Ethnic differences in cardiovascular response to stress CHAPTER INTRODUCTION The health research community is well aware of the impending global pandemic of coronary heart disease (CHD) in developed countries as well as the increase in rates of CHD in developing countries and economies in transition Globalization and rapid economic growth not only bring prosperity, but can also foster ill health with fast food, a sedentary lifestyle and little relaxation (Chockalingam, 2000) Over the past few decades the majority of research with regards to risk factors associated with CHD has focused on risk associated with populations of Western developed countries Although many of the risk factors identified are also relevant for non-Western populations, there is growing evidence that CHD incidence and mortality are unevenly distributed within and across populations of both developed and developing countries (Reddy &Yusuf, 1998) Prevalence of Coronary Heart Disease Epidemiological studies of international variations in CHD by specific ethnic groups and geographic regions have been highlighted in a report on the global burden of cardiovascular disease (Yusuf, Reddy, Ounpuu & Anand, 2001) Declining CHD death Ethnic differences in cardiovascular response to stress rates were found in most industrialized countries except in Eastern Europe and Russia where the trends remained upwards Among the Asian countries, CHD rates in Japan have declined more rapidly than in the Western countries By contrast, death rates from cardiovascular disease and CHD in particular, have shown an increasing trend in China (Woo & Donnan, 1989) and in India (Reddy & Yusuf, 1998) CHD rates in India are expected to rise further with increase in life expectancy and per capita income (Reddy, 1993) Murray and Lopez (1996) found that of all deaths in 1990, 25% were attributable to cardiovascular disease in India Although, the relatively few mortality studies from India make it difficult to present an accurate picture of disease prevalence in the country, there is some evidence that CHD prevalence has markedly increased in urban India (Gupta & Gupta, 1996) Worldwide researchers have consistently found higher rates of CHD incidence and mortality among individuals of South Asian origin Sheth, Nair, Nargundkar, Anand, and Yusuf (1999) investigated ethnic variations in major causes of death in Canada and documented trends within ethnic groups of South Asians, Chinese and Europeans, for heart disease Rates of death from ischemic heart disease, expressed per 100,000 population, were highest among the Canadians of South Asian origin (men 320.2, women 144.5) followed by Canadians of European origin (men 319.6, women 109.9) Mortality rates were lowest among Canadians of Chinese origin (men 107.0, women 40.0) Research done Ethnic differences in cardiovascular response to stress in the United Kingdom also points out that South Asians are at excess risk of CHD (Bhopal, 2000) In comparing South Asians and Europeans, electrocardiograph evidence has shown a 37% excess of CHD in South Asians (McKeigue, Ferrie, Pierpoint, & Marmot, 1993; Bhopal et al., 1999) To compare 10-year risk of CHD, stroke and combined CHD, Cappuccio, Ookeshott, Strazzullo and Kerry (2002) applied the Framingham risk estimates to ethnic minorities in UK Among the ethnic groups of Whites, South Asians and Blacks, people of African origin had the lowest 10-year risk estimate of CHD adjusted for age and sex (7%) The Whites showed 8.8% risk estimate, while the South Asians showed the highest estimated risk of 9.2% The estimated risk of combined cardiovascular risk was also highest in South Asians (12.5%) compared to 11.9% among Whites and 10.5% in people of African origin Likewise, in the Asian context of Singapore, death rates for heart disease (22.1 %) are second only to those for cancer (Ministry of Health, Singapore, 2006) with the three major ethnic groups – Chinese, Malays and Indians showing variations in cardiovascular disease incidence and mortality In 1990, Hughes, Lun and Yeo found that Indians had higher mortality from ischemic heart disease than the Chinese and Malays, with age-standardized relative risk ratios of Indians vs Chinese (males 3.8, females 3.4) and Indian vs Malays (males 1.9, females 1.6) For hypertensive disease Malays had highest mortality, while few ethnic differences were found for cerebrovascular disease across the Ethnic differences in cardiovascular response to stress three ethnic groups In yet another study of risk factors and incident of CHD in Chinese, Malay, and Indian males, Lee et al (2001) found Indians to be at greatest risk of CHD, compared to Chinese (3.0; 2.0-4.8) and Malays (3.4; 1.9-3.3) Emerging Factors of Ethnicity, Sex and Migrant populations Ethnicity is emerging as an important demographic factor in heart disease prevalence and mortality In fact, the American Heart Association Taskforce on Strategic Research Direction (S.C Smith et al., 2001) identified ethnicity as one of the priority topics in understanding why subgroups in a population experience CHD differently compared to other populations in terms of prevalence of risk factors, risk-factor management, access to care, lifestyle and metabolic risk factors, psycho-social risk factors, as well as genetic variations (Roberts, Bonow, Loscalzo & Mosca, 2000) Ethnicity is a construct that encompasses both genetic and cultural differences (Anand, 1999) As individuals of different ethnic backgrounds tend to live in specific regions, disparity in disease by ethnicity is a function of geographic differences, which in turn reflect distinct lifestyles and socio-economic status Such differences in rates of CHD become apparent in studies across countries For instance, the Seven Countries Study (Menotti et al., 1993) found low CHD rates in Japan and Mediterranean countries as compared to higher CHD rates in Finland and the United States (US) These differences were largely attributed to differences in diet, serum cholesterol and blood pressure Ethnic differences in cardiovascular response to stress However, this study did not look beyond traditional biological risk factors at other aspects such as psychosocial variables to explain differences in rates of CHD Such studies highlight the need to examine ethnic differences associated with CHD in populations at risk with a focus on underlying psychosocial variables Sex differences also exist in CHD Women are more likely than men, to have angina pectoris with normal coronary arteries, more likely to have poor outcomes after bypass surgery, more likely to die after myocardial infarction and are influenced differently by risk factors such as hypertension, diabetes, and inflammation (Maguire, 2003) CHD and stroke remain the leading killers of women in America and most developed countries Although it is estimated that one in two women will eventually die of heart disease or stroke, until recently misperceptions still existed that CHD is not a real problem for women (American Heart Association, 1997) In light of the paucity of cardiovascular research among women, especially in the Asian context, there is a need to examine differences in CHD between men and women Recent epidemiological findings have also clarified that, although CHD affects women on an average of a decade later in life than men, this disease is the leading cause of death in women just as in men Despite their marked advantage in age-specific risk of CHD death, the greater likelihood of survival of women to advanced ages produces nearly equal numbers of actual deaths due to CHD in men and women United States data from Ethnic differences in cardiovascular response to stress the National Center for Health Statistics (1997) shows that 39% more males than females die from heart disease between the ages of 45 and 64 However, after the age of 65 years, the death rate due to heart disease in women actually exceeds that in men by 22% This suggests that any protective effects of being female are largely gone by the age of 65 Substantial ethnic differences in CHD deaths in women have also been documented (Mosca et al., 1997) To the best of our knowledge, few studies have examined risk factors related to coronary heart disease among women in an Asian context, let alone looked at ethnic differences Migrant / minority populations have consistently been found to be at a higher risk for CHD Literature on health behaviors and disease indicates an increase in behavioral risk factors (e.g high fat diet, sedentary lifestyle) as well as biological risk factors (e.g obesity, hypertension) when individuals migrate to more prosperous countries There is also increasing evidence that socio-cultural and psychological factors play a crucial role in an immigrant’s health across the world (Hovey & Magana, 2000) As mentioned earlier, South Asian migrant populations (primarily Indians) have been found to show high rates of CHD incidence in Europe (Phillimore, Beattie, & Townsend, 1994), USA (Goslar et al., 1997; Brown & James, 2000) and Canada (Sheth et al, 1999) However, most of these studies drew no comparisons of these migrant Indian populations with their counterparts in India Ethnic differences in cardiovascular response to stress Extensive research thus points to the diversity in prevalence and mortality due to coronary heart disease across countries and ethnic descent within a country, as well as sex More specifically, research findings indicate increased incidence of coronary heart disease among people of South Asian origin Indians in particular seem to be at increased risk of CHD However, most studies have looked at South Asians as a group including people from India, Pakistan, and Bangladesh It must also be noted that research that has examined specific ethnic groups such as Indians, has been conducted among migrant populations – whether in the West (Canada, United Kingdom) or in South-East Asia (Singapore) This raises the question of whether it is ethnicity per se that explains increased incidence and risk of CHD, a migrant/minority status, other psychosocial factors, or perhaps a combination of ethnic, minority, and psychosocial factors that provide the underlying explanation We now continue with examining some of the explanations that have been put forth to describe and understand ethnic differences in coronary heart disease Factors Explaining Differences in Incidence of CHD The possibilities of genetic determinism, inherent biological make-up, as well as traditional factors emerging from lifestyle aspects of individuals from different ethnic backgrounds, provide some explanations for increased cardiovascular risk for certain ethnic groups Researchers have long attributed cause of disease to an individual’s Ethnic differences in cardiovascular response to stress biological make up with traditional risk factors being presented as potentially critical factors explaining differences in incidence and mortality due to CHD However, such factors including hypertension, obesity, cholesterol, parental history or cigarette smoking account for less than 50% of CHD cases (Siegman, 1994) Research with regards to these explanatory factors also suggests that rates of coronary heart disease may be explained in part by differences across ethnicity, although underlying mechanisms remain unclear With increasing understanding that psychological and social processes play an important role in linking behavior and health (T.W Smith & Anderson, 1986), researchers have identified psychosocial factors such as stress, anger, depression and social support, to be related to CHD Of these factors, anger / hostility has been found to be a critical factor involved in CHD incidence and mortality (Abel, Larkin, & Edens, 1995) and is also linked to other identified psychosocial factors These psychosocial risk factors not occur in isolation, but tend to cluster in the same individuals and/or groups For instance, both men and women of lower socio-economic status are more likely to be depressed, hostile, socially isolated and engaged in high-risk behaviors such as smoking and drinking (Wamala, Mittleman, Schenck-Gustafsson, & Orth-Gomer, 1999) that contribute to CHD risk (Anand et al., 2001) One of the proposed mechanisms that may link psychosocial factors to CHD is cardiovascular reactivity (CVR) – that is, psychosocial factors that lead to increased CVR Ethnic differences in cardiovascular response to stress are considered to be critical risk factors for CHD Exaggerated cardiovascular responses to stressors have been associated with increased risk of hypertension (Everson, Kaplan, Goldberg, & Salonen, 1996), atherosclerosis (Barnett, Spence, Manuck, & Jennings, 1997), and ischemia (Krantz et al., 1991) It is the interaction between psychosocial factors such as anger / hostility and reactivity that the present study seeks to explore in an Asian population, with emphasis on the Indian ethnic group (migrant and native), which evidence suggests, is at most risk of developing CHD among the Asian populations Review of Literature A brief review of some traditional risk factors that have been identified as crucial for South Asians as a high-risk population is presented We shall then scrutinize the psychosocial factors that have been recognized as potential risk factors for CHD In particular, we shall examine anger / hostility in relation to CHD as well as its links to other psychosocial factors, followed by a review of studies examining migratory status as a possible factor involved in ethnic differences in CHD Finally, an overview of research in the area of cardiovascular reactivity, which has unmasked some pathways in which psychosocial factors produce different patterns of cardiovascular reactivity across ethnicity, sex and tasks, is presented Ethnic differences in cardiovascular response to stress 10 Traditional Risk Factors Related To Coronary Heart Disease Classical risk factors for CHD such as smoking, blood pressure (BP), obesity and cholesterol vary substantially across different ethnic groups and subgroups (Chaturvedi, 2003) Differences between European and non-European populations such as South Asians and people of African descent have been examined previously (Liu et al., 1996) Among established risk factors, R.Williams, Bhopal and Hunt (1994) found that South Asians in the UK had less exposure only for smoking while there was a relative excess of other known risk factors such as less exercise and more diabetes and central adiposity In Singapore, Indians are at a higher risk for heart disease with CHD rates among Indian men aged 30 – 69 years being 3.8 times those for Chinese and 1.9 times those for Malays (Hughes, Lun, & Yeo, 1990) However, these high rates remain unexplained by traditional risk factors such as cigarette smoking, hypertension, or increased low-density lipoprotein cholesterol (Hughes et al, 1997), which have been 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