Elsevier

The American Journal of Cardiology

Volume 135, 15 November 2020, Pages 68-76
The American Journal of Cardiology

Comparison of Frequency of Atrial Fibrillation in Blacks Versus Whites and the Utilization of Race in a Novel Risk Score

https://doi.org/10.1016/j.amjcard.2020.08.029Get rights and content

Highlights

  • Atrial fibrillation (AF) is less prevalent in African-Americans than in Caucasians

  • African-Americans have more AF risk factors than Caucasians

  • The above disparity is referred to as the AF ethnic paradox

  • Genetic, autonomic, and socio-economic factors contribute to the AF ethnic paradox

  • CHADSAVES risk score can help predicting inpatient AF

Blacks have a lower prevalence of atrial fibrillation (AF) compared with Whites. We sought to confirm previously reported ethnic trends in AF in Blacks and Whites in a large database, and develop a prediction score for AF. Over 330 million hospital discharges between the years 2003 to 2013 from the National Inpatient Sample database were analyzed. All hospitalizations with a diagnosis of AF formed the study cohort. Traditional risk factors for the development of AF were compared between Blacks and Whites. Univariate and multiple logistic regression analyses were used to formulate a risk score to predict AF–CHADSAVES (Congestive heart failure, Hypertension, Age>65 years, Diabetes Mellitus, prior Stroke, Age>75 years, Vascular disease, White Ethnicity, and previous cardiothoracic Surgery). AF prevalence in Whites was 11.3% vs 4.6% in Blacks (p < 0.001). Blacks were younger (33.8% vs 14.4% patients <65 years, p < 0.01) and had less males (46.3% vs 49.4%, p < 0.01). Blacks had more hypertension (71.3% vs 64.1%, p < 0.01), congestive heart failure (24.8% vs 22.6%, p < 0.01), diabetes mellitus with (7.5% vs 4.7%, p < 0.01) or without complications (30.3% vs 23.1%, p < 0.01), renal failure (29.7% vs 17.1%, p < 0.01), and obesity (13.1% vs 8.7%, p < 0.01). CHADSAVES predicted AF in the study population (NIS 2003 to 2013) with an AUC of 0.82 and verified in a validation cohort (NIS 2014) with an AUC of 0.85. In conclusion, our data confirm a significant AF ethnicity paradox. Despite a higher prevalence of traditional risk factors for AF, Blacks had >2-fold lower prevalence of AF compared with Whites. CHADSAVES can be used effectively to predict AF in inpatients.

Section snippets

Methods

The National Inpatient Sample (NIS) is the largest inpatient, all-payer inclusive, and publicly available database in the United States and is sponsored by the Agency for Healthcare Research and Quality (AHRQ) in collaboration with Healthcare Cost and Utilization Project (HCUP).13 The database includes a randomly selected, 20% stratified sample of discharges representing 95% of all the United States community hospitals and academic medical centers excluding long-term, acute care hospitals, and

Results

Out of a total of 338 million inpatient discharges in the NIS database from 2003 to2013, 29.9 million (8.8%) had a diagnosis of AF at discharge, 11.3% of AF discharges were White, and 4.6% were Black (Figure 1). The incidence of AF per 1,000 persons/year was 7.1 in Whites and 3.6 in Blacks (p < 0.001).

In patients with a discharge diagnosis of AF, Whites had a higher percentage of patients > 74 years of age (64.1%) as compared with Blacks (41.8%, p < 0.01). Similarly, Blacks with AF had a higher

Discussion

There exists an ethnic paradox, with Blacks having a higher prevalence of traditional cardiovascular risk factors but a lower prevalence of AF as compared with Whites. For almost a decade, the AF ethnicity paradox has been described in the literature.8,12,20,21 In a systematic review, Ugowe et al.20 comprehensively summarized a number of large cohort studies that reported ethnic differences in the prevalence and incidence of AF. Our study reflects a higher prevalence (4.6 to 11.3%) of AF than

Conclusion

African Americans, despite having a significantly higher prevalence of traditional risk factors compared with Whites, have a substantially lower prevalence of AF. The factors responsible for this difference could be older age and survival bias, a stronger genetic predisposition, and differences in clinical course with Whites experiencing more persistent AF and symptomatic AF as compared with Blacks. The CHADSAVES risk score may help predict patients at risk for developing AF in hospital

Disclosures

Dr. Kenneth Ellenbogen has received honoraria, lecture honoraria, grant support from Medtronic, and Boston Scientific, honoraria and consulting from Abbott, and Biotronik. The remaining authors have no relevant conflicts of interest to disclose.

Author Contributions

Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; Writing - review & editing.

Gurukripa N. Kowlgi: Conceptualization; Data curation; Formal analysis; Investigation; Roles/Writing - original draft; Writing - review & editing. Sampath Gunda: Data curation; Formal analysis; Investigation; Methodology; Project administration;

Declaration of Competing Interests

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

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