1. Ethnic Differences in the Prognostic Value of Coronary Artery Calcification for All-Cause Mortality Khurram Nasir MD MPH, Leslee J. Shaw PhD, Sandy T. Liu MD, Steven R. Weinstein MD, Tristen R. Mosler MD, Phillip R. Flores MD, Ferdinand R. Flores MD, Paolo Raggi MD, Daniel S. Berman MD, Roger S Blumenthal MD, & Matthew J. Budoff MD J Am Coll Cardiol 2007;50:953-960

2. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Objectives & Background Objectives: The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality. Background: Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than Non-Hispanic Whites (NHW). Some of this variability may be due to differing pathophysiologic mechanisms and effects of underlying atherosclerosis.

3. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Methods The study sample consisted of 14,812 asymptomatic subjects, including 637 African-Americans (AA), 1,065 Asians (AS), 1,334 Hispanics (HS), and 11,776 non-Hispanic whites (NHW), referred by their primary care physicians between 1991 and 2004 for CAC screening with EBT. Epidemiological methods for follow-up included ascertainment of events by individuals blinded to historical and CAC results. The occurrence of all-cause death was verified with the National Death Index. Individuals who underwent cardiovascular screening were followed up for a mean of 6.8 years ± 0.02 (standard error of the mean), with a range of 0.7-14.5 years.

4. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Prevalence of Cardiac Risk Factors in 14,812 Asymptomatic Individuals Undergoing CAC Screening Non Hispanic Whites N=11,776 African Americans N=637 Hispanics N=1334 Asians N=1065 Age (in years)57±11 53±1155±12<0.0001 Family History of Premature CAD (%) 60474849<0.0001 Smoking (%)9141180.002 Diabetes Mellitus (%)6181712<0.0001 Hypertension (%)28493638<0.0001 Female Gender (%)445752 <0.0001 Hyperlipidemia (%)474443450.105 Number of Risk Factors 0 1-2 ≥3 19 70 11 20 58 22 21 63 16 23 64 13 <0.0001

5. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Observed Frequency of CAC Score Subsets by Ethnicity (N=14,812) As compared to NHW, all ethnic groups had lower odds of having any as well as increasing burden of CAC (p<0.0001).

6. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Long-Term Survival in Ethnic Subsets (N=14,812)

7. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Cumulative Survival By CAC Scores in Ethnic Subsets

8. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Multivariable Model Relative Risk Ratios (RRR) for All- Cause Mortality By CAC scores According to Ethnicity CAC Scores OverallNon Hispanic Whites African Americans HispanicsAsians 0-101 (reference) 11-1004.9 (3.6-6.8)3.8 (2.6-5.6)4.1 (1.6-10.8) p=0.004 4.2 (1.9-9.5) P=0.001 9.3 (1.3-66.2) p=0.026 100- 400 10.5 (7.7-14.2)6.9 (4.8-9.9)12.3 (5.0-30.5)3.7 (1.4-10.3) P=0.011 13.1 (2.8-61.9) p=0.001 401- 1000 22.0 (16.0- 30.3) 10.8 (7.4-15.7)25.6 (9.9-66.3)19.1 (8.7- 42.3) 17.6 (3.7-84.7) >1,00045.3 (33.4- 61.6) 24.8 (17.3- 35.4) 39.5 (16.1- 97.4) 20.8 (7.5- 57.7) 53.3 (11.3- 251.2) Note: All comparisons are p<0.0001 except where indicated.

9. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Relative Risk Ratios of Mortality with CAC Score Subsets in Ethnic Minorities Compared with Non-Hispanic Whites

10. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Predicted Changes in Life Expectancy for Ethnic Subsets by CAC Scores

11. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Conclusions Consistent with prior reports, we found that ethnic minorities largely had an increased clustering of risk factors and lower baseline CAC scores compared to NHW. In addition increasing CAC burden was a associated with a greater mortality in all ethnic/racial groups independent of baseline risk factors, gender and age.

12. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:953-960 Implications A greater intensity of treatment in the presence of CAC may reduce the excess morbidity and mortality for ethnic minority patients. Our study findings provide support for the development of ethnic specific guidelines and more aggressive population-specific screening and educational programs focused on ethnic minorities.