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Observational Study
. 2022 Mar 1;7(3):259-267.
doi: 10.1001/jamacardio.2021.5340.

Differences in Cardiovascular Risk, Coronary Artery Disease, and Cardiac Events Between Black and White Individuals Enrolled in the PROMISE Trial

Lili Zhang  1   2 , Devvora Olalere  1 , Thomas Mayrhofer  1   3 , Daniel O Bittner  1   4 , Hamed Emami  1   5 , Nina M Meyersohn  1 , Stefan B Puchner  1   6 , Aiden Abidov  7 , Jamaluddin Moloo  8 , Rowena J Dolor  9 , Daniel B Mark  9 , Maros Ferencik  1   10 , Udo Hoffmann  1 , Pamela S Douglas  9 , Michael T Lu  1
Affiliations
Observational Study

Differences in Cardiovascular Risk, Coronary Artery Disease, and Cardiac Events Between Black and White Individuals Enrolled in the PROMISE Trial

Lili Zhang et al. JAMA Cardiol. .

Abstract

Importance: Race and ethnicity have been studied as risk factors in cardiovascular disease. How risk factors, epicardial coronary artery disease, and cardiac events differ between Black and White individuals undergoing noninvasive testing for coronary artery disease is not known.

Objective: To assess differences in cardiovascular risk burden, coronary plaque, and major adverse cardiac events between Black and White individuals assigned to receive coronary computed tomography angiography (CCTA) or functional testing for stable chest pain.

Design, setting, and participants: A nested observational cohort study within the PROMISE trial was conducted at 193 outpatient sites in North America. A total of 1071 non-Hispanic Black (hereafter Black) and 7693 non-Hispanic White (hereafter White) participants with stable chest pain undergoing noninvasive cardiovascular testing were included. This analysis was conducted from February 13, 2015, to November 2, 2021.

Main outcomes and measures: The primary end point was the composite of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 24.4 months.

Results: Among 1071 Black individuals (12.2%) (women, 646 [60.3%]; mean [SD] age, 59 [8] years) and 7693 White individuals (87.8%) (women, 4029 [52.4%]; mean [SD] age, 61.1 [8.4] years), Black participants had a higher cardiovascular risk burden (more hypertension and diabetes), yet there was a similarly low major adverse cardiovascular events rate over a median 2-year follow-up (32 [3.0%] vs 243 [3.2%]; P = .84). Sensitivity analyses restricted to the 79.8% (6993 of 8764) individuals with a normal or mildly abnormal noninvasive testing result and the 54.3% (4559 of 8396) not receiving statin therapy yielded similar findings. In comparison of Black and White individuals in the CCTA group (n = 3323), significant coronary stenosis (hazard ratio [HR], 7.21; 95% CI, 1.94-26.76 vs HR, 4.30; 95% CI, 2.62-7.04) and high-risk plaque (HR, 3.47; 95% CI, 1.00-12.06 vs HR, 2.21; 95% CI, 1.37-3.57) were associated with major adverse cardiovascular events in both Black and White patients. However, with respect to epicardial coronary artery disease burden, Black individuals had a less-prevalent coronary artery calcium score greater than 0 (45.1% vs 63.2%; P < .001), coronary stenosis greater than or equal to 50% (32 [8.7%] vs 430 [14.6%]; P = .001), and high-risk plaque (139 [37.6%] vs 1547 [52.4%]; P < .001).

Conclusions and relevance: The findings of this study suggest that, despite a greater cardiovascular risk burden in Black persons, rates of coronary artery calcium, stenosis, and high-risk plaque observed via CCTA were lower in Black persons than White persons. This result suggests differences in cardiovascular risk burden and coronary plaque in Black and White individuals with stable chest pain.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Abidov reported receiving grants from Astellas Pharma, Boehringer Ingelheim, and Kiniksa outside the submitted work. Dr Moloo reported other from University of Colorado Clinical trial support during the conduct of the study. Dr Mark reported receiving grants from the National Heart, Lung, and Blood Institute and National Institutes of Health during the conduct of the study and grants from HeartFlow, Merck, and Mayo Clinic outside the submitted work. Dr Ferencik reported receiving grants from American Heart Association during the conduct of the study; grants from the National Institutes of Health and consulting fees from Biograph Inc outside the submitted work. Dr Hoffmann reported receiving consulting fees from Duke University and Recor Medical and grants from KOWA, Astra Zeneca, Medimmune, and HeartFlow on behalf of Massachusetts General Hospital outside the submitted work. Dr Douglas reported receiving grants from HeartFlow outside the submitted work. Dr Lu reported receiving grants from AstraZeneca/MedImmune and Kowa, and consulting fees from PQBypass outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cumulative Major Adverse Cardiac Events in Black and White Individuals
Figure 2.
Figure 2.. Associations Between Coronary Computed Tomography Angiography Features and Major Adverse Cardiac Events for Black and White Individuals
Multivariable Cox proportional hazard models adjusting for Framingham risk score. There were no statistically significant differences between Black and White persons. The size of each square is proportional to the percent weight that each racial group contributed to the overall association. CAC indicates coronary artery calcium; HR, hazard ratio.
See this image and copyright information in PMC

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