The Multiethnic Study of Atherosclerosis (MESA) Cardiovascular Risk in Hispanics

Michael H. Criqui MD, MPH

Distinguished Professor and Chief, Division of Preventive Medicine

Department of Family and Preventive Medicine

Distinguished Professor, Department of Medicine

UCSD School of Medicine

22nd Annual Southwestern Conference on Medicine

Tucson, AZ, April 5, 2013

Financial disclosure - none

Go AS et al. Heart Disease and Stroke Statistics--2013 Update.

Circulation 2013; 2013;127:e6-e245.

Franklin, B. A. et al. Circulation 2011;123:2274-2283

Risk factor framework and the progression of cardiovascular

disease, with types of prevention interventions

The Hispanic Paradox refers to the epidemiologic finding that Hispanic-

Americans, despite lower average socioeconomic status, tend to have

paradoxically better health outcomes than non-Hispanic white Americans

Abraido-Lanza et al. Am J Public Health 1999;89:1543-8.

Go AS et al. Heart Disease and Stroke Statistics--2013 Update.

Circulation 2013; 2013;127:e6-e245.

ATP-III Defined High LDL-C by Ethnicity, NHANESHyre et al. Ann Epidemiol 2007;17:548-55

Table 1. Age-Adjusted Prevalence of Individual Metabolic Abnormalities of the Metabolic Syndrome Among 8814 US Adults Aged ≥≥≥≥20 Years, National Health and Nutrition Examination

Survey III, 1988-1994*.

Ford, E. S. et al. JAMA 2002;287:356-359

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Table 2. Age-Adjusted Prevalence of 1 or More Abnormalities of the Metabolic Syndrome Among 8814 US Adults ≥≥≥≥20 Years, National Health and Nutrition Examination Survey III, 1988-

1994*.

Ford, E. S. et al. JAMA 2002;287:356-359

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Figure 2. Age-Adjusted Prevalence of the Metabolic Syndrome Among 8814 US Adults Aged at Least 20 Years, by Sex and Race or Ethnicity, National Health and Nutrition Examination

Survey III, 1988-1994 Data are presented as percentage (SE).

Ford, E. S. et al. JAMA 2002;287:356-359

Copyright restrictions may apply.

Metabolic Syndrome, MI, and Stroke in NHANES Ninomiya et al. Circulation 2004;109:42-6

Peripheral Arterial Disease in the San Diego

Population Study Criqui et al Circulation 2005;112:2703-7

Peripheral Arterial Disease in the San Diego

Population Study Criqui et al Circulation 2005;112:2703-7

Peripheral Arterial Disease in the San Diego

Population Study Criqui et al Circulation 2005;112:2703-7

Multi-Ethnic Study of Atherosclerosis (MESA)

• 10 year prospective study, 6 Field Centers – NHW, Hispanic, Afr-Amer, Chinese men and women

aged 45-84 at baseline

• Multiple risk factors assessed, including newer

factors (eg. inflammation, infection, genetics)

• Carotid ultrasound for plaque and IMT

• Coronary calcium by CT

• Aortic calcium by CT

• Endothelial function, brachial artery

• Ankle-brachial index (ABI)

• These and other measures are being evaluated in

the MESA

Inflammatory markers by ethnicity in the MESAVeeranna et al. Int J Cardiol. 2012 Jan 10. [Epub ahead of print]

Ethnicity, inflammatory markers, and CVD incidence in MESA Veeranna et al. Int J Cardiol. 2012 Jan 10. [Epub ahead of print]

Low Ankle-Brachial Index in MESA Allison et al JACC 2006;48: 1190-7.

Low Ankle-Brachial Index in MESA Allison et al JACC 2006;48: 1190-7.

Low Ankle-Brachial Index in MESA Allison et al JACC 2006;48: 1190-7

Low Ankle-Brachial Index in MESA Allison et al JACC 2006;48: 1190-7

Cardiovascular Event Incidence by ABI Category: the Multi-Ethnic Study of

Atherosclerosis (MESA)Criqui et al, JACC 2010;56:1506-12

ABI category remained significant after adjustment for standard CVD risk factors,

novel CVD risk factors, CAC, CIMT, and major ECG abnormalities

Cardiovascular Event Incidence by Continuous ABI , Stratified

by Ethnicity in the Multi-Ethnic Study of Atherosclerosis

(MESA)Criqui et al, JACC 2010;56:1506-12

Ethnicity Hazard Ratio

Non-Hispanic Whites 0.74

African-Americans 0.87

Hispanics 0.80

Chinese 0.83

i.e., the higher the ABI, the lower the risk of CVD events (ABIs < 1.40 excluded)

Measures of Incremental Value of the ABI

increase in the AUC (ROC), p= 0.022

IDI, p = 0.003NRI, p = 0.51 (NS)

Distribution of arm systolic blood pressure differences in MESA, right

minus leftAboyans et al. Atherosclerosis 2010;211:266-70

Subclavian stenosis (arm SBP diff ≥≥≥≥15 mm/Hg) prevalence in

MESA, by sex and ethnicityAboyans et al. Atherosclerosis 2010;211:266-70

Men Women

N % N %

Non-Hispanic White 58 4.6 75 5.6

African-American 53 6.3 85 8.3

Hispanic 11 1.5 17 2.2

Chinese 3 0.8 5 1.2

Total 125 3.9 182 5.1

Subclavian Stenosis in 2 population cohorts and 2

vascular lab cohorts Shadman et al JACC 2004;44: 618-23

Normal coronaries

with little or no

plaque build-up.

Mild calcification and

early plaque build-up.

Extensive calcification

and plaque build-up.

Heart Scans from 3 Individuals Classified

at Same CHD Risk According to FRS

50th percentile of CAC by age and ethnicity in MESA

Sirineni et al. Int J Cardiovasc Imaging 2008; 24:107–11

Detrano R et al. N Engl J

Med 2008;358:1336-1345

Detrano R et al. N Engl J Med 2008;358:1336-1345

Abdominal Aortic Calcium, with CT slice 5cm cephalad

to the aortic bifurcation

Distribution of sex and ethnicity by the presence of

CAC and AAC in MESA

CAC = 0 CAC > 0 AAC = 0 AAC > 0

N 833 1141 561 1413

Men 38.0 59.5 47.4 51.7

Women 62.0 40.5 52.6 48.3

NH White 33.7 44.7 29.2 44.3

African-Amer 14.1 12.4 12.3 13.5

Hispanic 25.1 17.7 27.6 18.1

Chinese 27.2 25.2 30.8 24.1

. Criqui et al. ATVB 2010;30:2289-96.

Correlates of AAC and CAC. Criqui et al. ATVB 2010;30:2289-96.

COX models for Hard CHD and Hard CVD for the Nine Categories of AAC and

CAC, adjusted for the GFRS and ethnicity Criqui et al, submitted

Test for interaction showed results were similar across ethnicities

Abdominal Aortic Diameter in MESA Laughlin et al. EJVEVS 2011;41:481-7

CVD Event Rates per 1000 person years by

Ethnicity in MESA, Average 5.3 Years of Follow-up

• 317 first CVD events: 226 CHD, 89 strokes, 9

“other” CVD deaths

Men Women

NHW 14.9 8.4

Afr-Amer 14.5 7.4

Hispanic 16.1 6.4

Chinese 10.2 3.7

Criqui et al. JACC 2010;1506-12.

Design and implementation of the Hispanic Community

Health Study/Study of Latinos Sorlie PC et al. Ann Epidemiol. 2010;20:629-41

Prevalence of major cardiovascular risk factors and

cardiovascular diseases among Hispanic/Latino individuals

of diverse backgrounds in the United States

JAMA 2012;308:1775-84

Daviglus ML, Talavera GA, Avilés-Santa ML, Allison M, Cai J,

Criqui MH, Gellman M, Giachello AL, Gouskova N,

Kaplan RC, LaVange L, Penedo F, Perreira K, Pirzada A,

Schneiderman N, Wassertheil-Smoller S, Sorlie PD,

Stamler J.

Conclusions

• Compared to non-Hispanic whites, Hispanics have higher levels of obesity,

diabetes, hypertension, dyslipidemia (but not elevated LDL), and the

metabolic syndrome.

• Subclinical atherosclerosis is paradoxically less severe in Hispanics vs. non-

Hispanic whites

• Hispanics in general have paradoxically better CVD outcomes than non-

Hispanic whites

• For clinical and public health purposes, the univariate rate for CVD in

Hispanics is the relevant metric. The multivariate rate is much lower since

it adjusts away the risk associated with higher levels of risk factors in

Hispanics

• Increasing obesity in the US and differential access to health care may

narrow the gap between Hispanic and non-Hispanic white CVD outcomes