What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiovascular disease (n=15906). Intervention: Elevated cumulative social risk score (≥3) vs. Cumulative social risk score of 0. Primary outcome: Cardiovascular death (HR 1.46, 95% CI 1.23-1.74).

What does this research mean for the field?

An elevated cumulative social risk score increases the risk of cardiovascular death by up to 46%, with traditional risk factors—most notably smoking—explaining approximately one-third of this disparity. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

October 15, 2020Open Access

The role of traditional risk factors in explaining the social disparities in cardiovascular death: The national health and Nutrition Examination Survey III (NHANES III)

WZWei ZhangQingdao University MAMuhammad Imtiaz AhmadMedical College of Wisconsin ESElsayed Z. SolimanBrigham Young University

Key Result

An elevated cumulative social risk score (≥3) increased the risk of cardiovascular death by 46% (HR 1.46) compared to a score of 0, with traditional risk factors like smoking explaining about one third of this disparity.

Study Design

Type

Cohort (n=15,906)

Multicenter

Yes

Structured PICO

Do traditional cardiovascular risk factors explain the association between cumulative social risk exposure and cardiovascular death in US adults?

Population

15,906 US adults from the Third National Health and Nutrition Examination Survey (NHANES III) who were free of prior cardiovascular disease (coronary heart disease, heart failure, and stroke) at enrollment. Mean age 45.6, 53.4% women, 57.7% minority race.

Intervention

Elevated cumulative social risk score (1, 2, or ≥3) based on baseline social risk factors: minority race, poverty-income ratio <1, education <12 grade, and living single.

Comparator

Individuals with a cumulative social risk score of 0.

Outcome

Cardiovascular (CVD) deathhard clinical

Traditional cardiovascular risk factors, particularly smoking, explain approximately one-third of the social disparities in cardiovascular mortality, highlighting targeted smoking cessation as a key intervention for socially disadvantaged populations.

Main Result

Effect estimate: HR 1.46 (95% CI 1.23-1.74)

Absolute Event Rate: 8.6% vs 6.8%

Limitations

Diet and physical activity were not included in the analysis.
Changes in baseline CVD metrics and social risk information during follow-up were not quantified.
Information on access to medical care and medical adherence was not measured.
Current smoking was defined by self-report.
Definitions of hypertension, dyslipidemia, and diabetes did not account for whether they were controlled with treatment.
Equal score was assigned to each social risk factor.

Abstract

OBJECTIVE: ─ To assess the role of traditional risk factors in explaining the association between cumulative social risk exposure and disparities in CVD death among US adults. METHODS: ─ The study included 15,906 participants from the Third National Health and Nutrition Examination Survey III who were CVD-free at enrollment. Baseline social risk factors (minority race, poverty-income ratio<1, education<12 grade, and living single) were used to create a cumulative social risk score (0 to ≥3). CVD death served as the primary outcome. We assessed the contribution of each major CVD risk factor to the link between cumulative social risk exposure and CVD death. RESULTS: ─ During a median follow-up of 14 years, 1309 CVD deaths occurred. Participants with elevated cumulative social risk score were at increased risk of CVD death, with hazard ratio 1.19(95%CI 1.01-1.41), 1.52(95%CI 1.28-1.79), and 1.46 (95%CI 1.23-1.74) in individuals with score 1, 2 and ≥ 3 respectively, compared with individuals with score of 0. Traditional CVD risk factors explained about one third of the disparities in CVD death in individuals with the elevated social risk exposure. Among the one third effect by combined CVD risk factors, current smoking contributed the largest proportion, accounting for approximately one half of the combined risk factors effect, followed by obesity and diabetes. CONCLUSIONS: ─Among the traditional risk factors, control of smoking appears to be the greatest opportunity to attenuate the social disparities in CVD death. While these findings call for further studies to identify other pathways that explain the elevated CVD mortality in socially disadvantaged population.

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