Broadening Our Understanding of Survival After Myocardial Infarction

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HomeCirculationVol. 121, No. 3Broadening Our Understanding of Survival After Myocardial Infarction Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBBroadening Our Understanding of Survival After Myocardial InfarctionThe Association of Neighborhood With Outcomes John Spertus John SpertusJohn Spertus From the Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City, Kansas City, Mo. Search for more papers by this author Originally published26 Jan 2010https://doi.org/10.1161/CIR.0b013e3181d0b9c0Circulation. 2010;121:348–350As clinicians and scientists, it is common to presume that clinical outcomes after myocardial infarction (MI) are most profoundly influenced by the pathogenesis of the disease itself, including genetics, cardiovascular risk factors, inflammatory state, disease severity (eg, the number and severity of obstructed coronary arteries), and the treatments that we offer. Consequently, our efforts to optimize the outcomes of our patients are aimed at following clinical guidelines in care for individual patients.1–3 When our profession seeks to influence systems of care and public policy, our focus has been on increasing access to lifesaving therapies.4 Because they appear outside of physicians’ locus of control, risk factors related to patients’ socioeconomic status are often not considered targets for intervention.Article see p 375Although numerous studies have defined an adverse association between lower socioeconomic status and post-MI treatment5 and outcomes,6–8 little work has been done to develop interventions to overcome these disparities. We also have not sought to systematically understand mediating factors that may influence the prognostic associations of socioeconomic risk factors with outcomes. The reasons there have been such little progress in overcoming socioeconomic status barriers, despite the national priorities to create equity in health care,9–11 are multifactorial and include both the difficulties in measuring socioeconomic status and the challenges in overcoming them. In a critical review of the science linking socioeconomic status to health outcomes, Braveman and colleagues12 demonstrated that different measures of socioeconomic status are not interchangeable, that direct measures of wealth are seldom used, and that researchers rarely include a broad portfolio of measures in their studies.Further compounding the challenges of examining socioeconomic status is the fact that although patients may have unique factors related to their income and education, they also live in neighborhoods that are based in part on these characteristics. Thus, although the research community is beginning to quantify and examine the association of socioeconomic status with outcomes, we have seldom considered neighborhood as a risk factor independent of patients’ individual socioeconomic status. In fact, many have used the zip code as a surrogate for patients’ socioeconomic status,8,13 which further blurs the distinction between the individual and residential components of socioeconomic status. This has occurred despite previous research showing that even after adjustment for patient-level measures of socioeconomic status, neighborhoods of residence can be independently associated with the prevalence of cardiovascular risk factors and the development of cardiovascular disease.14 Thus, understanding the independent influence of personal and regional socioeconomic factors in the context of traditional clinical risk factors is desperately needed if we are to collectively overcome existing disparities in outcomes.15In the context of a need to better understand the socioeconomic determinants of post-MI outcomes and with the recognition that multiple measures are needed, Gerber and colleagues16 provide a unique and important extension of existing research on socioeconomic determinants of survival after MI. In this issue of Circulation, they describe the long-term survival of 1179 patients in central Israel surviving their first MI. With an astoundingly representative cohort from their region (98% of eligible patients participating), they extensively adjusted for demographic and clinical factors to examine the independent association of socioeconomic status on long-term survival. Importantly, they included both individual-level and residential estimates of socioeconomic status. Using a composite index of neighborhood socioeconomic status developed and validated by the Israel Central Bureau of Statistics,17 they were able to classify the relative resources of the neighborhoods in which patients resided at the time of their MI. They found, even after adjusting for a range of demographic (age, gender), clinical (eg, diabetes, hypertension, smoking, obesity, sedentary lifestyle, comorbidities, MI type), and treatment (acute reperfusion for ST-elevation MI, coronary revascularization) variables, that both personal and neighborhood socioeconomic factors were independently associated with survival in the next 13 years. Importantly, the association of neighborhood socioeconomic status was even stronger for cardiovascular death than for overall survival, which suggests that there is unique risk along the biological pathway of coronary disease that contributes to excess cardiovascular mortality. Because one may expect that living in more disadvantaged neighborhoods may increase the risk of death due to noncardiovascular causes, such as cancer or violence, it appears that the stronger association with cardiovascular mortality underscores the importance of neighborhood on post-MI outcomes. 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.As with any good study, once we believe the association, we are left wanting more information. Were there differences in the prescription or use of secondary prevention medications among patients residing in different neighborhoods? Were there differences in the use of cardiac rehabilitation and subsequent revascularization over time? Were there differences in depression or stress, known risk factors for poor cardiovascular outcomes18–22 that may have confounded the observed associations? Are there environmental factors, such as the small particulate matter from coal-burning power plants or industry, a known risk factor for cardiovascular disease,23 that may have confounded the association between neighborhood socioeconomic status and survival? Without a deeper understanding of the potential mechanisms for the observed association between neighborhoods and outcomes, it is difficult to know how best to mediate the described disparities.In light of the probable association between both patient-level and environmental determinants of prognosis after MI, the cardiovascular community is challenged to address both of these risk factors, in addition to our standard efforts at secondary prevention.24 I believe that this will require a series of critical steps. First, researchers are going to have to increase their efforts to carefully measure the socioeconomic status of patients at both the personal and residential levels to better understand the association between these parameters and clinical outcomes. Then, a concerted effort to investigate the potential mechanisms of these associations will be needed. The next challenge will be to develop novel interventions directed at both personal and neighborhood risks that can mitigate these adverse outcomes. Although one may imagine that access to care in the United States would be associated with patients’ socioeconomic status,25 it is sobering to recognize that in Israel, where there is universal access to health care, it is unlikely that increasing access alone would eradicate the observed disparities in outcomes. Once we have determined how and why residential socioeconomic status influences outcome, the medical community will need to begin advocating for public policy changes that can target the presumed causes of neighborhoods’ association with poor health outcomes. In so doing, we will be able to move closer to the American ideal of equity in health and outcomes9 and optimize the prognosis of our patients.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresDr Spertus has received significant research and grant support from the National Institutes of Health, the American Heart Association, the American College of Cardiology Foundation, Lilly, Cordis, Amgen, and Bristol-Myers Squibb/Sanofi; is a consultant for Amgen, Novartis, and United Healthcare; and owns the copyright to the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire. He also has an equity interest in Health Outcomes Sciences, LLC.FootnotesCorrespondence to John Spertus, MD, MPH, Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City, 4401 Wornall Rd, 5th Floor MAHI, Kansas City, MO 64111. E-mail [email protected] References 1 Kushner FG, Hand M, Smith SC Jr, King SB III, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE Jr, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009; 120: 2271–2306.LinkGoogle Scholar2 Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr, Anbe DT, Kushner FG, Ornato JP, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, writing on behalf of the 2004 Writing Committee. Circulation. 2008; 117: 296–329.LinkGoogle Scholar3 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007; 116: e148–e304.LinkGoogle Scholar4 Antman EM. Time is muscle: translation into practice. J Am Coll Cardiol. 2008; 52: 1216–1221.CrossrefMedlineGoogle Scholar5 Rao SV, Kaul P, Newby LK, Lincoff AM, Hochman J, Harrington RA, Mark DB, Peterson ED. Poverty,process of care,and outcome in acute coronary syndromes. J Am Coll Cardiol. 2003; 41: 1948–1954.CrossrefMedlineGoogle Scholar6 Bernheim SM, Spertus JA, Reid KJ, Bradley EH, Desai RA, Peterson ED, Rathore SS, Normand SL, Jones PG, Rahimi A, Krumholz HM. Socioeconomic disparities in outcomes after acute myocardial infarction. Am Heart J. 2007; 153: 313–319.CrossrefMedlineGoogle Scholar7 Rahimi AR, Spertus JA, Reid KJ, Bernheim SM, Krumholz HM. Financial barriers to health care and outcomes after acute myocardial infarction. JAMA. 2007; 297: 1063–1072.CrossrefMedlineGoogle Scholar8 Rao SV, Schulman KA, Curtis LH, Gersh BJ, Jollis JG. Socioeconomic status and outcome following acute myocardial infarction in elderly patients. Arch Intern Med. 2004; 164: 1128–1133.CrossrefMedlineGoogle Scholar9 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-First Century. Washington, DC: National Academy Press; 2001.Google Scholar10 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.Google Scholar11 US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000.Google Scholar12 Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, Posner S. Socioeconomic status in health research: one size does not fit all. JAMA. 2005; 294: 2879–2888.CrossrefMedlineGoogle Scholar13 Smith GD, Neaton JD, Wentworth D, Stamler R, Stamler J. Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial, I: white men. Am J Public Health. 1996; 86: 486–496.CrossrefMedlineGoogle Scholar14 Diez Roux AV, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, Sorlie P, Szklo M, Tyroler HA, Watson RL. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001; 345: 99–106.CrossrefMedlineGoogle Scholar15 Diez Roux AV. Towards a realistic and relevant public health: the challenges of useful simplification. J Public Health (Oxf). 2008; 30: 230–231.CrossrefMedlineGoogle Scholar16 Gerber Y, Benyamini Y, Goldbourt U, Drory Y; for the Israel Study Group on First Acute Myocardial Infarction. Neighborhood socioeconomic context and long-term survival after myocardial infarction. Circulation. 2010; 121: 375–383.LinkGoogle Scholar17 Burck L, Feinstein Y. Characterization and Classification of Geographical Units by the Socioeconomic Level of the Population. Series of 1995 Census of Population and Housing publications. Publication No. 13. Jerusalem, Israel; Central Bureau of Statistics; 2000.Google Scholar18 Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA. 1993; 270: 1819–1825.CrossrefMedlineGoogle Scholar19 Rumsfeld JS, Jones PG, Whooley MA, Sullivan MD, Pitt B, Weintraub WS, Spertus JA. Depression predicts mortality and hospitalization in patients with myocardial infarction complicated by heart failure. Am Heart J. 2005; 150: 961–967.CrossrefMedlineGoogle Scholar20 Huffman JC, Smith FA, Blais MA, Januzzi JL, Fricchione GL. Anxiety, independent of depressive symptoms, is associated with in-hospital cardiac complications after acute myocardial infarction. J Psychosom Res. 2008; 65: 557–563.CrossrefMedlineGoogle Scholar21 Hamer M, Molloy GJ, Stamatakis E. Psychological distress as a risk factor for cardiovascular events: pathophysiological and behavioral mechanisms. J Am Coll Cardiol. 2008; 52: 2156–2162.CrossrefMedlineGoogle Scholar22 Shemesh E, Yehuda R, Milo O, Dinur I, Rudnick A, Vered Z, Cotter G. Posttraumatic stress, nonadherence, and adverse outcome in survivors of a myocardial infarction. Psychosom Med. 2004; 66: 521–526.CrossrefMedlineGoogle Scholar23 Brook RD, Franklin B, Cascio W, Hong Y, Howard G, Lipsett M, Luepker R, Mittleman M, Samet J, Smith SC Jr, Tager I. Air pollution and cardiovascular disease: a statement for healthcare professionals from the Expert Panel on Population and Prevention Science of the American Heart Association. Circulation. 2004; 109: 2655–2671.LinkGoogle Scholar24 Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006; 113: 2363–2372.LinkGoogle Scholar25 Daugherty SL, Ho PM, Spertus JA, Jones PG, Bach RG, Krumholz HM, Peterson ED, Rumsfeld JS, Masoudi FA. Association of early follow-up after acute myocardial infarction with higher rates of medication use. Arch Intern Med. 2008; 168: 485–491.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByGarcia M, Almuwaqqat Z, Moazzami K, Young A, Lima B, Sullivan S, Kaseer B, Lewis T, Hammadah M, Levantsevych O, Elon L, Bremner J, Raggi P, Shah A, Quyyumi A and Vaccarino V (2021) Racial Disparities in Adverse Cardiovascular Outcomes After a Myocardial Infarction in Young or Middle‐Aged Patients, Journal of the American Heart Association, 10:17, Online publication date: 7-Sep-2021. Tonne C and Wilkinson P (2013) Long-term exposure to air pollution is associated with survival following acute coronary syndrome, European Heart Journal, 10.1093/eurheartj/ehs480, 34:17, (1306-1311), Online publication date: 1-May-2013., Online publication date: 1-May-2013. Katzenellenbogen J, Sanfilippo F, Hobbs M, Briffa T, Ridout S, Knuiman M, Dimer L, Taylor K, Thompson P and Thompson S (2011) Aboriginal to non-Aboriginal differentials in 2-year outcomes following non-fatal first-ever acute MI persist after adjustment for comorbidity, European Journal of Preventive Cardiology, 10.1177/1741826711417925, 19:5, (983-990), Online publication date: 1-Oct-2012. Koren A, Steinberg D, Drory Y and Gerber Y (2012) Socioeconomic environment and recurrent coronary events after initial myocardial infarction, Annals of Epidemiology, 10.1016/j.annepidem.2012.04.023, 22:8, (541-546), Online publication date: 1-Aug-2012. Gerber Y, Myers V, Goldbourt U, Benyamini Y and Drory Y (2011) Neighborhood Socioeconomic Status and Leisure-Time Physical Activity After Myocardial Infarction, American Journal of Preventive Medicine, 10.1016/j.amepre.2011.05.016, 41:3, (266-273), Online publication date: 1-Sep-2011. January 26, 2010Vol 121, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/CIR.0b013e3181d0b9c0PMID: 20100985 Originally publishedJanuary 26, 2010 KeywordsEditorialsmortalitycardiovascular diseasesPDF download Advertisement SubjectsEpidemiologyEthics and PolicyMyocardial Infarction