Concomitant psychiatric, somatic, and social vulnerabilities in patients at greatest risk of cardiovascular disease: a latent class analysis

Abstract Background Psychiatric disorder and low socioeconomic position are associated with a higher risk of major adverse cardiovascular event (MACE) and limited access to healthcare. Syndemics refers to the synergistic interaction of multiple coexisting health conditions exacerbated by socioeconomic and environmental factors, and their combined effects on health. A syndemic approach may be helpful to understand the interaction between psychiatric, socioeconomic, and cardiovascular factors. Purpose Using a data-driven clustering approach, we aimed to identify classes of vulnerability and areas of unmet needs in cardiovascular risk management (CVRM) in a Dutch primary care setting by simultaneously analysing clinical, healthcare utilisation, demographic, and socioeconomic factors. Methods Patients were included if they were between 40–70 years old on January 1, 2018, and were registered for CVRM at a general practice prior to that date in South Holland, the Netherlands. Latent class analysis was performed based on 21 variables in seven themes: cardiovascular, multimorbidity, adverse lifestyle, psychiatric, age, demographic, and socioeconomic factors. Two outcomes were used to evaluate the difference between classes: 1) five-year risk of MACE and 2) healthcare expenditure in 2018-2022. Results A total of 43,916 patients were included. The four-class model was considered optimal (Figure 1). Class 1 (n = 15,607; 36%), "healthy and socioeconomically resilient", featured native Dutch, less senior, and rich patients. Class 2 (n = 7,440; 17%), "psychiatric, somatic, and social vulnerability", featured high risks in all variables. Class 3 (n = 6,038; 14%), "socioeconomic deprivation", featured young, female, and non-Dutch patients. Class 4 (n = 14,831; 34%), "somatic multimorbidity and older age", featured senior patients with common prior-cardiovascular disease and multimorbidity. Both the five-year risk of MACE and overall healthcare expenditure were the highest in class 2 and the second highest in class 4 (Table 1). Females were more frequently classified in class 2 and 3 compared to males. In class 2 and 4, abnormal body mass index and smokers were more prevalent whereas the reception of social support appeared to be not explanatory for the elevated risk of MACE. Conclusion Four distinct classes of patients in CVRM were identified, with patients in class 2 ("psychiatric, somatic, and social vulnerability") at both greatest risks for recurrent cardiovascular events and overall healthcare expenditure, potentially driven by adverse lifestyle factors. Our results indicate a potential syndemic relation between cardiovascular, psychiatric, and socioeconomic factors, and provide a quantitative argument for the urgent need for more integrated and person-centred care models to address multimorbidity, social determinants, and behavioural factors within the population at high risk of cardiovascular disease.Figure 1.Visualisation of LCAFor image description, please refer to the figure legend and surrounding text. Table 1.Association with outcomesFor image description, please refer to the figure legend and surrounding text.