Socioeconomic status and mortality after acute myocardial infarction

BACKGROUND: Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated. OBJECTIVE: To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI). DESIGN: Prospective cohort study. SETTING: Ontario, Canada. PATIENTS: 3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003. MEASUREMENTS: The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors. RESULTS: Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect. LIMITATIONS: Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals. CONCLUSIONS: Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the 'wealth-health gradient' in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix