Socioeconomic environment and recurrent coronary events after initial myocardial infarction

Abstract Purpose Longitudinal data linking area-level socioeconomic status (SES) to repeated acute coronary syndrome (ACS) events are limited. Using multiple failure-time data, we examined the association between neighborhood SES and ACS in a community-based cohort of myocardial infarction (MI) survivors. Methods Consecutive patients aged 65 years or younger discharged from eight hospitals in central Israel after first MI in 1992–1993 were followed through 2005. Recurrent MI and unstable angina pectoris (UAP) leading to hospitalization were recorded. Neighborhood SES was assessed through a composite census-derived index developed by the Israel Central Bureau of Statistics. Different variance-corrected proportional hazards models were used to account for multiple recurrent events: Andersen-Gill, Wei-Lin-Weissfeld (WLW), and Prentice-Williams-Peterson. Results During follow-up, 531 recurrent MIs and 1584 UAP episodes occurred among 1164 patients. Adjusting for known prognostic factors and individual SES using the Andersen-Gill model, higher estimated hazards were associated with poor neighborhood SES (hazard ratio, 1.55; 95% confidence interval [CI], 1.13–2.14 for recurrent MI; and hazard ratio, 1.48; 95% CI, 1.22–1.79 for UAP; in the 5th vs. 95th percentiles). The WLW and Prentice-Williams-Peterson models yielded similar results. When the two outcomes were combined, the WLW-derived hazard ratio was 1.64 (95% CI, 1.39–1.93). Conclusions MI survivors living in a deprived neighborhood are at higher risk of repeated hospital admissions because of ACS. Secondary prevention initiatives should incorporate multilevel approaches to increase effectiveness and reduce geographic health disparities.