Current issues of ACP Journal Club are published in Annals of Internal Medicine


Race and gender in coronary heart disease

ACP J Club. 1993 Nov-Dec;119:92. doi:10.7326/ACPJC-1993-119-3-092

Source Citation

Keil JE, Sutherland SE, Knapp RG, et al. Mortality rates and risk factors for coronary disease in black as compared with white men and women. N Engl J Med. 1993 Jul 8;329:73-8.



To estimate the mortality rates and risk factors for death from coronary heart disease (CHD) in white and black men and women.


30-year cohort study (Charleston Heart Study).


A county in south eastern United States.


2181 adults ≥ 35 years of age representing 84% of a randomly sampled population (741 white women, 454 black women, 653 white men, and 333 black men). Mean age at baseline (1960 to 1961) was 50 years. Vital status was known for 98% of white persons and 99% of black persons.

Assessment of risk factors

Participants were examined at baseline for blood pressure, serum cholesterol levels, body mass index, years of education, cigarette-smoking status (current vs. never or past), and diabetes status.

Main outcome measures

Death certificates provided data on mortality rates and cause of death.

Main results

After 30 years the mortality rates for CHD per 1000 person-years were 2.1 (95% Cl 1.6 to 2.6) for white women, 3.2 (Cl 2.3 to 4.0) for black women, 5.2 (Cl 4.1 to 6.3) for white men, and 4.6 (CI 3.0 to 6.2) for black men. Age-specific CHD mortality rates did not differ for the 2 groups of men or the 2 groups of women; the age-specific black-to-white CHD mortality ratio was 0.9 for men and 1.2 for women. The all-cause, black-towhite mortality ratio adjusted for age was 1.2 for men (Cl 1.0 to 1.4) and 1.5 for women (CI 1.3 to 1.8). When the all-cause mortality ratio was adjusted for all risk factors, the black-to-white mortality ratios were 1.0 (Cl 0.8 to 1.2) and 1.1 (CI 0.9 to 1.3) for men and women. Predictors of CHD mortality, adjusted for age and other factors, were systolic blood pressure in all groups, serum cholesterol level for white women, and smoking status in 1960 for white and black men and white women. Predictors of all-cause mortality were systolic blood pressure in all groups, smoking status (excluding black women), years of education in black women and white men, and diabetes in black men and both groups of women.


The 30-year mortality rates for coronary heart disease in black men and women and white men and women did not differ. The major risk factors for mortality from coronary heart disease were similar for black and white adults.

Source of funding: National Heart, Lung, and Blood Institute.

For article reprint: Dr. J.E. Keil, Charleston Heart Study, Room 908 Harborview Office Towers, Medical University of South Carolina, 171 Ashley Avenue, Charleston SC 29425-2239, USA. FAX 803-792-1123.


Epidemiologic studies allow us to discover and quantify the magnitude of the exposure-disease relation and offer the opportunity to alter the risk through intervention. Unlike the past, the diseases studied today are more likely to be chronic and have multiple contributing causes, each of which may play only a small role. CHD is a disease whose relation with race is difficult to determine. It is the leading cause of death in both black and white persons. Keil and colleagues, in an earlier publication (1), reported no difference in mortality rates between white and black men. In their present study, again, no difference in the CHD mortality rate between black and white persons was found. Interestingly, the level of education was more important than race in predicting CHD mortality rates. The results of this study are consistent with the findings of Pappas and colleagues (2), who reported no excess mortality attributable to race after adjusting for income in a survey of 13 491 deaths.

Socioeconomic status rather than race is a strong predictor of CHD mortality rates. Additionally, health knowledge and access do not completely account for the large gap in mortality between privileged and disadvantaged persons (3).

In conclusion, while we await the results of additional studies, not only should we pay equal attention to black and white persons to control established risk factors but we should also develop aggressive socioeconomic strategies to improve the level of education and income—both of which are primary but alterable risk factors for CHD mortality.

Vibhuti N. Singh, MD, MPH
University of Missouri Columbia, Missouri, USA