Rita Hamad1,2, Joanne Penko3,4, Dhruv S Kazi5,6, Pamela Coxson3,4, David Guzman3,7, Pengxiao C Wei4, Antoinette Mason8, Emily A Wang9, Lee Goldman10, Kevin Fiscella11, Kirsten Bibbins-Domingo3,4,7. 1. Department of Family & Community Medicine, University of California, San Francisco, San Francisco. 2. Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco. 3. Center for Vulnerable Populations, University of California, San Francisco, San Francisco. 4. Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco. 5. Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 6. Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 7. Department of Medicine, University of San Francisco, San Francisco, California. 8. Sutter Santa Rosa Family Medicine Residency, University of California, San Francisco, Santa Rosa. 9. Department of Medicine, Yale School of Medicine, New Haven, Connecticut. 10. Vagelos College of Physicians and Surgeons, Columbia University, New York, New York. 11. Department of Family Medicine, University of Rochester Medical Center, Rochester, New York.
Abstract
Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties. Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES. Design, Setting, and Participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations. Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma. Main Outcomes and Measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths. Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES. Conclusions and Relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.
Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties. Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES. Design, Setting, and Participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations. Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma. Main Outcomes and Measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths. Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES. Conclusions and Relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.
Authors: Nilay S Shah; Hongyan Ning; Lucia C Petito; Kiarri N Kershaw; Michael P Bancks; Jared P Reis; Jamal S Rana; Stephen Sidney; David R Jacobs; Catarina I Kiefe; Mercedes R Carnethon; Donald M Lloyd-Jones; Norrina B Allen; Sadiya S Khan Journal: Circulation Date: 2022-05-24 Impact factor: 39.918
Authors: Min Hee Kim; Gabriel L Schwartz; Justin S White; M Maria Glymour; Sean F Reardon; Kiarri N Kershaw; Scarlett Lin Gomez; Daniel F Collin; Pushkar P Inamdar; Guangyi Wang; Rita Hamad Journal: PLoS Med Date: 2022-06-21 Impact factor: 11.613
Authors: Per Nordberg; Martin Jonsson; Jacob Hollenberg; Mattias Ringh; Ritva Kiiski Berggren; Robin Hofmann; Per Svensson Journal: Sci Rep Date: 2022-07-15 Impact factor: 4.996