Low neighborhood socioeconomic status linked to poor MI survival
MedWire News: People from neighborhoods with low socioeconomic status (SES) have worse survival rates after myocardial infarction (MI) than those from more affluent neighborhoods, show the results of a study in Israel.
The association between neighborhood and survival was partly attributable to individual’s SES and clinical characteristics, but the authors say their data “support a multidimensional relationship between SES and MI survival and indicate the importance of enhancing preventive/rehabilitative healthcare services for post-MI patients residing in deprived neighborhoods.”
The study included 1179 MI patients aged 65 years or older who were admitted to eight hospitals between February 1992 and February 1993. Patients’ individual SES data, including family income, education, employment, and whether or not they were living with a steady partner were recorded at enrolment. Neighborhood SES was estimated for their address at the time of the initial event using a validated index from the Israel Central Bureau of Statistics, including demographic, schooling and education, standard of living, employment rate, and social benefits.
During follow-up lasting through 2005, 326 patients died.
Patients residing in less advantaged neighborhoods had higher mortality rates, with 13-year survival estimates across increasing tertiles of SES status of 61%, 74%, and 82% (p for trend <0.001).
Adjustment for sociodemographic variables, traditional risk factors, MI severity, and individual SES measures attenuated the risk increase, but patients in the lowest SES neighborhood tertile still had a significant 1.47-fold increased mortality hazard, and those in the middle tertile a nonsignificant 1.19-fold increased mortality risk, relative to those in the highest tertile (p for trend=0.02).
The association was stronger for cardiac deaths specifically, the researchers say, with respective 1.63- and 1.41-fold increased relative risks in the lowest and middle versus highest neighborhood SES tertiles.
“Further research is needed to identify the most relevant features of residential environments that affect cardiovascular incidence and prognosis,” conclude Yariv Gerber and team from Tel Aviv University in the journal Circulation.
John Spertus (University of Missouri-Kansas City, USA) said in an editorial accompanying the paper that the team’s work provides “a unique and important extension of existing research on socioeconomic determinants of survival after MI.”
The apparently stronger association with cardiovascular death than overall survival suggests “unique risk along the biological pathway of coronary disease that contributes to excess cardiovascular mortality,” he noted. Indeed, higher mortality through cancer and violence might be expected in more disadvantaged neighborhoods and therefore the association with cardiovascular mortality underscores the importance of neighborhood on post-MI outcomes, Spertus suggested.
“By defining the independent influence of neighborhood socioeconomic status on cardiovascular outcomes, particularly in a country with universal healthcare coverage, the authors have challenged the research community to better understand the causal mechanisms of this association so as to develop interventions that can overcome these disparities,” Spertus wrote. As there is universal access to healthcare in Israel, it is unlikely that improving access alone would eradicate the observed disparity, he pointed out.
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By Caroline Price