The Ethnic Rosetta Stone

Abstract

The discovery of the Rosetta stone in 1799 by Napoleon's forces digging a fort in el-Rashid (Rosetta) had a profound impact on translating the lost Egyptian language of hieroglyphics into Greek, a more easily comprehended modernday language.Translating population-based cardiovascular (CV) risk factors into individual preventive care paradigms is often like looking at hieroglyphics-to date there are hundreds of factors that can influence personal CV risk, and more appear in the published literature each year. Calculating a Framingham risk point score (1) is a common initial approach to translating these variable factors into an estimation of global CV risk. However, in point of fact, this scoring system merely defines the median risk for a population of similar total point scores, meaning that 50% of the same group is at a higher personal risk and 50% of the same group is at a lower personal risk. This is a partial, but incomplete, translation. See page 953Coronary artery calcification (CAC) quantification (calcium score) using noncontrast computed tomography has been shown in clinical and pathological studies to provide an "estimation" (partial translation) of the atherosclerotic plaque burden (2-4); furthermore, it has been shown in clinical studies to be incremental to and independent of conventional (Framingham designated) CV risk factors (5-8).Often these 2 methods of estimating personal CV risk are at odds with each other when individual translations are disparate and in line when individual translations are in accord. Thus, 2 camps are frequently found, one stating that CAC is "no better than risk factors" and the other stating CAC "is better than risk factors." The answer, in my opinion, lies in between, but the more complete translation for an individual requires improvement.Research has long shown that ethnic factors both dependent and independent of conventional CV "risk factors" play an important role for heart attack and stroke risk in the ethnically diverse population of the U.S. Even socioeconomic factors such as level of primary and secondary education affect long-term CV risk (9). These factors, which likely are amplified by genetics, cannot be reflected or modeled properly into conventional point risk scoring, but may be factors already incorporated into baseline CAC estimates of coronary atherosclerotic plaque burden.The Framingham risk score was largely (but not exclusively) derived from long-term data on enrollees that were non-Hispanic whites (NHW). To complicate the matter, the prognostic information derived from CAC to date, both as a total score and percentile rank score, was also largely (but not exclusively) derived from long-term data on enrollees that were also primarily NHW. If we have this much confusion in translation for one major ethnic group, then 'heaven help us' in our attempts to translate these hieroglyphics into broad-based ethnic CV risk assessments.Prior publications on CAC prevalence and scoring from different ethnic groups in the U.S. have been variable. Our original CAR...