Background Currently recognized risk factors for coronary arterydisease have been identified primarily from investigations ofwhite populations. In this investigation, we estimated mortalityrates for coronary disease and for any cause and identifiedrisk factors for death from coronary disease among whites andblacks.
Methods Data collected over a 30-year period in the CharlestonHeart Study were used to estimate mortality rates and quantifyassociations with risk factors assessed at the base-line examinationin 1960 and 1961 of 653 white men, 333 black men, 741 whitewomen, and 454 black women.
Results There were no significant racial differences in therate ratios for death from coronary disease; however, womenhad significantly lower death rates than men. Over the 30-yearperiod, the mortality rates for coronary disease per 1000 person-yearswere 5.2 for white men (95 percent confidence interval, 4.1to 6.3), 4.6 for black men (3.0 to 6.2), 2.1 for white women(1.6 to 2.6), and 3.2 for black women (2.3 to 4.0). Significant,or nearly significant, predictors of mortality due to coronarydisease were systolic blood pressure in all four groups; serumcholesterol level among white men, white women, and black women;and smoking among white men, white women, and black men. Althoughthe difference was not statistically significant, the risk ofdeath from coronary disease was consistently increased amongdiabetics in all four groups. A higher level of education waspredictive of lower rates of death due to coronary disease amongwhite men and black women. For all causes of death taken together,the rates for blacks were higher than the rates for whites.The presence of hypertension, a history of smoking, and a historyof diabetes were significant or nearly significant predictorsof mortality from any cause in all four groups.
Conclusions Although the rates of death from coronary diseasewere somewhat lower among black men than white men and higheramong black women than white women, the black:white mortalityrate ratios were not statistically significant, and the majorrisk factors for mortality from coronary disease were similarin blacks and whites in the 30-year follow-up of the CharlestonHeart Study.
There has been lingering concern in the public health communitythat there may be racial differences in risk factors for coronarydisease. The current recommendations for risk-factor modificationwere derived from numerous observational studies that followedthe pioneering cardiovascular cohort studies conducted in Framingham,Massachusetts1,2. Although the results of these studies weregenerally consistent in identifying risk factors for cardiovasculardiseases in racially or ethnically diverse populations, therewas a paucity of community-based investigations in black populations.
Early reports suggested that the risks of cardiovascular diseasesdiffered between blacks and whites: blacks were protected againstcoronary heart disease but had a much greater risk of stroke3,4.This paradox raised the question of why blacks did not havehigher rates of coronary disease than whites, given their excessof hypertension5,6. More than 10 years ago Gillum7 suggestedthat the myth of blacks' immunity to coronary disease was atbest a half-truth and at worst an obstacle to the understandingof coronary disease and to treatment for blacks. A similar concernled to the Charleston Heart Study8 and the Evans County HeartStudy6 in 1960. Although these studies evaluated blood pressure,cholesterol level, smoking status, and other risk factors forcoronary disease, they postulated that there were racial andsocial bases for the risk factors for coronary disease. Earlierfindings9 indicated that there were nonsignificant differencesin the rates of death from coronary disease between black menand white men in Charleston County, South Carolina. However,vital statistics and studies from Evans County, Georgia, indicatedthat the mortality rates for coronary disease were higher amongblacks at younger ages but lower at advanced ages, resultingin lower rates of mortality due to coronary disease with prolongedperiods of follow-up and advancing age.
The purpose of this study was to compare the 30-year coronarymortality experience of blacks and whites in the CharlestonHeart Study and to examine the predictors of coronary diseasemortality in this cohort. Since the certification of causesof death may be less reliable for older people, we also examinedthe rates and predictors of death from any cause.
Methods
The Charleston Heart Study, a population-based prospective cohortstudy begun in 1960, contained a random sample of blacks andwhites 35 years of age and older. The study cohort consistedof 2181 subjects and represented an overall response rate of84 percent to the population-based sampling plan. Details ofthe sampling procedure and other procedures have been publishedpreviously8,9. Except for Table 1, all the tables in this papershow data on participants 35 to 74 years of age.
Table 1. Base-Line Characteristics and Vital Status of the Charleston Heart Study Cohort.
The methods of measurement of base-line (1960 and 1961) levelsof most variables have been reported previously8. Variablesmeasured at base line included the first blood-pressure measurementtaken in the seated position, serum cholesterol level determinedby the direct-cholesterol method of Zlatkis et al.,10 body-massindex (the weight in kilograms divided by the square of theheight in meters), years of education, cigarette-smoking status(dichotomized as current vs. never or past), and diabetes statusascertained on the basis of medical history. The number of yearsof education was used as a surrogate for socioeconomic status.
The causes of death were derived from nosologists' coding ofthe underlying causes of death. Death certificates for the periodfrom 1960 through 1967 (which used codes from the seventh editionof the International Classification of Diseases [ICD]) wererecoded according to the eighth edition of the ICD. The ICDcodes used for coronary disease were 410 through 413 for theperiod from 1960 through 1978 and 410 through 414 (ICD, ninthedition) for the period from 1979 through 1990.
The prevalence of coronary heart disease at base line was about3 percent among black men, black women, and white women and8 percent among white men. Persons who were lost to follow-upwere not excluded from the analyses, but the data on these subjectswere censored at the time of the last contact. Mortality ratesfor coronary disease or for any cause were calculated with theSAS program Personyrs11 and expressed as age-adjusted ratesper 1000 person-years of observation. Survival curves for coronaryheart disease were plotted according to race and sex for the30-year period by the Kaplan-Meier method12,13. The overallsurvival curves were compared for black men and white men andfor black women and white women with the log-rank test. Theblack:white mortality ratios were derived from Cox proportional-hazardsregression analyses, first by including only age and race inthe model and then by including age, race, and the cardiovascularrisk factors. The proportional-hazards model was used to identifypredictors of survival with respect to death from coronary diseaseand all causes14. The putative risk factors in the regressionanalyses were age, systolic blood pressure, cholesterol level,body-mass index, smoking status, and diabetes status. The assumptions(of proportional hazard over time) made in the proportional-hazardsregression analyses were met for race in men and women accordingto goodness-of-fit tests and according to visual comparisonin men. The relative risk for continuous variables was calculatedon the basis of an increase of 1 SD in the values. Participantswith coronary heart disease at base line were included; theexclusion of such patients at base line made essentially nodifference in the estimates of relative risk. All P values werecalculated from two-tailed tests.
Results
Characteristics at Base Line and Vital Status in 1990
The base-line characteristics (1960 and 1961) and the vitalstatus (1960 through 1990) of the study participants are shownin Table 1. By the end of 1990, the vital status of 98 percentof the white participants and 99 percent of the black participantswas known.
Comparison of Mortality between Blacks and Whites
Table 2 shows the age-adjusted mortality rates for coronaryheart disease and for any cause of death in the four groupsdefined by race and sex. After 30 years of observation, theblack:white coronary mortality rate ratio was 0.9 (P = 0.33)for men and 1.2 (P = 0.20) for women (Table 3).
Table 3. Black:White Mortality Rate Ratios for Coronary Heart Disease and All Causes of Death, Adjusted for Age and for Other Risk Factors.
When age-specific mortality rates were examined for the 30-yearobservation period (data not shown), none of the white womenand black women were found to have died of coronary diseaseat 35 to 44 years of age. Not until the age of 65 was therea significant increase in the mortality rate among the women.The mortality rate was higher among black men at the ages of35 to 44 and 55 to 64 than among white men. However, there wereno statistically significant differences in age-specific coronarymortality rates between either the two groups of men or thetwo groups of women.
For all causes of death (Table 2), the age-adjusted rate wassignificantly higher for black women than white women. The ratefor black men was not significantly higher than the rate forwhite men. The excess deaths among black women were attributedto diabetes and to causes listed as ill-defined or unspecified.The excess mortality from any cause among black men was dueto stroke and ill-defined or unspecified causes. When the ratesof mortality from any cause were examined in 10-year age-specificstrata, black men had the highest rates, followed by white men,black women, and white women.
The black:white age-adjusted mortality rate ratios for coronaryheart disease (0.9 in men and 1.2 in women), when also adjustedfor cardiovascular disease risk factors, decreased to 0.7 inmen and 0.9 in women (Table 3). The black:white ratio for mortalityfrom any cause among men was 1.2 when adjusted only for ageand 1.0 after adjustment for all risk factors; the values forwomen were 1.5 and 1.1, respectively.
Kaplan-Meier survival analysis indicated that white men hadthe highest probability of death from coronary disease and whitewomen the lowest over the 30-year observation period (Figure 1).Black men and women had similar survival curves for thefirst 17 years, after which there was a divergence, with thecurve for black men more closely paralleling the curve for whitemen but with a greater probability of survival. There were nostatistically significant differences in the overall survivalcurves between black men and white men (P = 0.27 by the log-ranktest) or between black women and white women (P = 0.17).
Figure 1. Kaplan-Meier Estimates of the Probability of Death from Coronary Heart Disease in the Charleston Heart Study, 1960 through 1990.
The log-rank test revealed no significant differences in survival between black men and white men (P = 0.27) or black women and white women (P = 0.17).
Predictors of Coronary Mortality
Systolic blood pressure, whether adjusted for age or age andother risk factors, was a significant predictor of coronarymortality across all four groups (Table 4). The effect of body-massindex on the relative risk was not significant in any group,and a higher level of education was a significant and protectivefactor (relative risk, 0.79) only for white men. Additionalsex-specific analyses indicated no significant interactionsof race with any risk factors (data not shown). The relativerisk of coronary disease in the presence of elevated cholesterollevels (a change of 48.4 mg per deciliter) and after adjustmentfor age was highest for white women (1.34), black women (1.32),and white men (1.13); each of these values was significant ornearly significant.
Table 4. Relative Risk of Death from Coronary Heart Disease, 1960 through 1990, after Adjustment for Age and for Other Risk Factors.
A history of cigarette smoking in 1960 was associated with arelative risk of 3.12 in black men, 1.94 in white women, and1.60 in white men. Smoking was not a predictor of death fromcoronary heart disease in black women. A history of diabetesadjusted for all the risk factors was associated with a nonsignificantelevation in the risk of coronary disease in all four groups.
Predictors of Death from Any Cause
The relative risk of death from any cause in the presence ofelevated levels of systolic blood pressure or serum cholesterollevels, and a history of cigarette smoking or diabetes, wassignificant or nearly significant in all four groups. The exceptionswere for serum cholesterol level among men, diabetes statusamong white men, and smoking status among black women (Table 5).Body-mass index was not a significant predictor of deathin any group. A higher level of education was a significant(protective) predictor among white men (relative risk, 0.85)and black women (relative risk, 0.79).
Table 5. Relative Risk of Death from Any Cause, 1960 through 1990, after Adjustment for Age and for Other Risk Factors.
Discussion
This 30-year observational study of blacks and whites from asoutheastern area of the United States showed that there wereno statistically significant differences between blacks andwhites in coronary mortality rates, although there were significantdifferences in coronary mortality rate ratios between men andwomen. Black women fared better than black men, and white womenbetter than white men. There were no significant differencesin survival patterns between blacks and whites over the 30-yearperiod.
The rate of mortality due to coronary disease among black menwas slightly lower than the rate among white men (4.6 vs. 5.2per 1000 person-years). This difference, however, was not statisticallysignificant. The mortality ratio for blacks as compared withwhites was slightly less than 1 whether we considered the age-adjustedratio of 0.9 or the ratio of 0.7 adjusted for age and otherrisk factors (Table 3). The upper limit of the ratio after adjustmentfor age and other risk factors was only slightly greater than1. The rate among black men may be understated because moreblacks than whites died outside the hospital or because therewas insufficient information to determine the cause of deathfor more blacks. For example, during the period from 1960 through1990, 30 of 36 deaths whose causes were listed as ill-definedor unspecified occurred in blacks. However, the 20-year black:whitecoronary disease mortality ratio among men was 0.9 in EvansCounty,15 as compared with the 30-year ratio of 0.9 in the CharlestonHeart Study. These strikingly similar, independent findingsfrom two Southern community-based studies suggest that blackmen may be relatively protected from coronary disease.
The findings of lower rates of mortality from coronary heartdisease among black men in these two closed-cohort studies arenot discordant with national statistics, which indicate consistentlyhigher rates for white men than for black men for the periodfrom 1968 through 198616. Gillum17 examined black:white mortalityratios for coronary disease in the United States in 1986 todetermine age-specific coronary mortality. The ratio was 1.6for people 35 to 44 years of age, 1.2 for those 45 to 54 yearsof age, 1.0 for those 55 to 64 years of age, 0.9 for those 65to 74 years of age, 0.8 for those 75 to 84 years of age, and0.9 for those 85 years of age, reflecting a mortality crossoveramong older people.
On the basis of risk-factor profiles, it would seem reasonablefor blacks to have rates of mortality from coronary diseasethat equaled or exceeded those for whites. Although the totalcholesterol levels in blacks in our study were lower than thosein whites (Table 1), blood pressures were markedly higher inblacks than whites. The proportion of smokers was similar amongblack men and white men; only 27 percent of black women, ascompared with 40 percent of white women, reported smoking cigarettes.On average, blacks had lower levels of education than whites.The prevalence of diabetes among blacks may be understated because,in 1960, blacks in the study area had less access to medicalcare than whites, and thus we were unable to determine whetherthey had a history of diabetes. Black men and white men hadessentially the same distribution of values for body-mass index.The mean body-mass index of black women was significantly higherthan that of white women (27.3 vs. 24.4).
For all causes of death, the rate was highest among black men(18.9 per 1000 person-years), but it was not significantly higherthan the rate (15.3 per 1000 person-years) among white men.The rate of death from any cause was significantly and substantiallylower among women than among men, but the rate among black womenwas significantly higher than the rate among white women (12.7vs. 7.3 per 1000 person-years).
The finding of elevated blood pressure, elevated serum cholesterollevel, and a history of cigarette smoking as risk factors forcoronary disease in white men and white women was expected.The lower level of association of diabetes and death from coronaryheart disease in white men may be explained by an increasedcontrol of diabetes. The finding of a similar spectrum of riskfactors among blacks and whites is important because it is derivedfrom 30 years of observation of a closed cohort. After a 20-yearstudy of black men in Evans County, Georgia, Tyroler et al.15reported that systolic blood pressure and cigarette smokingwere significant predictors of coronary mortality. Our studyconfirms these earlier findings, but presents evidence thatthere are similarities between blacks and whites in other riskfactors, such as cholesterol level and diabetes.
It is interesting that single assessments of blood pressure,serum cholesterol level, smoking status, and diabetes statusmade 30 years ago are predictors of mortality, even though inthe past decade there has been considerable emphasis on modifyingthese risk factors.
A lower level of education was a significant predictor of coronarydisease and mortality from any cause only among white men andblack women. The absence of such an effect among black men andwhite women needs additional investigation.
Our data suggest that the major coronary heart disease riskfactors predict mortality among blacks as well as whites. Ottenet al.18 have shown in a national probability sample that smoking,systolic blood pressure, cholesterol level, body-mass index,and diabetes explain some of the excess mortality from any causeamong blacks. They also reported that 38 percent of the excessmortality among blacks, as compared with whites, can be explainedby family income. As Ragland and Brand19 have suggested, withthe use of a long follow-up period, it can be inferred thatthe predictive variables are robust. Our findings are consistentwith others inferring that the standard, major risk factorsfor coronary heart disease are predictive for both blacks andwhites. However, the risk of coronary disease may vary betweenblacks and whites. In the two cohort studies of community-basedsamples in the southeastern United States, the risk appearedsomewhat higher for white men than black men and for black womenthan white women at comparable levels of the standard cardiovascularrisk factors. This suggests that other determinants of coronarydisease, such as high-density lipoprotein cholesterol level20and fibrinolytic activity, reported as differentially distributedacross these populations, may have resulted in different absolutelevels of coronary heart disease. The failure to identify a"significant" level of risk for risk factors may be due to alack of statistical power to detect an effect or to the truelack of an association between risk factor and coronary heartdisease mortality. It is obvious that there is not a lineareffect between every variable and mortality. The cholesterollevel21 and the body-mass index may require quadratic or cubicterms specific for race and sex to explain their relation withmortality properly.
Other potentially biasing factors, such as errors in death-certificatediagnoses and lack of response to the initial request for participation,have to be considered. The lack of complete comparability betweenthe eighth and ninth editions of the ICD codes for coronarydisease could influence the differences in rates between blacksand whites. Repeated contacts by the investigators with participantsduring the observation period may have also had an unintendedinterventional effect. Larger-scale studies including blacksmust be advocated to overcome the limitations of past or ongoingstudies. The findings regarding cardiovascular risk factorsin blacks and whites are based on limited numbers in studiescarried out in one region of the United States (i.e., the Southeast),and the results therefore are not necessarily generalizableto the whole country. However, the available cohort data indicatethat, while we await the results of additional observationalstudies and clinical trials, we should pay equal attention tocontrolling the standard major risk factors in blacks and inwhites.
Supported by a grant (R01 HL31397) from the National Heart,Lung, and Blood Institute.
We are indebted to the late Dr. Edwin Boyle, Jr., founder ofthe Charleston Heart Study, for his contributions to the implementationof this study.
Source Information
From the Charleston Heart Study, Medical University of South Carolina, Charleston (J.E.K., S.E.S., R.G.K., D.T.L., P.C.G.), and the Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill (H.A.T.).
Address reprint requests to Dr. Keil at the Charleston Heart Study, Rm. 908 Harborview Office Towers, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425-2239.
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85 years of age, reflecting a mortality crossover among older people. 
