Alderman MH, Cohen HW, Madhavan S.
Myocardial infarction in treated hypertensive patients: the paradox of lower incidence but higher mortality in young blacks compared with whites.
Circulation 2000;101(10):1109-14.

This study examined the incidence and outcome of acute myocardial infarction in a population of treated hypertensive patients. The study subjects – males enrolled in a work-site hypertension control program in New York City from 1973 to 1996 – were prospectively followed.

The overall age-adjusted myocardial infarction (MI) incidence among both younger and older subjects was roughly twice as high for whites as blacks (RR for younger whites versus younger blacks was 1.91, 95% CI was 1.09 to 3.35; RR for older whites versus younger blacks was 1.91, 95% CI was 1.23 to 2.97). The authors note that attained blood pressure (BP) differed slightly to the disadvantage of blacks. It is noteworthy that the case definition of MI in this study included patients with MI and patients who had undergone angioplasty or coronary bypass surgery.

The age-adjusted MI mortality for younger blacks tended to exceed that of younger whites (although the difference was not statistically significant). Among patients of at least 60 years of age, the rate for blacks was significantly lower than for whites. These patterns held after adjustment for potential confounding and interacting variables. Furthermore, the authors found that smoking status and blood sugar level while in treatment did not distinguish the experience of the two racial groups. (However, both smoking and diabetes were more common among younger black than white men, and were significantly associated with both the occurrences of events and the likelihood of their being fatal.)

In this study of hypertensive subjects recruited at a work-site, the excess mortality of young blacks compared with whites cannot be ascribed to racial differences in BP control, access to health care, SES, risk factor management, or a higher incidence of events. With regard to the influence of other factors, the authors suggest that it is possible that differences in other risk factors--smoking and diabetes--might have been influential in explaining the results. These factors might have had a greater effect on the severity than on the incidence of events.

The authors conclude that "young black men achieving good BP control in this multiracial hypertensive treatment program still suffered greater coronary mortality than did young white men despite a lower incidence of MI. This apparent paradox, seen only among younger subjects, is due to the sharply higher case fatality rate of young black men. Although the available data cannot account for these findings, very different use of revascularization and a more frequent history of diabetes and smoking point to possible clinical explanations."