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Social Determinants of Health and Cardiovascular Disease

Linking Poverty and Disease

Lower socioeconomic status (SES) has been associated with a higher risk for cardiovascular disease (CVD) and events. However, the mechanisms linking poverty and low fiscal resources to CVD are unclear. Factors believed to contribute include living and working in low SES neighborhoods, reduced access to quality health care, lower education levels and health literacy, and disparities in health behaviors. Yet these factors alone do not completely explain the large variances in CVD relationships and outcomes. The premise is that lower SES leads to greater psychosocial stress, subsequent systemic inflammation, and triggering a number of other CVD pathogenic processes.1 Questions remain about how this actually occurs.

Stress-Associated Neurobiological Pathway

A recent study testing the hypothesis that increased stress from lower SES triggers amygdala activity in the brain found that individuals who lived in zip codes with lower SES or higher crime rates were at an increased risk for a major adverse cardiac event such as a heart attack, unstable angina, heart failure, or cardiac death.

The researchers initially studied 509 individuals without known CVD, and in a subset of 289, used high definition and contrast imaging to quantify metabolic activity in the amygdala. The amygdala is the part of the brain engaged in discerning the degree of threats posed by external stimuli and is involved in emotions. The researchers also examined bone marrow as a measure of hematopoiesis and the arterial wall as a measure of atherosclerotic inflammation. They tracked the development of incident CVD over a median of 4 years and adjusted for smoking, obesity, age, and sex. They also conducted several mediation analyses to examine pathways among the variables.

The findings were that lower SES was associated with higher persistent activation of the amygdala and an increased risk of CVD.1 The data shed light on a possible mechanism of how low SES- related stress provokes neurobiological activity and negative CVD consequences.

Additional Factors Tied to Cardiovascular Health

Why should CV nurses be concerned about SES and where someone lives and works? Neighborhood characteristics such as food access, aspects of the built environment, safety, and social cohesion joblessness, food insecurity, and racial discrimination have been individually linked with cardiovascular health.2, 3 Racial and ethnic aspects are also important. Several studies of at-risk neighborhoods for CVD, specifically for Black populations living in the urban South, identified census tracts with lower or higher rates of CVD outcomes than would be expected on the basis of their neighborhood SES.4  The at-risk neighborhoods were characterized by lower education and income, and higher rates of elders and persons with disability, incarceration rates, adverse outcomes from CVD, and additionally no vehicle in the household.4-6 

What’s a Nurse to Do?

The evidence emerging from these studies provides direction to researchers to study modifiable stress and SES further in relation to specific CVD risk factors.  Clinically based cardiovascular nurses can be cognizant of social determinants of health to create more precise and focused prevention plans for individuals and families residing in low resourced neighborhoods. Strategies should focus on reducing sources of modifiable CVD risk and support of healthy CVD behaviors (for example, reducing smoking and calorie-dense foods, counseling for physical activity appropriate to resources and safety, stress management). The evidence emerging from these studies provides increased support for policy and advocacy to create healthier communities.

Related Online CE

Race and Ethnicity’s Impact on Heart Disease – 0.9 CE contact hours, $0 for members and non-members

References        

  1. Tawakol A, Osborne MT, Wang Y, Hammed B, Tung B, Patrich T, Oberfeld B, Ishai A, Shin LM, Nahrendorf M, Warner ET, Wasfy J, Fayad ZA, Koenen K, Ridker PM, Pitman RK, Armstrong KA. Stress-Associated Neurobiological Pathway Linking Socioeconomic Disparities to Cardiovascular Disease. Journal of the American College of Cardiology. Jul 2 2019;73(25):3243-3255.
  2. Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The Impact of Neighborhoods on CV Risk. Global heart. Sep 2016;11(3):353-363.
  3. Mensah GA, Jaquish C, Srinivas P, Papanicolaou GJ, Wei GS, Redmond N, Roberts MC, Nelson C, Aviles-Santa L, Puggal M, Green Parker MC, Minear MA, Barfield W, Fenton KN, Boyce CA, Engelgau MM, Khoury MJ. Emerging Concepts in Precision Medicine and Cardiovascular Diseases in Racial and Ethnic Minority Populations. Circulation research. Jun 21 2019;125(1):7-13.
  4. Kim JH, Lewis TT, Topel ML, Mubasher M, Li C, Vaccarino V, Mujahid MS, Sims M, Quyyumi AA, Taylor HA, Jr., Baltrus PT. Identification of Resilient and At-Risk Neighborhoods for Cardiovascular Disease Among Black Residents: the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity Study. Preventing chronic disease. May 9 2019;16:E57.
  5. Topel ML, Kelli HM, Lewis TT, Dunbar SB, Vaccarino V, Taylor HA, Quyyumi AA. High neighborhood incarceration rate is associated with cardiometabolic disease in nonincarcerated black individuals. Annals of epidemiology. Jul 2018;28(7):489-492.
  6. Topel ML, Kim JH, Mujahid MS, Sullivan SM, Ko YA, Vaccarino V, Quyyumi AA, Lewis TT. Neighborhood Socioeconomic Status and Adverse Outcomes in Patients With Cardiovascular Disease. The American journal of cardiology. Jan 15 2019;123(2):284-290.

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