bernard j. gersh, mb, chb, dphil
TRANSCRIPT
Gersh_SES Outcomes of CVD_requested disclosure slide_revisedBernard
J. Gersh, MB, ChB, DPhil
1
Financial Disclosures:
Other Financial Disclosures: Data Safety Monitoring Board Member for: Baim Institute; Boston Scientifc Corporation; Cardiovascular Research Foundation; Duke Clinical Research Institute; Duke University; Icahn School of Medicine at Mount Sinai; Kowa Research Institute, Inc; Mount Sinai St Lukes. Steering Committee for Thrombosis Research Institute and Medtronic Inc.
2
11/23/20
2
Strategies for Prevention of CAD
Lipid-lowering, Platelet inhibitors BP control
Population-based Individual interventions in high-risk populations
Information (G2) WHO “best buys”
• Tobacco • Alcohol • Diet/salt and sugar reduction
• Replacing trans-fats with polyunsaturated fats
• Physical activity
• Industry
• Legislators
Taxes Regulatory changes Air quality Environmental management
3984713-4
3
©2019 MFMER | 3900718-7
The Impact of Socioeconomic Status on the Development and Outcomes of
CVD: Challenges and Opportunities
Stages of the Epidemiologic Transition
Omran: Milbank Mem Fund Q, 1971; Olshansly: Millbank Mem Fund Q, 1986
Description Life expectancy Dominant form of CVD death
Stage 1 Pestilence and famine
Infectious (RHD) Nutritional
5-10
15-35
IHD*
• IHD** • Stroke • CHF
>70 yr Ischemic
Proportion of death due to CVD (%)
% of world’s population
Stages of the Epidemiologic Transition
*Greater in high socioeconomic groups **Younger pt – lower SES; Elderly – higher SES
3818256-05
6
11/23/20
4
3485205-11
Angina pectoris “It is a rare disease… a case a year is about average, even in the large metropolitan hospitals.”
Osler: Principles and Practice of Medicine, 1912
Recent MI (UK prior to WWI) 1-2 necropsies/year with recent coronary thrombosis/AMI The London Hospital
Morris: Lancet, 1951
CHD (USA) “The disease in my youth was hardly a problem…but I know that my professors did have occasional cases among their well-to-do patients whom they cared for at home
White PD: Am J Pub Health, 1957
“Seven-fold increase from 1907-44 to 1944-49 in the number of cases of coronary heart disease.”
7
0
5
10
15
20
25
1990 1995 2000 2005 2010 2015
The Epidemic of CVD in China (1990-2015) An Epidemiological Catastrophe in a Sea of Prosperity
Shen and Ge: Circulation 2018
“CAD was once rare in China; in a large central hospital in Shanghai during the 1950’s <10 patients per year were hospitalized with MI.”
Dong Chi: J Internal Med 1959
M or
ta lit
y ra
te s
(1 /1
00 ,0
Pr ev
al en
3983534-2
8
11/23/20
5
• England and Wales • Social class defined by Registrar General
Marmot BMJ 1978
Men
Year of death Year of death 1931 1951 1961 1971
500
300
1000
2000
4000
8000
9
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0.0
0.5
1.0
1.5
2.0
Socioeconomic Status and Risk of MI in Africa – INTERHEART Study
80% of Pts from South Africa Income
Redrawn from: Steyn; Circ 2005
O dd
s ra
• County-level analysis (age ³35 yrs) • Age-adjusted
Percentage of Counties in the Top Quintile of Heart Disease Mortality by Region
% c
10
20
30
40
50
1973-74 1991-92 2009-10
The strong associations between SES and CV disease rates and
outcomes are a global phenomenon
3485205-09
12
11/23/20
7
1990 2016
DE OHNC
NV TX
MO NV
Age-Standardized (CVD DALYs/100,000 Persons and (SDI) in 1990 and 2016
Roth: JAMA Cardiol, 2018
Differences in CVD burden are largely attributable to modifiable risk exposures.
SDI
3981394-2
13
Physical Activity Poverty
• 132,130 • Medicare beneficiaries
Cooperative Cardiovascular Project
Arch Intern Med, 2004
Income level Income level +
clinical predictors Income level +
Male: 77.7y Female: 85.5y
Male: 70.7y Female: 78.4y
Effect of Deprivation on CHD Mortality • Population-level datasets • UK • 2015
C H
D m
or ta
lit y
ra te
3896776-3
• Income • Employment • Education • Health • Crime • Barriers to housing
and services living environment
Low Score – less deprived
0.5 1.0 1.5 2.0
Dewan: JACC HF, 2018
• 15,126 pts • 54 countries • Enrolled in 2 large HF trials • 3 Gini coefficient (GC)
tertiles of equality
Diabetes >5 years since diagnosis of HF
10 unit increase in Gini coeffient~ 10 years increase in age Previous hospital for HF
Previous MI 5% decrease in LVEF
5 kg/m2 increase in BMI 10 ml/min/1.73 m2 increase in BMI
10 bpm increase in HR 10 gm/L decrease in hemoglobin
10 mm Hg increase in SBP Current smoker
500 US$ decrease in per capita income Hospital bed density
Hypertension Atrial fibrillation
Impact on Cardiovascular Death
0.5 1.0 1.5 2.0
Male gender
10 unit in GC ~
10 yrs in age
Previous hospital for HF
Socio-economic Factors and H.F. Outcomes in a Universal Care System
• 17,122 pts • Danish National
Registries • HFrEF (EF ≤40%)
Neither cohabitation status nor educational level were associated with mortality or readmission rates
Redrawn from: Schjødt JACC HF, 2019 3973910-1
Lack of access and insurance for care is not the issue.
Risks of Clinical Outcomes Among Lower-Income Patients with Incident Heart Failure
No Income-Related Risk
Higher risk
3264667-4
Haynes: Am J Epidem, July 1983 Years
5.3
Wife’s education ≤8 ≥9 ≤8 9-12 ≥13 ≤12 ≥13
Husband’s education ≤8 9-12 ≥13
20
11/23/20
11
©2015 MFMER |
Time course of the Impact of Changes in SES upon CV Health
Rapid onset but control of risk factors can have surprisingly early and large
positive benefits
• 1.1 million est.
• 85% black 59% women Mean age 52-8 yr CV risk factors – 87%
1,593 New Cases of Cardiovascular Disease
Other diagnoses
Heart failure 44%
Hypertension 19%
Spectrum of Heart Disease in Urban Blacks in S Africa – 2006
The Heart of Soweto Study
3496927-13
Mortality from Circulatory Diseases in Norway in 1927-48 Standard Population = Population of Norway in 1940
1927 1930 1935 1940 1945 1948
CRUDE
Age-corrected
50
55
60
65
70
75
80
Notzon: JAMA, 1998 Years
decline in life expectancy
U.S. females Russian females
3983534-1
• Health and retirement study • US adults • Age 51-61 years at entry
Negative Wealth Shock • Loss of 75% net worth
over a 2 year period
Potential mechanisms – multiple • Psychosocial stress • Substance abuse/marital discord • ¯ Spending on health-related goods and services
Pool: JAMA, 2018
100
80
60
40
20
0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Positive wealth without shock Negative wealth shock Asset poverty at baseline
Years of follow-up
25
3882947-18
80
100
120
140
160
C H
D m
or ta
lit y
(p er
1 00
,0 00
Al l-c
au se
m or
ta tli
ty (p
er 1
00 ,0
7 9 11 13 15 17 19 21
D ia
be te
s m
or ta
lit y
(p er
1 00
,0 00
105
110
115
120
125
Every cloud has a silver lining
26
11/23/20
14
0.6
1.2
1.8
2.4
0
5
10
15
20
1980 1990 2000 2010
Population-Wide Weight Loss and Regain in Relation to Diabetes Burden and CV Mortality in Cuba
• Cross-sectioned surveys • 1980-2010
Franco: BMJ 2013
ia be
te s
pr ev
al en
ce (p
er 1
00 p
eo pl
Year
3264667-9
Baseline
• 10 Aborigines • Derby, Western Australia • Diabetics
“The major metabolic abnormalities of diabetes were either greatly improved or completely normalized”
28
11/23/20
15
Income Inequality and Mortality: Why they are Related?
“Income inequality goes hand in hand with underinvestment in human resources.”
“Inequality may make people miserable before it kills them.”
– George Davey Smith BMJ 1996
3896776-4
29
©2020 Mayo Foundation for Medical Education and Research |
Trends in CV Prevalence by Income Level • NHANES • 1999-2016 • 44186 participants
0
1
2
3
4
5
Substantial and increasing disparities in CVD prevalence
Pr ev
al en
Highest-resources group (20%) Remainder of population group (80%)
3977902-1
Social Conditions as Fundamental Causes of Health Inequalities
Link and Phelan J. Health Soc. Behavior, 1995
Chronic poverty
Space
Impact on healthier lifestyle decisions
Inflammation Catecholamines Cortisol
Social Norms and Peer Influence
31
N.Y. Times Magazine, 2019
• An antidepressant • A sleep aid • A diet • An exercise prescription • Stress reliever • A contraceptive preventing
teenage pregnancy • Prevents premature death • Protects children from neglect
“When people live so close to the bone, a small setback can quickly spiral
into a major trauma”
32
11/23/20
17
Multiple associations between socioeconomic status and DNA methylation across multiple genes
Poverty associated with levels of DNA methylation (DNAm) – a key epigenetic marker that has the
potential to shape gene expression at more than 2,500 sites across more than 1,500 genes
Poverty leaves it mark on nearly 10% of the genes in the human genome”
3849840-03
33
Strategies for Prevention of CAD
Lipid-lowering, Platelet inhibitors BP control
Population-based Individual interventions in high-risk populations
Information (G2) WHO “best buys”
• Tobacco • Alcohol • Diet/salt and sugar reduction
• Replacing trans-fats with polyunsaturated fats
• Physical activity
• Industry
• Legislators
Redrawn from: *TIPS Lancet, 2005 TIPS-K Clinical Trials Registry – India (CTRI)
Taxes Regulatory changes Air quality Environmental management
3984713-4
34
11/23/20
18
©2019 MFMER |
Increasing acknowledgement that social determinants explain more of the variance in health outcomes and disparities than do narrower constructs of access to and quality of medical care
Ann Intern Med, 2018
1
Financial Disclosures:
Other Financial Disclosures: Data Safety Monitoring Board Member for: Baim Institute; Boston Scientifc Corporation; Cardiovascular Research Foundation; Duke Clinical Research Institute; Duke University; Icahn School of Medicine at Mount Sinai; Kowa Research Institute, Inc; Mount Sinai St Lukes. Steering Committee for Thrombosis Research Institute and Medtronic Inc.
2
11/23/20
2
Strategies for Prevention of CAD
Lipid-lowering, Platelet inhibitors BP control
Population-based Individual interventions in high-risk populations
Information (G2) WHO “best buys”
• Tobacco • Alcohol • Diet/salt and sugar reduction
• Replacing trans-fats with polyunsaturated fats
• Physical activity
• Industry
• Legislators
Taxes Regulatory changes Air quality Environmental management
3984713-4
3
©2019 MFMER | 3900718-7
The Impact of Socioeconomic Status on the Development and Outcomes of
CVD: Challenges and Opportunities
Stages of the Epidemiologic Transition
Omran: Milbank Mem Fund Q, 1971; Olshansly: Millbank Mem Fund Q, 1986
Description Life expectancy Dominant form of CVD death
Stage 1 Pestilence and famine
Infectious (RHD) Nutritional
5-10
15-35
IHD*
• IHD** • Stroke • CHF
>70 yr Ischemic
Proportion of death due to CVD (%)
% of world’s population
Stages of the Epidemiologic Transition
*Greater in high socioeconomic groups **Younger pt – lower SES; Elderly – higher SES
3818256-05
6
11/23/20
4
3485205-11
Angina pectoris “It is a rare disease… a case a year is about average, even in the large metropolitan hospitals.”
Osler: Principles and Practice of Medicine, 1912
Recent MI (UK prior to WWI) 1-2 necropsies/year with recent coronary thrombosis/AMI The London Hospital
Morris: Lancet, 1951
CHD (USA) “The disease in my youth was hardly a problem…but I know that my professors did have occasional cases among their well-to-do patients whom they cared for at home
White PD: Am J Pub Health, 1957
“Seven-fold increase from 1907-44 to 1944-49 in the number of cases of coronary heart disease.”
7
0
5
10
15
20
25
1990 1995 2000 2005 2010 2015
The Epidemic of CVD in China (1990-2015) An Epidemiological Catastrophe in a Sea of Prosperity
Shen and Ge: Circulation 2018
“CAD was once rare in China; in a large central hospital in Shanghai during the 1950’s <10 patients per year were hospitalized with MI.”
Dong Chi: J Internal Med 1959
M or
ta lit
y ra
te s
(1 /1
00 ,0
Pr ev
al en
3983534-2
8
11/23/20
5
• England and Wales • Social class defined by Registrar General
Marmot BMJ 1978
Men
Year of death Year of death 1931 1951 1961 1971
500
300
1000
2000
4000
8000
9
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0.0
0.5
1.0
1.5
2.0
Socioeconomic Status and Risk of MI in Africa – INTERHEART Study
80% of Pts from South Africa Income
Redrawn from: Steyn; Circ 2005
O dd
s ra
• County-level analysis (age ³35 yrs) • Age-adjusted
Percentage of Counties in the Top Quintile of Heart Disease Mortality by Region
% c
10
20
30
40
50
1973-74 1991-92 2009-10
The strong associations between SES and CV disease rates and
outcomes are a global phenomenon
3485205-09
12
11/23/20
7
1990 2016
DE OHNC
NV TX
MO NV
Age-Standardized (CVD DALYs/100,000 Persons and (SDI) in 1990 and 2016
Roth: JAMA Cardiol, 2018
Differences in CVD burden are largely attributable to modifiable risk exposures.
SDI
3981394-2
13
Physical Activity Poverty
• 132,130 • Medicare beneficiaries
Cooperative Cardiovascular Project
Arch Intern Med, 2004
Income level Income level +
clinical predictors Income level +
Male: 77.7y Female: 85.5y
Male: 70.7y Female: 78.4y
Effect of Deprivation on CHD Mortality • Population-level datasets • UK • 2015
C H
D m
or ta
lit y
ra te
3896776-3
• Income • Employment • Education • Health • Crime • Barriers to housing
and services living environment
Low Score – less deprived
0.5 1.0 1.5 2.0
Dewan: JACC HF, 2018
• 15,126 pts • 54 countries • Enrolled in 2 large HF trials • 3 Gini coefficient (GC)
tertiles of equality
Diabetes >5 years since diagnosis of HF
10 unit increase in Gini coeffient~ 10 years increase in age Previous hospital for HF
Previous MI 5% decrease in LVEF
5 kg/m2 increase in BMI 10 ml/min/1.73 m2 increase in BMI
10 bpm increase in HR 10 gm/L decrease in hemoglobin
10 mm Hg increase in SBP Current smoker
500 US$ decrease in per capita income Hospital bed density
Hypertension Atrial fibrillation
Impact on Cardiovascular Death
0.5 1.0 1.5 2.0
Male gender
10 unit in GC ~
10 yrs in age
Previous hospital for HF
Socio-economic Factors and H.F. Outcomes in a Universal Care System
• 17,122 pts • Danish National
Registries • HFrEF (EF ≤40%)
Neither cohabitation status nor educational level were associated with mortality or readmission rates
Redrawn from: Schjødt JACC HF, 2019 3973910-1
Lack of access and insurance for care is not the issue.
Risks of Clinical Outcomes Among Lower-Income Patients with Incident Heart Failure
No Income-Related Risk
Higher risk
3264667-4
Haynes: Am J Epidem, July 1983 Years
5.3
Wife’s education ≤8 ≥9 ≤8 9-12 ≥13 ≤12 ≥13
Husband’s education ≤8 9-12 ≥13
20
11/23/20
11
©2015 MFMER |
Time course of the Impact of Changes in SES upon CV Health
Rapid onset but control of risk factors can have surprisingly early and large
positive benefits
• 1.1 million est.
• 85% black 59% women Mean age 52-8 yr CV risk factors – 87%
1,593 New Cases of Cardiovascular Disease
Other diagnoses
Heart failure 44%
Hypertension 19%
Spectrum of Heart Disease in Urban Blacks in S Africa – 2006
The Heart of Soweto Study
3496927-13
Mortality from Circulatory Diseases in Norway in 1927-48 Standard Population = Population of Norway in 1940
1927 1930 1935 1940 1945 1948
CRUDE
Age-corrected
50
55
60
65
70
75
80
Notzon: JAMA, 1998 Years
decline in life expectancy
U.S. females Russian females
3983534-1
• Health and retirement study • US adults • Age 51-61 years at entry
Negative Wealth Shock • Loss of 75% net worth
over a 2 year period
Potential mechanisms – multiple • Psychosocial stress • Substance abuse/marital discord • ¯ Spending on health-related goods and services
Pool: JAMA, 2018
100
80
60
40
20
0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Positive wealth without shock Negative wealth shock Asset poverty at baseline
Years of follow-up
25
3882947-18
80
100
120
140
160
C H
D m
or ta
lit y
(p er
1 00
,0 00
Al l-c
au se
m or
ta tli
ty (p
er 1
00 ,0
7 9 11 13 15 17 19 21
D ia
be te
s m
or ta
lit y
(p er
1 00
,0 00
105
110
115
120
125
Every cloud has a silver lining
26
11/23/20
14
0.6
1.2
1.8
2.4
0
5
10
15
20
1980 1990 2000 2010
Population-Wide Weight Loss and Regain in Relation to Diabetes Burden and CV Mortality in Cuba
• Cross-sectioned surveys • 1980-2010
Franco: BMJ 2013
ia be
te s
pr ev
al en
ce (p
er 1
00 p
eo pl
Year
3264667-9
Baseline
• 10 Aborigines • Derby, Western Australia • Diabetics
“The major metabolic abnormalities of diabetes were either greatly improved or completely normalized”
28
11/23/20
15
Income Inequality and Mortality: Why they are Related?
“Income inequality goes hand in hand with underinvestment in human resources.”
“Inequality may make people miserable before it kills them.”
– George Davey Smith BMJ 1996
3896776-4
29
©2020 Mayo Foundation for Medical Education and Research |
Trends in CV Prevalence by Income Level • NHANES • 1999-2016 • 44186 participants
0
1
2
3
4
5
Substantial and increasing disparities in CVD prevalence
Pr ev
al en
Highest-resources group (20%) Remainder of population group (80%)
3977902-1
Social Conditions as Fundamental Causes of Health Inequalities
Link and Phelan J. Health Soc. Behavior, 1995
Chronic poverty
Space
Impact on healthier lifestyle decisions
Inflammation Catecholamines Cortisol
Social Norms and Peer Influence
31
N.Y. Times Magazine, 2019
• An antidepressant • A sleep aid • A diet • An exercise prescription • Stress reliever • A contraceptive preventing
teenage pregnancy • Prevents premature death • Protects children from neglect
“When people live so close to the bone, a small setback can quickly spiral
into a major trauma”
32
11/23/20
17
Multiple associations between socioeconomic status and DNA methylation across multiple genes
Poverty associated with levels of DNA methylation (DNAm) – a key epigenetic marker that has the
potential to shape gene expression at more than 2,500 sites across more than 1,500 genes
Poverty leaves it mark on nearly 10% of the genes in the human genome”
3849840-03
33
Strategies for Prevention of CAD
Lipid-lowering, Platelet inhibitors BP control
Population-based Individual interventions in high-risk populations
Information (G2) WHO “best buys”
• Tobacco • Alcohol • Diet/salt and sugar reduction
• Replacing trans-fats with polyunsaturated fats
• Physical activity
• Industry
• Legislators
Redrawn from: *TIPS Lancet, 2005 TIPS-K Clinical Trials Registry – India (CTRI)
Taxes Regulatory changes Air quality Environmental management
3984713-4
34
11/23/20
18
©2019 MFMER |
Increasing acknowledgement that social determinants explain more of the variance in health outcomes and disparities than do narrower constructs of access to and quality of medical care
Ann Intern Med, 2018