Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation

Abstract

Purpose: Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention. Methods: Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance. Results: The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A1c, with more abnormal lipid profiles (all Ps < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both Ps < .001). Conclusion: Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.

Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status

“…This sample was a population at higher risk for complications, as generally seen in patients with lower SES. 5 More than 40% were smoking at the time of diagnosis (a subgroup for which attendance is particularly difficult), 52,53 CRF levels were exceptionally low, and many had concerning scores on depression or cognitive functioning. Additionally, during the trial, 315 ED visits, 126 hospitalizations, and 10 deaths also occurred.…”

“…However, disparities by SES are largely due to modifiable behaviors . Patients with lower SES have higher-risk cardiac profiles (smoking, obesity, diabetes, and lower cardiorespiratory fitness [CRF]), which result in increased rates of cardiac events . Thus, the increased morbidity and mortality following a cardiac event in individuals with lower SES may be modifiable by engaging in cardiac rehabilitation …”

“…2 Patients with lower SES have higher-risk cardiac profiles (smoking, obesity, diabetes, and lower cardiorespiratory fitness [CRF]), which result in increased rates of cardiac events. [3][4][5] Thus, the increased morbidity and mortality following a cardiac event in individuals with lower SES may be modifiable by engaging in cardiac rehabilitation. 6 Cardiac rehabilitation is a structured program of supervised exercise and risk-factor control that is standard of care (class 1 American Heart Association/American College of Cardiology recommendation) following a myocardial infarction (MI) or coronary revascularization.…”

Cardiac Rehabilitation

“…Based on their findings, Khadanga and colleagues propose the incorporation of more patient-centric interventions within standard CR programs aimed to specifically address the disparate CVD risk factor profiles noted in their study 11. For example, they suggest implementing referrals to interventions for psychological symptom treatment and incorporating behavioral weight loss programs with comprehensive diet and exercise education.…”

“…Despite its clear evidence base for reducing CVD and all-cause mortality, it is highly underutilized by populations experiencing socioeconomic disadvantage 10. In this issue of the Journal of Cardiopulmonary Rehabilitation and Prevention , Khadanga and colleagues provide a prospective cohort analysis examining differences in risk factor profiles among >3000 patients enrolling in outpatient phase 2 CR based on SES 11. Utilizing enrollment in Medicaid as a marker of low SES, the authors found striking differences in risk factor profiles between patients enrolled in Medicaid and those enrolled in Medicare or private insurance.…”