344 Coronary Heart Disease and Hypertension
their decision making, diagnosis, and treatment of CAD
(American Medical Association, 1991).
In addition to standard risk factors, psychosocial factors
also contribute extensively to a woman•s risk of developing
CAD. The Framingham Heart Study longitudinally followed
participants for 20 years and assessed CAD risk factors spe-
ci“c to women. After controlling for standard biological risk
factors, the researchers found that among all women tension
and infrequent vacations (once every six years or less) were
independent predictors of coronary death. Among homemak-
ers (the group most likely to be effected by psychosocial risk
factors), loneliness, infrequent vacations, and the belief that
one is more prone to heart disease were all predictors of the
development of heart disease. The researchers argue that
these “ndings re”ect a coronary-prone situation in which
women may feel isolated and lacking control, rather than
a coronary-prone personality as is often believed (Eaker,
Pinsky, & Castelli, 1992).
Similarly, there are also disparities in the treatment and
care of African American cardiac patients in comparison to
their Caucasian counterparts. Oberman and Cutter (1984)
found that African American patients were less likely to un-
dergo cardiac catheterization or bypass surgery than Cau-
casian patients, while Haywood (1984) found that African
Americans enrolled in a beta-blocker trial had higher long-
term mortality rates than Caucasians. These studies were
notable because the investigators were able to control for dis-
ease burden in their analyses, thus refuting the idea that racial
cardiac care differences could be largely attributed to differ-
ences in disease severity. However, a more recent study
found that the lower number of cardiac catheterizations
among African Americans was a re”ection of overuse in the
Caucasian population (Ferguson, Adams, & Weinberger,
1998). Another study, which controlled for the •appropriate-
nessŽ of surgery, demonstrated that racial disparities in
CABG rates are independent of available clinical factors
(Laouri et al., 1997). One possible reason for these disparities
may be the difference in anatomic manifestations of coronary
disease between African Americans and Caucasians. It is
known that the prevalence of cardiac risk factors (diabetes,
hypertension, etc.) and the clustering of several risk factors
for a single patient are higher in African American patients,
yet despite this higher risk pro“le, they are diagnosed with
less extensive diseases at time of catheterization (Peniston,
Lu, Papademetriou, & Fletcher, 2000). Furthermore, these re-
searchers also found that African Americans were less likely
to be treated with beta-blockers at the time of catheterization.
If this trend were to persist on a long-term basis, African
Americans would be more likely to have negative prognoses
in the future.
Socioeconomic status may also contribute to cardiac treat-
ment and outcome. An important study by Wenneker and
Epstein (1989) used zip codes to provide an estimate of indi-
vidual income. After controlling for income in this way and
for other clinical and demographic variables, they found that
African Americans still received signi“cantly fewer cardiac
catheterizations and CABG surgeries. Another study in New
York state that also used zip code-based income estimates
found race to independently predict use of catheterization
and CABG (Hannan, Kilburn, O•Donnell, Lukacik, &
Shields, 1991). Geography and/or distance from the hospital
may also play a role in coronary care disparity among African
Americans and Caucasians. While Taylor, Meyers, Morse,
and Pearson (1997) found that controlling for distance to the
hospital did little to negate racial differences in procedure
rates, others studies showed opposing results (Blustein &
Weitzman, 1995; Goldberg, Hartz, Jacobsen, Krakauer, &
Rimm, 1992). Goldberg et al. also found that extent of
disparity in CABG use among different races varied geo-
graphically, with the greatest disparity in the rural southeast.
Differences in health insurance status may also contribute to
African American/Caucasian differences in cardiac care.
Studies in Massachusetts, New York state, and Los Angeles
County all controlled for insurance status still found race dif-
ferences in cardiac procedures to persist (Carlisle, Leake, &
Shapiro, 1997; Hannan et al., 1991; Wenneker et al., 1989).
Two large studies of the Veterans Administration hospital
system, which provides nearly identical coverage to all eligible
veterans, found that racial differences still existed (Peterson,
Wright, Daley, & Thibault, 1994; Whittle, Conigliaro, Good, &
Lofgren, 1993). It should be noted that other studies have
found little evidence of race differences based on health insur-
ance status (Daumit, Hermann, Coresh, & Powe, 1999; Taylor
et al., 1997).
Also among the psychological variables currently being
studied is the in”uence of patient preferences and physician
decision making. One study found a strong trend toward an
independent association between race and likelihood of un-
dergoing cardiac catheterization (Schecter et al., 1996).
Whittle, Conigliaro, Good, and Joswiak (1997) found that
52% of African Americans would accept their physician•s
recommendation for PTCA (percutaneous transluminal coro-
nary angiography) while 70% of Caucasians would accept
the decision. The reasons behind these disparities are surely
multifaceted and may include trust in the medical system and
cultural/religious beliefs (Sheifer, Escarce, & Schulman,
2000). Physician decision making also appears to play a role
in race differences in cardiac care, with conscious or subcon-
scious racial biases possibly in”uencing the decision-making
process (Thomson, 1997). Schulman et al. (1999) assessed