Mortality After Myocardial Infarction Role of Social and Behavioral Factors

Abstract

Prospective epidemiologic studies of coronary heart disease, carried out at the Health Insurance Plan of Greater New York (HIP) during the past 25 years, are reviewed to examine the extent to which social or psychosocial factors influence the mortality of men after myocardial infarction (MI). Follow-up of a cohort of 882 men with first MI diagnosed in the years 1961–65 and of a second cohort of 1739 men with acute MI experienced in 1972–75 provided the observations used to assess the prognostic role of clinical features and of personal and social characteristics of the patients.

Both in the 1960’s and the 1970’x, men with little education showed a higher risk of death over five years of follow-up than better-educated, otherwise comparable men. Differences that might account for these findings could not be established from comparisons of the low- and high-education groups. We then sought ways to test the hypothesis that low education was serving here as a marker for relatively high levels of psychosocial stress which placed MI patients at excess risk of death.

Most recently, as an HIP ancillary study to the Beta Blocker Heart Attack Trial (BHAT), psychosocial interviews with 2320 male survivors of acute MI permitted definition of two variables strongly associated with increased 3-year mortality risk. With other important prognostic factors controlled, patients classified as socially isolated and at high life stress showed more than four times the risk of death found among men with low levels of both stress and isolation, as defined. High life stress and social isolation were most prevalent among the least educated men and least prevalent among the best educated. The inverse association of education with mortality in this post-MI population reflects the gradient in prevalence of the defined psychosocial characteristics.