December 4, 2025European Journal of Preventive Cardiology0 citationsOpen Access

A Novel Cumulative Social Advantage Metric for Enhancing the Cardiovascular Health Construct and Predicting Mortality Risk

CICarmen R. IsasiRutgers, The State University of New Jersey

Key Points

Individuals in the highest category of social advantage had significantly lower mortality risks compared to those in the lowest category.
The study utilized Cox proportional hazards models to analyze all-cause and cardiovascular mortality risks over nearly two decades.
A cumulative social advantage metric was identified as a critical factor in predicting cardiovascular health outcomes among various racial and ethnic groups.
Future investigations should explore additional resilience factors, particularly in Hispanic adults, to strengthen predictive models of health.

Abstract

Abstract Aims The Life’s Essential 8 (LE8) guidelines acknowledge that social determinants of health (SDoH) shape cardiovascular health (CVH) but do not include an SDoH metric. This study evaluated a multidimensional and readily measurable social advantage metric (SAM) in relation to mortality and whether its inclusion as a ninth CVH metric enhances its predictive value. Methods Participants were 46,366 adults (age:20-79y, 51% female, 11% Black, 13% Hispanic) from the 1999-2018 National Health and Nutrition Examination Survey. A SAM score (range:0-100, higher denoting greater advantage) was created using nine SDoH metrics predictive of CVH (acculturation, education, poverty-to-income ratio, employment status, health insurance coverage, healthcare access and utilization, food security, home ownership, and social support). Multivariable Cox proportional hazards models compared all-cause and cardiovascular mortality risk across a priori defined categories (high:80-100, moderate:50-79, low:0-49) of the SAM and an enhanced CVH score including SAM as a ninth metric. Results The mean SAM was 59, with variation by race and ethnicity (White:66, Black:47, Hispanic:36). Individuals in the highest versus lowest SAM category had 67% and 69% lower risks of all-cause and cardiovascular mortality risk, respectively (p-trend0.001). Those in the highest enhanced CVH category had lower all-cause (HR(95%CI): 0.22(0.14-0.34)) and cardiovascular mortality (HR(95%CI): 0.17(0.07-0.41)) risk. Predictive performance of the enhanced score was comparable to LE8 alone (C-statistic=0.835 vs. 0.831, p0.001). Associations varied by race and ethnicity (p-interaction0.01), but not sex, with significant mortality prediction in White and Black but not Hispanic adults. Conclusions An enhanced CVH score including SDoH metric strongly predicted mortality among US adults. Future research should examine the concept of social advantage and additional factors that confer resilience, particularly among Hispanic adults.

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