Are There Differences in Vascular Disease Between Ethnic and Racial Groups?
1998; Lippincott Williams & Wilkins; Volume: 29; Issue: 1 Linguagem: Inglês
10.1161/01.str.29.1.2
ISSN1524-4628
Autores Tópico(s)Cerebrovascular and Carotid Artery Diseases
ResumoHomeStrokeVol. 29, No. 1Are There Differences in Vascular Disease Between Ethnic and Racial Groups? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBAre There Differences in Vascular Disease Between Ethnic and Racial Groups? Askiel Bruno Askiel BrunoAskiel Bruno From the Cerebrovascular Program, Department of Neurology, Indiana University School of Medicine, Indianapolis. Originally published1 Jan 1998https://doi.org/10.1161/01.STR.29.1.2Stroke. 1998;29:2–3The study of disease differences between ethnic and racial groups is complicated by the genetic, environmental, and cultural heterogeneity within each group. Despite these complications, the study of well-defined groups of people can yield medical information useful to improve health in these groups. For example, moyamoya disease has a predilection for Japanese people, the incidence of stroke is higher in blacks than in whites,1 and occlusive cerebrovascular lesions are more likely to be intracranial in blacks than whites.234 This information can be used to optimize risk factor screening and management, acute stroke treatment, and secondary stroke prevention in the various ethnic and racial groups.Relatively little is known about cerebrovascular disease in Hispanics and Native Americans in the southwestern United States. Hispanics constitute ≈9.0% of the US population according to the 1990 US census, and a large majority of them live in the southwestern United States. The ancestors of the Hispanics in the southwestern United States are mainly the settlers and conquerors who came from Spain starting in the 16th century. Since their arrival in the southern part of North America, there has been cultural and genetic interaction between the Spanish and the various Native American tribes living in this region. The Hispanics who relatively recently immigrated from Mexico to the southwestern United States have a similar ancestry.Differences in vascular risks have been measured between US Hispanics and non-Hispanic whites. US Hispanics appear to have a lower prevalence and severity of arterial hypertension and lower levels of serum cholesterol but higher prevalence of diabetes mellitus, tobacco smoking, and obesity than non-Hispanic whites.5 These differences in vascular risks may lead to variances in the manifestation of cerebrovascular disease between Hispanics and non-Hispanic whites. The incidence of intracerebral hemorrhage6 and subarachnoid hemorrhage7 in central New Mexico is significantly higher among Hispanics than non-Hispanic whites. The reasons for these differences have not been investigated. It is important and interesting to observe that Hispanics in New York City, who have different ancestry than Hispanics in New Mexico, also have an increased incidence of hemorrhagic strokes as compared with whites.8 Although the prevalence is probably very low, familial cerebral cavernous vascular malformations predominate in Hispanics in the southwestern United States.910Native Americans constitute ≈0.8% of the US population according to the 1990 US census. The Native Americans came to the Americas from Asia tens of thousands of years ago, when the Bering Straights area was land connecting the two continents. Before the arrival of Europeans in the Americas, Native Americans had already spread over the continents and developed a variety of cultures influenced by various ecological conditions. In the southwestern United States, Native Americans have been divided into four groups, the Yuma, Pima-Papago, Pueblo, and Apache. These groups probably are exposed to different vascular risks and have different attitudes toward health and illness. These differences are likely to influence the extent of detection and control of vascular risks. Since the arrival of Europeans in the Americas, cultural and genetic integration with Native Americans has been occurring to some degree. Some Native Americans live on reservations, but most live in neighboring communities and periodically visit their native reservation. Consequently, Native Americans in the southwestern United States are heterogeneous people. An example of a physiological difference between the Native American tribes in the southwestern United States is the unusually high prevalence of diabetes mellitus among the Pima Indians of Arizona.1112 Studying a combination of Native American groups may mask differences between them.The available cardiovascular data on Native Americans from various parts of the United States, mainly from the National Health and Nutrition Examination Survey I and II, suggest that they may have a higher prevalence of diabetes mellitus, tobacco smoking, and obesity than whites.13 Additional well-documented cardiovascular risk factor information, including alcoholism and drug abuse, in well-defined homogeneous Native American populations is needed to optimize vascular disease prevention efforts.The best way to study differences between ethnic or racial groups is to investigate community populations by using standardized diagnostic criteria and verified diagnoses. Hospital-based studies are prone to patient selection bias. Patients referred to a given medical center are selected on the basis of their health insurance coverage, a specific disorder in which the receiving medical center specializes, the interest and confidence with which the referring physicians treat patients with similar disorders, presence of other complicating diseases, and proximity to the medical center. A large proportion of patients with similar disorders, living in the same community, are probably not referred to the study center unless it is the only medical facility for a given community. This is beyond the control of the investigators. Because of this unavoidable bias, results from a hospital-based study may or may not apply to the same groups of people living in the community. For example, in the study published in this issue of the journal,14 the proportion of stroke patients with intracerebral hemorrhage is unusually high among whites (37%) and Hispanics (48%). The expected proportion of intracerebral hemorrhages among whites is 10%, based on various other stroke registries. The proportion of strokes due to intracerebral hemorrhage among Hispanics has not been studied in a southwestern US community population, but in New York City it was 11%.8 This is one reason why the subjects in this study are unlikely to be a representative sample of stroke patients in the community.Another possible source of confusion from epidemiological studies is when results are based solely on diagnostic codes or death certificates. These documents are completed by a variety of people without specific standardized guidelines. In some instances, the diagnosis of stroke may be questionable or key diagnostic tests may be missing. This could lead to coding inaccuracies. In instances in which the cause of death is unconfirmed, the designation may be based on the presence of risk factors and other available clinical information. The accuracy of such determinations is likely to be low. Consequently, the accuracy of these medical documents are variable, and the results based on them may be erroneous. Review of pertinent medical records with standardized and reasonably strict criteria to confirm the diagnoses will minimize errors.Only community-based studies, with proper standardized definitions and verified diagnoses of the disorders being investigated, will convincingly answer the important questions regarding vascular differences between various ethnic and racial groups. In addition, to maximize the chances of demonstrating differences between ethnic and racial groups, if they exist, each group should be defined to make it as homogeneous as is reasonably possible. Ancestry, environment, and culture should be similar within each group.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.Reviews of this manuscript were directed by Hermes Kontos, MD, and Marie-Germaine Bousser, MD. Because of possible conflict of interest, Drs Mark Dyken and José Biller were not involved in the reviews.FootnotesCorrespondence to Askiel Bruno, MD, Neurology Department, 541 Clinical Dr, Room 365, Indiana University School of Medicine, Indianapolis, IN 46202-5111. References 1 Caplan LR. Strokes in African-Americans. Circulation..1991; 83:1469-1471.CrossrefMedlineGoogle Scholar2 Gorelick P, Caplan L, Langenberg P, Hier D, Pessin M, Patel D, Taber J. Clinical and angiographic comparison of asymptomatic occlusive cerebrovascular disease. Neurology..1988; 38:852-858.CrossrefMedlineGoogle Scholar3 Inzitari D, Hachinski VC, Taylor DW, Barnett HJ. Racial differences in the anterior circulation in cerebrovascular disease: how much can be explained by risk factors? Arch Neurol..1990; 47:1080-1084.CrossrefMedlineGoogle Scholar4 Wityk R, Lehman D, Klag M, Coresh J, Ahn H, Litt B. Race and sex differences in the distribution of cerebral atherosclerosis. Stroke..1996; 27:1974-1980.CrossrefMedlineGoogle Scholar5 Gillum RF. Epidemiology of stroke in Hispanic Americans. Stroke..1995; 26:1707-1712.CrossrefMedlineGoogle Scholar6 Bruno A, Carter S, Qualls C, Nolte KB. Incidence of spontaneous intracerebral hemorrhage among Hispanics and non-Hispanic whites in New Mexico. Neurology..1996; 47:405-408.CrossrefMedlineGoogle Scholar7 Bruno A, Carter S, Qualls C, Nolte KB. Incidence of spontaneous subarachnoid hemorrhage among Hispanics and non-Hispanic whites in New Mexico. Ethn Dis..1997; 7:1234-1235.Google Scholar8 Sacco RL, Hauser WA, Mohr JP. Hospitalized stroke in blacks and Hispanics in Northern Manhattan. Stroke..1991; 22:1491-1496.CrossrefMedlineGoogle Scholar9 Rigamonti D, Hadley MN, Drayer BP, Johnson PC, Hoenig-Rigamonti K, Knight JT, Spetzler RF. Cerebral cavernous malformations: incidence and familial occurrence. N Engl J Med.1988; 319:343-347.CrossrefMedlineGoogle Scholar10 Kattapong VJ, Hart BL, Davis LE. Familial cerebral cavernous angiomas: clinical and radiologic studies. Neurology.1995; 45:492-497.CrossrefMedlineGoogle Scholar11 Knowler WC, Pettitt DJ, Saad MF, Bennett PH. Diabetes mellitus in the Pima Indians: incidence, risk factors and pathogenesis. Diabetes Metab Rev.1990; 6:1-27.CrossrefMedlineGoogle Scholar12 Mitchell B, Stern M. Recent developments in the epidemiology of diabetes in the Americas. World Health Stat Q..1992; 45:347-349.MedlineGoogle Scholar13 Gillum RF. The epidemiology of stroke in Native Americans. Stroke..1995; 26:514-521.CrossrefMedlineGoogle Scholar14 Frey JL, Jahnke HK, Bulfinch EW. Differences in stroke between white, Hispanic, and Native American populations: the Barrow Neurological Institute Stroke Database. Stroke..1997; 29:29-33.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Krishna V and Kim D Ethnic differences in risk factors for subarachnoid hemorrhage, Journal of Neurosurgery, 10.3171/JNS-07/09/0522, 107:3, (522-529) Ohno S and Ishigatsubo Y (2006) The Incidence of Lofgren's Syndrome in Japanese: The Number of Patients Affected, Number of Patients Diagnosed and Number of Cases Reported, Internal Medicine, 10.2169/internalmedicine.45.0150, 45:12, (745-746), . Staub L and Morgenstern L (2000) STROKE IN HISPANIC AMERICANS, Neurologic Clinics, 10.1016/S0733-8619(05)70193-6, 18:2, (291-307), Online publication date: 1-May-2000. Raaymakers T, Rinkel G and Ramos L (1998) Initial and follow-up screening for aneurysms in families with familial subarachnoid hemorrhage, Neurology, 10.1212/WNL.51.4.1125, 51:4, (1125-1130), Online publication date: 1-Oct-1998. January 1998Vol 29, Issue 1 Advertisement Article InformationMetrics Copyright © 1998 by American Heart Associationhttps://doi.org/10.1161/01.STR.29.1.2 Originally publishedJanuary 1, 1998 Keywordsstrokeethnic groupsracial differencesgeneticsvascular diseasesPDF download Advertisement
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