Abstract
Introduction:
Factors used to calculate cardiovascular disease (CVD) risk scores include age, sex, race, cholesterol, blood pressure, diabetes, and smoking status, but exclude social determinants of health (SDOH).
Objectives:
To determine whether SDOH factors are independently associated with CVD risk.
Methods:
The National Health and Nutrition Examination Survey is an annual, cross-sectional representative survey of the US adult population. We combined years 1999-2018 and included participants age 40-79 without CVD history, and with information to calculate CVD risk (n=23,877). Ten-year risk of ASCVD was calculated using the AHA/ACC pooled cohort equation. SDOH were conceptualized using self-reported educational attainment and income. We used linear regression models to estimate the association between SDOH and ASCVD risk adjusting for age, sex, race, marital status, and insurance. All analyses accounted for the complex survey design.
Results:
Among US adults, income of ≥ $100k was reported in 23% (SE: 1.1) of those with CVD risk <5%, but only 10% (SE: 0.9) of those with CVD risk ≥ 20%. Similarly, having graduated college was reported in 38% (SE: 1.1) of those with CVD risk < 5% but only 20% (SE: 0.9) of those with CVD risk ≥ 20%. From fully adjusted linear regression models, compared to those with highest income (>$100k), income < $25k was associated with a 5.3% (95% CI: 4.5, 6.1) greater CVD risk, while individuals at income levels $25k-$44.9k, $45-74.9k, and $75-$99.9k, experienced a 3.2% (95% CI: 2.4, 4.1), 1.5% (95% CI: 0.8, 1.5), and 1.1% (95% CI: 0.5, 1.7), greater CVD risk, respectively. Additionally, compared to college graduates, less than a high school education was associated with a 4.4% (95% CI: 3.7, 5.1) greater CVD risk, while high school graduates or some amount of college still experienced a 2.8% (95% CI: 2.3, 3.3) and 1.6% (95% CI: 1.2, 2.1) greater CVD risk, respectively.
Conclusion:
In a large US population-based sample of adults, we found strong graded associations between lower income and lower educational attainment with greater CVD risk. Though SDOH are not inputs into calculators of ASCVD risk, they are strongly associated with ASCVD risk scores.
