Socioeconomic Correlates of Incident Heart Failure and Consequent Mortality: The All of Us Program

Although socioeconomic status (SES) is a known determinant of cardiovascular disease, the independent risks of incident heart failure (HF) and consequent mortality portended by individual and neighborhood measures of SES remain less established.

This study sought to evaluate the prospective associations of SES with HF in adults without HF and SES with all-cause mortality in those with HF.

The authors identified adults from the National Institutes of Health-run All of Us Research Program (2018-present) who consented to share their electronic health records. Among 280,431 participants free of HF and 10,550 participants with prevalent HF, Cox proportional hazards models assessed associations of income, education, and Area Deprivation Index (ADI) with risks of incident HF and mortality.

Over 41 ± 23 months, 6,783 of 280,431 participants developed HF. Compared with household income ≥$200,000, risk was higher for $100,000 to <$200,000 (HR: 1.29; 95% CI: 1.12-1.48), $50,000 to <$100,000 (HR: 1.82; 95% CI: 1.60-2.09), $25,000 to <$50,000 (HR: 2.24; 95% CI: 1.95-2.57), and <$25,000 (HR: 3.02; 95% CI: 2.63-3.47). Relative to college graduates, risk was higher for those with some college (HR: 1.37; 95% CI: 1.28-1.46), General Educational Development (HR: 1.46; 95% CI: 1.36-1.58), and less than high school (HR: 1.40; 95% CI: 1.26-1.55). Compared with the least deprived tertile of ADI, risk was higher in the middle tertile (HR: 1.21; 95% CI: 1.14-1.29) and the most deprived tertile (HR: 1.18; 95% CI: 1.11-1.26). Non-White participants and residents of the most deprived ADI tertiles experienced less benefit from higher education. Among those with prevalent HF, each $10,000 increase in income was associated with 3% lower all-cause mortality.

Lower income, education, and high neighborhood deprivation independently associate with incident HF, whereas only income was associated with mortality. Higher education was less protective in non-White participants and individuals residing in deprived neighborhoods. Addressing these disparities is essential to reducing HF burden and consequent mortality.