Impact of Socioeconomic Status on Mortality and Readmission in Patients With Heart Failure With Reduced Ejection Fraction: The ARIC Study

BACKGROUND: Low socioeconomic status (SES) is associated with a higher risk of heart failure (HF). The contribution of indi-vidual and neighborhood SES to the prognosis and quality of care for HF with reduced ejection fraction is not clear yet has important implications. METHODS AND RESULTS: We examined 728 participants of the ARIC (Atherosclerosis Risk in Communities) study (mean age, 78.2 years; 34% Black participants; 46% women) hospitalized with HF with reduced ejection fraction (ejection fraction <50%) between 2005 and 2018. We assessed associations between education, income, and area deprivation index with mortality and HF readmission using multivariable Cox models. We also evaluated the use of guideline-directed medical therapy (optimal: ≥3 of ß-blockers, mineralocorticoid receptor antagonist, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers; acceptable: at least 2) at discharge. During a median follow-up of 3.2 years, 58.7% were readmitted with HF, and 74.0% died. Low income was associated with higher mortality (hazard ratio [HR], 1.52 [95% CI, 1.14– 2.04]) and readmission (HR, 1.45 [95% CI, 1.04– 2.03]). Similarly, low education was associated with mortality (HR, 1.27 [95% CI, 1.01–1.59]) and readmission (HR, 1.62 [95% CI, 1.24– 2.12]). The highest versus lowest area deprivation index quartile was associated with readmission (HR, 1.69 [95% CI, 1.11– 2.58]) but not necessarily with mortality. The prevalence of optimal guideline-directed medical therapy and acceptable guideline-directed medical therapy was 5.5% and 54.4%, respectively, but did not significantly differ by SES. CONCLUSIONS: Among patients hospitalized with HF with reduced ejection fraction, low SES was independently associated with mortality and HF readmission. A targeted secondary prevention approach that focuses intensive efforts on patients with low SES will be necessary to improve outcomes of those with HF with reduced ejection fraction.