Impact of Socioeconomic Status on Mortality and Readmission in Patients With Heart Failure With Reduced Ejection Fraction: The ARIC Study

Abstract

Background Low socioeconomic status (SES) is associated with a higher risk of heart failure (HF). The contribution of individual and neighborhood SES to the prognosis and quality of care for HF with reduced ejection fraction is not clear yet has important implications. Methods and Results We examined 728 participants of the ARIC (Atherosclerosis Risk in Communities) study (mean age, 78.2 years; 34% Black participants; 46% women) hospitalized with HF with reduced ejection fraction (ejection fraction <50%) between 2005 and 2018. We assessed associations between education, income, and area deprivation index with mortality and HF readmission using multivariable Cox models. We also evaluated the use of guideline‐directed medical therapy (optimal: ≥3 of ß‐blockers, mineralocorticoid receptor antagonist, angiotensin‐converting enzyme inhibitors, or angiotensin receptor blockers; acceptable: at least 2) at discharge. During a median follow‐up of 3.2 years, 58.7% were readmitted with HF, and 74.0% died. Low income was associated with higher mortality (hazard ratio [HR], 1.52 [95% CI, 1.14–2.04]) and readmission (HR, 1.45 [95% CI, 1.04–2.03]). Similarly, low education was associated with mortality (HR, 1.27 [95% CI, 1.01–1.59]) and readmission (HR, 1.62 [95% CI, 1.24–2.12]). The highest versus lowest area deprivation index quartile was associated with readmission (HR, 1.69 [95% CI, 1.11–2.58]) but not necessarily with mortality. The prevalence of optimal guideline‐directed medical therapy and acceptable guideline‐directed medical therapy was 5.5% and 54.4%, respectively, but did not significantly differ by SES. Conclusions Among patients hospitalized with HF with reduced ejection fraction, low SES was independently associated with mortality and HF readmission. A targeted secondary prevention approach that focuses intensive efforts on patients with low SES will be necessary to improve outcomes of those with HF with reduced ejection fraction.