This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (33)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Cardiovascular System  • Cardiovascular Disease/ Myocardial Infarction  • Alert me on articles by topic  Social Bookmarking   What's this?

Mehdi H. Shishehbor, DO, MPH; David Litaker, MD, PhD; Claire E. Pothier, MS, MPH; Michael S. Lauer, MD

JAMA. 2006;295:784-792.

Context  Lower socioeconomic status (SES) confers heightened cardiovascular risk and mortality, although the mediating pathways are unclear.

Objective  To evaluate the extent to which exercise physiologic characteristics account for the association between lower SES and mortality.

Design, Setting, and Participants  Prospective cohort study of 30 043 consecutive patients living in 7 counties in northeast Ohio referred between 1990 and 2002 for symptom-limited stress testing for evaluation of known or suspected coronary artery disease. Follow-up for mortality continued through February 2004.

Main Outcome Measures  Estimated functional capacity in metabolic equivalents and heart rate recovery, physiologic characteristics that are determined directly from exercise; testing and all-cause mortality during a median follow-up of 6.5 years.

Results  Multivariable models adjusting for demographics, insurance status, smoking status, and clinical confounders demonstrated a strong association between a composite SES score based on census block data and functional capacity (adjusted odds ratio comparing 25th with 75th percentile values, 1.72; 95% confidence interval [CI], 1.56-1.89; P<.001) as well as heart rate recovery (adjusted odds ratio comparing 25th with 75th percentile values, 1.18; 95% CI, 1.07-1.30; P<.001). There were 2174 deaths, with mortality risk increasing from 5% to 10% as SES decreased by quartile (P<.001). Cox proportional hazards models that included all confounding variables except exercise physiologic characteristics demonstrated increased mortality as SES decreased (adjusted hazard ratio comparing 25th with 75th percentile values, 1.32; 95% CI, 1.22-1.42; P<.001). After further adding functional capacity and heart rate recovery, the magnitude of this relationship was reduced (comparing 25th with 75th percentile values; adjusted hazard ratio, 1.17; 95% CI, 1.08-1.26; P<.001), with these variables explaining 47% of the association.

Conclusions  Impaired functional capacity and abnormal heart rate recovery were strongly associated with lower SES and accounted for a major proportion of the correlation between SES and mortality. Efforts to modify these clinical features among patients with low SES may narrow disparities in mortality.

Author Affiliations: Department of Cardiovascular Medicine, The Cleveland Clinic (Drs Shishehbor and Lauer and Ms Pothier); Department of Medicine, Louis Stokes Cleveland VA Medical Center (Dr Litaker), Department of Epidemiology and Biostatistics (Drs Lauer and Litaker), Case Western Reserve University, Cleveland, Ohio.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED LETTERS

Mediators of the Association Between Mortality Risk and Socioeconomic Status
Mark Hamer
JAMA. 2006;296(7):763.
EXTRACT | FULL TEXT  

Mediators of the Association Between Mortality Risk and Socioeconomic Status
Daniel J. Brotman
JAMA. 2006;296(7):763-764.
EXTRACT | FULL TEXT  

Mediators of the Association Between Mortality Risk and Socioeconomic Status—Reply
Mehdi H. Shishehbor, David Litaker, and Michael S. Lauer
JAMA. 2006;296(7):764.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Commentary: Heart rate and blood pressure: risk factors or risk markers?
Carnethon
Int J Epidemiol 2009;0:dyp325v1-dyp325.
FULL TEXT  

Television viewing and other screen-based entertainment in relation to multiple socioeconomic status indicators and area deprivation: the Scottish Health Survey 2003
Stamatakis et al.
J. Epidemiol. Community Health 2009;63:734-740.
ABSTRACT | FULL TEXT  

Socioeconomic Position and Graft Failure in Pediatric Heart Transplant Recipients
Singh et al.
Circ Heart Fail 2009;2:160-165.
ABSTRACT | FULL TEXT  

Impact of Drug-Eluting Versus Bare-Metal Stents on Mortality in Patients With Anemia
Shishehbor et al.
J Am Coll Cardiol Intv 2009;2:329-336.
ABSTRACT | FULL TEXT  

Autonomic function and prognosis
LAUER
Cleveland Clinic Journal of Medicine 2009;76:S18-S22.
ABSTRACT | FULL TEXT  

Comorbidity delays diagnosis and increases disability at diagnosis in MS
Marrie et al.
Neurology 2009;72:117-124.
ABSTRACT | FULL TEXT  

Socioeconomic Status and Coronary Heart Disease Risk Prediction
Fiscella and Tancredi
JAMA 2008;300:2666-2668.
FULL TEXT  

The Clinical Significance of Aerobic Exercise Testing and Prescription: From Apparently Healthy to Confirmed Cardiovascular Disease
Arena et al.
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2008;2:519-536.
ABSTRACT  

Long-Term Impact of Drug-Eluting Stents Versus Bare-Metal Stents on All-Cause Mortality
Shishehbor et al.
J Am Coll Cardiol 2008;52:1041-1048.
ABSTRACT | FULL TEXT  

Racial Differences in Diurnal Blood Pressure and Heart Rate Patterns: Results From the Dietary Approaches to Stop Hypertension (DASH) Trial
Jehn et al.
Arch Intern Med 2008;168:996-1002.
ABSTRACT | FULL TEXT  

When does work stress hurt? Testing the interaction with socioeconomic position in the Heinz Nixdorf Recall Study
Wege et al.
J. Epidemiol. Community Health 2008;62:338-341.
ABSTRACT | FULL TEXT  

Physical Activity and Reduced Risk of Cardiovascular Events: Potential Mediating Mechanisms
Mora et al.
Circulation 2007;116:2110-2118.
ABSTRACT | FULL TEXT  

Exploring the Surgeon Volume Outcome Relationship Among Women With Breast Cancer
Nattinger et al.
Arch Intern Med 2007;167:1958-1963.
ABSTRACT | FULL TEXT  

Baseline Health, Socioeconomic Status, and 10-Year Mortality Among Older Middle-Aged Americans: Findings From the Health and Retirement Study, 1992 2002
Feinglass et al.
Journals of Gerontology Series B: Psychological Sciences and Social Science 2007;62:S209-S217.
ABSTRACT | FULL TEXT  

The value of risk scores
Jurgensen
Heart 2006;92:1713-1714.
ABSTRACT | FULL TEXT  

Cardiovascular Risk in Midlife and Psychological Well-being Among Older Men.
Strandberg et al.
Arch Intern Med 2006;166:2266-2271.
ABSTRACT | FULL TEXT  

The Year in Epidemiology, Health Services Research, and Outcomes Research
Krumholz and Masoudi
J Am Coll Cardiol 2006;48:1886-1895.
FULL TEXT  

Mediators of the association between mortality risk and socioeconomic status.
Hamer
JAMA 2006;296:763-763.
FULL TEXT  

Mediators of the association between mortality risk and socioeconomic status.
Brotman
JAMA 2006;296:763-764.
FULL TEXT  

Low-fat diet and cardiovascular disease.
Aberegg and Majure
JAMA 2006;296:280-280.
FULL TEXT  

Status Syndrome: A Challenge to Medicine
Marmot
JAMA 2006;295:1304-1307.
FULL TEXT  

What's new in the other general journals.
Fister
BMJ 2006;332:477-478.
FULL TEXT