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Neighborhood marginalization is associated with increased risks for mortality and hospitalization in young survivors of acute myocardial infarction (AMI), according to a Canadian study.

The population-based, retrospective cohort study involving 65,464 Ontario patients younger than 65 years who survived AMI found that those in the most marginalized quintile had significantly greater hazards of all-cause death over 30 days (hazard ratio [HR], 2.43) and hospitalization from all causes (HR, 1.16) but not recurrent AMI.

“You’re two and a half more times more likely to die within 30 days if you live in a marginalized neighborhood compared with the least marginalized neighborhood,” study author Leo E. Akioyamen, MD, a resident in internal medicine at the University of Toronto, Toronto, told Medscape Medical News. “It is pretty striking.”

The study was published online on July 2 in JAMA Network Open.

Sociodemographics and Outcomes

“We took a population of younger adults and designed a study in which we took a look at what happened to them when they went back to the neighborhoods they came from,” said Akioyamen. “We followed them for up to 3 years, and we essentially controlled for all the variables that we typically think account for most of the socioeconomic differences in outcomes.”

The patients included in the analysis underwent invasive evaluation between April 2010 and March 2019. Eligible participants survived for at least 7 days after hospital discharge. The study population had a median age of 56 years, and 22.9% of participants were women.

One year following the index AMI, patients in the most marginalized neighborhood experienced the highest risk for all-cause death (adjusted HR [AHR], 1.80) and hospitalization from all causes (AHR, 1.20).

Investigators observed that the differences in outcomes persisted at 3 years after discharge. Mortality rates ranged from 2.2% in the least marginalized neighborhood quintile to 5.2% in the most marginalized neighborhood quintile.

Three years following the first AMI hospitalization, the risk for all-cause death rose with increasing marginalization (second quintile: AHR, 1.13; third quintile: AHR, 1.25; fourth quintile: AHR, 1.35; fifth quintile: AHR, 1.52). Over 3 years, patients in the most marginalized quintile also had a greater risk for hospitalization from all causes (AHR, 1.21) and AMI (AHR, 1.20).

“What we also observed were gradients ,” said Akioyamen. “We showed that with increasing neighborhood marginalization, we saw increasing risks of death and other bad outcomes such as heart attacks and hospitalizations.” 

The authors also observed a care gap over a 1-year period, in which patients living in the least marginalized neighborhoods vs those living in the most marginalized neighborhoods had greater contact with primary care physicians (96.1% vs 91.6%) and cardiologists (88.0% vs 75.7%).

Prospective Analysis Needed

Commenting on the findings for Medscape Medical News, Dipti Itchhaporia, MD, Eric and Sheila Samson Endowed Chair in Cardiovascular Health at the University of California, Irvine, pointed out that the study probes a challenging question.

“It’s a provocative study, but I am not sure it’s completely generalizable,” she said. “It certainly would benefit from further research into a more vigorous study design. Even though the study uses a large, robust dataset, there could still be missing data or unmeasured confounding variables that can affect the findings.”

Lifestyle data such as diet and exercise are not captured through the study design, nor are variables like family history. “We come away knowing these patients are not doing well, but I’m not sure we come away with the answer as to why, exactly,” said Itchhaporia. Prospective study designs might uncover unknown variables that affect outcomes. “We need more studies to really be able to drill down to see what would be important to know.”

Cost No Barrier

The findings indicate that barriers other than cost and insurance status are affecting health outcomes of this patient population, Miles Marchand, MD, clinical assistant professor of cardiology at the University of British Columbia in Vancouver, told Medscape Medical News.

“The real novelty and importance of this study is that it is performed in a country with universal healthcare coverage,” said Marchand. “In this healthcare environment, disparate health outcomes cannot be explained solely by financial differences in access to care; other contributing factors may be at play.”

Marchand commended the authors for using a robust study sample but agreed that the causal factors remain unknown. “One of the [study’s] main strengths is its use of large database linkages, resulting in a large cohort size,” he said. “One of the key limitations is that we don’t know the exact reason for disparities between neighborhoods. Why is it that a more marginalized neighborhood is at higher risk than a less marginalized neighborhood? This study is not able to answer that question.”

This study was funded by an Institute of Circulatory and Respiratory Health/Canadian Institutes of Health Research Team Grant to the Cardiovascular Health in Ambulatory Care Research Team. Akioyamen, Itchhaporia, and Marchand reported having no relevant financial relationships.