The role of the socio-economic environment on medical outcomes after ST-segment elevation myocardial infarction

Untangling the Complex Multidimensionality of the Social Determinants of Cardiovascular Health: A Systematic Review

BACKGROUND

The cardiovascular literature is limited by the lack of consensus on what are the best metrics for reporting social determinants of health (SDH) or social deprivation, and if they should be reported as a single metric or separately by their domains.

METHODS

A systematic review of the literature on cardiovascular surgeries and procedures was conducted, identifying articles from January 1, 2010, to December 31, 2023, that studied the relationship between health outcomes after cardiovascular procedures or surgeries and SDH/social deprivation. The cardiovascular procedures/surgeries of interest were coronary and valve surgeries and procedures including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), valve replacement or repair, and transcatheter aortic valve intervention.

RESULTS

After screening 638 articles, we identified 47 papers that met our inclusion and exclusion criteria. The most common procedure evaluated was CABG and PCI; 46 of the studies focused on these 2 procedures. Almost all of the articles reported a different metric for SDH/social deprivation (41 different metrics); despite this, all of the metrics showed a consistent relationship with worse outcomes associated with greater degrees of SDH/deprivation. Only 9 reported on the individual domains of SDH/social deprivation; 3 studies showed a discordant relationship.

CONCLUSIONS

Although our systematic review identified numerous articles evaluating the relationship between SDH/social deprivation in cardiovascular disease, there was substantial heterogeneity in which metric was used and how it was reported. This reinforces the need for standards as to the best metrics for SDH/social deprivation as well as best practices for reporting.

Socioeconomic environment and survival in patients after ST-segment elevation myocardial infarction (STEMI): a longitudinal study for the City of Vienna

OBJECTIVES

This study investigates the relationship between socioeconomic environment (SEE) and survival after ST-segment elevation myocardial infarction (STEMI) separately for women and men in the City of Vienna, Austria.

DESIGN

Hospital-based observational data of STEMI patients are linked with district-level information on SEE and the mortality register, enabling survival analyses with a 19-year follow-up (2000-2018).

SETTING

The analysis is set at the main tertiary care hospital of the City of Vienna. On weekends, it is the only hospital in charge of treating STEMIs and thus provides representative data for the Viennese population.

PARTICIPANTS

The study comprises a total of 1481 patients with STEMI, including women and men aged 24-94 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures are age at STEMI and age at death. We further distinguish between deaths from coronary artery disease (CAD), deaths from acute coronary syndrome (ACS), and other causes of death. SEE is proxied via mean individual gross income from employment in each municipal district.

RESULTS

Results are based on Kaplan-Meier survival probability estimates, Cox proportional hazard regressions and competing risk models, always using age as the time scale. Descriptive findings suggest a socioeconomic gradient in the age at death after STEMI. This finding is, however, not supported by the regression results. Female patients with STEMI have better survival outcomes, but only for deaths related to CAD (HR: 0.668, 95% CIs 0.452 to 0.985) and other causes of deaths (HR: 0.627, 95% CIs 0.444 to 0.884), and not for deaths from the more acute ACS.

CONCLUSIONS

Additional research is necessary to further disentangle the interaction between SEE and age at STEMI, as our findings suggest that individuals from poorer districts have STEMI at younger ages, which indicates vulnerability in regard to health conditions in these neighbourhoods.

Impact of Patient Unawareness and Socioeconomic Factors on Patient Presentation to Primary Percutaneous Coronary Intervention

Fundamento:

O desconhecimento do paciente sobre o infarto agudo do miocárdio, suas complicações e os benefícios da revascularização precoce é um ponto crucial na determinação dos desfechos. Além disso, a relação entre fatores socioeconômicos e apresentação do paciente à intervenção coronária percutânea primária (ICPP) não foi totalmente estudada.

Objetivos:

Nosso objetivo foi investigar se o desconhecimento do paciente e outros fatores socioeconômicos impactam na apresentação do paciente à ICPP.

Métodos:

O estudo compreendeu 570 pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) revascularizados por ICPP. Os pacientes foram classificados em dois grupos de acordo com o tempo total de isquemia (tempo desde o início dos sintomas do IAMCSST até a dilatação com balão); grupo I: Pacientes com apresentação precoce (1-12 horas). Grupo II: Pacientes com apresentação tardia (>12-24 horas). Fatores socioeconômicos, desfechos clínicos incluindo mortalidade e eventos cardíacos adversos maiores (ECAM) foram avaliados em cada grupo. O valor de p < 0,05 foi considerado estatisticamente significante.

Resultados:

Existem diferentes fatores socioeconômicos que afetam a apresentação do paciente à ICPP. A análise de regressão multivariada identificou os preditores socioeconômicos independentes da seguinte forma: baixa escolaridade - OR 4,357 (IC95% 1,087–17,47, p=0,038), isolamento social - OR 4,390 (IC95% 1,158–16,64, p=0,030) e desconhecimento sobre os benefícios da revascularização precoce - OR 4,396 (IC95% 1,652–11,69, p =0,003). A mortalidade e ECAM foram mais altas no grupo II.

Conclusão:

O desconhecimento do paciente e o baixo nível socioeconômico foram associados à apresentação tardia para a ICPP, com desfechos mais adversos.

Knowledge and Prevalence of Risk Factors for Coronary Artery Disease in Patients after Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

BACKGROUND

Percutaneous coronary intervention (PCI) is associated with a short hospital stay and fast recovery. However, it might be related to insufficient implementation of lifestyle changes after the procedure. Conversely, coronary artery bypass grafting (CABG) is a highly invasive technique that requires a prolonged hospital stay and long rehabilitation with more opportunities for education. This study aimed to evaluate the impact of CABG on adherence to lifestyle modifications and knowledge about coronary artery disease (CAD) in comparison with PCI. We also evaluated the level of education and tried to define groups of patients that might require targeted education.

METHODS

Data was collected using a self-designed 56-item questionnaire. Questions assessed the knowledge of CAD risk factors and the level of their control.

RESULTS

The study group consisted of 155 consecutive patients admitted to the Cardiology Department. Patients with a history of PCI (68%) (at least 8 weeks before) were included in the prior-PCI group, and patients with previous surgical revascularization (also at least 8 weeks before) were assigned to the prior-CABG group (32%). The knowledge score was higher in the prior-CABG group. The median (IQR) results in the prior-PCI vs. prior-CABG group were, respectively: 20 (12-24) vs. 22 (19-25) [points, per 31 max.]; p = 0.01. Similar results were obtained in the level of risk control (prior-PCI vs. prior-CABG, respectively: 6 (4-7) vs. 7 (6-8) [points, per 15 max.]; p = 0.002).

CONCLUSIONS

The method of treatment of CAD might impact the implementation of lifestyle modifications after the procedure. More effort is required to improve secondary prevention, especially in PCI patients.

Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis

BACKGROUND

Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation.

METHODS

All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0-100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation.

RESULTS

A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk CONCLUSION: Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.