Black patients have higher incident fatal coronary heart disease (CHD) rates than
do their White counterparts. Racial differences in out-of-hospital fatal CHD could
explain the excess risk in fatal CHD among Black patients. We examined racial disparities
in in- and out-of-hospital fatal CHD among participants with no history of CHD, and
whether socioeconomic status might play a role in this association. We used data from
the ARIC (Atherosclerosis Risk in Communities) study, including 4,095 Black and 10,884
White participants, followed between 1987 and 1989 until 2017. Race was self-reported.
We examined racial differences in in- and out-of-hospital fatal CHD with hierarchical
proportional hazard models. We then examined the role of income in these associations,
using Cox marginal structural models for a mediation analysis. The incidence of out-of-hospital
and in-hospital fatal CHD was 1.3 and 2.2 in Black participants, and 1.0 and 1.1 in
White participants, respectively, per 1,000 person-years. The gender- and age-adjusted
hazard ratios comparing out-of-hospital and in-hospital incident fatal CHD in Black
with that in White participants were 1.65 (1.32 to 2.07) and 2.37 (1.96 to 2.86),
respectively. The income-controlled direct effects of race in Black versus White participants
decreased to 1.33 (1.01 to 1.74) for fatal out-of-hospital and to 2.03 (1.61 to 2.55)
for fatal in-hospital CHD in Cox marginal structural models. In conclusion, higher
rates of fatal in-hospital CHD in Black participants than in their White counterparts
likely drive the overall racial differences in fatal CHD. Income largely explained
racial differences in both fatal out-of-hospital CHD and fatal in-hospital CHD.
KEYWORDS
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Article info
Publication history
Published online: March 11, 2023
Received in revised form:
January 16,
2023
Received:
October 4,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
The Atherosclerosis Risk in Communities (ARIC) study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, under contract numbers: HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, and HHSN268201700004I. Dr. Islek is funded by the American Heart Association (Dallas, Texas) predoctoral fellowship, award number: 19PRE34380062. Dr. Ali is partially supported by the Georgia Center for Diabetes Translation Research (Atlanta, Georgia) funded by the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, P30DK111024. Research reported in this publication was also supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, under award number K24HL148521.
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