Disclosures: One author reports various ties to industry. The other authors and Mensah report no relevant financial disclosures.
June 05, 2020
3 min read

Low socioeconomic status may explain more than half of excess risk for MI, CHD death

Disclosures: One author reports various ties to industry. The other authors and Mensah report no relevant financial disclosures.
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U.S. adults of low socioeconomic status experienced double the incidence of MI and CHD-related deaths than individuals of higher status, but less than half of excess events were attributable to traditional risk factors.

The remainder of excess events were associated with CHD risk factors conferred by lower socioeconomic standing, according to research published in JAMA Cardiology.

Source: Adobe Stock.

This computer simulation study used the Cardiovascular Disease Policy Model to assess the incidence of CHD and stroke incidence, prevalence and mortality among all U.S. adults aged 35 to 64 years, stratified by socioeconomic status. The researchers defined low socioeconomic status as income below 150% of the federal poverty level or educational level of less than a high school diploma.

Compared with individuals of higher status, men and women of low socioeconomic status had twice the excess risk for MI per 10,000 person-years (men of low socioeconomic status, 34.8; 95% uncertainty interval [UI], 31-38.8; men of high socioeconomic status, 17.6; 95% UI, 16-18.6; women of low socioeconomic status, 15.1; 95% UI, 13.4-16.9; women of high socioeconomic status, 6.8; 95% UI, 6.3-7.4), according to the researchers.

In addition, similar observations were made for prevalence of CHD death per 10,000 person-years (men of low socioeconomic status, 14.3; 95% UI, 13-15.7; men of high socioeconomic status, 7.6; 95% UI, 7.3-7.9; women of low socioeconomic status, 5.6; 95% UI, 5-6.2; women of high socioeconomic status, 2.5; 95% UI, 2.3-2.6).

Moreover, after researchers adjusted for higher levels of traditional risk factors, the simulation estimated that about 60% of the excess risk for MI and CHD death was associated with socioeconomic status and other upstream risk factors.

Kirsten Bibbins-Domingo

“The study has important implications for practicing clinicians. First, addressing traditional risk factors only is not enough to modify risk of premature cardiovascular disease in their patients. Many practices are now making themselves aware of and addressing some of the greater social needs of their poor patients — like providing access to resources for food insecurity or other financial needs,” Kirsten Bibbins-Domingo, PhD, MD, MAS, professor of epidemiology and biostatistics at the University of California, San Francisco, told Healio. “Second, our standard ACC/AHA risk equations for assessing cardiovascular risk may underestimate risk in patients of low socioeconomic status, as is acknowledged by the guidelines. Finally, when focusing on traditional risk factors, excess tobacco use is one of the sources of the major disparity between low and higher socioeconomic status and should be a focus, in addition to lowering LDL, blood pressure and diabetes risk.”

Projections for a younger cohort

In other findings, the simulation projected that among a cohort of 1.3 million adults with low socioeconomic status who were aged 35 years in 2015, approximately 19% will develop CHD by age 65 years, with 48% of events in excess of those expected for individuals with higher socioeconomic status.


“We believe that the findings from this study underscore the need to broaden the understanding of CHD risk and to develop interventions that go beyond traditional clinical risk factors,” the researchers wrote. “To reduce the socioeconomic disparities in CHD, we must focus future research on the implementation and evaluation of clinical, community-based and population-level interventions that target upstream risk factors associated with low socioeconomic status, such as poverty and education.

“Many clinicians, practices and hospitals have increased their activities addressing increased social need among their poor patients through individual and community efforts,” Bibbins-Domingo said in an interview. “We need more information about what interventions work and how to do this most effectively if we are going to continue to improve heart health for our poor patients.”

‘The time has now come’

“As Nobel laureate Angus Deaton, PhD, FBA, pointed out in the book The Great Escape: Health, Wealth, and the Origins of Inequality, life is better now than at almost any time in history, but he also emphasized that his thesis is far from complete,” George A. Mensah, MD, director of the Center for Translation Research and Implementation Science at the NHLBI, wrote in a related editorial. “We have evidence that the dramatic decreases in CHD mortality seen in the United States in the past century have now stalled, and for many African American men and women, American Indian or Alaska Native men and women, and middle-aged white women in rural counties and counties with low-socioeconomic status markers, CVD mortality rates remain too high or are increasing and not declining as in the rest of the country. Addressing traditional CVD risk factors is necessary but not sufficient for preventing premature CVD mortality. The time has now come to also tackle the social, environmental and socioeconomic determinants of health and associated cardiovascular health disparities.”