Influence of Socioeconomic Status on Lifestyle Behavior Modifications Among Survivors of Acute Myocardial Infarction

doi:10.1016/j.amjcard.2008.08.022

The American Journal of Cardiology

Volume 102, Issue 12, 15 December 2008, Pages 1583-1588

https://doi.org/10.1016/j.amjcard.2008.08.022 Get rights and content

The impact of secondary prevention initiatives on survival in higher-risk socioeconomically disadvantaged patients after acute myocardial infarction (AMI) may depend on behavioral adaptive responsiveness, uptake, and adherence to healthier lifestyles. From December 1999 to February 2003, 1,801 patients in Ontario, Canada were interviewed regarding their lifestyle behaviors at 30 days after their index AMI hospitalization. Data were obtained using self-reported surveys, medical chart abstraction, and administrative data linkage. Multivariate analyses were adjusted for baseline sociodemographic, cardiac risk severity, and co-morbid conditions. Socioeconomically disadvantaged patients had greater cardiac risk severity at baseline than did their wealthier better-educated counterparts. Compared with lower-income patients, patients with higher incomes were less likely to smoke (adjusted odds ratio [OR] for highest vs lowest income tertiles 0.36, 95% confidence interval [CI] 0.21 to 0.63, p <0.001), more likely to participate in exercise (adjusted OR 1.40, 95% CI 1.07 to 1.85, p = 0.02), and more likely to decrease or discontinue alcohol use (adjusted OR 1.64, 95% CI 1.16 to 2.34, p = 0.06). The relation between education and lifestyle behaviors was less pronounced for education than for income. After adjustment for baseline factors, patients who acknowledged participation in regular physical exercise at 1 month had a significantly lower long-term mortality than those who did not. In conclusion, socioeconomically disadvantaged patients were sicker at baseline and less behaviorally responsive to embarking on healthy lifestyle changes after AMI than were those of higher socioeconomic status.

Section snippets

Methods

The study is a substudy of the Socio-Economic and Acute Myocardial Infarction Study (SESAMI) study, a prospective observational study of patients hospitalized for AMI throughout Ontario, Canada.⁷ Data came from (1) a baseline survey, (2) chart abstraction from the index AMI, (3) a 1-month follow-up telephone survey, and (4) linked health administrative data. The study received research ethics approval at each participating institution.

Of the 2,696 consecutive patients who were alive and

Results

The mean age of the cohort was 62.6 ± 12.8 years; 28.2% were women. Compared with their wealthier or higher-educated counterparts, lower-income and educated patients were older, more often non-Caucasian, had greater baseline cardiovascular risk (i.e., as measured using GRACE), and had more pre-existing co-morbid conditions (Table 1).

In our cohort, 30.3% acknowledged that they were smokers at baseline (i.e., ascertained at time of index AMI hospitalization). Of these smokers, 29.4% stated they

Discussion

Our study demonstrated that socioeconomically disadvantaged patients were less likely to modify or adapt to healthier lifestyle behaviors during the early convalescent periods after AMI than were those of higher SES despite having poorer prognosis and greater illness severity at baseline. In particular, poorer patients reported lower propensities to stop or decrease smoking and/or alcohol consumption and were less likely to partake in regular exercise during the weeks after AMI

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To determine the association between food insecurity and pediatric nonalcoholic fatty liver disease (NAFLD).
Cross-sectional study of patients < 21 years of age with histologically confirmed NAFLD. The Household Food Security Survey Module was administered to determine food insecurity status. Skin lipidomics were performed to explore pathophysiologic mechanisms.
Seventy-three patients with histologically confirmed NAFLD completed the Household Food Security Survey Module. Of these, the majority were male (81%) and non-Hispanic (53%), with a mean age at biopsy of 13 ± 3 years. Food insecurity was seen in 42% (n = 31). Comparison of features between food insecure and food secure subgroups revealed no differences in sex, ethnicity, BMI z-score, aminotransferases, or histologic severity. However, children experiencing food insecurity presented on average 2 years before their food secure counterparts (12.3 ± 3.0 vs 14.4 ± 3.6 years, P = .015). A subset of 31 patients provided skin samples. Skin lipidomics revealed that food insecurity was associated with down-regulated features from the lipoamino acid class of lipids, previously linked to inflammation and adipocyte differentiation.
Food insecurity is highly prevalent in children with NAFLD and is associated with earlier presentation. Lipidomic analyses suggest a possible pathophysiologic link that warrants further exploration.
Factors influencing kinesiophobia during the “blanking period” after radiofrequency catheter ablation in patients with atrial fibrillation by the fear-avoidance model
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The influencing factors of kinesiophobia (fear of movement) in patients with atrial fibrillation(AF)during the post-operative “Blanking Period” are not known. The aims were to investigate the status of kinesiophobia in patients with AF during the post-operative “Blanking Period”, then further describe the occurrence and analyze the influencing factors of patients' kinesiophobia by the Fear-Avoidance Model.
In total,400 patients diagnosed with atrial fibrillation, during the post-operative “Blanking Period” from the selected hospital were included in this study. The Tampa Scale for Kinesiophobia Heart (TSK-SV Heart), the Self-efficacy for Exercise (SEE) scale, and the Geriatric Locomotive Function Scale (GLFS) were used to assess kinesiophobia, exercise self-efficacy, and physical function. The study adopted a cross-sectional design.
The score of kinesiophobia during the “Blanking Period” after operation in patients with atrial fibrillation was (44.06 ± 10.77), and the rate of high kinesiophobia was 71.61%.Logistic regression results showed that age, education, household monthly income, resting heart rate, EHRA symptom classification, exercise self-efficacy, and physical function influenced the kinesiophobia of patients during the post-operative “Blanking Period”(p<0.05， p<0.01).
Kinesiophobia is common in patients with atrial fibrillation during the postoperative “Blanking Period”, and the fear of movement is related to age, education, household monthly income, resting heart rate, EHRA symptom classification, exercise self-efficacy, and physical function. Clinical and nursing staff should pay close attention to the psychological problems in the post-operation “Blanking Period” of exercise rehabilitation in patients with atrial fibrillation, make timely interventions to reduce patients' fear of movement, and improve patients' compliance with exercise rehabilitation.
Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis
2021, CJC Open
Citation Excerpt :
Four studies examined referral to or participation in cardiac rehabilitation.21,32,38,39 Eleven studies included Ontario populations,11,21,24,30-33,35,37-39 4 were from Alberta,25,27,28,34 2 were from Quebec26,36 and 2 included patients from more than 4 provinces16,29 (Table 1). Several patient cohorts overlapped across studies.
Low socioeconomic status (SES) is an important prognosticator for those with acute myocardial infarction (AMI), having previously been described to be associated with increased short-term mortality. Whether this effect persists over time, and whether access to cardiac interventions is equitable within Canada’s universal health care system, remains unknown.
We conducted a systematic review to determine the associations of SES with mortality and access to a spectrum of interventions including cardiac catheterization, revascularization, and cardiac rehabilitation. Electronic databases (EMBASE and MEDLINE) were searched in March 2019 and December 2019. Original studies from Canada examining associations between SES and any of the above outcomes in AMI patients were included. Meta-analyses were conducted using random effects models.
Nineteen studies were included, 11 of which could be meta-analyzed. Low SES was associated with a 48% and 34% increase in short-term and intermediate-term mortality, respectively. There was a trend toward increased long-term mortality more than 1-year post-event (pooled odds ratio [OR] 1.34 [95% confidence interval {CI} 0.95-1.88]). Low SES was also associated with lower rates of cardiac catheterization (pooled OR 0.80 [95% CI 0.65-0.99]) and revascularization (pooled OR 0.76 [95% CI 0.63-0.90]) post-AMI. Studies on cardiac rehabilitation showed reduced access and participation in low-SES groups.
Low SES is associated with not only increased mortality post-AMI, but also reduced access to cardiac interventions that have demonstrated benefits for mortality and morbidity. Interventions that improve access to catheterization, revascularization, and cardiac rehabilitation for low-SES populations are needed if true equitable care in Canada is desired.
Le statut socio-économique (SSE) inférieur est un facteur pronostique important chez les personnes ayant subi un infarctus aigu du myocarde (IAM) qui semble être associé à un risque accru de mortalité à court terme. On ignore si cet effet persiste avec le temps et si l'accès aux interventions cardiaques est équitable au sein du système de soins de santé universel canadien.
Nous avons réalisé une revue systématique afin de caractériser les associations entre le SSE et la mortalité et l'accès à une gamme d'interventions, y compris le cathétérisme, la revascularisation et la réadaptation cardiaque. Les recherches ont été effectuées dans les bases de données électroniques EMBASE et MEDLINE en mars 2019 et en décembre 2019. Certaines études originales réalisées au Canada sur les associations entre le SSE et l'un ou l'autre des résultats ci-haut chez des patients ayant subi un IAM ont été incluses. Des méta-analyses à partir de modèles à effets aléatoires ont été réalisées.
Dix-neuf études ont été incluses, dont 11 qui ont pu être méta-analysées. Un SSE inférieur était associé à une augmentation de 48 % et de 34 % de la mortalité à court terme et de la mortalité à moyen terme, respectivement. On a observé une tendance à l'augmentation de la mortalité à long terme plus d'un an après l'événement (rapport de cotes [RC] agrégé 1,34 [intervalle de confiance {IC} à 95 % : de 0,95 à 1,88]). Le SSE inférieur était également associé à des taux plus faibles de cathétérisme cardiaque (RC agrégé 0,80 [IC à 95 % : de 0,65 à 0,99]) et de revascularisation (RC agrégé 0,76 [IC à 95 % : de 0,63 à 0,90]) après un IAM. Les études sur la réadaptation cardiaque ont montré une diminution de l'accès et de la participation dans les groupes de SSE inférieur.
Un SSE inférieur est associé, après un IAM, non seulement à une mortalité accrue, mais aussi à un accès réduit aux interventions cardiaques dont les effets positifs sur la mortalité et la morbidité ont été démontrés. Il est nécessaire de mettre en œuvre des interventions qui améliorent l'accès au cathétérisme, à la revascularisation et à la réadaptation cardiaque des populations de SSE inférieur si l'on veut que le système de soins canadien soit réellement équitable.
Effects of person-centred care after an event of acute coronary syndrome: Two-year follow-up of a randomised controlled trial
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To assess the long-term effect of person-centred care (PCC) in patients with acute coronary syndrome (ACS).
Patients with ACS were randomly assigned to treatment as usual (control group) or an added PCC intervention for six months. The primary endpoint was a composite score of changes in general self-efficacy ≥ five units, return to work or to a prior activity level and re-hospitalisation or death.
The composite score improved in the PCC intervention group (n = 94) at a two-year follow-up compared with the control group (n = 105) (18.1%, n = 17 vs. 10.5%, n = 11; P = 0.127). In the per-protocol analysis (n = 183) the improvement was significant in favour of the PCC intervention (n = 78) compared with usual care (n = 105) (21.8%, n = 17 vs. 10.5%, n = 11; P = 0.039). This effect was driven by the finding that more patients in the PCC group improved their general self-efficacy score ≥ 5 units (32.2%, n = 19 vs. 17.3%, n = 14; P = 0.046). The composite score improvement was significantly higher in the PCC intervention group without post-secondary education (n = 33) in comparison with corresponding patients in the control group (n = 50) (30.3%, n = 10 vs. 10.0%, n = 5; P = 0.024).
Implementation of PCC results in sustained improvements in health outcome in patients with ACS. PCC can be incorporated into conventional cardiac prevention programmes to improve equity in uptake and patient health outcomes.
Swedish registry, Researchweb.org, ID NR 65791.
A Pilot Trial of a Lifestyle Intervention for Stroke Survivors: Design of Healthy Eating and Lifestyle after Stroke (HEALS)
2017, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Studies have shown that adherence to such lifestyle factors is poor among stroke survivors, particularly those of socioeconomically disadvantaged racial and ethnic backgrounds.2 Socioeconomically disadvantaged minority populations have the highest rate of obesity3 and are less likely than their wealthier counterparts to lead healthy lifestyles.4 The reasons for these differences include lack of resources, limited access to healthy foods, low self-efficacy and motivation, and poor health literacy.5
Stroke survivors have high rates of subsequent cardiovascular and recurrent cerebrovascular events, and mortality. While healthy lifestyle practices - including a diet rich in fruits and vegetables, limited alcohol intake, and regular physical activity - can mitigate these outcomes, few stroke survivors adhere to them. Minorities from socioeconomically disadvantaged communities who obtain care in safety-net health systems experience the most barriers to implementing healthy lifestyle changes after stroke.
To report the design of Healthy Eating and Lifestyle After Stroke (HEALS), a randomized controlled trial (RCT) was designed to test the feasibility of using a manualized, lifestyle management intervention in a safety-net setting to improve lifestyle practices among ethnically diverse individuals with stroke or transient ischemic attack (TIA).
Design: Pilot RCT. Participants: Inclusion criteria: 1) Adults (≥40 years) with ischemic stroke or TIA (≥ 90 days prior); 2) English- or Spanish-speaking. Setting: Outpatient clinic, safety-net setting. Intervention: Weekly two-hour small group sessions led by an occupational therapist for six weeks. The sessions focused on implementing nutrition, physical activity, and self-management strategies tailored to each participant's goals. Main Outcome Measures: Body mass index, diet, and physical activity.
Recruitment for this study is complete. If the HEALS intervention study is feasible and effective, it will serve as a platform for a large-scale RCT that will investigate the efficacy and cost-effectiveness of life management interventions for racially and ethnically diverse, low-income individuals with a history of stroke or TIA who seek healthcare in the safety-net system.
Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine
2017, Progress in Cardiovascular Diseases
Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25–0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

View all citing articles on Scopus

: The Socio-Economic and Acute Myocardial Infarction (SESAMI) study is supported by an operating grant from the Canadian Institutes of Health Research. The SESAMI pilot study was supported by the 1988 Michael Smith Award of Excellence from the Medical Research Council of Canada. The Institute for Clinical Evaluative Sciences is supported in part by a grant from the Ontario Ministry of Health. Dr. Alter is a career investigator with the Heart and Stroke Foundation of Ontario and the chief scientific officer of Intervent Canada (PrevCan), a therapeutic lifestyle and disease-management program; Dr. Gordon is the chief medical and scientific officer of Nationwide Better Health, Savannah, Georgia.

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Coronary artery diseaseInfluence of Socioeconomic Status on Lifestyle Behavior Modifications Among Survivors of Acute Myocardial Infarction

Section snippets

Methods

Results

Discussion

Am Heart J

Public Health

Nutrition

Womens Health Issues

Am Heart J

Soc Sci Med

Am J Prev Med

Prev Med

Coronary interventions and their impact on post myocardial infarction survival

Clin Cardiol

Practical algorithms for pharmacologic management of the post myocardial infarction patient

Clin Cardiol

Smoking habits and predictors of continued smoking in patients with acute coronary syndromes

J Adv Nurs

A systematic review of interventions to improve diabetes care in socially disadvantaged populations

Diabetes Care

Predictors of smoking cessation after coronary artery bypass graft surgeryResults of a randomized trial with 5-year follow-up

Ann Intern Med

Risk factor modification after myocardial infarction

Ann Intern Med

Coronary artery disease
Influence of Socioeconomic Status on Lifestyle Behavior Modifications Among Survivors of Acute Myocardial Infarction