Author + information
- Pooja Dewan, MBChBa,
- Rasmus Rørth, MDa,b,
- Pardeep S. Jhund, MBChB, PhDa,
- Joao Pedro Ferreira, PhDc,
- Faiez Zannad, PhDc,
- Li Shen, MBChB, PhDa,
- Lars Køber, MD, DMScb,
- William T. Abraham, MDd,
- Akshay S. Desai, MD, MPHe,
- Kenneth Dickstein, MD, PhDf,
- Milton Packer, MDg,
- Jean L. Rouleau, MDh,
- Scott D. Solomon, MDe,
- Karl Swedberg, MD, PhDi,
- Michael R. Zile, MDj,
- John J.V. McMurray, MDa,∗ (, )
- for the PARADIGM-HF and ATMOSPHERE Investigators
- aBritish Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- bDepartment of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
- cInserm CIC 1433, Université de Lorraine, CHRU de Nancy, Nancy, France
- dDivision of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, Ohio
- eCardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- fDepartment of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway
- gBaylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
- hInstitut de Cardiologie de Montréal, Université de Montréal, Montréal, Quebec, Canada
- iDepartment of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden, and National Heart and Lung Institute, Imperial College, London
- jDivision of Cardiology, Medical University of South Carolina, and Ralph H. Johnson Veterans Administration Medical Centre, Charleston, South Carolina
- ↵∗Address for correspondence:
Prof. John J. V. McMurray, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, United Kingdom.
Objectives This study examined the relationship between income inequality and heart failure outcomes.
Background The income inequality hypothesis postulates that population health is influenced by income distribution within a society, with greater inequality associated with worse outcomes.
Methods This study analyzed heart failure outcomes in 2 large trials conducted in 54 countries. Countries were divided by tertiles of Gini coefficients (where 0% represented absolute income equality and 100% represented absolute income inequality), and heart failure outcomes were adjusted for standard prognostic variables, country per capita income, education index, and hospital bed, and health worker density.
Results Of the 15,126 patients studied, 5,320 patients lived in Gini coefficient tertile 1 countries (coefficient: <33%), 6,124 patients lived in tertile 2 countries (33% to 41%), and 3,772 patients lived in tertile 3 countries (>41%). Patients in tertile 3 were younger than tertile 1 patients, were more often women, and had less comorbidity and several indicators of less severe heart failure, yet the tertile 3-to-1 hazard ratios (HR) for the primary composite outcome of cardiovascular death or heart failure hospitalization were 1.57 (95% confidence interval [CI]: 1.38 to 1.79) and 1.48 for all-cause death (95% CI: 1.29 to 1.71) after adjustment for recognized prognostic variables. After additional adjustments were made for per capita income, education index, hospital bed density, and health worker density, these HRs were 1.46 (95% CI: 1.25 to 1.70) and 1.30 (95% CI: 1.10 to 1.53), respectively.
Conclusions Greater income inequality was associated with worse heart failure outcomes, with an impact similar to those of major comorbidities. Better understanding of the societal and personal bases of these findings may suggest approaches to improve heart failure outcomes.
The ATMOSPHERE and PARADIGM-HF trials were funded by Novartis directly to authors or to their institutions for participation in one or both of these trials (except for Drs. Dewan, Rørth, Shen, Ferreira, and Zannad).
- Received August 22, 2018.
- Revision received October 29, 2018.
- Accepted November 2, 2018.
- 2018 The Authors