Insights into the pathophysiology of atherosclerosis and prognosis of black Americans with acute coronary syndromes

Background: Disparities in prognosis for black and white patients with coronary heart disease have been widely reported. For several reasons it is unclear to what extent biologic factors contribute to these differences. Methods: The current medical literature regarding the pathophysiologic characteristics of cardiovascular disease is reviewed with emphasis on how racially mediated biologic differences may affect the manifestation, treatment, and prognosis of patients with coronary heart disease, particularly patients with acute coronary syndromes. Results: Black patients with coronary heart disease have a higher prevalence of ischemic heart disease risk factors, including hypertension, left ventricular hypertrophy, diabetes, and tobacco use. Other factors related to atherosclerosis, vascular reactivity, and thrombolysis that quantitatively and functionally differ among racial groups are identified. Prospective, randomized trials comparing outcomes among patients with acute coronary syndromes have included only a fraction of the available black population, although they reveal a similar short-term mortality rate for black and white patients. Several factors, including enhanced fibrinolysis among black patients with acute myocardial infarction, may in part counterbalance better understood and more prevalent comorbidities to equalize short-term (30-day) survival. All-cause, long-term (1-year) mortality appears worse for black patients compared with white patients with similar cardiovascular risk profiles. Conclusion: As racially mediated biologic differences between black and white patients become better understood, targeted interventions to prevent coronary heart disease and treat acute coronary syndromes in black patients can be developed.