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CME / ABIM MOC / CE

Does High Cardiovascular Burden Always Equate to High Event Rates?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 2/11/2022
  • Valid for credit through: 2/11/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, emergency medicine clinicians, family medicine/primary care clinicians, internists, nurses, and other members of the health care team who treat and manage patients with high cardiovascular disease burden.

The goal of this activity is to describe differences in cardiovascular disease risk burden, coronary plaque, and major adverse cardiac events between non-Hispanic Black and non-Hispanic White individuals assigned to receive coronary computed tomography angiography or functional testing for stable chest pain, based on a nested observational cohort study within the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial.

Upon completion of this activity, participants will:

  • Assess the differences in cardiovascular disease risk burden, coronary plaque, and major adverse cardiac events between Blacks and Whites assigned to receive coronary computed tomography angiography or functional testing for stable chest pain, based on a nested observational cohort study within the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial
  • Evaluate the clinical and public health implications of differences in cardiovascular disease risk burden, coronary plaque, and major adverse cardiac events between Blacks and Whites assigned to receive coronary computed tomography angiography or functional testing for stable chest pain, based on a nested observational cohort study within the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Own stock, stock options, or bonds from the following ineligible company(ies): AbbVie (former)

Editor/CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Does High Cardiovascular Burden Always Equate to High Event Rates?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/11/2022

Valid for credit through: 2/11/2023

processing....

Clinical Context

Higher incidence of long-term coronary artery disease (CAD) complications in Blacks than in Whites may result from higher burden of cardiovascular disease (CVD) risk factors and differences in socioeconomic and health care delivery factors. Coronary computed tomography angiography (CCTA) is a noninvasive imaging test that can directly visualize coronary plaque, the extent of which estimates the probability of major adverse cardiac events (MACE).

Study Synopsis and Perspective

Black adults with chest pain have a higher burden of CVD risk factors compared with White adults, but they have a similarly low incidence of MACE over the course of 2 years, new data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial suggest.

Black adults tend to have a higher incidence of long-term CAD morbidity and mortality compared with White adults--differences that may be a result of a higher burden of CVD risk factors as well as disparities in socioeconomic status and access to healthcare.

Yet how CVD risk factors, epicardial CAD, and cardiac events differ between Black and White adults undergoing noninvasive testing for CAD is unclear.

To investigate, researchers did a post hoc analysis of 1071 Black adults (mean age, 59 years; 60% women) and 7693 non-Hispanic White adults (mean age, 61 years; 52% women) with stable chest pain who underwent CCTA for suspected CAD as part of the previously reported PROMISE trial.

The study, by Lili Zhang, MD, from the Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, and colleagues, was published online December 22 in JAMA Cardiology.

Black adults had a higher CV risk burden than White adults, including significantly higher body mass index (32.3 vs 30.4 kg/m2P<.001), more hypertension (82.6% vs 62.6%; P<.001), diabetes (32.2% vs 18.4%; P<.001), CAD risk equivalent (36.2% vs 22.4%; P<.001), metabolic syndrome (43.5% vs 36.4%; P<.001), and a sedentary lifestyle (58.4% vs 47.4; P<.001).

Overall, the average number of reported CV risk factors per patient was significantly higher in Black individuals compared with White patients (2.47 vs 2.35; P<.001).

Yet despite the significantly higher CV risk burden, Black and White persons had a "similarly low" rate of MACE during a median follow-up of 24.4 months (3.0% vs 3.2%; P=.84), Dr Zhang and colleagues report.

Sensitivity analyses restricted to the 79.8% of participants with a normal or mildly abnormal noninvasive CCTA result and the 54.3% not receiving statin therapy yielded similar findings.

Significant coronary stenosis and high-risk plaque were associated with MACE in both Black and White patients.

However, with respect to epicardial CAD burden, Black patients had a less-prevalent coronary artery calcium score higher than 0 (45.1% vs 63.2%; P<.001), coronary stenosis at least 50% (8.7% vs 14.6%; P=.001), and high-risk plaque (37.6% vs 52.4%; P<.001).

The finding that Black individuals had more CV risk factors yet less coronary plaque on CCTA and similar MACE at 2 years "underscores the limits of our understanding of the relationship between risk factors and plaque in Black and White persons," write Dr Zhang and colleagues.

They caution that although the PROMISE trial included a diverse pool of patients with suspected CAD, it may not reflect the broader population in whom CAD is not suspected.

Also, the number of Black participants included was modest and follow-up was limited to 24 months. Therefore, the results should be interpreted in the context of 2-year MACE and may not capture differences that would emerge over the course of 10 years, the study team says.

Finally, they say the study may be underpowered to detect the differences in MACE between Black and White individuals because of the low rate of MACE.

The PROMISE study was funded by National Heart, Lung, and Blood Institute.

JAMA Cardiol. Published online December 22, 2021.[1]

Study Highlights

  • This nested observational cohort study within the PROMISE trial took place at 193 outpatient sites in North America.
  • Participants were 1071 Blacks (60.3% women; mean age, 59±8 years) and 7693 Whites (52.4% women; mean age, 61.1±8.4 years) with stable chest pain undergoing noninvasive cardiovascular testing.
  • Data were analyzed from February 13, 2015, to November 2, 2021.
  • The primary end point was the composite of death, myocardial infarction, or hospitalization for unstable angina during a median follow-up of 24.4 months.
  • Blacks had higher cardiovascular risk burden than Whites, including significantly higher body mass index (32.3 vs 30.4 kg/m2; P<.001), more hypertension (82.6% vs 62.6%; P<.001), diabetes (32.2% vs 18.4%; P<.001), CAD risk equivalent (36.2% vs 22.4%; P<.001), metabolic syndrome (43.5% vs 36.4%; P<.001), and sedentary lifestyle (58.4% vs 47.5%; P<.001).
  • Blacks had a significantly higher average number of reported CV risk factors per patient than Whites (2.47 vs 2.35; P<.001), but a similarly low rate of MACE (3.0% vs 3.2%; P=.84).
  • Findings were similar in sensitivity analyses restricted to the 79.8% of individuals with normal or mildly abnormal noninvasive testing and the 54.3% of those not treated with statins.
  • In the CCTA group (n=3323), factors associated with MACE in both Blacks and Whites were significant coronary stenosis (hazard ratio [HR], 7.21 [95% confidence interval (CI), 1.94-26.76] vs 4.30 [95% CI, 2.62-7.04]) and high-risk plaque (HR, 3.47 [95% CI, 1.00-12.06] vs 2.21 [95% CI, 1.37-3.57]).
  • However, regarding epicardial CAD burden, Blacks had lower prevalence of coronary artery calcium score higher than 0 (45.1% vs 63.2%; P<.001), coronary stenosis at least 50% (8.7% vs 14.6%; P=.001), and high-risk plaque (37.6% vs 52.4%; P<.001).
  • The investigators concluded that despite a greater self-identified cardiovascular risk burden in Blacks, rates of coronary artery calcium, stenosis, and high-risk plaque seen on CCTA were lower in Blacks than Whites, suggesting differences in cardiovascular risk burden and coronary plaque in Blacks and Whites with stable chest pain.
  • However, both groups had similarly low rate of MACE over the course of a 2-year follow-up, and Blacks had lower rates of epicardial CAD.
  • Most associations between CCTA features and MACE were similar between Blacks and Whites.
  • 2021 American College of Cardiology/American Heart Association guidelines for chest pain evaluation and diagnosis now provide a class 1 recommendation for CCTA to assess stable chest pain in patients at intermediate to high risk without known CAD.
  • CCTA may therefore be used with increasing frequency for both Black and White patients, making exploration of population differences more relevant to clinical care decisions.
  • Reasons for lower prevalence and extent of coronary artery calcium in Blacks than in Whites, even after adjusting for CAD risk factors, are unexplained, but genetic factors may play a role.
  • Although Blacks were less likely than Whites to have coronary plaque, they were more likely to have exclusively noncalcified plaque, which has important implications for the use of calcium-scoring computed tomography vs CCTA.
  • Study limitations include possible lack of generalizability to the broader population in whom CAD is not suspected, modest number of Black participants, and follow-up limited to a median of 24.4 months, which may not capture differences that would emerge over the course of 10 years.
  • In addition, the study may be underpowered to detect differences in MACE between Blacks and Whites because of the low rate of MACE, the analysis did not include prevention and lifestyle, and CCTA allows for assessment of epicardial CAD but not of microvascular disease, which could potentially explain the similar risk for MACE despite the lower burden of epicardial CAD in Blacks.

Clinical Implications

  • Despite a greater self-identified cardiovascular risk burden in Blacks, rates of coronary artery calcium, stenosis, and high-risk plaque seen on CCTA were lower in Blacks than Whites, suggesting differences in cardiovascular risk burden and coronary plaque in Blacks and Whites with stable chest pain.
  • However, both groups had similarly low rate of MACE during 2-year follow-up, and Blacks had lower rates of epicardial CAD.
  • Implications for the Health Care Team: CCTA may be used with increasing frequency for both Black and White patients, making exploration of population differences more relevant to clinical care decisions.

 

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