Do Mexican Americans Really Have Low Rates of Cardiovascular Disease?

doi:10.1006/pmed.1998.0464

Preventive Medicine

Volume 29, Issue 6, December 1999, Pages S90-S95

https://doi.org/10.1006/pmed.1998.0464 Get rights and content

Abstract

In this article we challenge the conclusion made from vital statistics that Hispanic Americans have lower all-cause and cardiovascular disease (CVD) mortality than non-Hispanic whites. There is reason to believe that vital statistics underascertain minority, and in particular Hispanic, deaths. Cohort studies minimize many of these limitations. In the San Antonio Heart Study risk factor distributions predicted higher all-cause and CVD mortality among Mexican Americans than among non-Hispanic whites. Follow-up of the cohort confirmed a mortality ratio of 1.38 for all-cause and 1.30 for CVD mortality for Mexican Americans vs non-Hispanic whites. This excess risk was confined to U.S.-born Mexican Americans, since immigrants from Mexico had very low mortality despite low socioeconomic status. We attribute this latter finding to a “healthy migrant effect.”

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Cited by (48)

Is there a Hispanic Health Paradox in sensitivity to air pollution? Hospital admissions for asthma, chronic obstructive pulmonary disease and congestive heart failure associated with NO<inf>2</inf> and PM<inf>2.5</inf> in El Paso, TX, 2005-2010
2015, Atmospheric Environment
Citation Excerpt :
Specifically, the risk of diabetes is especially pronounced for US born Mexican-Americans (Schneiderman et al., Aug 2014) which comprise the majority of El Paso's Hispanic population. US-born Mexican-Americans also have relatively high rates of cardiovascular disease (Stern and Wei, 1999). Both diabetes and cardiovascular disease may intensify the association between PM2.5 and cardiovascular events (Franchini and Mannucci, 2011), but were unmeasured in our models due to the lack of available data.
Linkages between pollution and morbidity have been observed in numerous studies. But race/ethnicity has been underemphasized as a modifier of that association, and few studies have tested for a Hispanic Health Paradox in sensitivity to air pollution.
Daily asthma, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) hospital admissions in El Paso, Texas were studied in age groups and insurance groups. Daily PM_2.5 and NO₂ were calculated from pollution monitors and all models adjusted for apparent temperature and wind speed. Conditional logistic regression for the case-crossover design was used for a between-group comparison and for a within-group comparison for Hispanics.
Hispanics were at lower risk than non-Hispanic whites and non-Hispanics of other races for NO₂-associated admissions, but at greater risk for PM_2.5-associated admissions. While Hispanics were generally protected with regards to NO₂, Hispanic children (vs. Elderly) faced increased risk for asthma and uninsured Hispanics (vs. Private) faced increased risk for COPD admissions. While Hispanics were at increased risk of PM_2.5-associated admissions, certain characteristics heightened their risks: being a Hispanic child (vs. Elderly) for asthma; being a Hispanic with Medicare (vs. Private) for asthma; and being a Hispanic with private insurance (vs. all other insurance types) for CHF. The main effect of pollution on admissions was more significant for asthma and CHF than for COPD, which had the fewest cases.
There was heterogeneity in sensitivity to air pollution based on social characteristics and moderate evidence for a Hispanic Health Paradox in sensitivity to NO₂.
Minor isolated Q waves and cardiovascular events in the MESA study
2013, American Journal of Medicine
Citation Excerpt :
Hispanics reportedly have lower all-cause and cardiovascular mortality despite increased prevalence of traditional cardiovascular risk factors, which has been called the “Hispanic Paradox.”23 Nevertheless, it has been suggested that vital statistics under-ascertain minority deaths, especially in Hispanics, and that cohort studies may provide better estimates.24 In the San Antonio Heart Study,25 risk factor distributions predicted higher all-cause and cardiovascular mortality among Mexican Americans than among non-Hispanic whites.
The significance of minor isolated Q waves in the resting electrocardiograms (ECGs) of apparently healthy individuals is unknown.
To examine the association between minor isolated Q waves and incident cardiovascular disease events in the Multi-Ethnic Study of Atherosclerosis (MESA).
This analysis included 6551 MESA participants (38% white, 28% black, 22% Hispanic, 12% Chinese) who were free of cardiovascular disease at enrollment. Cox proportional hazards models were used to examine the association between minor isolated Q waves defined by the Minnesota ECG Classification with adjudicated incident cardiovascular events.
During up to 7.8 years of follow-up, 423 events occurred, with a rate of 10.7 events per 1000 person-years. A significant interaction between minor isolated Q waves and race/ethnicity was observed (P = .030). In models stratified by race/ethnicity and adjusted for demographics, socioeconomic status, common cardiovascular risk factors, and other ECG abnormalities, presence of isolated minor Q waves was significantly associated with incident cardiovascular events in Hispanics (hazard ratio [HR] 2.62; 95% confidence interval [CI], 1.42-4.82), but not in whites (HR 0.65; 95% CI, 0.32-1.33) or blacks (HR 1.46; 95% CI, 0.74-2.89). Despite the statistically significant association in the Chinese population, the small number of events precluded solid conclusions in this race/ethnicity.
The prognostic significance of minor isolated Q waves varies across races/ethnicities; they carry a high risk for future cardiovascular events in apparently healthy Hispanics, but not in whites or blacks.
Coronary Death and Myocardial Infarction among Hispanics in the Northern Manhattan Study: Exploring the Hispanic Paradox
2012, Annals of Epidemiology
Citation Excerpt :
This was not the case in our study because the loss to follow-up was less than 1% (26). An alternative hypothesis is that Hispanics who migrate to the U.S. are overall healthier than other Hispanics, leading to the healthy migrant effect (3, 35). U.S.-born Hispanics, as opposed to foreign born, may have higher rates of cardiovascular disease compared to NHW (14, 35).
Prior studies have reported that Hispanics have lower cardiovascular disease (CVD) mortality despite a higher burden of risk factors. We examined whether Hispanic ethnicity was associated with a lower risk of nonfatal myocardial infarction (MI) coronary death (CD) and vascular death.
A total of 2671 participants in the Northern Manhattan Study without clinical CVD were prospectively evaluated. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the association of race–ethnicity with nonfatal MI, CD, and vascular death after adjusting for demographic and CVD risk factors.
Mean age was 68.8 (10.4) years; 52.8% were Hispanic (88% Caribbean-Hispanic). Hispanics were more likely to have hypertension (73.1% vs. 62.2%, p < .001) and diabetes (22.0% vs. 13.3%, p < .001), and less likely to perform any physical activity (50.1% vs. 69.2%, p < .001) compared to non-Hispanic whites (NHW). During a mean 10 years of follow-up there were 154 nonfatal MIs, 186 CD, and 386 vascular deaths. In fully adjusted models, Hispanics had a lower risk of CD (adjusted HR = 0.36, 95% CI: 0.21–0.60), and vascular death (adjusted HR = 0.62, 95% CI: 0.43–0.89), but not nonfatal MI (adjusted HR = 0.95, 95% CI: 0.56–1.60) when compared to NHW.
We found a “Hispanic paradox” for coronary and vascular deaths, but not nonfatal MI.
Racial/ethnic differences in the prevalence of atrial fibrillation among older adults - A cross-sectional study
2010, Journal of the National Medical Association
Atrial fibrillation affects 4% to 8% of individuals over 60 years of age based on studies of predominantly white populations, whether this is true among nonwhite individuals is not clear. This study was undertaken to define racial/ethnic differences in atrial fibrillation prevalence among a large community cohort.
This is a cross-sectional study. In 2008, there were 430 317 members aged 60 years or older in a large California health maintenance organization. By searching International Classification of Diseases, Ninth Revision codes and electronic electrocardiographic archives, we identified all members in this age group with primary, nonvalvular atrial fibrillation. Race/ethnicity data were assigned using health plan enrollment, service utilization, Asian/Hispanic surname and geocoding methods, and was available for 80.5% of members (79.8% of non-atrial fibrillation and 92% of atrial fibrillation), 99% of which were white, black, Asian, or Hispanic. We assessed the age- and gender-specific atrial fibrillation prevalence rates for each racial/ethnic group. The effect of race/ethnicity on atrial fibrillation was analyzed with logistic regression methods adjusting for potential confounders.
The overall atrial fibrillation prevalence was 5.3%. Among members with assigned race/ethnicity data, the prevalence among whites, blacks, Asians, and Hispanics was 8.0%, 3.8%, 3.9%, and 3.6%, respectively. The adjusted odds ratios (95% confidence intervals) of atrial fibrillation among blacks, Asians, and Hispanics with whites as referent were 0.49 (0.47-0.52), 0.68 (0.64-0.72), and 0.58 (0.55-0.61), respectively.
Atrial fibrillation is less prevalent in older non-white individuals than whites. White race/ethnicity is associated with significantly greater odds for atrial fibrillation compared to blacks, Asians, and Hispanics, after adjusting for comorbidities associated with the development of atrial fibrillation.
Disparities in Rates of Acute MI Hospitalization and Coronary Procedures on the US-Mexico Border
2010, American Journal of Medicine
Hospitalization rates for acute myocardial infarction can provide insight into the utilization of care by disadvantaged populations. However, these data have not been reported for the US-Mexico border region.
Hospital discharge public use data files for 2000 were obtained from the health departments of Arizona, California, and Texas. The diagnosis of acute myocardial infarction was based on International Classification of Diseases-9th Revision, Clinical Modification code 410 as a primary discharge diagnosis. In addition, cardiac catheterization, coronary angioplasty, and bypass grafting procedures were enumerated. Discharges were classified as occurring in hospitals in border counties and nonborder counties.
Overall, 12,464 hospital discharges in border counties had acute myocardial infarction listed as the first diagnosis. Among those aged 45-64 and ≥65 years in border counties, Texas had the lowest discharge rates (eg, at ≥65 years: Texas 95, California 134 per 10,000), lower than in nonborder counties. Among those aged ≥65 years, rates in Texas also were lower in border than nonborder counties, a pattern not seen in other states. On the contrary, rates of catheterization and bypass grafting were highest in Texas, whereas the rates of bypass grafting were actually higher in border than in nonborder counties. In border and nonborder counties of the combined states, hospitalization rates of acute myocardial infarction in Hispanics were lower than those of non-Hispanics. Rates varied little between border and nonborder counties within ethnic groups. A similar pattern was observed for the hospital use of angioplasty and coronary bypass surgery.
Our findings suggest possible underutilization of hospital in-patient care for coronary artery disease by Hispanics who were residents of Texas border counties. Further studies are needed to test this hypothesis using more recent data.
Ethnic differences in aortic valve thickness and related clinical factors
2010, American Heart Journal
Citation Excerpt :
The finding that Hispanics generally have a worse cardiovascular profile but less cardiovascular risk is called the Hispanic paradox.19,20 The Hispanic paradox remains controversial21,22 but seems to be supported by our results. Analogous to our results with AV thickness, the Multi-Ethnic Study of Atherosclerosis recently found that Hispanics had lower prevalence of CAC than non-Hispanic whites and that the relative risk for having CAC was the lowest in Hispanics after adjustment for clinical factors.10
Prior studies suggest that the causes of calcific aortic valve (AV) disease involve chronic inflammation, lipoprotein levels, and calcium metabolism, all of which may differ among race-ethnic groups. We sought to determine whether AV thickness differs by race-ethnicity in a large multiethnic population-based cohort.
The Northern Manhattan Study includes stroke-free community-based Hispanic (57%), non-Hispanic black (22%), and non-Hispanic white (21%) participants. The relation between AV thickness on transthoracic echocardiography and clinical risk factors for atherosclerosis was evaluated among 2,085 participants using polytomous logistic regression models. Aortic valve thickness was graded in 3 categories (normal, mild, and moderate/severe) based on leaflet thickening and calcification.
Mild AV thickness was present in 44.4% and moderate/severe thickness in 5.7% of the cohort, with the lowest frequency of moderate/severe thickness seen particularly among Hispanic women. In multivariate models adjusting for age, sex, race-ethnicity, body mass index, hypertension, coronary artery disease, blood glucose, and high-density lipoprotein cholesterol, Hispanics had significantly less moderate/severe AV thickness (odds ratio 0.43, 95% CI 0.25-0.73) than non-Hispanic whites. Men were almost 2-fold as likely to have moderate/severe AV thickness compared with women (odds ratio 1.96, 95% CI 1.24-3.10).
In this large multiethnic population-based cohort, there were ethnic differences in the degree of AV thickness. Hispanic ethnicity was strongly protective against AV thickness. This effect was not related to traditional risk factors, suggesting that unmeasured factors related to Hispanic ethnicity and AV thickness may be responsible.

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^☆: This work was supported by grants from the National Heart, Lung, and Blood Institute (HL24799 and HL36820).

²: To whom reprint requests should be addressed. Fax: (210) 567-6955. E-mail: [email protected].

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Regular ArticleDo Mexican Americans Really Have Low Rates of Cardiovascular Disease?☆

Abstract

Ann Epidemiol

Ann Epidemiol

The mortality of Spanish-surname persons in Texas, 1969–71

Mortality by cause among Spanish-surnamed Californians, 1969–71

Soc Sci Q

Altitude and ischemic heart disease in tricultural New Mexico: an example of confounding

Am J Epidemiol

Ischemic heart disease mortality in Hispanics, American Indians, and non-Hispanic whites in New Mexico, 1958–82

Circulation

Secular trends in ischemic heart disease and stroke mortality from 1970 to 1976 in Spanish-surnamed and other white individuals in Bexar County, Texas

Circulation

Secular decline in death rates due to ischemic heart disease in Mexican-Americans and non-Hispanic whites in Texas, 1970–80

Circulation

Acute myocardial infarction and coronary heart disease mortality among Mexican Americans and non-Hispanic whites in Texas, 1980 through 1989

Ethnic Dis

Overweight and mortality in Mexican Americans

Int J Obes

Regular Article
Do Mexican Americans Really Have Low Rates of Cardiovascular Disease?☆