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• W1966852017 abstract "African Americans have a greater risk of cardiovascular disease (CVD) than Caucasians in early chronic kidney disease; however, limited data describe racial and ethnic differences in the risk of incident myocardial infarction (MI) among patients with end-stage renal disease (ESRD). We conducted a prospective, observational cohort study among 271 102 incident dialysis patients receiving renal replacement therapy enrolled in the United States Renal Data System (USRDS) for whom Medicare was the primary insurer between 1995 and 2000. The incidence and risk of any MI (non-fatal or fatal) estimated by Cox proportional hazards models was the primary outcome of interest. Of those with prevalent CVD at baseline (118 708), 14 849 had an incident non-fatal MI compared with 9926 events for those without prevalent CVD (152 394). Patients with prevalent CVD had higher crude rates of combined fatal and non-fatal MI (99.3/1000 person-years vs 42.9/1000 person-years) compared with those without prevalent CVD. Among those with prevalent CVD, African Americans (adjusted relative risk (aRR)=0.65, 95% confidence interval (CI):0.62–0.68), Asian Americans (aRR=0.74, 95% CI: 0.66–0.83), and Hispanics (aRR=0.72, 95% CI: 0.68–0.77) were 26–35% less likely to have an incident MI compared to Caucasians. Similarly, among those without prevalent CVD, racial/ethnic minorities were 26–42% less likely to have an incident MI compared to Caucasians. We conclude that in a national setting where comparable access to dialysis and associated medical care, exist, racial/ethnic minorities were found to have a lower risk of non-fatal and fatal MI than Caucasians. African Americans have a greater risk of cardiovascular disease (CVD) than Caucasians in early chronic kidney disease; however, limited data describe racial and ethnic differences in the risk of incident myocardial infarction (MI) among patients with end-stage renal disease (ESRD). We conducted a prospective, observational cohort study among 271 102 incident dialysis patients receiving renal replacement therapy enrolled in the United States Renal Data System (USRDS) for whom Medicare was the primary insurer between 1995 and 2000. The incidence and risk of any MI (non-fatal or fatal) estimated by Cox proportional hazards models was the primary outcome of interest. Of those with prevalent CVD at baseline (118 708), 14 849 had an incident non-fatal MI compared with 9926 events for those without prevalent CVD (152 394). Patients with prevalent CVD had higher crude rates of combined fatal and non-fatal MI (99.3/1000 person-years vs 42.9/1000 person-years) compared with those without prevalent CVD. Among those with prevalent CVD, African Americans (adjusted relative risk (aRR)=0.65, 95% confidence interval (CI):0.62–0.68), Asian Americans (aRR=0.74, 95% CI: 0.66–0.83), and Hispanics (aRR=0.72, 95% CI: 0.68–0.77) were 26–35% less likely to have an incident MI compared to Caucasians. Similarly, among those without prevalent CVD, racial/ethnic minorities were 26–42% less likely to have an incident MI compared to Caucasians. We conclude that in a national setting where comparable access to dialysis and associated medical care, exist, racial/ethnic minorities were found to have a lower risk of non-fatal and fatal MI than Caucasians. Cardiovascular disease (CVD) is the primary cause of death in the general population and in patients with end-stage renal disease (ESRD).1USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2002Google Scholar Patients on dialysis are reported to have a 30-fold greater risk of CVD associated mortality than the general population.2Levey A.S. Beto J.A. Coronado B.E. et al.Controlling the epidemic of cardiovascular disease in chronic renal disease: what do we know? What do we need to learn? Where do we go from here? National Kidney Foundation Task Force on Cardiovascular Disease.Am J Kidney Dis. 1998; 32: 853-906Abstract Full Text PDF PubMed Scopus (796) Google Scholar Among individuals with chronic renal insufficiency, racial and ethnic (racial/ethnic) minorities have been found to have higher rates of CVD than Caucasians,3Weiner D.E. Tighiouart H. Amin M.G. et al.Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies.J Am Soc Nephrol. 2004; 15: 1307-1315Crossref PubMed Scopus (978) Google Scholar but limited data exist that compare racial and ethnic differences in incident myocardial infarction (MI) among those with ESRD. Utilizing data from the United States Renal Data System (USRDS), Trespalacios et al.4Trespalacios F.C. Taylor A.J. Agodoa L.Y. Abbott K.C. Incident acute coronary syndromes in chronic dialysis patients in the United States.Kidney Int. 2002; 62: 1799-1805Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar found that African Americans were less likely to have prevalent coronary heart disease than Caucasians, but racial/ethnic differences in admissions for acute coronary syndrome or MI were not assessed. Also, racial/ethnic differences in the risk of atherosclerotic disease (cardiovascular, stroke, peripheral vascular disease) were assessed recently, but risk of MI was not assessed separately.5Parekh R.S. Zhang L. Fivush B.A. Klag M.J. Incidence of atherosclerosis by race in the Dialysis Morbidity and Mortality Study: a sample of the US ESRD population.J Am Soc Nephrol. 2005; 16: 1420-1426Crossref PubMed Scopus (36) Google Scholar Initiated in 1972, the ESRD Medicare entitlement program has allowed for governmental reimbursement for initiation and continuation of dialysis across the United States. In that regard, the Medicare program was one of the first nationwide programs that offered a form of national health insurance coverage. We hypothesized that in the setting where medical insurance access is comparable, racial/ethnic differences in incident fatal and non-fatal MI would be minimized if access to care is the primary factor accounting for racial/ethnic disparities in incident MI. Using data from the USRDS, which records data from all patients who initiate dialysis in the United States, we sought to evaluate racial/ethnic differences in incident non-fatal and fatal MI in the setting where comparable insurance coverage for renal replacement therapy, physician reimbursement, and hospitalizations exists for all subjects. Data were available for 506 922 ESRD patients who initiated renal replacement therapy between January 1, 1995 and December 31, 2000. Of these, 201 870 (39.8%) patients were not eligible for Medicare insurance coverage within 90 days of starting renal replacement therapy and were excluded. Of the remaining patients, 33 950 (6.7%) were further excluded owing to an incomplete medical evidence form, before transplant or MI, or for not having Medicare coverage before December 31, 2000, which resulted in 271 102 patients identified for the current analysis. Of those identified, 118 708 (43.8%) had prevalent CVD, whereas 152 394 (56.2%) did not have prevalent CVD. Overall, 52.0% were male, 52.1% were Caucasian, 31.6% were African American, 3.0% were Asian American, and 11.5% were Hispanic. Diabetes (45.3%) was the primary cause of ESRD, followed by hypertension (28.1%) and glomerulonephritis (9.0%). On average, patients were anemic (hemoglobin 9.5±1.8 g/dl), elderly (mean age 63.5±15.3 years), slightly malnourished (albumin 3.2±0.7 g/dl), and had low creatinine clearances (3.0±6.0 ml/min) at the initiation of dialysis. Prevalent erythropoietin (EPO) use was observed in approximately a quarter of all patients (25.4%). Those of other race/ethnicity (n=4679; 1.7%) were younger and more likely to have diabetes compared to the remaining groups. Among those with prevalent CVD (Table 1), the majority were Caucasian (60.0%), followed by African Americans (25.6%), Hispanics (10.1%), Asian Americans (2.57%), and those of other race/ethnicity (1.69%). African Americans, Hispanics, and Asians were more likely to be female, were more likely to be less than 60 years of age, and were more likely to have diabetes than Caucasians. Those of other race/ethnicity (79.0%) contained the greatest proportion of those with diabetes as the underlying renal disease. EPO use before initiation of dialysis was less likely for African Americans and Hispanics compared with Caucasians and Asians, although baseline laboratory values were similar among all groups within the cohort.Table 1Baseline demographics of USRDS Medicare cohortOverallCaucasianAfrican AmericanAsian AmericanHispanicOtherPrevalent CVD Total118 70871 186 (60.0%)30 452 (25.6%)3051 (2.57%)11 997 (10.1%)2007 (1.69%) Female57 904 (48.8%)31 604 (44.4%)17 550 (57.6%)1575 (51.6%)6056 (50.5%)1114 (55.5%)Age group Less than 45 years5996 (5.05%)2297 (3.23%)2713 (8.91%)147 (4.82%)706 (5.88%)131 (6.53%) 45–59 years20 606 (17.4%)8807 (12.4%)7540 (24.8%)446 (14.6%)3168 (26.4%)643 (32.0%) 60–74 years55 049 (46.4%)33 366 (46.9%)13 599 (44.7%)1372 (45.0%)5760 (48.0%)945 (47.1%) 75 years and older37 057 (31.2%)26 716 (37.5%)6600 (21.7%)1086 (35.6%)2363 (19.7%)288 (14.4%)Cause of ESRD Diabetes62 712 (52.8%)33 528 (47.1%)16 720 (54.9%)1832 (60.0%)9036 (75.3%)1586 (79.0%) Hypertension34 130 (28.8%)21 649 (30.4%)9784 (32.1%)730 (23.9%)1755 (14.6%)211 (10.5%) Glomerulonephritis6996 (5.89%)4908 (6.89%)1329 (4.36%)230 (7.54%)444 (3.7%)85 (4.24%) Other14 870 (12.5%)11 101 (15.6%)2619 (8.6%)259 (8.49%)762 (6.35%)125 (6.23%)Baseline lab values (N (%) or mean (s.d.))aPrevalent CVD baseline lab missing values: inability to ambulate (0.03%), hemoglobin (12.2%), albumin (21.4%), BUN (5.89%), and EPO use (0.06%). Inability to ambulate7413 (6.24%)4328 (6.08%)2085 (6.85%)163 (5.34%)726 (6.05%)109 (5.43%) EPO use predialysis31 030 (26.1%)19 910 (28.0%)6929 (22.8%)940 (30.8%)2758 (23.0%)489 (24.4%) Age at start68.1 (12.2)70.4 (11.1)64.3 (13.3)69.3 (12.5)64.7 (12.0)62.6 (11.6) Albumin (g/dl)3.14 (0.63)3.18 (0.61)3.1 (0.63)3.05 (0.64)3.03 (0.63)2.91 (0.64) Hemoglobin (g/dl)9.65 (1.68)9.84 (1.62)9.25 (1.75)9.65 (1.75)9.53 (1.68)9.39 (1.65) BUN (mg/dl)91.1 (32.8)93.0 (33.2)88.1 (32.0)91.4 (32.8)87.6 (31.7)87.7 (31.2) Creatinine clearance (ml/min)3.52 (6.41)3.72 (6.66)3.04 (5.98)2.99 (5.48)3.72 (6.16)3.17 (5.78) Serum creatinine (mg/dl)6.99 (3.02)6.53 (2.63)7.98 (3.52)7.38 (3.17)7.08 (3.12)7.17 (3.13) Height (cm)167.0 (12.9)168.0 (12.7)167.0 (12.9)159.0 (11.6)161.0 (12.8)165.0 (12.8) Weight (kg)73.5 (19.2)73.7 (18.6)76.1 (21.0)59.9 (16.3)69.1 (17.0)72.8 (18.5)No prevalent CVD Total152 39469 946 (45.9%)55 330 (36.3%)5191 (3.41%)19 241 (12.6%)2672 (1.75%) Female72 201 (47.4%)31 692 (45.3%)27 776 (50.2%)2619 (50.5%)8703 (45.2%)1405 (52.6%)Age group Less than 45 years31 858 (20.9%)11 104 (15.9%)14 833 (26.8%)994 (19.2%)4362 (22.7%)560 (21.0%) 45–59 years36 633 (24.0%)12 968 (18.5%)15 628 (28.2%)1166 (22.5%)5882 (30.6%)986 (36.9%) 60–74 years54 546 (35.8%)27 374 (39.1%)17 604 (31.8%)1909 (36.8%)6775 (35.2%)880 (32.9%) 75 years and older29 357 (19.3%)18 500 (26.4%)7265 (13.1%)1122 (21.6%)2222 (11.6%)246 (9.21%)Cause of ESRD Diabetes60 207 (39.5%)24 651 (35.2%)20 821 (37.6%)2164 (41.7%)10 820 (56.2%)1745 (65.3%) Hypertension42 027 (27.6%)16 633 (23.8%)20 326 (36.7%)1333 (25.7%)3436 (17.9%)296 (11.1%) Glomerulonephritis17 346 (11.4%)9167 (13.1%)4940 (8.93%)889 (17.1%)2045 (10.6%)302 (11.3%) Other32 813 (21.5%)19 495 (27.9%)9242 (16.7%)805 (15.5%)2940 (15.3%)329 (12.3%)Baseline lab values (N (%) or mean (s.d.))bNo prevalent CVD baseline lab missing values: hemoglobin (13.0%), albumin (23.2%), BUN (7.36%), and EPO use (0.06%). Inability to ambulate4175 (2.74%)1948 (2.79%)1567 (2.83%)100 (1.93%)487 (2.53%)72 (2.69%) EPO use predialysis37 921 (24.9%)20 084 (28.7%)11 444 (20.7%)1576 (30.4%)4212 (21.9%)601 (22.5%) Age at start59.8 (16.4)63.5 (16.0)56.3 (16.2)60.9 (16.6)56.9 (15.6)56.3 (14.4) Albumin (g/dl)3.2 (0.69)3.26 (0.67)3.15 (0.71)3.2 (0.67)3.15 (0.69)3.01 (0.7) Hemoglobin (g/dl)9.44 (1.81)9.76 (1.75)9.09 (1.83)9.5 (1.88)9.35 (1.79)9.28 (1.78) BUN (mg/dl)89.7 (34.0)90.0 (33.8)89.4 (34.3)92.1 (34.9)89.7 (33.5)85.4 (32.1) Creatinine clearance (ml/min)2.56 (5.65)2.9 (5.88)2.15 (5.39)2.22 (5.03)2.63 (5.64)2.34 (4.95) Serum creatinine (mg/dl)8.73 (4.05)7.82 (3.36)9.87 (4.54)8.86 (4.0)8.76 (4.07)8.55 (3.82) Height (cm)167.0 (13.3)168.0 (12.8)168.0 (13.4)160.0 (12.1)163.0 (13.4)165.0 (13.0) Weight (kg)73.9 (19.9)73.9 (19.4)76.5 (20.9)60.5 (16.5)70.2 (17.7)74.4 (19.6)BUN, blood urea nitrogen; CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; s.d., standard deviation; USRDS, United States Renal Data System.a Prevalent CVD baseline lab missing values: inability to ambulate (0.03%), hemoglobin (12.2%), albumin (21.4%), BUN (5.89%), and EPO use (0.06%).b No prevalent CVD baseline lab missing values: hemoglobin (13.0%), albumin (23.2%), BUN (7.36%), and EPO use (0.06%). Open table in a new tab BUN, blood urea nitrogen; CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; s.d., standard deviation; USRDS, United States Renal Data System. Compared to those with prevalent CVD, those without prevalent CVD (Table 1) had greater proportions of African Americans (36.3%), Hispanics (12.6%), Asian Americans (3.41%), and those of other race/ethnicity (1.75%) than Caucasians (45.9%). Similar to what was found among those with prevalent CVD, diabetes was the primary cause of ESRD and greatest for those of other race/ethnicity, Hispanics, Asians, and African Americans (in that order) compared to Caucasians. Pre-dialysis EPO use was lowest for African Americans compared to other racial/ethnic groups, and African Americans were, on average, the youngest group to initiate renal replacement therapy. Hemoglobin levels were lower for those without prevalent CVD compared to those with prevalent CVD, and African Americans without prevalent CVD had the lowest hemoglobin level of all groups (9.09±1.83%). On average, baseline serum creatinine levels were higher for racial/ethnic minority groups than Caucasians in both those with and without prevalent CVD, whereas African Americans started dialysis with the highest average baseline serum creatinine. Also, racial and ethnic minorities of both CVD groups had the lowest baseline serum albumin levels compared to Caucasians. Unadjusted MI event rates were approximately two-fold greater among those with prevalent CVD compared to those without (Table 2), and highest among those less than 45 years of age (2.8-fold greater). Among those with prevalent CVD, greater non-fatal and combined MI event rates were observed for men, Caucasians, the elderly, those with hypertension as the primary cause of ESRD, and for those without pre-dialysis EPO use. Those 75 years and older, Caucasians, and those unable to ambulate had both the highest overall non-fatal and highest overall combined MI event rates. Similarly, among those without prevalent CVD, the elderly, Caucasians, those with diabetes, and those unable to ambulate were more likely to have both non-fatal and combined MI, although rates were similar between men and women and between those with and without predialysis EPO use.Table 2Non-fatal and combined MI event rates (95% CI)N, totalN, non-fatal MIN, combined MINon-fatal MI rate (per 1000) (95% CI)Combined MI rate (per 1000) (95% CI)aCI, confidence interval.Prevalent CVD Total118 70814 84918 34980.3 (79.0, 81.6)99.3 (97.8, 100.7)Gender Men60 8047782966283.5 (81.7, 85.4)103.7 (101.6, 105.8) Women57 9047067868777.1 (75.3, 78.9)94.7 (92.8, 96.7)Age group Less than 45 years599638548331.0 (28.0, 34.2)38.9 (35.5, 42.4) 45–59 years20 6062026257354.0 (51.7, 56.4)68.6 (66.0, 71.3) 60–74 years55 0497444918084.9 (83.0, 86.9)104.8 (102.6, 106.9) 75 years and older37 05749946113105.6 (102.7, 108.5)129.2 (126.0, 132.5)Race Caucasian71 186992112 13998.3 (96.4, 100.3)120.3 (118.2, 122.5) African American30 4523046377555.5 (53.5, 57.5)68.7 (66.6, 70.9) Asian American305136047372.4 (65.1, 80.0)95.1 (86.5, 103.7) Hispanic11 9971326169864.7 (61.2, 68.2)82.8 (78.9, 86.7) Other200719326154.6 (47.1, 62.5)73.8 (64.8, 82.7)Cause of ESRD Diabetes62 7127924990180.3 (78.6, 82.1)100.4 (98.4, 102.3) Hypertension34 1304511552286.0 (83.5, 88.5)105.3 (102.5, 108.1) Glomerulonephritis699677695962.3 (58.0, 66.7)77.0 (72.1, 81.8) Other14 8701638196777.0 (73.3, 80.7)92.4 (88.3, 96.5)Ability to ambulate111 25514 02617 27380.0 (78.7, 81.3)98.5 (97.0, 100.0)Inability to ambulate7413817107087.2 (81.3, 93.2)114.2 (107.3, 121.0)No EPO predialysis87 61011 20713 83281.8 (80.3, 83.4)101.0 (99.3, 102.7)EPO predialysis31 0303638451176.1 (73.6, 78.6)94.3 (91.6, 97.1)No Prevalent CVDTotal152 394992612 47534.2 (33.5, 34.8)42.9 (42.2, 43.7)Gender Men80 1935099648533.5 (32.6, 34.4)42.6 (41.6, 43.6) Women72 2014827599034.9 (33.9, 35.9)43.3 (42.2, 44.4)Age group Less than 45 years31 85876196810.6 (9.9, 11.4)13.5 (12.7, 14.4) 45–59 years36 6331986252327.1 (25.9, 28.3)34.4 (33.0, 35.7) 60–74 years54 5464594572645.4 (44.1, 46.7)56.6 (55.1, 58.0) 75 years and older29 3572585325858.4 (56.2, 60.7)73.6 (71.1, 76.2)Race Caucasian69 9465391668743.8 (42.6, 44.9)54.3 (53.0, 55.6) African American55 3303015383526.7 (25.7, 27.6)33.9 (32.8, 35.0) Asian American519133241033.6 (30.1, 37.4)41.5 (37.5, 45.6) Hispanic19 2411051136427.2 (25.6, 28.8)35.3 (33.4, 37.1) Other267213517723.9 (20.1, 28.1)31.4 (26.8, 36.0)Cause of ESRD Diabetes60 2074848612143.8 (42.6, 45.0)55.3 (53.9, 56.7) Hypertension42 0272903363235.8 (34.6, 37.2)44.8 (43.4, 46.3) Glomerulonephritis17 34673992119.5 (18.2, 21.0)24.4 (22.8, 25.9) Other32 8131436180123.6 (22.4, 24.8)29.6 (28.2, 30.9)Ability to ambulate148 219966112 12534.0 (33.3, 34.7)42.7 (41.9, 43.4)Inability to ambulate417526535041.8 (36.9, 46.9)55.1 (49.4, 60.9)No EPO predialysis114 3857426939733.6 (32.8, 34.4)42.5 (41.6, 43.4)EPO predialysis37 9212498307536.1 (34.7, 37.5)44.4 (42.8, 46.0)CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; CI, class interval; MI, myocardial infarction.Combined MI includes fatal and non-fatal MI events.a CI, confidence interval. Open table in a new tab CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; CI, class interval; MI, myocardial infarction. Combined MI includes fatal and non-fatal MI events. We determined estimates of the adjusted relative risk (aRR) of incident non-fatal and combined MI separately for subgroups defined by prevalent CVD status (Table 3). Risk estimates were similar for models of non-fatal MI compared with combined MI; thus, results are shown only for the combined end point. All estimates were adjusted for age at the start of renal replacement therapy, gender, primary cause of ESRD, dialysis modality (hemodialysis, peritoneal dialysis, and transplant) and transplant waiting list status as well as available baseline laboratory values. Final models were restricted to 81 106 (prevalent) and 100 998 (non-prevalent CVD) subjects owing to missing laboratory values, although these restrictions changed the point estimates of the results minimally.Table 3Relative risk of combined non-fatal and fatal MI adjusted for baseline covariatesaAfter restricted to patients without missing covariates, N=81 106 and 100 998 for prevalent CVD and no prevalent CVD respectively.Prevalent CVDNo prevalent CVDCovariateRelative risk (95% CI)P-valueRelative risk (95% CI)P-valueGender (women vs men)0.88 (0.84, 0.92)<0.0010.87 (0.82, 0.91)<0.001Age per 10 years1.19 (1.17, 1.21)<0.0011.32 (1.30, 1.35)<0.001Race Caucasian1.0—1.0— African American0.65 (0.62, 0.68)<0.0010.67 (0.64, 0.71)<0.001 Asian American0.74 (0.66, 0.83)<0.0010.72 (0.63, 0.81)<0.001 Hispanic0.72 (0.68, 0.77)<0.0010.65 (0.60, 0.70)<0.001 Other0.65 (0.56, 0.75)<0.0010.58 (0.49, 0.70)<0.001Cause of ESRD Diabetes1.0—1.0— Hypertension0.88 (0.84, 0.92)<0.0010.72 (0.68, 0.76)<0.001 Glomerulonephritis0.75 (0.69, 0.81)<0.0010.49 (0.45, 0.53)<0.001 Other0.78 (0.73, 0.82)<0.0010.50 (0.47, 0.54)<0.001Modality Hemodialysis1.0—1.0— Peritoneal dialysis0.98 (0.92, 1.05)0.5881.06 (0.99, 1.15)0.099 Transplant0.47 (0.38, 0.59)<0.0010.41 (0.35, 0.48)<0.001Wait list0.68 (0.59, 0.80)<0.0010.68 (0.60, 0.76)<0.001Baseline Hypertension0.98 (0.93, 1.02)0.3090.94 (0.89, 0.99)0.011 Peripheral vascular disease1.21 (1.16, 1.26)<0.0011.27 (1.18, 1.37)<0.001 Inability to ambulate1.00 (0.93, 1.08)0.9611.05 (0.92, 1.20)0.453 EPO use0.89 (0.86, 0.93)<0.0010.94 (0.89, 0.99)0.015 Albumin (g/dl)0.93 (0.90, 0.96)<0.0010.89 (0.86, 0.92)<0.001 Hemoglobin (g/dl)1.04 (1.02, 1.05)<0.0011.03 (1.02, 1.05)<0.001 BUN (mg/dl)1.00 (1.00, 1.00)0.8281.00 (1.00, 1.00)0.395 Creatinine clearance (ml/min)1.00 (0.99, 1.00)0.061.00 (0.99, 1.00)0.128 Height per 10 cm0.99 (0.97, 1.00)0.1290.99 (0.97, 1.01)0.171 Weight per 10 kg0.96 (0.95, 0.97)<0.0010.96 (0.95, 0.97)<0.001BUN, blood urea nitrogen; CI, class interval; CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; MI, myocardial infarction.a After restricted to patients without missing covariates, N=81 106 and 100 998 for prevalent CVD and no prevalent CVD respectively. Open table in a new tab BUN, blood urea nitrogen; CI, class interval; CVD, cardiovascular disease; EPO, erythropoietin; ESRD, end-stage renal disease; MI, myocardial infarction. Among those with prevalent CVD, African Americans were estimated to have the lowest risk of combined MI (aRR=0.65, 95% confidence interval (CI): (0.62, 0.68)) compared to Caucasians. Asian Americans with prevalent CVD had a 26% decreased risk (aRR=0.74, 95% CI: (0.66, 0.83)), whereas Hispanics (aRR=0.72, 95% CI: (0.68, 0.77)) had lower adjusted risk of incident non-fatal and fatal MI compared to Caucasians. With respect to other known risk factors, among those with prevalent CVD, increasing age, male gender, and renal failure owing to diabetic nephropathy were all independently associated with a greater risk of combined MI. Compared to patients on hemodialysis, those on peritoneal dialysis had a 2% lower risk of combined MI (aRR= 0.98, 95% CI: (0.93, 1.02)), whereas those on the wait list were 32% less likely to have an event compared to those not wait-listed on hemodialysis. Additionally, when other causes of cardiovascular death were added to the combined end-point, modest changes to the point estimates were found (data not shown). Similarly, among those without prevalent CVD, African Americans had a 33% lower risk of combined MI (aRR=0.67, 95% CI: (0.64, 0.71)) compared to Caucasians. Asian Americans without prevalent CVD had 28% lower risk (aRR=0.72, 95% CI: (0.63, 0.81)), whereas Hispanics had a 35% lower adjusted risk of combined MI event (aRR=0.65, 95% CI: (0.60, 0.70)), compared to Caucasians (Table 3). Compared to patients on hemodialysis, those on peritoneal dialysis without prevalent CVD had an insignificantly elevated relative risk of combined MI (aRR non-prevalent CVD 1.06, 95% CI: (0.99, 1.15)). Additionally, those on the waiting list were 32% less likely to have an event compared to those not wait-listed on hemodialysis, whereas those who received a transplant were 69% less likely to have an event compared to those on hemodialysis. Among a national cohort of patients who had Medicare as their primary insurance, prevalent CVD was a significant risk factor for recurrent MI, whereas belonging to a racial/ethnic minority group was associated with a lower risk of non-fatal and combined fatal and non-fatal MI compared with Caucasians. Racial/ethnic differences in risk were similar among those with and without prevalent CVD diagnosed at the time of initiation of dialysis. Because African Americans are less likely to be diagnosed with cardiovascular events prospectively in the general population, we felt that it was important to also explore cardiac-related deaths as a combined outcome with non-fatal MI. Studies have shown that African Americans have been more likely to present with out of hospital cardiac arrests than Caucasians and less likely to have cardiac procedures ordered compared with Caucasians,6Conigliaro J. Whittle J. Good C.B. et al.Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors.Arch Intern Med. 2000; 160: 1329-1335Crossref PubMed Scopus (90) Google Scholar, 7Wenneker M.B. Epstein A.M. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts.JAMA. 1989; 261: 253-257Crossref PubMed Scopus (400) Google Scholar, 8Whittle J. Conigliaro J. Good C.B. Lofgren R.P. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs Medical System.N Engl J Med. 1993; 329: 621-627Crossref PubMed Scopus (385) Google Scholar, 9Weitzman S. Cooper L. Chambless L. et al.Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states.Am J Cardiol. 1997; 79: 722-726Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 10Whittle J. Conigliaro J. Good C.B. Joswiak M. Do patient preferences contribute to racial differences in cardiovascular procedure use?.J Gen Intern Med. 1997; 12: 267-273Crossref PubMed Google Scholar, 11Petersen L.A. Wright S.M. Peterson E.D. Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction.Med Care. 2002; 40: 86-96PubMed Google Scholar, 12Maynard C. Every N.R. Martin J.S. Weaver W.D. Long-term implications of racial differences in the use of revascularization procedures (the Myocardial Infarction Triage and Intervention registry).Am Heart J. 1997; 133: 656-662Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar although this may be negligible in the dialysis population.13Daumit G.L. Hermann J.A. Coresh J. Powe N.R. Use of cardiovascular procedures among black persons and white persons: a 7-year nationwide study in patients with renal disease.Ann Intern Med. 1999; 130: 173-182Crossref PubMed Scopus (78) Google Scholar We found that for both non-fatal and combined MI, African Americans and other minority groups had a lower risk of incident MI events compared to Caucasians regardless of which combined end-point was examined. Recently, limited studies have evaluated racial/ethnic differences in the risk of incident MI and MI-associated mortality in a national dialysis population. Trespalacios4Trespalacios F.C. Taylor A.J. Agodoa L.Y. Abbott K.C. Incident acute coronary syndromes in chronic dialysis patients in the United States.Kidney Int. 2002; 62: 1799-1805Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar evaluated the risk of acute coronary syndrome in the USRDS Dialysis Morbidity and Mortality Study, Wave II, and found that African Americans were 46% less likely to have prevalent CVD; however, the risk of incident cardiac event was not reported separately by race or ethnicity. In a report that used combined data from CMS and the USRDS, Ganesh14Ganesh S.K. Hulbert-Shearon T. Port F.K. et al.Mortality differences by dialysis modality among incident ESRD patients with and without coronary artery disease.J Am Soc Nephrol. 2003; 14: 415-424Crossref PubMed Scopus (182) Google Scholar evaluated all-cause mortality in hemodialysis and peritoneal dialysis patients, and found that Caucasians had a 1.25-fold greater risk of mortality than non-white subjects (aRR=1.25, 95% CI: 1.22–1.29); however, individual racial and ethnic groups risk of cardiac-related mortality was not assessed. Finally, utilizing USRDS data, Parekh et al5Parekh R.S. Zhang L. Fivush B.A. Klag M.J. Incidence of atherosclerosis by race in the Dialysis Morbidity and Mortality Study: a sample of the US ESRD population.J Am Soc Nephrol. 2005; 16: 1420-1426Crossref PubMed Scopus (36) Google Scholar also found that African Americans had a lower incidence of atherosclerosis events, results that are similar to ours except that their final outcome included all causes of atherosclerotic disease, such as coronary artery disease and peripheral vascular disease.5Parekh R.S. Zhang L. Fivush B.A. Klag M.J. Incidence of atherosclerosis by race in the Dialysis Morbidity and Mortality Study: a sample of the US ESRD population.J Am Soc Nephrol. 2005; 16: 1420-1426Crossref PubMed Scopus (36) Google Scholar Although the current study results are robust, results from studies evaluating racial and ethnic differences in incident MI in populations with earlier stages of chronic kidney disease before the initiation of dialysis have been inconsistent. In a meta-analysis that combined four community cohort studies, Weiner3Weiner D.E. Tighiouart H. Amin M.G. et al.Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies.J Am Soc Nephrol. 2004; 15: 1307-1315Crossref PubMed Scopus (978) Google Scholar reported that African Americans had a 1.8-fold greater risk of a combined cardiac/stroke/death outcome than Caucasians, and that African Americans with chronic kidney disease had a greater risk of having an MI than white subjects. Conversely, using data from a large managed care system population with diabetes, Karter15Karter A.J. Ferrara A. Liu J.Y. et al.Ethnic disparities in diabetic complications in an insured population.JAMA. 2002; 287: 2519-2527Crossref PubMed Scopus (648) Google Scholar reported that African Americans and other minority populations were less likely to have an incident MI, but were as likely to be diagnosed with congestive heart failure compared with Caucasians. In addition, we previously reported that diabetic African-American veterans and other" @default.
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