Socioeconomic status is associated with process times in the emergency department for patients with chest pain.

Objective: Emergency department length of stay (EDLOS) is linked to crowding and patient outcomes whereas worse prognosis in low socioeconomic status remains poorly understood. We studied whether income was associated with ED process times among patients with chest pain. Methods: This was a registry-based cohort study on 124,980 patients arriving at 14 Swedish EDs between 2015 and 2019 with chest pain as their chief complaint. Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles, whether the time to physician assessment exceeded triage priority recommendations as well as EDLOS were evaluated using crude and multivariable regression models adjusted for age, gender, sociodemographic variables, and ED-management circumstances. Results: Patients with the lowest income were more likely to be assessed by physician later than triage recommendations (crude odds ratio [OR] 1.25 (95% confidence interval [CI] 1.20-1.29) and have an EDLOS exceeding 6 h (crude OR 1.22 (95% CI 1.17-1.27). Among patients subsequently diagnosed with major adverse cardiac events, patients with the lowest income were more likely to be assessed by a physician later than triage recommendations, crude OR 1.19 (95% CI 1.02-1.40). In the fully adjusted model, the average EDLOS was 13 min (5.6%) longer among patients in the lowest income quintile, 4:11 [h:min], (95% CI 4:08-4:13), compared to patients in the highest income quintile, 3:58 (95% CI 3:56-4:00). Conclusions: Among ED chest pain patients, low income was associated with longer time to physician than recommended by triage and longer EDLOS. Longer process times may have a negative impact due to crowding in the ED and delay diagnosis and timely treatment of the individual patient.

Socioeconomic Disparities and Mediators for Recurrent Atherosclerotic Cardiovascular Disease Events After a First Myocardial Infarction.

BACKGROUND: Low socioeconomic status is associated with worse secondary prevention use and prognosis after myocardial infarction (MI). Actions for health equity improvements warrant identification of risk mediators. Therefore, we assessed mediators of the association between socioeconomic status and first recurrent atherosclerotic cardiovascular disease event (rASCVD) after MI. METHODS: In this cohort study on 1-year survivors of first-ever MI with Swedish universal health coverage ages 18 to 76 years, individual-level data from SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) and linked national registries was collected from 2006 through 2020. Exposure was socioeconomic status by disposable income quintile (principal proxy), educational level, and marital status. The primary outcome was rASCVD and secondary outcomes were cardiovascular and all-cause mortality. We initially assessed the incremental attenuation of hazard ratios with 95% CIs in sequential multivariable models adding groups of potential mediators (ie, previous risk factors, acute presentation and infarct severity, initial therapies, and secondary prevention). Thereafter, the proportion of excess rASCVD associated with a low income mediated through nonparticipation in cardiac rehabilitation, suboptimal statin management, a cardiometabolic risk profile, persistent smoking, and blood pressure above target after MI were calculated using causal mediation analysis. RESULTS: Among 68 775 participants (73.8% men), 7064 rASCVD occurred during a mean 5.7-year follow-up. Income, adjusted for age, sex, and calendar year, was associated with rASCVD (hazard ratio, 1.63 [95% CI, 1.51-1.76] in the lowest versus highest income quintile). Risk attenuated most by adjustment for previous risk factors and by adding secondary prevention variables for a final model (hazard ratio, 1.38 [95% CI, 1.26-1.51]) in the lowest versus highest income quintile. The proportions of the excess 15-year rASCVD risk in the lowest income quintile mediated through nonparticipation in cardiac rehabilitation, cardiometabolic risk profile, persistent smoking, and poor blood pressure control were 3.3% (95% CI 2.1-4.8), 3.9% (95% CI, 2.9-5.5), 15.2% (95% 9.1-25.7), and 1.0% (95% CI 0.6-1.5), respectively. Risk mediation through optimal statin management was negligible. CONCLUSIONS: Nonparticipation in cardiac rehabilitation, a cardiometabolic risk profile, and persistent smoking mediate income-dependent prognosis after MI. In the absence of randomized trials, this causal inference approach may guide decisions to improve health equity.

Association of Socioeconomic Status With Risk Factor Target Achievements and Use of Secondary Prevention After Myocardial Infarction.

Importance: Low socioeconomic status (SES) is associated with poor long-term prognosis after myocardial infarction (MI). Plausible underlying mechanisms have received limited study. Objective: To assess whether SES is associated with risk factor target achievements or with risk-modifying activities, including cardiac rehabilitation programs, monitoring, and drug therapies, during the first year after MI. Design, Setting, and Participants: This cohort study included a population-based consecutive sample of 30 191 one-year survivors of first-ever MI who were 18 to 76 years of age, resided in the general community in Sweden, were followed up until their routine 11- to 15-month revisit, and were registered in the national registry Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) from 2006 through 2013. Data analyses were performed from January to August 2020. Exposure: Individual-level SES by proxy disposable income quintile. Secondary exposures were educational level and marital status. Main Outcomes and Measures: Odds ratios (ORs) with 95% CIs for achieved risk factor targets at the 1-year revisit and for use of guideline-recommended secondary prevention activities. Results: The study comprised 30 191 participants (72.9% men) with a mean (SD) age of 63.0 (8.6) years. Overall, higher SES was associated with better target achievements and use of most secondary prevention. The highest (vs lowest) income quintile was associated with achieved smoking cessation (OR, 2.05; 95% CI, 1.78-2.35), target blood pressure levels (OR, 1.17; 95% CI, 1.07-1.27), and glycated hemoglobin levels (OR, 1.57; 95% CI, 1.19-2.06). The highest-income quintile was associated not only with participation in physical training programs (OR, 2.28; 95% CI, 2.11-2.46) and patient educational sessions (OR, 2.29; 95% CI, 2.12-2.47) in cardiac rehabilitation but also with more monitoring of lipid profiles (OR, 1.20; 95% CI, 1.08-1.33) and intensification of statin therapy (OR, 1.22; 95% CI, 1.11-1.35) during the first year after MI. One year after MI, the highest-income quintile was associated with persistent use of statins (OR, 1.26; 95% CI, 1.10-1.45), high-intensity statins (OR, 1.10; 95% CI, 1.00-1.21), and renin-angiotensin-aldosterone system inhibitors (OR, 1.27; 95% CI, 1.08-1.49). Conclusions and Relevance: Findings indicated that, in a publicly financed health care system, higher SES was associated with better achievement of most risk factor targets, programs aimed at lifestyle change, and evidence-based drug therapies after MI. Observed differences in secondary prevention activity may be a factor in higher long-term risk of recurrent disease among individuals with low SES.

Association of clinical trial participation after myocardial infarction with socioeconomic status, clinical characteristics, and outcomes.

Aims: To investigate whether participants in clinical trials after myocardial infarction (MI) are representable for the post-MI population concerning characteristics, secondary prevention, and prognosis. Methods and results: Cohort study on 31 792 attendants to 1-year revisits after MI throughout Sweden (n = 2941 clinical trial participants) between 2008 and 2013 identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Individual-level data on socioeconomic status (SES) (disposable income, educational level, and marital status) and outcomes (first recurrent non-fatal MI, coronary heart disease death, fatal or non-fatal stroke until study end 2018) were linked from other national registries. Trial participants were more likely to be men [risk ratio 1.09; 95% confidence interval (CI) 1.07-1.11], and married (1.07; 1.04-1.10), have a highest-quintile income (1.42; 1.36-1.48), and post-secondary education (1.25; 1.18-1.33), while less likely to have a history of MI (0.88; 0.80-0.97), be persistent smokers (0.83; 0.75-0.92) and have left ventricular dysfunction (0.59; 0.44-0.79) compared to non-participants. During a mean 6.7-year follow-up, 5206 outcome events occurred. Risk was lower in trial participants (hazard ratio 0.80; 95% CI 0.72-0.89), also after adjusting for clinical characteristics and post-MI therapies (0.85; 0.77-0.94) and additionally for SES (0.88; 0.79-0.97). Conclusions: Clinical trial participants post-MI are more often male, have higher SES, a more advantageous risk profile, and better prognosis. Additional unmeasured participation bias was implied. Questionable external validity of post-MI trials highlights the importance of complementary studies using real-world data.

Abdominal obesity and the risk of recurrent atherosclerotic cardiovascular disease after myocardial infarction.

BACKGROUND: The association between abdominal obesity and recurrent atherosclerotic cardiovascular disease after myocardial infarction remains unknown. OBJECTIVE: The purpose of this study was to investigate the prevalence of abdominal obesity and its association with recurrent atherosclerotic cardiovascular disease in patients after a first myocardial infarction. DESIGN AND METHODS: In this register-based observational cohort, 22,882 patients were identified from the national Swedish Web-system for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry at a clinical revisit 4-10 weeks after their first myocardial infarction 2005-2014. Patients were followed for recurrent atherosclerotic cardiovascular disease defined as non-fatal myocardial infarction, coronary heart disease death, non-fatal or fatal ischaemic stroke. Univariate and multivariable-adjusted Cox regression models were used to calculate hazard ratios and 95% confidence intervals in quintiles of waist circumference as well as three categories of body mass index including normal weight, overweight and obesity. RESULTS: The majority of patients had abdominal obesity. During a median follow-up time of 3.8 years, 1232 men (7.3%) and 469 women (7.9%) experienced a recurrent atherosclerotic cardiovascular disease event. In the univariate analysis, risk was elevated in the fifth quintile (hazard ratio 1.22, 95% confidence interval 1.07-1.39) compared with the first. In the multivariable-adjusted analysis, risk was elevated in the fourth and fifth quintiles (hazard ratio 1.21, confidence interval 1.03-1.43 and hazard ratio 1.25, confidence interval 1.04-1.50), respectively. Gender-stratified analyses showed similar associations in men, while U-shaped associations were observed in women and the body mass index analyses. CONCLUSIONS: Abdominal obesity was common in post-myocardial infarction patients and larger waist circumference was independently associated with recurrent atherosclerotic cardiovascular disease, particularly in men. We recommend utilising waist circumference to identify patients at increased risk of recurrent atherosclerotic cardiovascular disease after myocardial infarction.

Lipid levels achieved after a first myocardial infarction and the prediction of recurrent atherosclerotic cardiovascular disease.

BACKGROUND: Low density lipoprotein cholesterol (LDL-C) goals post-myocardial infarction (MI) are debated, and the significance of achieved blood lipid levels for predicting a first recurrent atherosclerotic cardiovascular disease (rASCVD) event post-MI is unclear. METHODS: This was a cohort study on first-ever MI survivors aged ≤76 years attending 4-14 week revisits throughout Sweden 2005-2013. Personal-level data was collected from SWEDEHEART and linked national registries. Exposures were quintiles of LDL-C, high density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglycerides (TGs) at the revisit. Group level associations with rASCVD (nonfatal MI or coronary heart disease death or fatal or nonfatal ischemic stroke) were estimated in Cox regression models. Predictive capacity was estimated by differences in C-statistic, integrated discriminatory improvement, and net reclassification improvement when adding each blood lipid to a validated risk prediction model. RESULTS: 25,643 patients, 96.9% on statin therapy, were followed during a mean of 4.1 years. rASCVD occurred in 2173 patients (8.5%). For LDL-C and TC, moderate associations with rASCVD were observed only in the 5th vs. the lowest (referent) quintiles. For TGs and HDL-C increased risks were observed in quintiles 3-5 vs. the lowest. Minor predictive improvements were observed when lipid fractions were added to the risk model but the discrimination overall was poor (C-statistics <0.6). CONCLUSIONS: Our data question the importance of LDL-C levels achieved at first revisit post-MI for decisions on continued treatment intensity considering the weak association with rASCVD observed in this post-MI cohort.

Socioeconomic status predicts second cardiovascular event in 29,226 survivors of a first myocardial infarction.

Background Risk assessment post-myocardial infarction needs improvement, and risk factors derived from general populations apply differently in secondary prevention. The prediction of subsequent cardiovascular events post-myocardial infarction by socioeconomic status has previously been poorly studied. Design Swedish nationwide cohort study. Methods A total of 29,226 men and women (27%), 40-76 years of age, registered at the standardised one year revisit after a first myocardial infarction in the secondary prevention quality registry of SWEDEHEART 2006-2014. Personal-level data on socioeconomic status measured by disposable income and educational level, marital status, and the primary endpoint, first recurrent event of atherosclerotic cardiovascular disease, defined as non-fatal myocardial infarction or coronary heart disease death or fatal or non-fatal stroke were obtained from linked national registries. Results During the mean 4.1-year follow-up, 2284 (7.8%) first recurrent manifestations of atherosclerotic cardiovascular disease occurred. Both socioeconomic status indicators and marital status were associated with the primary endpoint in multivariable Cox regression models. In a comprehensively adjusted model, including secondary preventive treatment, the hazard ratio for the highest versus lowest quintile of disposable income was 0.73 (95% confidence interval 0.62-0.83). The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was stronger in men as was the risk associated with being unmarried (tests for interaction P < 0.05). Conclusions Among one year survivors of a first myocardial infarction, first recurrent manifestation of atherosclerotic cardiovascular disease was predicted by disposable income, level of education and marital status. The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was independent of secondary preventive treatment but further study on causal pathways is needed.