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3 Cardiovascular disease: prevalence and risk factors
This chapter deals with the prevalence of cardiovascular disease (CVD). Despite the reduction in mortality from CVD since the 1970s in most industrialised countries, cardiovascular disease, and in particular coronary heart disease, is still the leading cause of death in the western world.1,2 According to recent data, ischaemic heart disease accounts for the largest proportion of deaths among men in England, regardless of country of birth, but some minority ethnic groups appear to be particularly prone: men born in the Indian subcontinent show higher mortality, and those from the Caribbean lower mortality, compared with all men. Cerebrovascular disease is the next major cause of death for men from the Caribbean and the Indian subcontinent,3 and stroke mortality rates among Black Caribbean communities are about twice the average rates found in England and Wales. This is also reflected in morbidity data.4 The 1999 Health Survey provides a large-scale representative sample to investigate differences between minority ethnic groups and to look at subgroups of the South Asian population in England. This chapter reports the prevalence of self-reported CVD conditions and investigates differences in specific conditions between minority ethnic groups, examines CVD by socio-economic characteristics, and looks at electrocardiographic (ECG) measurements. It also examines relationship between various risk factors and CVD. Informants were asked whether they ever suffered from any of the following conditions: angina, heart attack, stroke, heart murmur, abnormal heart rhythm, 'other' heart trouble, diabetes or high blood pressure, and (if they responded affirmatively) if they had ever been told they had the condition by a doctor. For the purpose of this report, informants were classified as having a particular condition only if they reported that the diagnosis was confirmed by a doctor (or by a nurse in the case of blood pressure). This implies that people have been able to recognise and report symptoms in order for a doctor to make the diagnosis, and that they have understood and recalled the diagnosis. No attempt was made to assess these self-reported diagnoses objectively. The ability to recognise symptoms and the propensity to report them may well vary between groups, and differences in the reported prevalence of these conditions may be at least partly due to factors such as these. It should be noted that high blood pressure and diabetes are generally considered to be predisposing factors rather than cardiovascular conditions per se, but have been included in this chapter for comparability with previous surveys. Blood pressure is dealt with more fully in Chapter 7, Sections 7.3 and 7.4, which present blood pressure distributions and examine the prevalence of measured high blood pressure. Section 7.4 also shows the proportion who said they had been diagnosed as having high blood pressure ('reported high blood pressure'), which is the blood pressure measurement referred to in the present chapter. 3.2.2 Definitions used in this survey The following definitions of the conditions mentioned above were used: Any CVD condition Informants were classified as having any CVD condition if they reported ever having any of the following conditions confirmed by a doctor (or a nurse in case of blood pressure): angina, heart attack, stroke, heart murmur, irregular heart rhythm, 'other heart trouble', high blood pressure or diabetes. Ischaemic heart disease Informants were classified as having ischaemic heart disease (IHD) if they reported ever having had angina or a heart attack confirmed by a doctor. Ischaemic heart disease or stroke Informants were classified as having ischaemic heart disease or stroke (IHD or stroke) if they reported ever having had angina, a heart attack or a stroke confirmed by a doctor. 'Severity' of CVD conditions As in previous Health Survey reports, a hierarchical measure of 'severity'
of CVD conditions was used, considering the categories as mutually exclusive.
This definition of severity is somewhat arbitrary, and it is used for
descriptive purposes only. It does not necessarily correlate with quality
of life or risk of death. The hierarchy is defined below, from greatest
severity to least.
3.2.3 Rose Angina Questionnaire In addition to the self-reported prevalence of angina and heart attack, the Rose questionnaire on angina and heart attack ('Rose Angina Questionnaire') was used as an alternative means of estimating the prevalence of these conditions. The Rose Angina Questionnaire was originally developed to identify the characteristic symptom complex known as angina in a standard way.5 Its validity has been established predominantly in white populations by studies that compared the questionnaire to clinical diagnosis.6,7 When the performance of the Rose Angina questionnaire has been compared across different ethnic groups some inconsistencies have been reported.8 From this questionnaire, informants were classified as having angina symptoms based on standard criteria.9 Angina was then classified as grade 1 or grade 2, with grade 2 being the most severe. Based on the Rose Angina Questionnaire, informants were classified as having had a possible myocardial infarction (heart attack) if they reported having ever had an attack of severe pain across the front of the chest, lasting for half an hour or more. This is referred to in this chapter as 'possible myocardial infarction'. 3.2.4 Electrocardiographic (ECG) measurement ECG was recorded during the nurse visit in people aged 35 and over, excluding those with a pacemaker and those who had chest surgery in the preceding three weeks. Pregnant women were also excluded. All minority ethnic group members aged 35 and over were included, but only a sub-sample of the general population sample. (See 'The nurse visit' in Chapter 1: Introduction, Section 1.5.6.) Details of the equipment used, and of the analysis methods, are presented below (Section 3.5). 3.3 Prevalence and severity of CVD conditions, by minority ethnic group 3.3.1 Angina and heart attack In men, the observed prevalence of angina was lowest among Black Caribbean men (1.9%) and Chinese men (1.8%) while it was highest among Indian men (5.4%), who had virtually the same prevalence as men in the general population (5.3%). Like the observed prevalences, age-standardised risk ratios for angina, relative to men in the general population, were low for Black Caribbean men (0.32) and Chinese men (0.38). Angina risk ratios above 1 were seen for men in all three South Asian groups, but only the Bangladeshi difference was significant. The angina risk ratio of Irish men was close to 1. In the general population and in all minority ethnic groups except Black Caribbeans, the prevalence of angina was much lower among women. The age-standardised risks of angina for women in the minority ethnic groups did not differ significantly from those of women in the general population, with the exception of those of Chinese origin, who showed a significantly lower risk ratio (0.2).
Standardised heart attack rates showed a similar pattern to those for angina. Table 3.1, Figure 3A 3.3.2 Stroke In the general population, men (2.3%) had a slightly higher prevalence
of stroke than women (2.1%). Stroke was reported less often than heart
attack or angina, except for Black Caribbean men: the observed prevalence
of stroke among Black Caribbeans was 3.2% (angina was reported by 1.9%
of Black Caribbean men). After adjusting for age, rates of stroke among
Black Caribbean men were over two-thirds higher than in the general
population (risk ratio 1.66). Indian men also had higher rates than
the general population (1.42). Among women, Chinese women showed low
observed (0.2%) and age-standardised rates (risk ratio 0.29), while
all other groups did not differ significantly from the general population. 3.3.3 Diabetes The observed and age-standardised prevalence of diabetes in men and
women is shown in the inset table and in Figure 3B.
The observed prevalence of diabetes was generally higher in men than in women. Men and women in all minority ethnic groups, except for Irish women, showed higher observed rates than the general population. In men, the highest observed prevalence was among Bangladeshis (10.6%), although the other South Asian groups also showed high rates (Pakistanis 8.7%, Indians 7.7%), as did Black Caribbean men (7.8%). Among women, Black Caribbean women showed the highest observed prevalence of diabetes (7.9%). The highest age-standardised rates of diabetes were found among South
Asian men and women: in particular Pakistanis and Bangladeshis of both
sexes showed rates over five times higher than the general population.
Indian men and women were almost three times as likely as the general
population to report diabetes. Among Black Caribbeans the rates were
also considerably higher than those of the general population (risk
ratio for men 2.51, for women 4.19). Chinese and Irish rates were not
significantly different from those of the general population. 3.3.4 Heart murmur, abnormal heart rhythm, 'other' heart trouble These conditions were in general reported less often by men and women
of minority ethnic groups than the general population. People of South
Asian origin in particular reported very low rates of heart murmur compared
with the general population. 3.3.5 Summary of CVD condition prevalence by minority ethnic group In summary, for all the above mentioned conditions with the exception of diabetes, Chinese men and women had lower rates than the general population, and for diabetes the Chinese rates were not significantly higher than those of the general population. All South Asian groups showed higher rates for most conditions than the general population. Both Pakistanis and Bangladeshis showed higher rates for most conditions than Indians. This confirms previous findings.10 Black Caribbean men had significantly lower prevalence of angina and heart attack than the general population, and higher prevalence of diabetes. Irish people did not differ substantially from the general population in the prevalence of CVD conditions. With the exception of heart murmur, where no clear age pattern emerged, all CVD conditions generally increased in prevalence with age in all minority ethnic groups. Tables 3.1, 3.2 (and Chapter 7, Section 7.4) 3.3.6 Severity Table 3.3 shows CVD conditions grouped and ranked in order of their severity. For the most severe category (i.e. heart attack or stroke) the differences between men and women were larger than for the other categories of severity, with men showing higher rates in all minority ethnic groups. For this category, all the minority ethnic groups showed lower rates than the general population, either observed or age standardised. Self-reported high blood pressure (confirmed by a doctor or a nurse) and diabetes together accounted for the majority of CVD cases in all minority ethnic groups and in both sexes. The observed prevalence (of high blood pressure and/or diabetes other than cases also reporting IHD or stroke) in men ranged from 11.5% (in Chinese) to 21.0% (in Black Caribbeans) and in women from 9.2% (in Bangladeshis) to 25.9% (in Black Caribbeans). After age standardisation, prevalence among Black Caribbeans was still significantly higher than in the general population in both sexes (risk ratios 1.18 in men, 1.21 in women). This was mainly accounted for by higher prevalence of high blood pressure (see also Chapter 7). Pakistani men and women, and Indian women, also showed significantly higher rates of high blood pressure or diabetes than the general population. In all severity categories a general increase with age was observed
in all minority ethnic groups and in both sexes. The fact that women
had higher rates than men was due mainly to higher rates of high blood
pressure among elderly women. 3.3.7 Rose Angina Questionnaire When angina was assessed by means of the Rose questionnaire the differences between minority ethnic groups and the general population were smaller than those assessed by the self-reported diagnosis. Angina prevalences for Bangladeshis and Indians were still higher than those of the general population but the difference was no longer statistically significant. Chinese angina prevalences, however, were still significantly lower than those of the general population. Symptoms of possible myocardial infarction, according to the Rose Questionnaire, were relatively high among Pakistanis and Bangladeshis from age 55 onwards. Differences from self-reported diagnoses were larger in women of South Asian origin: in these groups all the Rose angina symptoms were lower than doctor-diagnosed angina, while symptoms of possible myocardial infarction were much higher among Bangladeshis. In summary, among the minority ethnic groups, the Rose Angina questionnaire
does not seem to produce similar responses to the self-reported diagnoses.
This confirms previous findings8 and could be due to cultural
differences in identifying and/or describing the symptoms. 3.3.8 CVD, IHD and IHD or stroke Prevalence of any CVD condition Tables 3.1 and 3.2 showed the prevalence of each reported CVD condition separately. Overall, the proportion reporting ever having any of the CVD conditions varied greatly between minority ethnic groups, ranging from 15% among Chinese men and women to about 30% for Black Caribbean men and women. However, most of this variation stemmed from their different age profiles, and the age-standardised risk ratios were generally not significantly different from 1 in both sexes, except for the lower rates of Chinese men (0.60) and women (0.76) and the higher rates of Black Caribbean women (1.41). Prevalence of IHD and IHD or stroke The observed prevalence of IHD (heart attack or angina), and of IHD or stroke, among Chinese men was low (2.1% and 2.9% respectively), and their age-standardised rates were about one third of those of the general population. The age-standardised IHD risk ratios for Indian, Pakistani and Bangladeshi
men were 1.31, 1.41 and 1.53 respectively, and those for IHD or stroke
were not dissimilar. These prevalence differences between South Asian
men and men in the general population, though apparently large, were
individually not significant. This does not mean that South Asian prevalences
were not higher, but only that the evidence is inconclusive for each
group considered individually. An aggregate analysis of South Asian
men showed significantly high age-standardised risk ratios for both
IHD and IHD or stroke.
Consistently with the low mortality from IHD that has been found among
Black Caribbeans,11 Black Caribbean men and women were less
likely to report IHD or IHD and stroke. The risk ratios for Irish men
and women were very close to those in the general population for both
IHD and IHD or stroke. The highest prevalence of IHD, and IHD or stroke, among men's age groups was found among Indian men aged 55 and over (24.5% and 29.2% respectively). Pakistani men in the same age group had lower prevalences (19.9% and 21.3%) and Bangladeshi men lower still (15.4% and 17.8%). The general population figures for men over 55 were 18.2% for IHD and 21.9% for IHD or stroke but the younger profile of the minority ethnic groups even within this older age group must be borne in mind. Prevalence was low among Chinese and Black Caribbean men over 55 (IHD 5.8% and 5.6% respectively, IHD or stroke 9.7% and 12.4% respectively). In Black Caribbean women, the prevalences of IHD and to some extent
of IHD or stroke were very similar to those of men of the same age,
while in the other minority ethnic groups prevalence was lower in women
than in men of the same age group. 3.4 CVD by socio-economic variables 3.4.1 Social class of head of household The observed differences in CVD prevalence between men in non-manual and manual social classes were not marked, with the exception of Black Caribbean men, of whom about a fifth (19.4%) in non-manual social classes reported CVD compared with about a third in manual classes (32.4%). However, these differences seem to be largely due to the age differential. After age standardisation the risk ratios in the two groups were very similar (0.97, 0.96) and not significantly different from those of the general population. For IHD and IHD or stroke higher prevalences in manual than in non-manual social classes were observed in all groups of men except South Asian men: among Indian, Pakistani and Bangladeshi men both observed prevalences and standardised risk ratios showed higher levels of IHD and of IHD or stroke among non-manual social classes. For example, among Indian men, the observed rates for IHD were 11.0% in non-manual social classes and 3.8% in manual, and the corresponding risk ratios were 2.06 and 0.76. Women's patterns were similar to men's, but less clear than in men since women's prevalence for all conditions was generally lower. In summary, only small fluctuations by social class were observed;
those from manual social classes did not show consistently higher rates
than those in non-manual social classes. This could be due to a true
lack of difference in prevalence between social classes, or it could
be accounted for by reduced or differential access to diagnosis. It
could also be an indication of an inadequate control for socio-economic
differentials, if the widely used measures of socio-economic status
do not adequately account for ethnic differences in social position.
3.4.2 Equivalised household income The sample was divided into equivalised household income tertiles which were applied to all minority ethnic groups: they are not group-specific, and do not divide each group into equal thirds. The income levels that form the boundaries of the tertiles are the same for each group. For details see Volume 2, Appendix D: Glossary. Analysis by income reveals a similar picture to that already outlined for social class. The higher CVD risk groups were middle and higher-income Bangladeshi men, higher-income Bangladeshi women and middle and higher-income Black Caribbean women. For IHD, Black Caribbeans had a low risk across income groups in both
sexes, reflecting the low overall risk in this minority ethnic group.
In general the minority ethnic groups did not show any particular trend
in IHD and IHD or stroke by income. 3.5.1 Equipment and definitions The equipment used was a portable ECG machine, the Fukuda Denshi FCP-2155 Multi-channel Electrocardiograph. This is an interpretative electrocardiograph which measures and analyses the standard 12-lead ECG. The detailed measurement protocol is contained in Appendix B. The analysis results involve automatic interpretation and Minnesota coding.12 The Minnesota coding was originally designed to determine prevalence information in epidemiological studies.13 ECG measurement is important as an objective measurement to assess heart disease given that its findings are strictly related to heart disease manifestations such as for example death of heart muscle (infarction). It should be appreciated that the automatic interpretation was not checked by an expert. The FCP-2155 analysis algorithm has been tested by the manufacturer using standards developed by the European Community, the United States and Japan, allowing for a common standard as interpreted by different cardiologists. No automated analysis is completely reliable, indeed there is the possibility that no cardiac disease exists despite an abnormal report ('false positive'). A high proportion of false positives will determine a low specificity of the measurement. Disease can also be present despite a normal ECG interpretation ('false negative'). A high proportion of false negatives will determine a low sensitivity of the measurement. Sensitivity and specificity vary by category of conditions. A list of conditions with the diagnostic accuracy is given by the manufacturer.14 As stated above ECGs were coded automatically according to the Minnesota classification. Modifications of patterns, suggestive of ischaemic heart disease, were grouped into a broad category of positive ECG which included: major Q waves, defined as Minnesota codes 1-1 or 1-2, S-T depression (Minnesota codes 4-1 to 4-4), T wave inversion or flattening (5-1 to 5-3) and left bundle branch block (7-1-1). Moreover, major Q waves were also examined as a separate category. 3.5.2 Positive ECG and major Q waves The results reported in these sections relate only to persons aged 35 and over. All eligible minority ethnic group members aged 35 and over who had a nurse visit were measured, but in the general population sample only a sub-sample was visited by the survey nurse, not all persons of this age, the total number measured being 239 men and 277 women (see Section 3.2.4 above). The age-standardised risk ratio for positive ECG was low among Indian men (0.73) and very low among Chinese men (0.51). For major Q waves, Pakistani men had a significantly higher level of positive ECG than the general population, their risk ratio being 1.44. The even higher risk ratio for Bangladeshi men (1.75) was not significant at the 95% level. Chinese men again had a low risk ratio (0.58). Women from all minority ethnic groups showed a risk ratio above 1 for positive ECG measurements, varying between 1.14 for Bangladeshis to 1.60 for Indians. Only the Indian figure, however, was significant at the 95% level. In contrast, for major Q waves women's risk ratios were always below 1 (except for Irish women). Bangladeshi women showed very low rates for major Q waves, although the bases for this group were small. The low rates were significant for Bangladeshi women and Black Caribbean women, and those for Chinese women verged on significance. Both positive ECG measurements and major Q waves increased with age
in both sexes and in all minority ethnic groups. In general, positive ECG measurements and major Q waves were more common among those who reported a CVD condition than those without. The bases were nevertheless too small to show statistical significance. (Data not shown.) For some of the risk factors examined, the differences between people with and without CVD varied between minority ethnic groups and between these and the general population. The observed prevalence of overweight or obesity (BMI>25 kg/m2) was higher in those with CVD than in those without, in both sexes and all minority ethnic groups. After age adjustment, higher overweight or obesity prevalence among those with CVD was seen only among Indian and Bangladeshi women. Raised waist-hip ratio (>=0.95 in men and >=0.85 in women) showed more marked differences than overweight or obesity as already shown in previous years for the general population.15 The observed prevalence of raised waist-hip ratio was doubled, or more than doubled, in those with CVD than those without. After age adjustment, all groups (except Bangladeshi men) showed higher risk ratios in those with CVD, the largest differences being observed among Indian and Bangladeshi women. Among men, the observed prevalence of raised total cholesterol (a level of 6.5 mmol/l or more) tended to be higher among those with CVD than those without CVD, although the reverse was true among Black Caribbean men. Among women, a similar but more marked difference was found. Age standardisation reduced these differences: the risk ratios were higher in those with CVD only among Indians and Pakistani women and Chinese men. Within those with CVD, the risk ratio for raised cholesterol was significantly higher for Indian (1.59) and Chinese men (1.61) than for men in the general population with CVD (0.98). Among women, higher age-standardised ratios were seen only for Pakistani women (1.94). In all minority ethnic groups, with the exception of Irish men and women, current cigarette smoking was more common among those with CVD than those without, while the age-standardised ratios generally showed lower risk ratios among those without CVD, with a few exceptions (for example Pakistani men). The risk ratios were bigger among the minority ethnic groups than the general population within men with CVD, while the opposite was true for women. Chapter 4 provides more information on cigarette smoking. Alcohol consumption was in general low among minority ethnic groups, with few people, especially among women, consuming more than the weekly levels advised until 1996 (14 units/week for women, 21 units/week for men). There was a general tendency for risk ratios to be higher among those without than those with CVD, with the exception of Chinese men. Chapter 5 provides more information on alcohol consumption. High blood pressure (defined as taking medications or having a systolic
blood pressure of 140 mmHg or over, or a diastolic blood pressure of
90 mmHg or over) was generally higher, both in the observed and age-standardised
figures, among those with CVD. The extent to which CVD risk factors could account for differences in CVD and IHD prevalence between the minority ethnic groups and the general population was examined, separately for men and women, by means of logistic regression models, with CVD (or IHD) as the dependent variable and age (16-34, 35-54, 55+), smoking (current, yes or no), BMI (¾25 vs >25 kg/m2), social class (non-manual vs manual), high waist-hip ratio (>=0.95 men, >=0.85 women), total cholesterol (<6.5 vs 6.5+ mmol/l), blood pressure (<140/90 vs 140/90+ mmHg), and minority ethnic group as explanatory variables. The nature of the study should be borne in mind when interpreting the results: cross-sectional surveys do not allow the detection of causal relationships given that risk factors are measured after the event (CVD).
a Adjusted for age, BMI, WHR, total cholesterol, social class, smoking, blood pressure. When all these risk factors were taken into account, the differences in prevalence between each minority ethnic group and the reference population were small, and none was significant, although there was a suggestion of an increased risk for Pakistani and Bangladeshi men for CVD; and Indian and Pakistani men and Bangladeshi women for IHD; and a decreased risk for Black Caribbean men and women and Chinese women for IHD. As already shown in previous years for the general population,15
age, high blood pressure and high WHR were the factors that remained
independently associated with CVD and IHD when the other factors were
taken into account, and that was true for most minority ethnic groups.
(Data not shown.) References and notes 1 American Heart Association. Heart and Stroke Facts. 1994 Statistical Supplement. Dallas, Texas: American Heart Association, 1994. 2 Thorn TJ. International mortality from heart disease: rates and trends. Int J Epidemiol 1989; 18:S20-8. 3 Drever F, Whitehead M (eds). Health Inequalities. Decennial supplement. Series DS No.15. London, The Stationery Office, 1997. 4 Baralajan R, Soni Raleigh V. Ethnicity and health in England. London, HMSO, 1995. 5 Rose GA, Blackburn H. Cardiovascular survey methods. World Health Organization Monograph 1986; 56:1-188. 6 Bass EB, Follansbee WP, Orchard TJ. Comparison of supplemented Rose Questionnaire to exercise tallium testing in men and in women. J Clin Epidemiol 1981; 42:385-94. 7 Blackwalder WC, Kagan A, Gordon T, Rhoads GG. Comparisons of methods for diagnosing angina pectoris: the Honolulu heart study. Int J Epidemiol 1981; 10:211-15. 8 Fischbaker CM, Bhopal R, White M, Unwin N, Alberti KGM. The comparative performance of the Rose Angina questionnaire in South Asian population. J Epidemiol Community Health 2000; 54:786. 9 Rose defined angina as a chest pain or discomfort with the following characteristics:
Grade 1 angina occurs when the subject only experiences the chest pain when walking uphill or hurrying. Grade 2 angina occurs when the subject experiences the chest pain even when walking at an ordinary pace on the level. 10 Nazroo JY. The health of Britain's ethnic minorities: findings from a national survey. Policy Studies Institute, London, 1997. 11 Wild S, McKeigue P. Cross-sectional analysis of mortality by country of birth in England and Wales, 1970-92. BMJ 1997; 314:701-10. 12 Prineas RJ, Crow RS, Blackburn H. The Minnesota Code. Manual of electrocardiographic findings. John Wright, 1982. 13 Blackburn H, Keys A, Simonson E. The electrocardiogram in population studies: a classification system. Circulation 1960; 21:1160-75. 14 Fukuda Denshi Co. LTD. Operational Manual. Electrocardiogram analyzer. Autocardiner FCP-2155. According to the manual, for example a reported normal ECG has a sensitivity of 95.86% and a specificity of 99.55%. For an anterior myocardial infarction the sensitivity is reported at 92.64% and the specificity at 98.61%. 15 Primatesta P. Relationship of CVD to risk factors and socio-demographic factors (Chapter 4) in Erens B, Primatesta P (eds). Health Survey for England: Cardiovascular Disease 1998. The Stationery Office, London, 1999. 3.1 Prevalence of CVD conditions, by minority ethnic group 3.2 Prevalence of CVD conditions, by age within minority ethnic group 3.3 Severity of CVD conditions, by minority ethnic group 3.4 Severity of CVD conditions, by age within minority ethnic group 3.5 Prevalence of angina and MI symptoms (using the Rose Angina Questionnaire), by minority ethnic group 3.6 Prevalence of angina and MI symptoms (using the Rose Angina Questionnaire), by age within minority ethnic group 3.7 Prevalence of CVD/IHD/IHD or stroke, by minority ethnic group 3.8 Prevalence of CVD/IHD/IHD or stroke, by age within minority ethnic group 3.9 Prevalence of CVD/IHD/IHD or stroke, by social class of head of household within minority ethnic group 3.10 Prevalence of CVD/IHD/IHD or stroke, by equivalised household income tertile within minority ethnic group 3.11 Positive ECG measurements (by the Minnesota coding) in informants aged 35 and over, by minority ethnic group 3.12 Positive ECG measurements (by the Minnesota coding) in informants aged 35 and over, by age within minority ethnic group 3.13 Prevalence of risk factors amongst those with and without CVD conditions, by minority ethnic group
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