Race, Neighborhood Affects How Long You'll Live After Heart Attack
The risk of dying within five years of a heart attack is notably higher among poor Americans than their wealthier peers, but race also plays a role, a new study reveals.
While Black residents of poor neighborhoods appear to face a higher risk of death than their counterparts in wealthier ZIP codes, poor Black patients are also more likely to die after a heart attack than poor white patients, the researchers found.
For the study, the investigators analyzed neighborhood income and five-year death rates among nearly 32,000 heart attack survivors. All initially received care between 2006 and 2016 within the Kaiser Permanente Southern California hospital system. All had what the study authors characterized as "good health insurance."
The purpose of the study was to evaluate neighborhood income as a possible risk factor for increased death after heart attack, said lead author Dr. Jesse Goitia, a Kaiser cardiology fellow.
Each patient was given "a neighborhood disadvantage score" based on income, employment, education and household data by ZIP code.
Just under two-thirds of the patients lived in relatively wealthier neighborhoods. But more than one-third -- about 12,000 patients -- lived in disadvantaged areas, ranking in the bottom 75th percentile. In other words, only one-quarter of neighborhoods were poorer.
After a heart attack, Goitia said, patients from the poorer neighborhoods did have higher death rates.
The study found that those in the bottom-ranking ZIP codes faced a 5% higher risk of dying within five years of a heart attack.
"[That finding is] consistent with prior research showing lower socioeconomic status to be a risk for cardiovascular disease," Goitia said.
But, he added, there was a twist.
His team also found that Black patients from disadvantaged neighborhoods had the worst death rates of all racial and ethnic groups.
In other words, while "Black patients from well-resourced neighborhoods had outcomes similar to white patients from well-resourced neighborhoods," being Black and poor was deemed a worst-case scenario, Goitia said.
How much worse?
Black patients from poor neighborhoods faced a 19% greater risk of death within five years of a heart attack compared to richer white patients, the study found. Their risk was also 14% greater than that for poorer white patients.
As to why, Goitia said that, for now, his team's findings raise more questions than concrete conclusions.
"It is likely that patients from worse neighborhoods have risk factors for poor outcomes related to access to open spaces for physical activity, access to healthy foods, difficulty with making it to health care appointments and difficulty filling prescriptions," he said.
But the study does not address precisely why these factors seem to affect poor Black heart attack survivors more than poor white ones.
Dr. Michelle Albert, president of the Dallas-based Association of Black Cardiologists, joined Goitia in calling for more research.
"This study supports previous work indicating that neighborhood adversity is an underlying determinant of health," she said.
But, Albert added, more work is needed to understand how all kinds of factors that are hardwired into the way American society functions may lead to various forms of neighborhood deprivation.
In the meantime, Andrea Roberts, a senior research scientist at Harvard T.H. Chan School of Public Health in Boston, stressed that other studies have provided some important clues.
"From prior research, we know that Black Americans receive worse health care than whites, and we know that stressors like discrimination and poverty are toxic to your heart," said Roberts, who reviewed the findings.
"We also know that some factors that are bad for heart health are more common among Black Americans versus whites. Like obesity, for a variety of reasons," she added. "These include current experiences of discrimination, because stress is a risk factor for obesity, as well as the legacy of discrimination from past generations, which manifests as poverty."
But Roberts cautioned that the new study doesn't appear to address a number of concerns that could influence the findings. For example, the researchers didn't seem to assess the severity of participants' heart attacks.
It's possible that Black patients with mild heart attacks don't end up at the hospital, Roberts said, and the ones who go to the hospital had severe attacks -- explaining why their death rates are higher.
Or, she said, it might be that "Blacks have more [heart attacks] in general for whatever reason, or the more severe [heart attacks] kill them immediately, so they don't end up at the hospital."
All of that means that, on its own, the new research can't definitively speak to how much neighborhood deprivation interacts with race to increase the risk for post-heart attack death among Black patients, Roberts said.
Goitia and his colleagues are scheduled to present their findings May 17 at a virtual meeting of the American College of Cardiology.
Research presented at meetings should be considered preliminary until published in a peer-reviewed journal.
Learn more about race, ethnicity and heart disease at the U.S. Centers for Disease Control and Prevention.
SOURCES: Jesse Goitia, MD, cardiology fellow, Kaiser Permanente Los Angeles Medical Center; Andrea Roberts, PhD, MPH, senior research scientist, Harvard T.H. Chan School of Public Health, Boston; Michelle Albert, MD, MPH, president, Association of Black Cardiologists, Dallas; American College of Cardiology, online meeting, May 17, 2021
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