Registry Shines Light on High ASCVD Burden in Arab Americans

Arab Americans have substantial burdens of modifiable cardiometabolic risk factors, with rates of premature atherosclerotic cardiovascular disease (ASCVD) that suggest a distinct high-risk phenotype, according to an analysis from the SALAM registry.

While CV health disparities among different demographic groups is nothing new, the SALAM researchers say the frequent misclassification of Arab Americans is an ongoing and underrecognized issue. Grouping them within broad racial categories in electronic health records—including as “Caucasian” or “non-Hispanic white”—has long diluted the ability to accurately identify and study potentially unique aspects of CVD in this ethnicity.

“We started by looking into the literature a couple of years ago now to see what has been published about the Arab American community in the United States with respect to cardiovascular disease, and we saw some small studies here and there but nothing concrete,” senior author Sadeer Al-Kindi, MD (Houston Methodist Hospital, TX), told TCTMD. 

The SALAM registry became a reality due to the large and diverse Middle Eastern community residing in Houston. Lacking an ethnicity checkbox for those who identify as Middle Eastern or Arab American, the researchers used a validated Arab name algorithm to identify a population of nearly 50,000 people. This database allowed them to evaluate traditional CV risk factors and characterize the prevalence of ASCVD and premature ASCVD.

“What we found is there is a high prevalence of cardiometabolic conditions. What stood out as the important one is diabetes, and that is actually in line with prior, smaller papers that have shown that diabetes is highly prevalent in this community,” Al-Kindi said. “Even at lower BMI ranges, we’re seeing higher prevalence of diabetes compared with other ethnic groups. This is something that has not been widely recognized.”

In the paper, published recently in JACC: Advances, Al-Kindi and colleagues, led by Jad Ardakani, MD (Houston Methodist Hospital), say this first report from SALAM is important in the context of evolving conversations around the quantification of ethnicity in clinical risk stratification.

“At a time when race and ethnicity are increasingly being removed from clinical algorithms in favor of race-neutral approaches, this study highlights a potential unintended consequence of such efforts for populations like Arab Americans, whose cardiovascular risk profile may be obscured rather than clarified by aggregation into broader racial categories,” they write.

SALAM Insights

Among the 49,440 patients (mean age 44 years; 53.1% women), 36.5% had hyperlipidemia, 28.5% had hypertension, and 16.3% had diabetes. The rate of ASCVD was 15.2% and the rate of premature ASCVD (before age 55 in men and before age 65 in women) was 3.4%. For the latter, the rates were the same in men and women (P = 0.786).

Age-related patterns of cardiometabolic conditions also were similar in men and women. Hypertension increased progressively with age and was present in more than 80% of those over age 80. Similarly, dyslipidemia and diabetes showed a steady increase with age. The prevalence of diabetes was approximately 1% to 4% in those under age 40, 34% in those ages 60-69, and more than 40% in those 70 years of age and older.

ASCVD prevalence rose from less than 2% in individuals under age 40 to 31% in those in their 60s and nearly 60% by age 80. The pattern was similar for chronic kidney disease, topping out at 44% in the oldest age group.

The only cardiometabolic condition for which women consistently had a higher prevalence than men was obesity, which was observed across multiple age groups.

Compared with adults without ASCVD or premature ASCVD, those with the conditions had a greater overall prevalence of hyperlipidemia, hypertension, diabetes, and smoking prevalence. Those with premature ASCVD were an average of 15 years younger than those with overall ASCVD and as a group had the highest mean BMI levels, which the authors say is further evidence of a more pronounced metabolic risk profile in this population.

We’re realizing more and more that ethnic origins, genetics, life experiences, and culture are very important determinants of health. Sadeer Al-Kindi

Among the traditional CV risk factors independently associated with ASCVD on multivariable logistic regression analysis, hyperlipidemia came out on top (OR 3.36; 95% CI 3.13-3.61), followed by hypertension (OR 3.14; 95% CI 2.91-3.39), smoking (OR 2.17; 95% CI 2.00-2.36), and diabetes (OR 1.51; 95% CI 1.41-1.61). The observations were consistent across men and women, with similar effect sizes for all risk factors.

Similarly, for premature ASCVD, the strongest predictors were hyperlipidemia (OR 4.18; 95% CI 3.684.74) and hypertension (OR 3.88; 95% CI 3.39-4.45), followed by smoking (OR 1.75; 95% CI 1.53-1.99), with only a modest association with diabetes. Increasing age also was a predictor of premature ASCVD, and female sex was associated with a higher prevalence compared with male sex.

Other sex-related analyses showed a stronger association of hyperlipidemia and premature ASCVD in men compared with women, and a stronger association of hypertension in women compared with men. While diabetes was a strong predictor of premature ASCVD in women, it was not so for men.

Collaboration and More Data Ahead

To TCTMD, Al-Kindi said the SALAM group is beginning to collaborate with investigators in other areas of the US that have large Middle Eastern and North African (MENA) populations, including Michigan, which has the second-highest concentration of any state other than California. Having a large established registry, he added, will enhance the power of the observations from SALAM and allow for meaningful comparisons with other populations.

“We’re realizing more and more that ethnic origins, genetics, life experiences, and culture are very important determinants of health. They’ve been previously lumped under social determinants of health, but I would say that there are maybe cultural determinants of health that we need to take into account and understand further. They may be isolated from, or different from, the social determinants of health that we try to capture for cardiovascular disease,” he noted. 

Greater understanding of CVD patterns in these ethnic groups is important not only because the risk may be different and they may have unique cardiometabolic phenotypes, but also because treatments and management decisions may all need to be different. Furthermore, broader recognition of these differences could impact things like public health messaging and patient education, resulting in improvements in prevention efforts and early intervention.

“I think this is [pointing the way] towards personalized precision population health, as opposed to treating everybody the same,” Al-Kindi added.