Death from coronary heart disease (CHD) was found to be approximately twice as high in Black vs White hospitalized adults in the United States 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 United States, 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. The study 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. Patient income was stratified as less than $16,000, $16,000 to $25,000, $25,000 to $35,000, $35,000 to $50,000, and more than $50,000.

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Cardiovascular risk factors (total cholesterol, smoking status, prevalent diabetes, prevalent hypertension, and body mass index), medical history, and sociodemographic data, such as household income and years of education, were evaluated at baseline. 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 fatal CHD during follow-up.

The 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, hazard ratios for income-controlled direct effects of race in Black vs White participants 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 for fatal incident CHD in sex- and age-adjusted models was 2.02 (95% CI, 1.75-2.33), which decreased 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.


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

This article originally appeared on The Cardiology Advisor