDS (men=5296, women=7822), and ≥65 years of age in CHS (men=1836, women=2790) and REGARDS (men=3381, women=4112), all without a history of CHD, were analyzed. Fatal and nonfatal CHD incidence was assessed from baseline (ARIC=1987–1989, CHS=1989–1990, REGARDS=2003–2007) through up to 11 years of follow-up. Results: Age-adjusted hazard ratios comparing black versus white men 45 to 64 years of age in ARIC and REGARDS were 2.09 (95% confidence interval, 1.42–3.06) and 2.11 (1.32–3.38), respectively, for fatal CHD, and 0.82 (0.64–1.05) and 0.94 (0.69–1.28), respectively, for nonfatal CHD. After adjustment for social determinants of health and cardiovascular risk factors, hazard ratios in ARIC and REGARDS were 1.19 (95% confidence interval, 0.74–1.92) and 1.09 (0.62–1.93), respectively, for fatal CHD, and 0.64 (0.47–0.86) and 0.67 (0.48–0.95), respectively, for nonfatal CHD. Similar patterns were present among men ≥65 years of age in CHS and REGARDS. Among women 45 to 64 years of age in ARIC and REGARDS, age-adjusted hazard ratios comparing blacks versus whites were 2.61 (95% confidence interval, 1.57–4.34) and 1.79 (1.06–3.03), respectively, for fatal CHD, and 1.47 (1.13–1.91) and 1.29 (0.91–1.83), respectively, for nonfatal CHD. After multivariable adjustment, hazard ratios in ARIC and REGARDS were 0.67 (95% confidence interval, 0.36–1.24) and 1.00 (0.54–1.85), respectively, for fatal CHD, and 0.70 (0.51–0.97) and 0.70 (0.46–1.06), respectively, for nonfatal CHD. Racial differences in CHD incidence were attenuated among older women. CHD case fatality was higher among black versus white men and women, and the difference remained similar after multivariable adjustment. Conclusions: After accounting for social determinants of health and risk factors, black men and women have similar risk for fatal CHD compared with white men and women, respectively. However, the risk for nonfatal CHD is consistently lower for black versus white men and women.