YOUNG-MI: Long-term Survival Significantly Affected by Neighborhood, Socioeconomic Factors

For patients who suffered a myocardial infarction (MI) at age 50 years or younger, socioeconomic disadvantage was linked to increased mortality—both all-cause and cardiovascular—even after adjusting for clinical comorbidities, according to an analysis of the Mass General Brigham YOUNG-MI Registry.

These findings suggest that “neighborhood and socioeconomic factors have a role in long-term post-MI survival among a young patient population, reinforcing the need for a better understanding of the association between socioeconomic disadvantage and poor outcomes in cardiovascular disease,” Adam N. Berman, MD, of Brigham and Women’s Hospital, Harvard Medical School, Boston, and colleagues wrote in JAMA Cardiology.

In this analysis, Berman and colleagues included 2,002 patients from the YOUNG-MI registry (median age: 45 years; 80.3% male) with a known Area Deprivation Index (ADI). To determine ADI, each patient’s home address was mapped, and patients were ranked into three groups: least disadvantaged, middle, and most disadvantaged.

Those in the most disadvantaged neighborhoods were more likely to be Black or Hispanic, have no private or public insurance, have higher rates of traditional cardiovascular risk factors including hypertension and diabetes, more likely to smoke and use illicit drugs, and less likely to receive cardiac catheterization and subsequent revascularization during hospitalization. A larger number of women lived in the most disadvantaged neighborhoods, and patients in the most disadvantaged neighborhoods were more likely to smoke tobacco products and use illicit drugs, the researchers added.

After a median follow-up of 11.3 years, 12.0% of the 2,002 patients died. In all, 1,964 patients survived to hospital discharge. Among those in the most disadvantaged socioeconomic group, 13.6% died, compared with 12.6% in the mid-range group and 5.7% in the least disadvantaged group.

Berman and colleagues adjusted for available covariates and found a statistically significant association between rank of neighborhood disadvantage and all-cause mortality (adjusted HR: 1.08; 95% CI: 1.02-1.15; P=0.006), for an 8% increase in all-cause mortality. Even after adjustment, socioeconomic disadvantage was associated with a 32% higher all-cause mortality (HR: 1.32; 95% CI: 1.10-1.60; P=0.004) and a 57% higher cardiovascular mortality (HR: 1.57; 95% CI: 1.17-2.10; P=0.003).

Among the 241 deaths, 47.7% were determined to be due to cardiovascular causes. Among the 1,964 patients who survived to hospital discharge, cardiovascular mortality occurred in 6.8% of those in the most disadvantaged groups, compared with 4.6% in the middle group, and 2.2% in the least disadvantaged group (P for trend˂0.001). For each single rank increase in socioeconomic disadvantage, there was a 13% increase (HR: 1.13: 95% CI: 1.03-1.23) in cardiovascular mortality.

“Taken into clinical context, individuals who lived in areas with the highest level of socioeconomic disadvantage had an approximately 80% higher risk for all-cause mortality and an approximately 130% higher risk for cardiovascular mortality compared with those who lived in the least disadvantaged neighborhoods,” wrote Berman and colleagues.

When researchers controlled for insurance, these associations remained significant, with “negligible change to the effect size.”

According to Berman et al: “This finding suggests that the presence and type of insurance alone do not mediate the impact of neighborhood-level disadvantage and that neighborhood-level disadvantage is associated with long-term mortality risk beyond personal markers of poverty (e.g., Medicaid enrollment or no insurance).”

“The study by Berman and colleagues adds substantively to the understanding of the social determinants of cardiovascular outcomes. Amid changing public thinking after the killing of George Floyd in May 2020, the study also prods us to consider the actions that should be taken in response to those social determinants,” wrote Edward P. Havranek, MD, of Denver Health Medical Center, University of Colorado School of Medicine, in an accompanying editorial.

He focused on the implications of these results regarding the role of clinicians and medical professionals in improving outcomes for patients, outlining two possible actionable responses. The first—from a public health perspective—is to advocate for social change.

“Disadvantaged neighborhoods need to be safe enough for residents to be physically active, for example. Residents of disadvantaged neighborhoods need local programs that promote preventive services. Beyond improving the lot of those who live in disadvantaged neighborhoods, we can advocate for confronting the reasons we have disadvantaged neighborhoods in the first place,” Havranek wrote.

The second response must come from health care organizations and policy makers in ensuring equal access to medical services, equitable care, and specialized services.

For example, noted Havranek, “Rates of cardiac catheterization (92.0% vs 95.9%) and coronary revascularization (80.7% vs 87.4%) were lower in patients from the most disadvantaged neighborhoods compared with those from the least disadvantaged neighborhoods. There appeared to be no clinical reasons for these differences, so they likely represent a disparity.”

These and other barriers to health care are key to improving outcomes in socioeconomically disadvantaged patients.

“The authors have also highlighted that socioeconomic disadvantage is not only a problem that society is responsible for addressing, but it is also a problem that individuals who work in health care organizations are, thankfully, in a position to do something about,” Havranek concluded.

Limitations of the study include its retrospective nature, the presumption that patients who moved after the time of their MI most likely moved to neighborhoods that were socioeconomically similar, and the inclusion of only patients living in Massachusetts from two medical centers in one geographic location.

1. Among individuals who experienced their first myocardial infarction at a young age, neighborhood and socioeconomic factors played a role in long-term survival.

2. The reseaerchers urged clinicians and health care professionals to work towards overcoming the barriers to care for patients who are at a socioeconomic disadvantage.

Liz Meszaros, Deputy Managing Editor, BreakingMED™

Cat ID: 358

Topic ID: 74,358,585,730,358,192,925