JOURNAL OF WOMEN’S HEALTH
Volume 14, Number 2, 2005
© Mary Ann Liebert, Inc.
The Gender Gap in Coronary Heart Disease Mortality:
Is There a Difference between Blacks and Whites?
Data from the U.S. Cohorts Pooling Project
JENNIFER E. HO, M.D.,1FURCY PAULTRE, Ph.D.,2and LORI MOSCA, M.D., Ph.D.2
Background: The gender difference (gender gap) in mortality due to coronary heart disease
(CHD) decreases with age. This relationship has not been well characterized in diverse pop-
Methods: To examine the gender gap in CHD mortality across age groups and to compare
the age dependency of the gender gap between blacks and whites, we conducted a prospec-
tive cohort study combining data from 9 U.S. epidemiological studies (Atherosclerosis Risk
in Communities Study [ARIC], Charleston Heart Study, Evans County Study, Framingham
Heart Study [original and offspring cohorts], National Health Examination Follow-up Study
[NHEFS], Rancho Bernardo Study, San Antonio Heart Study, and Tecumseh Community
Health Study). Baseline examinations were performed between 1958 and 1990 (depending on
the study), and mean follow-up was 13.7 years in general communities in several U.S. geo-
graphic areas. We included 39,614 subjects ?30 years and free of cardiovascular disease (CVD)
at baseline (18% blacks, 37% men). Completion of follow-up was ?97% for all studies. As the
main outcome measures, age-specific CHD mortality rates and male/female CHD mortality
hazard ratios were calculated using Cox hazards regression.
Results: During 542,605 person-years of follow-up, 2,812 CHD deaths were observed (18%
in blacks, 46% in men). At age 45, white men were at a 6-fold increased risk compared with
white women (95% confidence interval [95% CI] 4.6–7.9), whereas black men had a 2-fold in-
creased risk of fatal CHD compared with black women (1.4–3.6). At age 95, men and women
were at equal risk in both whites (0.9–1.4) and blacks (0.7–1.6). The difference in the age de-
pendency of the gender gap between blacks and whites was significant (p ? 0.0001).
Conclusions: The gender difference in CHD mortality was more pronounced in whites than
in blacks at younger ages. This discrepancy was not explained by adjustment for CHD risk
factors and suggests that other factors may be responsible for the ethnic variation in the gen-
1Harvard Medical School, Boston, Massachusetts.
2Columbia University, New York, New York.
This research was supported by the Stanley J. Sarnoff Endowment for Cardiovascular Science (J.E.H.), the National
Heart, Lung and Blood Institute (K08 HL 03681), and the American Heart Association (9750703N).
HO ET AL.
age-specific CHD mortality rates are strikingly
higher in men compared with women.1In general,
both CHD incidence and mortality rates in women
lag 10 years behind those of men.2It is well estab-
lished that the gender difference is more pro-
nounced at younger ages, such that 1 in 17 women
has had a coronary event before age 60, in contrast
with 1 in 5 men. The gender difference has been re-
ported to decrease with age, and after age 60, CHD
accounts for 1 in 4 deaths in both sexes3(Table 1).
Previous U.S.-based studies addressing gender
differences in CHD mortality have been limited
to predominantly Caucasian populations.4–6
Many studies have also examined black and
white differences in CHD mortality, but none has
directly compared the gender gap between eth-
The gender gap in CHD mortality has been at-
tributed to various factors. Differential preva-
lence and impact of traditional cardiovascular
risk factors have been shown to account for part
but not all of the gender difference.15,16Estrogen
has been implicated as a possible protective fac-
tor in women because of an observed 2-fold in-
creased CHD incidence in surgically postmeno-
pausal vs. premenopausal women of the same
age.17However, the use of hormone replacement
therapy (HRT) has not been shown to reduce
CHD events in postmenopausal women,18and
LTHOUGH CORONARY HEART DISEASE (CHD) is
the leading cause of death in men and women,
the role of endogenous estrogen in the cardio-
protection of women compared with men is not
completely understood. International data sug-
gest that geography, secular trends, and envi-
ronmental factors also play a role in gender dif-
ferences in CHD occurrence.11
The purpose of this study was to examine the
relation between age and gender differences in
CHD mortality and to compare the age depen-
dency of the gender gap between blacks and
whites in more than 39,000 persons who partici-
pated in the long-term epidemiological studies
included in the U.S. Cohorts Pooling Project. In
addition, we sought to determine if adjustment
for traditional cardiovascular risk factors attenu-
ated gender differences in CHD mortality.
MATERIALS AND METHODS
The U.S. Cohorts Pooling Project is a prospec-
tive study that combines data from the following
nine long-term epidemiological studies based in
the United States: Atherosclerosis Risk in Com-
munities Study (ARIC), Charleston Heart Study,
Evans County Study, Framingham Heart Study
(original and offspring cohort), National Health
Examination Follow-up Study (NHEFS), Rancho
Bernardo Study, San Antonio Heart Study, and
the Tecumseh Community Health Study. Details
of sampling procedures, study designs, and
methods for each of the respective studies have
TABLE 1.AGE-SPECIFIC CHD MORTALITY FOR WHITES AND BLACKS
Men Women MenWomen
No. of CHD
No. of CHD
deaths (PY of
No. of CHD
deaths (PY of
No. of CHD
deaths (PY of
GENDER, RACE, AND CHD
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New York Presbyterian Hospital
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