Although race, ethnicity, and geographic ancestry have been associated with differences in disease prevalence, expression, and outcomes, the public and academic discourse surrounding the role of race/ethnicity in health and disease has been intense and complex. In the United States and many parts of the world, racial/ethnic differences have been used for social and political purposes to confer advantage to some and disadvantage to others based on presumed natural superiority or inferiority. As a result, a philosophic and policy goal of the late 20th century has been to eliminate use of inherent racial/ethnic differences for purposes of societal stratification and advantage. However, recent advances in genetics and pharmacogenetics have resulted in renewed discussion of biologic and genetic correlates of race and geographic ancestry, raising new questions about the nature and meaning of race in health care.1-8 Factors adding complexity to the analysis of the health impact of race/ethnicity are the high prevalence of racial misclassification and the admixture of populations typical of the United States. However, despite the recent genetic data, it remains true that African Americans and other non-European minorities have had societally imposed disadvantages in economics, education, and access to healthy environments, as well as faced barriers to adequate health care, all of which increase disease prevalence, morbidity, and mortality. Thus, discussions about cardiovascular health by racial and ethnic groups require the context that environmental factors in their broadest sense and some genetic factors are operative in determining health risk among different racial/ethnic groups. In this chapter, we accept that race/ethnicity/geographic descent includes clustering of some common genetic and epigenetic factors and also social, environmental, and lifestyle variables, which have a huge impact on cardiovascular health. A critical challenge for multidisciplinary researchers will be to define the relative contributions of each of these variables to cardiovascular health and disease and to discover how to use knowledge from biologic and social sciences to bring equity in cardiovascular health outcomes across racial/ethnic populations.
Cardiovascular disease (CVD) has been recognized as the dominant cause of death in the United States for at least 50 years, with heart disease ranking first and stroke third.9,10 Figure 104–1 shows the prevalence of CVD and the percentage of deaths attributable to CVD by major US ethnic groups. Although coronary heart disease (CHD) death rates in all major demographic groups have declined in the United States, the decline in CHD has not been uniform across racial/ethnic groups. For example, in African American men, it declined by 33.3% between 1979 and 1998 compared with 46.1% in white men. At the same time, CHD death rates decreased by 26.6% in African American women compared with 40.1% in white women. Analysis of annual rates of first heart attack, first cerebral infarction, and first cerebral hemorrhage by age, sex, and African American or white race demonstrates higher rates of all three entities in African Americans compared with whites10 (Figs. 104–2, 104–3, 104–4).