risk management

Silent Myocardial Infarction and Cumulative Social Risk

Poverty, minority race, low education attainment, and social isolation are some of the social risk factors an individual may experience. And according to results of a new analysis1, a person who is exposed to more than 1 of these social risk factors is at an increased risk for silent myocardial infarction (SMI).

Assessing data from the third US National Health and Nutrition Examination Survey2, researchers used a cumulative social risk score (0 to ≥3) that comprised a poverty-income ratio less than 1, minority race, education attainment lower than grade 12, and living single. 

Compared with a score of 0, a cumulative social risk score of 3 or more was associated with a higher prevalence of SMI. The researchers also determined that the risk of mortality was greater among those with both SMI and cumulative social risk than among those with cumulative social risk alone.

Elsayed Z. Soliman, MD, MSc, MS, was the senior author of this research. He is professor of epidemiology and cardiology at Wake Forest School of Medicine in Winston-Salem, North Carolina, where he also serves as the director of the Epidemiological Cardiology Research Center. He answered our questions about his team’s findings and explained how they “add to the growing body of literature that indicate the need for cardiologists to incorporate social risk factors into their cardiovascular (CV) prevention strategies.”

CONSULTANT360: What knowledge gaps were you hoping to bridge with your analysis?

Elsayed Soliman: We already know that social risk factors such as minority race, poverty, low education attainment, and social isolation could lead to CV morbidity and mortality. However, it was unclear whether cumulative exposure to these social risk factors is associated with increased risk of SMI, which represents almost half of all myocardial infarctions.3 Also, it was unclear whether the joint presence of social risk factors with SMI impacts their associations with future outcomes. We sought to fill these gaps in knowledge by using data from the third US National Health and Nutrition Examination Survey.

C360: What should be cardiologists’ key takeaways of this study? How do you suggest cardiologists implement these key takeaways into their everyday practice?

ES: In our study, we found that cumulative exposure to social risk is associated with an increased risk of SMI and that the concomitant presence of cumulative social risk and SMI is associated with an increased risk of mortality compared with the presence of either alone. These findings add to the growing body of literature that indicate the need for cardiologists to incorporate social risk factors into their CV prevention strategies. That is to say, in addition to the traditional CV risk factors such as hypertension and diabetes, cardiologists should consider social risk factors such as minority race, poverty, low education attainment, and social isolation when evaluating future risk of CV disease.

C360: Did any combinations of social risk factors in particular have a greater impact on silent myocardial infarction risk? If so, what were those combinations?

ES: We did not test different combinations of social risk factors. However, in addition to using a composite score of different social risk factors, we examined each social risk factor separately. When we did that, we found that poverty was the strongest risk factor of SMI.

C360: What do you feel is the most effective way for a cardiologist to determine patients’ cumulative social risk? What questionnaires should be administered, and what types of conversations should be had?

ES: In our study, we determined exposure to cumulative social risk by using a score composed of a number of social risk factors (minority race, poverty-income ratio <1, educational attainment below grade 12, and living single reflecting social isolation). Given the interrelated nature of social risk factors, using a score would be an effective method in our opinion. Regarding conversations with patients and understanding issues surrounding this topic, a useful source would be the American Heart Association’s Scientific Statement on “Social Determinants of Risk and Outcomes for Cardiovascular Disease.”4 The statement summarizes the current state of knowledge about social risk factors and suggests effective interventions to attenuate their adverse influences.

C360: In what way should the fact that a patient has been exposed to cumulative social risk affect the monitoring or preventative measures for SMI? What if a patient has concomitant presence of cumulative social risk and SMI—how should that affect the patient's treatment plan, especially compared with someone with SMI without cumulative social risk?

ES: According to our study, patients exposed to cumulative social risk are at a higher risk for SMI. This may warrant more screening for SMI and more aggressive treatment of CV risk factors among this high-risk group. However, further research is needed to test the cost-effectiveness of more screening for SMI and the ideal preventive strategy among those patients. Nevertheless, practice guidelines from scientific societies on how to manage high-risk patients already exist and would be applicable here as well. This includes not only medical therapy for management of CV risk factors, but also lifestyle modifications such as more physical activity.

References:

  1. Patel N, Ahmad MI, Zhang W, Soliman EZ. Interrelations of cumulative social risk, silent myocardial infarction, and mortality in the general population. Am J Cardiol. 2020;125(12):182301828. doi:10.1016/j.amjcard.2020.03.026
  2. Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994. Centers for Disease Control and Prevention. https://wwwn.cdc.gov/nchs/nhanes/nhanes3/default.aspx
  3. Zhang ZM, Rautaharju PM, Prineas RJ, et al. Race and sex differences in the incidence and prognostic significance of silent myocardial infarction in the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2016;133(22):2141-8. doi:10.1161/CIRCULATIONAHA.115.021177
  4. Havranek EP, Mujahid MS, Barr DA, et al; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873-898. doi:10.1161/CIR.0000000000000228