OBJECTIVE
To evaluate the association of neighborhood-level income and individual-level education
with post-myocardial infarction (MI) mortality in community patients.
PATIENTS AND METHODS
From November 1, 2002, through May 31, 2006, 705 (mean ± SD age, 69±15 years; 44%
women) residents of Olmsted County, MN, who experienced an MI meeting standardized
criteria were prospectively enrolled and followed up. The neighborhood's median household
income was estimated by census tract data; education was self-reported. Demographic
and clinical variables were obtained from the medical records.
RESULTS
Living in a less affluent neighborhood and having a low educational level were both
associated with older age and more comorbidity. During follow-up (median, 13 months),
155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval
[CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile)
and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were
independently associated with mortality risk. Adjustment for demographics and various
post-MI prognostic indicators attenuated these estimates, yet excess risk persisted
for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous
variable, each $10,000 increase in annual income was associated with a 10% reduction
in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99).
CONCLUSION
In this geographically defined cohort of patients with MI, low individual education
and poor neighborhood income were associated with a worse clinical presentation. Poor
neighborhood income was a powerful predictor of mortality even after controlling for
a variety of potential confounding factors. These data confirm the socioeconomic disparities
in health after MI.
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REFERENCES
- Relation of education to sudden death after myocardial infarction.N Engl J Med. 1978; 299: 60-65
- Comparison of long-term outcome after acute myocardial infarction in patients never graduated from high school with that in more educated patients.Am J Cardiol. 1993; 71: 1031-1035
- Socioeconomic status in health research: one size does not fit all.JAMA. 2005; 294: 2879-2888
- Bringing context back into epidemiology: variables and fallacies in multilevel analysis.Am J Public Health. 1998; 88: 216-222
- Pathways between socioeconomic determinants of health.J Epidemiol Community Health. 2004; 58: 327-332
- Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review.J Epidemiol Community Health. 2001; 55: 111-122
- Neighborhood of residence and incidence of coronary heart disease.N Engl J Med. 2001; 345: 99-106
- Mortality effects of community socioeconomic status.Epidemiology. 1997; 8: 42-47
- Socioeconomic position and health: the independent contribution of community socioeconomic context.Annu Rev Sociol. 1999; 25: 489-516
- An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations.Health Serv Res. 2001; 36: 711-732
- Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods.Circulation. 2005 Jun 14; 111 (Epub 2005 Jun 6.): 3063-3070
- Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction.N Engl J Med. 1999; 341: 1359-1367
- Poverty, process of care, and outcome in acute coronary syndromes.J Am Coll Cardiol. 2003; 41: 1948-1954
- Socioeconomic status and mortality after acute myocardial infarction.Ann Intern Med. 2006; 144: 82-93
- Relation of socioeconomic position to the case fatality, prognosis and treatment of myocardial infarction events: the FINMONICA MI Register Study.J Epidemiol Community Health. 2001; 55: 475-482
- Mortality after acute myocardial infarction according to income and education.J Epidemiol Community Health. 2006; 60: 351-356
- Socioeconomic status and outcome following acute myocardial infarction in elderly patients.Arch Intern Med. 2004; 164: 1128-1133
- The association between educational level and risk of cardiovascular disease fatality among women with cardiovascular disease.Women's Health Issues. 2005; 15: 80-88
- Effects of socioeconomic status on mortality after acute myocardial infarction.Am J Med. 2007; 120: 33-39
- Socioeconomic disparities in outcomes after acute myocardial infarction.Am Heart J. 2007; 153: 313-319
- Socioeconomic differentials in recurrent ischaemia and mortality after acute myocardial infarction.Heart. 2001; 85: 390-394
- External validity of clinical trials in acute myocardial infarction.Arch Intern Med. 2007; 167: 68-73
- Impracticability of informed consent in the Registry of the Canadian Stroke Network.N Engl J Med. 2004; 350: 1414-1421
- History of the Rochester Epidemiology Project.Mayo Clin Proc. 1996; 71: 266-274
- American FactFinder.(Accessed March 20, 2008.)
- Redefinition of myocardial infarction: prospective evaluation in the community.Circulation. 2006 Aug 22; 114 (Epub 2006 Aug 14.): 790-797
- European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials.Am Heart J. 2002; 144: 981-986
- Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute.Circulation. 2003 Nov 18; 108 (Epub 2003 Nov 10.): 2543-2549
- Participation bias assessment in a community-based study of myocardial infarction, 2002-2005.Mayo Clin Proc. 2007; 82: 933-938
- Use of census-based aggregate variables to proxy for socioeconomic group: evidence from national samples.Am J Epidemiol. 1998; 148: 475-486
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383
- Secular trends in deaths from cardiovascular diseases: a 25-year community study.Circulation. 2006 May 16; 113 (Epub 2006 May 8.): 2285-2292
- Inequalities in health: report of a research working group (The Black Report). DHSS, London, UK1980
- The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986.N Engl J Med. 1993; 329: 103-109
- Neighborhood socioeconomic context, individual income and myocardial infarction.Epidemiology. 2006; 17: 14-23
- Neighborhood socioeconomic environment and incidence of coronary heart disease: a follow-up study of 25,319 women and men in Sweden.Am J Epidemiol. 2004; 159: 655-662
- Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State.Circulation. 2000; 102: III107-III115
- Race, sex, poverty, and the medical treatment of acute myocardial infarction in the elderly.Circulation. 2000; 102: 642-648
- Health literacy and mortality among elderly persons.Arch Intern Med. 2007; 167: 1503-1509
- Functional recovery after myocardial infarction in men: the independent effects of social class.Ann Intern Med. 1997; 127: 518-525
- Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited.Heart. 1999; 82: 373-377
- Impact of medication therapy discontinuation on mortality after myocardial infarction.Arch Intern Med. 2006; 166: 1842-1847
Article Info
Footnotes
This study was funded by grants from the Public Health Service and the National Institutes of Health ( AR30582, R01 HL 59205, and R01 HL 72435 ). Dr Roger is an Established Investigator of the American Heart Association.
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© 2008 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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