Discussion

250 Presentation RESEARCH IN CORONARY HEART DISEASE IN BLACKS: ISSUES AND CHALLENGES CHARLES K. FRANCIS, MD Columbia University College of Physicians and Surgeons Abstract: Research on coronary heart disease (CHD) has contributed to the decline in cardiovascular disease morbidity and mortality during the past three decades. However, life expectancy and rates of illness and death from CHD have not improved for blacL· as for whites. Blacks have not experienced the full benefit of research advancements for a variety of reasons, including insufficient scientific data, lack of research focused on minority populations, and limited access to health care resources and technology. In order to address these disparities in prevention, diagnosis, treatment, and outcomes of CHD in Mach, the National Heart Lung, and Blood Institute convened a Working Croup on Research in Coronary Heart Disease in BlacL·. In its deliberations, the working group identified 10 priority research areas, which are treatment, epidemiology (data collection and analysis), evaluation of chest pain and diagnosis of CHD, prevention and behavior, risk factors, genetics, vascular biology, left ventricular hypertrophy, coronary microvasculature, and sudden cardiac death. Key words: Coronary heart disease, blach, epidemiology, risk factors, vascular biology, left ventricular hypertrophy, coronary microvasculature , sudden cardiac death, treatment Research on coronary heart disease (CHD) has contributed to the decline in cardiovascular disease morbidity and mortality that has occurred during the past three decades in the United States. However, life expectancy and rates of illness and death from CHD have not improved as much for blacks as for This article previously appeared as the Executrix Summary section of the Report of the Working Group on Research in Coronary Heart Disease in Blacks, published by the National Heart, Lung, and Blood Institute of the National Institutes of Health, March 1994. Journal of Health Care for the Poor and Underserved · Vol. 8, No. 3 · 1997 Francis 251 whites. Blacks have not experienced the full benefit of research advancements for a variety of reasons, including insufficient scientific data, lack of research focused on minority populations, and limited access to health care resources and technology. Consistent and universally accepted racial and ethnic categories have not been established, and definitions may vary according to the social and scientific context. The limited database currently available leaves a number of paradoxes unresolved. Controversy remains, in particular, regarding both chest pain and sudden death. Available data indicate that the probability of dying from CHD is greater in black Americans than in white Americans and that there is a higher prevalence of smoking, hypertension, diabetes, obesity, and left ventricular hypertrophy (LVH) in blacks. Blacks are also less likely to receive coronary angiography or coronary revascularization. In order to address these and other disparities in prevention, diagnosis, treatment, and outcomes of CHD in blacks, the National Heart, Lung, and Blood Institute (NHLBI) convened a Working Group on Research in Coronary Heart Disease in Blacks. This working group assessed the state of the science and identified research opportunities in four main areas of CHD in blacks: pathogenesis and pathophysiological mechanisms, clinical expression, diagnosis , and treatment; disease patterns and risk factors; and behavioral variables and strategies for education and prevention. In its deliberations, the working group identified 10 priority research areas, which are, in order of research priority: • Treatment • Epidemiology (data collection and analysis) • Evaluation of chest pain and diagnosis of CHD • Prevention and behavior • Risk factors • Genetics • Vascular biology • Left ventricular hypertrophy • Coronary microvasculature • Sudden cardiac death Although most studies show that there is little difference in the nature of the atherosclerotic process leading to CHD in blacks, it has become evident that there are important differences in the social and economic context in which CHD develops in blacks. It is difficult to determine whether phenotypic characteristics common in blacks, such as high blood pressure and LVH, play a primary role in the pathogenesis of CHD in blacks or are merely markers for more fundamental differences in mechanisms of disease. It is not clear whether differences in the biology of CHD or in the clinical expression of common pathogenetic processes account for reported racial differences. Differences in access to cardiovascular care, the impact of risk factors, or variations in clinical therapeutic responsiveness may be as responsible for the well-documented 252...