Fatal Coronary Heart Disease Higher Among Black vs White Adults in the US

Income may explain the racial differences in fatal in- and out-of-hospital coronary artery disease.

Death from coronary heart disease (CHD) was found to be approximately twice as high in Black vs White adults in the US in-hospital and at a 30% greater rate out-of-hospital, according to study findings published in The American Journal of Cardiology.

Researchers aimed to explore incidence rates of in- and out-of-hospital deaths among adults with and without CHD in the US, as well as the role of income on fatal CHD rates.

A community-based cohort study was conducted using data from the Atherosclerosis Risk in Communities (ARIC) study.

Participants were evaluated at baseline, including cardiovascular risk factors, medical history, and sociodemographic data, such as household income and years of education. Patients were re-evaluated every 3 years for 9 years, with follow-up evaluations from 2011 to 2013, 2016 to 2017, and 2018 to 2019.

Data on CHD events were collected from hospital discharges, state death certificates, and follow-up. CHD events were defined as a probable or definite acute myocardial infarction or a fatal CHD during follow-up.

Income plays a pronounced role in this disparity for both in- and out-of-hospital deaths, also suggesting a key role of healthcare access.

Income was stratified by less than $16,000; $16,000 to $25,000; $25,000 to $35,000; $35,000 to $50,000; and $50,000 or more.

Cardiovascular risk factors included total cholesterol, smoking status, prevalent diabetes, prevalent hypertension, and body mass index.

The analysis included 10,884 White participants (mean age, 54.2±5.7 years) and 4095 Black participants (mean age, 53.4±5.8 years). The total cohort included 57% women.

Researchers observed that the in-hospital incidence of fatal CHD for Black vs White participants was 2.2 vs 1.1 per 1000 person years, respectively, and the out-of-hospital incidence of fatal CHD was 1.3 vs 1.0 per 1000 person years, respectively.

The sex- and age-adjusted hazard ratio comparing incident fatal CHD in Black vs White participants out-of-hospital was 1.65 (95% CI, 1.32-2.07) and in-hospital was 2.37 (95% CI, 1.96-2.86).

In addition, income-controlled direct effects of race in Black vs White participants hazard ratios were 2.03 for fatal in-hospital CHD (95% CI, 1.61-2.55) and 1.33 for fatal out-of-hospital CHD (95% CI, 1.01-1.74).

The overall hazard ratio in Black vs White participants of fatal incident CHD in sex- and age-adjusted models was 2.02 (95% CI, 1.75-2.33), which reduced to 1.39 when income was included. Fatal CHD racial differences were not significant when both income and cardiovascular risk factors were included (hazard ratio, 1.01; 95% CI, 0.84-1.21).

Study limitations included patient segregation by site; inclusion of only baseline socioeconomic and cardiovascular risks factors; and not accounting for the role of racial differences in procedures and treatments.

“Black [patients] die from CHD at approximately twice the rate of White [patients], and the excess in mortality is seen irrespective of where these events occur, in or out of the hospital,” the study authors noted. They added, “Income plays a pronounced role in this disparity for both in- and out-of-hospital deaths, also suggesting a key role of healthcare access.”

Overall, the study authors suggested addressing the lack of health care coverage and diminished access to care for Black patients.

This article originally appeared on The Cardiology Advisor


Islek D, Alonso A, Rosamond W, et al. Racial differences in fatal out-of-hospital coronary heart disease and the role of income in the Atherosclerosis Risk in Communities Cohort Study (1987 to 2017). Am J Cardiol. 2023;194:102-110. doi:10.1016/j.amjcard.2023.01.042