And a new study published July 31, 2019, in the Journal of the American Heart Association has found that even when individuals in low-income regions have equal access to medical therapy, they still have far worse health outcomes. Andi Shahu, MD, a resident physician at Johns Hopkins Hospital in Baltimore, and colleagues reviewed data from 27,862 adults who were participating in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). ALLHAT enrolled men and women ages 55 and older with untreated or treated hypertension throughout the United States, Canada, Puerto Rico, and the Virgin Islands from 1994 to 2002. Participants in lower income areas tended to be female, black, Hispanic, have fewer years of education, and live in the South. This large clinical trial of high blood pressure treatment compared the effectiveness of three blood pressure–lowering drugs — a calcium channel blocker (amlodipine), an angiotensin-converting enzyme (ACE) inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). No matter their income, the randomized participants had access to blood pressure–lowering medication, guidance on how to take the medication, and a doctor who followed standard protocols for medical treatment. “We expected the intervention, on average, to result in similar blood pressure control across all groups,” says Dr. Shahu. “But this wasn’t the case; there were systemic differences by socioeconomic region.” “Participants at sites in low-income areas were much less likely to achieve blood pressure control than those in high-income areas, even though they were all enrolled in the same clinical trial that implemented a standard protocol for checking blood pressure and changing medication in order to lower their blood pressure,” Shahu says. “Likewise, participants in the low-income counties were also more likely to be hospitalized, pass away from complications related to heart failure, or be diagnosed with end-stage kidney disease,” he says.
Study Highlights Hurdles for the Disadvantaged
Over a six-year period, people who received care in low-income zones were one-half as likely to get their blood pressure under control. The study used a measure of 140/90 millimeters of mercury (mm Hg) as the threshold for high blood pressure, while the American Heart Association recognizes high blood pressure as 130/80 mm Hg. Participants in poorer sites faced 25 percent greater odds of dying from any cause and a 25 percent higher likelihood of hospitalization and death related to heart failure than those receiving care in higher-income areas. The risk of developing end-stage kidney disease was dramatically higher in the low-incomes areas — an 86 percent greater likelihood. Also, those in the least wealthy regions were 30 percent less likely to receive a procedure to open blood vessels to the heart when experiencing chest pain or heart attack.
Overcoming Other Factors That May Harm Heart Health
Sarah Samaan, MD, a cardiologist with Baylor Scott & White Legacy Heart Center in Plano, Texas, speculates that there may be other reasons behind the poor outcomes in poor regions. These include unhealthy diets, lack of exercise, and other lifestyle factors that may be more challenging for people with very limited means. “It is also notable that even though everyone studied had equal access to care, those in the lower socioeconomic groups were less likely to keep their scheduled office visits,” says Dr. Samaan. “It’s possible that access to transportation as well as a lower likelihood of learned healthy behaviors contributed to this discrepancy. Also, taking time off of work for appointments can mean a drop in income or even the loss of a job.” Study authors note that fewer office visits may have led to less opportunity to adjust medication or promote other cardiovascular prevention strategies. Shahu adds that people in low-income communities may experience more stressors in general (such as lack of neighborhood safety and job security, or drug, tobacco, or alcohol use), and that may lead to unhealthy results. “We do not have a way right now to analyze the unique effect of each of these factors, but it is important for us to recognize that they are present and that they may impact cardiovascular outcomes in our patients,” says Shahu, who hopes to look at these factors further in future research.
How to Overcome Obstacles to Better Heart Healthcare
“A healthy diet, for example, can be inexpensive, although it takes education and some effort to achieve,” Samaan says. “Reducing salt and calories does not cost anything, but requires education and, for some, a change in cultural norms.” The study spotlights the need for approaches that address disparities (for example, improving neighborhood housing and safety, increasing access to healthy foods and working to reduce “food deserts”) and encourage physician-patient discussion at every visit, according to study authors. “Prioritizing healthcare benefits everyone,” says Samaan. “It keeps people healthy and reduces long term disability and healthcare costs for chronic conditions.”
