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Carotid Artery Disease Among Broadly Defined Underrepresented Groups: The All of Us Research Program

Originally publishedhttps://doi.org/10.1161/STROKEAHA.121.037554Stroke. 2022;53:e88–e89

There are marked differences in the prevalence of carotid artery stenosis (CAS) and revascularization among underrepresented groups defined by race and ethnicity.1,2 It is increasingly recognized that underrepresented groups defined by factors other than race and ethnicity also carry a disproportionate burden of cardiovascular disease.3 We used the All of Us Research Program4 to test the hypothesis that the burden of CAS and the proportion of persons who undergo carotid revascularization differ in broadly defined underrepresented groups.

Methods

All data are publicly available at www.allofus.nih.gov. We performed a cross-sectional study including All of Us participants with available electronic health records data. We used a novel conceptual framework proposed by All of Us to study not only race/ethnic minorities but also other underrepresented groups defined by education (less than high school degree); income (≤35k US dollars); and gender identity/sexual orientation. Outcomes were ascertained using validated electronic health records codes (Table S1). We used logistic regression to model adjusted associations between underrepresented group status and outcomes, adjusting for age, sex, and cardiovascular risk factors. All of Us is approved and monitored by the dedicated All of Us Institutional Review Board. All participants provided consent.

Results

The study included 203 813 patients with electronic health records data (mean age 51.5 [SD, 17] years, 124 735 [61%] female; Table S2). The prevalence of CAS was 2.7% (n=5420). The proportion of patients who underwent carotid revascularization was 7.3% (n=395). Income <35K US dollars was associated with higher odds of CAS (odds ratio [OR], 1.15 [95% CI, 1.07–1.24]; P<0.001) and carotid revascularization (OR, 1.38 [95% CI, 1.04–1.83]; P=0.024). Black (OR, 0.87 [95% CI, 0.78–0.96]; P=0.006) and Hispanic participants (OR, 0.83 [95% CI, 0.73–0.94]; P=0.004) had lower odds of CAS, although Black participants (OR, 0.41 [95% CI, 0.24–0.68]; P=0.001) were less likely to receive any carotid revascularization (Table).

Table 1. Results From Multivariable Logistic Regression Models

Underrepresented groupsOutcomes
Carotid artery stenosisCarotid revascularization
OR (multivariable)
Race/ethnicity (n, %)
 WhiteReference
 Black0.87 (0.79–0.96, P=0.006)0.41 (0.24–0.68, P=0.001)
 Hispanic/Latino/a/x0.83 (0.73–0.94, P=0.004)1.02 (0.62–1.64, P=0.922)
 Asian1.11 (0.86–1.41, P=0.397)0.87 (0.21–2.45, P=0.821)
 Other/>10.93 (0.75–1.15, P=0.525)0.56 (0.17–1.37, P=0.265)
Sexual Diversity, n (%)
 Non-LGBTQIA+Reference
 LGBTQIA+0.99 (0.88–1.12, P=0.933)0.95 (0.58–1.49, P=0.839)
Education, n (%)
 High school completedReference
 Less than high school degree0.86 (0.75–1.00, P=0.046)0.90 (0.49–1.54, P=0.703)
Household income (n, %)
 >35KReference
 <35K1.15 (1.07–1.24, P<0.001)1.38 (1.04–1.83, P=0.024)

LGBTQIA+ indicates lesbian, gay, bisexual, transgender, queer, intersex, asexual, other; and OR, odds ratio.

Discussion

When considering underrepresented groups defined by factors other than race and ethnicity, persons with income <35k dollars were more likely to both have CAS and undergo revascularization. People with lower income have worse profiles of cardiovascular health,3 which could explain these findings. Consistent with prior reports, when evaluating underrepresented groups defined by race and ethnicity, we found that Black and Hispanic participants had a lower prevalence of CAS.1,2 Moreover, Black participants had lower estimates of carotid revascularization, which could be explained by lower rates of high-grade stenosis,1 but other factors should be explored further, including the potential presence of care access bias. Of note, our study may be subject to volunteer bias, leading to an increased number of healthy people enrolled. Additionally, not all the participants chose to share their electronic health records. These results highlight the need to extend cerebrovascular health disparities research beyond groups defined by race/ethnicity, a goal that will be significantly facilitated by the newly established All of Us research program.

Article Information

Supplemental Material

Table S1–S2

Nonstandard Abbreviations and Acronyms

CAS

carotid artery stenosis

OR

odds ratio

Footnotes

*C.C. Matouk and G.J. Falcone jointly supervised this work.

This manuscript was sent to Harold P. Adams, Jr, Guest Editor, for review by expert referees, editorial decision, and final disposition.

Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.121.037554.

For Sources of Funding and Disclosures, see page e89.

Presented in part at the International Stroke Conference, New Orleans, LA, and virtual, February 9–11, 2022.

Correspondence to: Guido J. Falcone, MD, 15 York St, LLCI 1004D, New Haven, CT 06520. Email

References

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