Estimating the contribution of overweight and obesity to ethnic inequalities in cardio-metabolic diseases in the Netherlands: a simulation study.

OBJECTIVES: Overweight and obesity (OWOB) starts in childhood, influences adult cardiovascular risk, and is not equally distributed across ethnic groups. It is unclear which effects can be expected from reductions in OWOB across the life course on inequalities in cardio-metabolic diseases in a multi-ethnic population. This study aims to estimate the effects of three scenarios of changes in OWOB (the Normal-Weight-for-All scenario, the No-Ethnic-Difference-over-the-Life-Course scenario, the and No-Ethnic-Differences-in-Childhood scenario). STUDY DESIGN: A simulation study. METHODS: We combine data from multiple data sources and use the Dynamic Modeling for Health Impact Assessment (DYNAMO-HIA) model to estimate the effects of three scenarios on the cumulative incidence of diabetes mellitus, ischaemic heart disease (IHD) and stroke between 18 and 70 years in the five largest ethnic groups in the Netherlands. RESULTS: In the scenario where all individuals have normal weight, the cumulative incidence decreased in all ethnic minority groups for all diseases, with largest decreases among South-Asian Surinamese, where the reduction of diabetes incidence exceeded 50%. In the scenario where the prevalence of OWOB in each ethnic-minority group was reduced to the current level among the Dutch-origin population, ethnic inequalities in cardio-metabolic diseases were substantially reduced, particularly when lowered prevalence of OWOB persisted across the lifespan. Reductions were the largest for diabetes and for the Asian Surinamese population. CONCLUSIONS: A substantial part of the well-known ethnic inequalities in incidence of diabetes, IHD, and stroke can be attributed to OWOB. Interventions aimed at reducing OWOB have clear potential to reduce the health inequalities in these outcomes, especially for diabetes, in particular when they have an impact across the lifespan.

Knowing our patients: a cross-sectional study of adult patients attending an urban Aboriginal and Torres Strait Islander primary healthcare service.

Many Aboriginal and Torres Strait Islander people live in urban areas, but epidemiological data about their health status and health needs are lacking. This knowledge is critical to informing and evaluating initiatives to improve service delivery and health outcomes. One potential data source is de-identified routinely collected clinical data. This cross-sectional study, conducted in an urban Aboriginal and Torres Strait Islander primary healthcare service, involved randomly selecting a sample of 400 patients aged ≥15 years, and manually extracting electronic health record data. In the sample, 49% of patients were aged <35 years, 56% were female and 38% were employed. Overall, 56% of females and 47% of males aged 35-54 years had depression, 26% had experienced a bereavement within the last 12 months, and while 44% were alcohol abstainers, 35% were drinking at high-risk levels. The present study cannot demonstrate causal relationships between the observed high rates of chronic disease in older people and frequent experiences of bereavement and high levels of mental ill health in young- and middle-aged adults. However, a life course approach provides a framework to understand the interconnectedness of these results, and suggests that strategies to blunt the intergenerational burden of chronic disease need to address the social and emotional wellbeing of youth.

The Burden of Cardiovascular Disease in Sub-Saharan Africa and the Black Diaspora.

For over four decades the National Medical Association (NMA) and the Association of Black Cardiologists (ABC) have sought to bring to national attention the disparate burden of cardiovascular disease (CVD) among African Americans. However, systematic inquiry has been inadequate into the burden of CVD in the poor countries of Sub-Saharan Africa (SSA) and the African diaspora in the Americas outside the USA. However, recently, the Global Burden of Disease Study (GBD) has offered new tools for such inquiry. Several initial efforts in that direction using 2010 data have been published. This article highlights some new findings for SSA for 2016. It also suggests that NMA and ABC further this effort by direct advocacy and collaboration with the GBD to make estimates of CVD burden in African Americans and South American Blacks explicitly available in future iterations.

Do black lives matter in public health research and training?

OBJECTIVE: To examine whether investments made in public health research align with the health burdens experienced by white and black Americans. METHODS: In this cross-sectional study of all deaths in the United States in 2015, we compared the distribution of potential years of life lost (PYLL) across 39 causes of death by race and identified key differences. We examined the relationship between cause-of-death-specific PYLL and key indicators of public health investment (federal funding and number of publications) by race using linear spline models. We also compared the number of courses available at the top schools of public health relevant to the top causes of death contributor to PYLL for black and white Americans. RESULTS: Homicide was the number one contributor to PYLL among black Americans, while ischemic heart disease was the number one contributor to PYLL among white Americans. Firearm-related violence accounted for 88% of black PYLL attributed to homicide and 71% of white PYLL attributed to homicide. Despite the high burden of PYLL, homicide research was the focus of few federal grants or publications. In comparison, ischemic heart disease garnered 341 grants and 594 publications. The number of public health courses available relevant to homicide (n = 9) was similar to those relevant to ischemic heart disease (n = 10). CONCLUSIONS: Black Americans are disproportionately affected by homicide, compared to white Americans. For both black and white Americans, the majority of PYLL due to homicide are firearm-related. Yet, homicide research is dramatically underrepresented in public health research investments in terms of grant funding and publications, despite available public health training opportunities. If left unchecked, the observed disproportionate distribution of investments in public health resources threatens to perpetuate a system that disadvantages black Americans.

Geographic Variations in Cardiovascular Disease Mortality Among Asian American Subgroups, 2003-2011.

BACKGROUND: There are well-documented geographical differences in cardiovascular disease (CVD) mortality for non-Hispanic whites. However, it remains unknown whether similar geographical variation in CVD mortality exists for Asian American subgroups. This study aims to examine geographical differences in CVD mortality among Asian American subgroups living in the United States and whether they are consistent with geographical differences observed among non-Hispanic whites. METHODS AND RESULTS: Using US death records from 2003 to 2011 (n=3 897 040 CVD deaths), age-adjusted CVD mortality rates per 100 000 population and age-adjusted mortality rate ratios were calculated for the 6 largest Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) and compared with non-Hispanic whites. There were consistently lower mortality rates for all Asian American subgroups compared with non-Hispanic whites across divisions for CVD mortality and ischemic heart disease mortality. However, cerebrovascular disease mortality demonstrated substantial geographical differences by Asian American subgroup. There were a number of regional divisions where certain Asian American subgroups (Filipino and Japanese men, Korean and Vietnamese men and women) possessed no mortality advantage compared with non-Hispanic whites. The most striking geographical variation was with Filipino men (age-adjusted mortality rate ratio=1.18; 95% CI, 1.14-1.24) and Japanese men (age-adjusted mortality rate ratio=1.05; 95% CI: 1.00-1.11) in the Pacific division who had significantly higher cerebrovascular mortality than non-Hispanic whites. CONCLUSIONS: There was substantial geographical variation in Asian American subgroup mortality for cerebrovascular disease when compared with non-Hispanic whites. It deserves increased attention to prioritize prevention and treatment in the Pacific division where approximately 80% of Filipinos CVD deaths and 90% of Japanese CVD deaths occur in the United States.

[Burden of disease attributed to high total cholesterol in 2013 in China].

Objective: To analyze the burden of disease attributed to high total cholesterol(TC)in 2013 in China. Methods: We used data from the 2013 Global Burden of Disease Study. The population attributable fraction was calculated to estimate the deaths and disability-adjusted life years(DALY)attributed to high TC. Disease burden was compared by age, gender, diseases and province(not including Taiwan, China). An average world population age structure for the period 2000- 2025 was adopted to calculate age-standardized rates. Results: In 2013, high TC caused 298 952 deaths in China, accounting for 3.3% of total deaths, and caused 6 332 thousand DALYs. DALYs attributed to high TC were highest among the 50-69 years age group(3 165 thousand person years), accounting for 50.0% of the total attributed DALYs. The DALY rate in the ≥70 years age group was 2 053.3/100 000, which was 10.3 times that of 15-49 age group(198.6/100 000). DALYs among men were 4 431 thousand person years, which was 2.3 times higher than in women(1 900 thousand person years), and the age-standardized DALY rate among men was 590.6/100 000, which was 2.3 times higher than in women(257.1/100 000). DALYs attributed to high TC were mainly caused by ischemic heart disease(IHD; 5 572 thousand person years), accounting for 88.0% of the total attributed DALYs. Deaths and DALYs attributed to high TC were highest in Shandong(31 002 and 628 thousand person years for deaths and DALYs, respectively), Henan(27 398 deaths and 587 thousand person years, respectively), Hebei(25 744 deaths and 589 thousand person years, respectively), accounting for 28.1% of total attributed deaths and 28.5% of total attributed DALYs. The number of deaths and DALY were lowest in Macao(75 deaths and 1 thousand person years, respectively)and Tibet(385 deaths and 10 thousand person years, respectively). The age standardized DALY rates were highest in Beijing(794.8/100 000), Hebei(732.7/100 000), and Jilin(709.1/100 000), and lowest in Shanghai(151.4/100 000), Zhejiang(168.1/100 000), and Hong Kong(182.0/100 000). Conclusion: The burden of disease attributed to high TC in 2013 in China was mainly the result of the IHD it causes, with greater influence among males and those aged ≥50 years, and variation among provinces.

Ethnic differences in case fatality following an acute ischaemic heart disease event in New Zealand: ANZACS-QI 13.

BACKGROUND: The aim of this study was to investigate ischaemic heart disease (IHD) case fatality in high-risk ethnic populations in New Zealand. DESIGN: This is a national data-linkage study using anonymised hospitalisation and mortality data. METHODS: Linked individual patient data were used to identify 35-84-year-olds who experienced IHD events (acute IHD hospitalisations and/or deaths) in 2009-2010. Subjects were classified as: (i) hospitalised with IHD and alive at 28 days post-event; (ii) hospitalised with IHD and died within 28 days; (iii) hospitalised with a non-IHD diagnosis and died from IHD within 28 days; or (iv) died from IHD but not hospitalised. Multinomial logistic regression was used to estimate the proportion of people in each group, as well as overall 28-day case fatality, adjusted for ethnic differences in demographic and comorbidity profiles. RESULTS: A total of 26,885 people experienced IHD events (11.3% Maori, 4.0% Pacific and 2.5% Indian); 3.3% of people died within 28 days of IHD hospitalisations, 5.1% died of IHD within 28 days of non-IHD hospitalisations and 13.0% died of IHD without any recent hospitalisation. Overall adjusted case fatality was 12.6% in Indian, 20.5% in European, 26.0% in Pacific and 27.6% in Maori people. Compared to Europeans, the adjusted odds of death were approximately 50% higher in Maori and Pacific people and 50% lower in Indians, regardless of whether they were hospitalised. CONCLUSIONS: Major ethnic inequalities in IHD case fatality occur with and without associated hospitalisations. Improvements in both primary prevention and hospital care will be required to reduce inequalities.

Impact of Socioeconomic Status, Ethnicity, and Urbanization on Risk Factor Profiles of Cardiovascular Disease in Africa.

Africa is a continent characterized by marked ethnic, sociodemographic, and economic diversity, with profound changes in many regions over the past 2 decades. This diversity has an impact on cardiovascular disease presentation and outcomes. Within Africa and within the individual countries, one can find regions having predominantly communicable diseases such as rheumatic heart disease, tuberculous pericarditis, or cardiomyopathy and others having a marked increase in noncommunicable disease such as hypertension and hypertensive heart disease. Ischemic heart disease remains rare in most countries. Difficulties in the planning and implementation of effective health care in most African countries are compounded by a paucity of studies and a low rate of investment in research and data acquisition. The fiduciary responsibilities of companies working in Africa should include the effective and efficient use of natural resources to promote the overall health of populations.

Cause-specific mortality by race in low-income Black and White people with Type 2 diabetes.

AIM: To investigate, with extended follow-up, cause-specific mortality among low-income Black and White Americans with Type 2 diabetes who have similar socio-economic status. METHODS: Black and White Americans aged 40-79 years with Type 2 diabetes (n = 12 498) were recruited from community health centres as part of the Southern Community Cohort Study. Multivariable Cox analysis was used to estimate mortality hazard ratios and 95% CIs for subsequent cause-specific mortality, based on both underlying and contributing causes of death. RESULTS: During the follow-up (median 5.9 years), 13.3% of the study population died. The leading causes of death in each race were ischaemic heart disease, respiratory disorders, cancer, renal failure and heart failure; however, Blacks were at a lower risk of dying from ischaemic heart disease (hazard ratio 0.70, 95% CI 0.54-0.91) or respiratory disorders (hazard ratio 0.70, 0.53-0.92) than Whites but had higher or similar mortality attributable to renal failure (hazard ratio 1.57, 95% CI 1.02-2.40), heart failure (hazard ratio 1.47, 95% CI 0.98-2.19) and cancer (hazard ratio 0.87, 95% CI 0.62-1.22). Risk factors for each cause of death were generally similar in each race. CONCLUSIONS: These findings suggest that the leading causes of death and their risk factors are largely similar among Black and White Americans with diabetes. For the two leading causes of death in each race, however, ischaemic heart disease and respiratory disorders, the magnitude of risk is lower among Black Americans and contributes to their higher survival rates.

Transfers to metropolitan hospitals and coronary angiography for rural Aboriginal and non-Aboriginal patients with acute ischaemic heart disease in Western Australia.

BACKGROUND: Aboriginal people have a disproportionately higher incidence rate of ischaemic heart disease (IHD) than non-Aboriginal people. The findings on Aboriginal disparity in receiving coronary artery procedures are inconclusive. We describe the profile and transfers of IHD patients admitted to rural hospitals as emergency admissions and investigate determinants of transfers and coronary angiography. METHODS: Person-linked hospital and mortality records were used to identify 28-day survivors of IHD events commencing at rural hospitals in Western Australia. Outcome measures were receipt of coronary angiography, transfer to a metropolitan hospital, and coronary angiography if transferred to a metropolitan hospital. RESULTS: Compared to non-Aboriginal patients, Aboriginal patients with IHD were more likely to be younger, have more co-morbidities, reside remotely, but less likely to have private insurance. After adjusting for demographic characteristics, Aboriginal people with MI were less likely to be transferred to a metropolitan hospital, and if transferred were less likely to receive coronary angiography. These disparities were not significant after adjusting for comorbidities and private insurance. In the full multivariate model age, comorbidities and private insurance were adversely associated with transfer to a metropolitan hospital and coronary angiography. CONCLUSION: Disparity in receiving coronary angiography following emergency admission for IHD to rural hospitals is mediated through the lower likelihood of being transferred to metropolitan hospitals where this procedure is performed. The likelihood of a transfer is increased if the patient has private insurance, however, rural Aboriginal people have a lower rate of private insurance than their non-Aboriginal counterparts. Health practitioners and policy makers can continue to claim that they treat Aboriginal and non-Aboriginal people alike based upon clinical indications, as private insurance is acting as a filter to reduce rural residents accessing interventional cardiology. If health practitioners and policy makers are truly committed to reducing health disparities, they must reflect upon the broader systems in which disparity is perpetuated and work towards a systems improvement.

Policy initiatives, culture and the prevention and control of chronic non-communicable diseases (NCDs) in the Caribbean.

OBJECTIVE: To explore interactions between disease burden, culture and the policy response to non-communicable diseases (NCDs) within the Caribbean, a region with some of the highest prevalence rates, morbidity and mortality from NCDs in the Americas. METHODS: We undertook a wide ranging narrative review, drawing on a variety of peer reviewed, government and intergovernmental literature. RESULTS: Although the Caribbean is highly diverse, linguistically and ethnically, it is possible to show how 'culture' at the macro-level has been shaped by shared historic, economic and political experiences and ties. We suggest four broad groupings of countries: the English-speaking Caribbean Community (CARICOM); the small island states that are still colonies or departments of colonial powers; three large-Spanish speaking countries; and Haiti, which although part of CARICOM is culturally distinct. We explore how NCD health policies in the region stem from and are influenced by the broad characteristics of these groupings, albeit played out in varied ways in individual countries. For example, the Port of Spain declaration (2007) on NCDs can be understood as the product of the co-operative and collaborative relationships with CARICOM, which are based on a shared broad culture. We note, however, that studies investigating the relationships between the formation of NCD policy and culture (at any level) are scarce. CONCLUSION: Within the Caribbean region it is possible to discern relationships between culture at the macro-level and the formation of NCD policy. However, there is little work that directly assesses the interactions between culture and NCD policy formation. The Caribbean with its cultural diversity and high burden of NCDs provides an ideal environment within which to undertake further studies to better understand the interactions between culture and health policy formation.

Access and society as determinants of ischaemic heart disease in indigenous populations.

BACKGROUND: Ischaemic Heart Disease (IHD) is a leading cause of death in New Zealand and the burden falls disproportionately on Maori, the indigenous population of Aotearoa New Zealand. METHODS: Data for Maori:non-Maori disparities in risk factors, hospitalisation, procedure receipt and mortality for IHD are analysed. Age-adjusted rates of IHD mortality (2000-2004) and publicly funded hospitalisations and procedures (2003-2005) for Maori and non-Maori are reported and compared. RESULTS: Significant inequalities between Maori and non-Maori in IHD risk factors, hospitalisations, mortality and the receipt of related procedures exist. IHD hospitalisation rates for Maori are 1.4 times that of non-Maori, however mortality rates are more than twice that of non-Maori. In recent years Maori revascularisation rates have increased (as have non-Maori rates) but are still considerably less than might be expected given the much higher mortality rates. CONCLUSION: Despite high need, Maori receive relatively low access to appropriate care for IHD. The role of society, policy, and the clinician are three key factors to be considered in reducing inequalities for IHD between Maori and non-Maori.

Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S.

OBJECTIVE: We assessed health status and behavioral risks in American Indians (AIs) from rural, northern plains reservation communities. METHODS: AI interviewers from the communities administered the core and optional modules of the Behavioral Risk Factor Surveillance System (BRFSS) to 404 AI adults randomly selected from housing lists from four AI tribal communities located on the northern plains of the U.S. The BRFSS interview assessed several health functioning areas including medical conditions, preventive screenings, and behavioral risks. We measured health disparities by comparing the AI sample data with a northern plains statewide (North Dakota) sample and a U.S. national sample. We compared outcomes with BRFSS statewide (North Dakota) and U.S. national data from telephone-based interviews. RESULTS: AI participants showed a significantly greater prevalence of diabetes, coronary heart disease, myocardial infarction, smoking, obesity, and heavy alcohol use than either the regional or national samples. They also reported being less likely to engage in leisure-time physical activity and to have had age-appropriate preventive screenings for several diseases including colorectal cancer, prostate cancer, breast cancer, and cardiovascular disease. CONCLUSIONS: Face-to-face interviews conducted by AI community members are an effective means of gathering health information about AIs living in rural, reservation communities. AIs living in these communities on the northern plains have a much higher prevalence of many health-risk behaviors and some medical conditions than are found in the general population. Improved health-care access, better preventive screenings, and culturally appropriate community-based health promotion programs and policies should be examined as possible ways to reduce health disparities.

Black-white differences in avoidable mortality in the USA, 1980-2005.

BACKGROUND: Avoidable Mortality (AM) describes causes of death that should not occur in the presence of high-quality and timely medical treatment and from causes that can be influenced at least in part by public policy/behaviour. This study analyses black-white disparities in AM. METHODS: Mortality under age 65 was analysed from: (1) conditions amenable to medical care; (2) those sensitive to public policy and/or behaviour change; (3) ischaemic heart disease; (4) HIV/AIDS; and (5) the remaining causes of death. Age-standardised death rates (ASDRs) were constructed for each race and sex group using vital statistics and census data from 1980-2005. Absolute rate differences and the proportionate contribution of each cause of death group to all-cause black-white mortality disparities are calculated based on the ASDRs. Negative binomial regression was used to model relative risks of death. RESULTS: In 2005, medical care amenable mortality was the largest source of absolute black-white mortality disparity, contributing 30% of the black-white difference in all-cause mortality among men and 42% among women; mortality subject to policy/behaviour interventions contributed 20% of the black-white difference for men and 4% for women. Although absolute black-white differences for most conditions diminished over time, relative disparities as measured by rate ratios showed little change, except for HIV/AIDS for which relative risks increased substantially for black men and women. CONCLUSIONS: There is considerable potential for narrowing of the black-white difference in AM, especially from causes amenable to medical care and (for men) policy/behaviour interventions.

Determinants of target organ damage in black hypertensive patients attending primary health care services in Cape Town: the Hi-Hi study.

BACKGROUND: In South Africa (SA) cardiovascular disease (CVD) is the second leading cause of death, with hypertension (HTN) being the predominant contributor to morbidity and mortality associated with this disease. We examined the prevalence and determinants of target organ damage (TOD) among urban black hypertensive South Africans attending primary health-care (PHC) services in Cape Town. METHODS: Patients on HTN treatment, 35-65 years of age, participated in this cross-sectional study. Data relating to sociodemographic factors, medical history, lifestyle patterns, and HTN care regimens were obtained. Blood and urine samples were analyzed and electrocardiographs (ECGs) were recorded. Sokolow-Lyon and Minnesota Code (MC) criteria were used for identifying left ventricular hypertrophy (LVH). Reduced creatinine clearance (Cockroft-Gault), microalbuminuria, proteinuria, and elevated serum creatinine levels were used for identifying "renal impairment by any criteria" (RIC). Ischemic ECG patterns were classified in terms of MC criteria. Multivariate logistic regression analyses were carried out to identify variables independently associated with TOD. RESULTS: The study sample comprised 403 participants. RIC was identified in 26%, LVH in 35%, and ischemic ECG patterns in 49% of the participants. Uncontrolled HTN and an absence of diabetes were associated with LVH as per Sokolow-Lyon criteria. Older age, the presence of diabetes, and the use of beta-blockers were associated with RIC. Ischemic ECG patterns were associated with uncontrolled HTN, older age, male gender, the consumption of less alcohol, and higher levels of low-density lipoprotein cholesterol (LDL-C). CONCLUSIONS: TOD is common in this group of black hypertensive patients attending PHC sites. Uncontrolled HTN and older age were most often associated with TOD. Reducing the burden of TOD will require improving the quality of HTN care in PHC settings.

Comparison of five-year outcome in African Americans versus Caucasians following percutaneous coronary intervention.

BACKGROUND: Studies regarding short-term outcomes after percutaneous coronary intervention (PCI) have reported no ethnic differences and data on long-term follow-up is conflicting and sparse. METHODS: 730 consecutive patients (67% African American) undergoing PCI from January 1999 to December 2000 at a tertiary care center in Detroit, MI, were followed up. End points studied included either all cause mortality collected from Social Security Death Index or first hospital admission after the index procedure due to myocardial infarction(MI), congestive heart failure(CHF), and revascularization (PCI or coronary artery bypass graft surgery). RESULTS: African-Americans undergoing PCI had significant differences in baseline cardiovascular co-morbidity and were more likely to present with acute myocardial infarction than Caucasians. On Kaplan Meier survival analysis and log rank test, each ethnic group had equivalent survival for cumulative end points upto 6-month follow-up, however longer follow-up to 5 year was characterized by lower survival rate in African Americans compared to Caucasians (41% vs. 54%, log rank P 0.01). After adjustment for potential confounders, AA ethnicity (Adjusted HR 1.62, 95% CI 1.01-1.28, P 0.04) remained a predictor of adverse cardiac outcome (Death/MI/CHF) at five-year follow-up (Cox regression propensity adjusted hazard analysis). CONCLUSIONS: African American patients undergoing PCI had unfavorable baseline cardiovascular characteristics but comparable short-term outcome compared to whites. However, at 5-year follow-up, African Americans had worse clinical outcome, higher incidence of acute myocardial infarction, congestive heart failure and significantly lower long-term survival.

Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE).

BACKGROUND: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce. METHODS: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative. RESULTS: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05). CONCLUSIONS: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

How low can it go? Projecting ischaemic heart disease mortality in New Zealand to 2015.

AIMS: This study aims to identify how ischaemic heart disease (IHD) mortality rates in New Zealand have varied between successive cohorts and time periods. This information is then used to project IHD mortality rates and counts (burdens) out to year 2011-15. METHODS: Age/period/cohort models were constructed (5-year periods and 5-year age groups, generating 10-year overlapping cohorts) using both frequentist and Bayesian methods. Data were available from 1956 for the total population and from 1981 for Maori. The projection period was 2001-5 to 2011-15. Uncertainty was quantified as the Bayesian 90% credible interval. RESULTS: IHD mortality rates for all age by gender groups increased from 1956-60 to peak in 1966-70, then declined by more than 60% to current (1996-2000) levels. However, the decline has been much shallower for Maori. This decline has resulted from increasingly favourable period effects since 1971-75 (less marked for Maori). However, no substantive cohort effects have been seen, at least from the 1891 to the 1951 cohort. Our model suggests that, for the first time, a substantive and unfavourable cohort effect may be emerging among recent birth cohorts. CONCLUSIONS: IHD mortality rates are projected to continue to fall from 2001-05 to 2011-15, albeit more slowly than in the past as the increasing (favourable) period effect is partly offset by an emerging (unfavourable) cohort effect. The result is a relatively small projected decline in absolute IHD mortality burden overall, but an actual increase among Maori.