Skip to main content


Log in

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity

  • Reviews and New Research Implications (S. Virani, Section Editor)
  • Published:
Current Atherosclerosis Reports Aims and scope Submit manuscript


Purpose of Review

We sought to examine the role of social and environmental conditions that determine an individual’s behaviors and risk of disease—collectively known as social determinants of health (SDOH)—in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

Recent Findings

Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework.


We examined existing evidence of the association between SDOH—organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context—and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others



Atherosclerosis Risk in Communities


Coronary heart disease




Cardiovascular disease


Heart failure


Multi-ethnic Study of Atherosclerosis


Myocardial infarction


Social determinants of health


Socioeconomic status


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–e528 This yearly report, prepared by the American Heart Association (AHA) in collaboration with National Institutes of Health (NIH) and other government agencies, provides the single, most comprehensive data on CVD statistics on a national level in the US. In an important shift from traditional risk factor–centered narrative, the 2019 report included a major focus on SDOH and explicitly highlighted the role of SDOH in contributing to the overall burden of heart disease and stroke in the US.

    Article  PubMed  Google Scholar 

  2. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661–9.

    Article  PubMed  Google Scholar 

  3. Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98.

    Article  PubMed  Google Scholar 

  4. Lang T, Lepage B, Schieber A-C, Lamy S, Kelly-Irving M. Social determinants of cardiovascular diseases. Public Health Rev. 2011;33(2):601–22.

    Article  Google Scholar 

  5. Schultz WM, Kelli HM, Lisko JC, Varghese T, Shen J, Sandesara P, et al. Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation. 2018;137(20):2166–78.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Artiga S, Hinton E. Beyond health care: the role of social determinants in promoting health and health equity. Health. 2019;20(10):1–13.

    Google Scholar 

  7. Fretz A, Schneider AL, McEvoy JW, Hoogeveen R, Ballantyne CM, Coresh J, et al. The association of socioeconomic status with subclinical myocardial damage, incident cardiovascular events, and mortality in the ARIC study. Am J Epidemiol. 2016;183(5):452–61.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CD. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol. 2015;14(12):1206–18.

    Article  PubMed  Google Scholar 

  9. Hamad R, Penko J, Kazi DS, Coxson P, Guzman D, Wei PC, et al. Association of low socioeconomic status with premature coronary heart disease in US adults. JAMA Cardiol. 2020.

  10. • Wang SY, ASL T, Claggett B, Chandra A, SAM K, Lutsey PL, et al. Longitudinal associations between income changes and incident cardiovascular disease: the atherosclerosis risk in communities study. JAMA Cardiol. 2019;4(12):1203–12 This study evaluated the longitudinal association between both increase and decrease in income and incident CVD and reported that a drop in income level predicted increased risk of CVD, whereas income increase predicted low risk of incident CVD. This is one of the few large-scale population-based studies to assess a causal link between a major SDOH and CVD.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Marmot MG, Shipley MJ, Rose G. Inequalities in death--specific explanations of a general pattern? Lancet. 1984;1(8384):1003–6.

    Article  CAS  PubMed  Google Scholar 

  12. Eshak ES, Honjo K, Iso H, Ikeda A, Inoue M, Sawada N, et al. Changes in the employment status and risk of stroke and stroke types. Stroke. 2017;48(5):1176–82.

    Article  PubMed  Google Scholar 

  13. Sareen J, Afifi TO, McMillan KA, Asmundson GJG. Relationship between household income and mental disorders: findings from a population-based longitudinal study. Arch Gen Psychiatry. 2011;68(4):419–27.

    Article  PubMed  Google Scholar 

  14. Patel V, Burns JK, Dhingra M, Tarver L, Kohrt BA, Lund C. Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms. World Psychiatry. 2018;17(1):76–89.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Dhar AK, Barton DA. Depression and the link with cardiovascular disease. Front Psychiatry. 2016;7:33.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Pampel FC, Krueger PM, Denney JT. Socioeconomic disparities in health behaviors. Annu Rev Sociol. 2010;36:349–70.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Holahan J. The 2007–09 Recession and health insurance coverage. Health Aff. 2011;30(1):145–52.

    Article  Google Scholar 

  18. Hudson DL, Puterman E, Bibbins-Domingo K, Matthews KA, Adler NE. Race, life course socioeconomic position, racial discrimination, depressive symptoms and self-rated health. Soc Sci Med. 2013;97:7–14.

    Article  PubMed  Google Scholar 

  19. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005;111(10):1233–41.

    Article  PubMed  Google Scholar 

  20. Kubota Y, Heiss G, MacLehose RF, Roetker NS, Folsom AR. Association of educational attainment with lifetime risk of cardiovascular disease: the atherosclerosis risk in communities study. JAMA Intern Med. 2017;177(8):1165–72.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Khaing W, Vallibhakara SA, Attia J, McEvoy M, Thakkinstian A. Effects of education and income on cardiovascular outcomes: a systematic review and meta-analysis. Eur J Prev Cardiol. 2017;24(10):1032–42.

    Article  PubMed  Google Scholar 

  22. Woolf SH. How are income and wealth linked to health and longevity? 2015

  23. Zajacova A, Lawrence EM. The relationship between education and health: reducing disparities through a contextual approach. Annu Rev Public Health. 2018;39:273–89.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Torpey E. Measuring the value of education. US Bureau of Labor Statistics: Career Outlook; 2018.

    Google Scholar 

  25. Hill HD, Ybarra MA. Less-educated workers' unstable employment: can the safety net help? Fast Focus. No. 19-2014. Institute for Research on Poverty. 2014

  26. Loucks EB, Pilote L, Lynch JW, Richard H, Almeida ND, Benjamin EJ, et al. Life course socioeconomic position is associated with inflammatory markers: the Framingham Offspring Study. Soc Sci Med. 2010;71(1):187–95.

    Article  PubMed  Google Scholar 

  27. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51(Suppl):S28–40.

    Article  PubMed  Google Scholar 

  28. Dégano IR, Marrugat J, Grau M, Salvador-González B, Ramos R, Zamora A, et al. The association between education and cardiovascular disease incidence is mediated by hypertension, diabetes, and body mass index. Sci Rep. 2017;7(1):12370.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  29. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107.

    Article  PubMed  Google Scholar 

  30. Office of Disease Prevention and Health Promotion. Healthy People 2020: social determinants of health [Available from:

  31. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–39.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Office of Disease Prevention and Health Promotion. Healthy People 2030 [Available from:

  33. Cutrona CE, Wallace G, Wesner KA. Neighborhood characteristics and depression: an examination of stress processes. Curr Dir Psychol Sci. 2006;15(4):188–92.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Howell NA, Tu JV, Moineddin R, Chu A, Booth GL. Association between neighborhood walkability and predicted 10-year cardiovascular disease risk: the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort. J Am Heart Assoc. 2019;8(21):e013146.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American adults in the Jackson Heart Study. Am J Public Health. 2016;106(12):2219–26.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Augustin T, Glass TA, James BD, Schwartz BS. Neighborhood psychosocial hazards and cardiovascular disease: the Baltimore Memory Study. Am J Public Health. 2008;98(9):1664–70.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Unger E, Diez-Roux AV, Lloyd-Jones DM, Mujahid MS, Nettleton JA, Bertoni A, et al. Association of neighborhood characteristics with cardiovascular health in the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7(4):524–31.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Yeager RA, Smith TR, Bhatnagar A. Green environments and cardiovascular health. Trends in Cardiovascular Medicine. 2020;30(4):241–6.

    Article  PubMed  Google Scholar 

  39. Dalton AM, Jones AP. Residential neighbourhood greenspace is associated with reduced risk of cardiovascular disease: a prospective cohort study. PLoS One. 2020;15(1):e0226524-e.

    Article  CAS  Google Scholar 

  40. Yeager R, Riggs DW, DeJarnett N, Tollerud DJ, Wilson J, Conklin DJ, et al. Association between residential greenness and cardiovascular disease risk. J Am Heart Assoc. 2018;7(24):e009117.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Pereira G, Foster S, Martin K, Christian H, Boruff BJ, Knuiman M, et al. The association between neighborhood greenness and cardiovascular disease: an observational study. BMC Public Health. 2012;12(1):466.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Jilani MH, Simon-Friedt B, Yahya T, Khan AY, Hassan SZ, Kash B, et al. Associations between particulate matter air pollution, presence and progression of subclinical coronary and carotid atherosclerosis: a systematic review. Atherosclerosis. 2020;306:22–32.

    Article  CAS  PubMed  Google Scholar 

  43. Gustafsson PE, San Sebastian M, Janlert U, Theorell T, Westerlund H, Hammarström A. Life-course accumulation of neighborhood disadvantage and allostatic load: empirical integration of three social determinants of health frameworks. Am J Public Health. 2014;104(5):904–10.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Cadar D, Abell J, Hackett R, Davies H, Llewellyn D, Batty G, et al. Associations of allostatic load with coronary heart disease and dementia in the English Longitudinal Study of Ageing. Innov Aging. 2018;2(Suppl 1):271.

    Article  PubMed Central  Google Scholar 

  45. Economic Research Service. Food access research atlas 2015. United States Department of Agriculture. 2015

  46. Cummins S, Macintyre S. "Food deserts"--evidence and assumption in health policy making. Bmj. 2002;325(7361):436–8.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Testa A, Jackson DB, Semenza DC, Vaughn MG. Food deserts and cardiovascular health among young adults. Public Health Nutr. 2020:1–8.

  48. Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–63.

    Article  PubMed  Google Scholar 

  49. Anand SS, Hawkes C, de Souza RJ, Mente A, Dehghan M, Nugent R, et al. Food consumption and its impact on cardiovascular disease: importance of solutions focused on the globalized food system: a report from the workshop convened by the World Heart Federation. J Am Coll Cardiol. 2015;66(14):1590–614.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Morland K, Diez Roux AV, Wing S. Supermarkets, other food stores, and obesity: the atherosclerosis risk in communities study. Am J Prev Med. 2006;30(4):333–9.

    Article  PubMed  Google Scholar 

  51. Morland K, Wing S, Diez RA. The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. Am J Public Health. 2002;92(11):1761–7.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Powell LM, Slater S, Mirtcheva D, Bao Y, Chaloupka FJ. Food store availability and neighborhood characteristics in the United States. Prev Med. 2007;44(3):189–95.

    Article  PubMed  Google Scholar 

  53. Cluss PA, Ewing L, King WC, Reis EC, Dodd JL, Penner B. Nutrition knowledge of low-income parents of obese children. Transl Behav Med. 2013;3(2):218–25.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Langford CP, Bowsher J, Maloney JP, Lillis PP. Social support: a conceptual analysis. J Adv Nurs. 1997;25(1):95–100.

    Article  CAS  PubMed  Google Scholar 

  55. Gallagher R, Luttik M-L, Jaarsma T. Social support and self-care in heart failure. J Cardiovasc Nurs. 2011;26(6):439–45.

    Article  PubMed  Google Scholar 

  56. Wu J-R, Frazier SK, Rayens MK, Lennie TA, Chung ML, Moser DK. Medication adherence, social support, and event-free survival in patients with heart failure. Health Psychol. 2013;32(6):637–46.

    Article  PubMed  Google Scholar 

  57. Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, Stampfer MJ, et al. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Community Health. 1996;50(3):245–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Cozier Y, Palmer JR, Horton NJ, Fredman L, Wise LA, Rosenberg L. Racial discrimination and the incidence of hypertension in US black women. Ann Epidemiol. 2006;16(9):681–7.

    Article  PubMed  Google Scholar 

  59. Brondolo E, Love EE, Pencille M, Schoenthaler A, Ogedegbe G. Racism and hypertension: a review of the empirical evidence and implications for clinical practice. Am J Hypertens. 2011;24(5):518–29.

    Article  PubMed  Google Scholar 

  60. Davis SK, Liu Y, Quarells RC, Din-Dzietharn R. Stress-related racial discrimination and hypertension likelihood in a population-based sample of African Americans: the Metro Atlanta Heart Disease Study. Ethn Dis. 2005;15(4):585–93.

    PubMed  Google Scholar 

  61. Rutledge T, Reis SE, Olson M, Owens J, Kelsey SF, Pepine CJ, et al. Social networks are associated with lower mortality rates among women with suspected coronary disease: the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation study. Psychosom Med. 2004;66(6):882–8.

    Article  PubMed  Google Scholar 

  62. Sundquist J, Johansson S-E, Yang M, Sundquist K. Low linking social capital as a predictor of coronary heart disease in Sweden: a cohort study of 2.8 million people. Soc Sci Med. 2006;62(4):954–63.

    Article  PubMed  Google Scholar 

  63. Brown AGM, Hudson LB, Chui K, Metayer N, Lebron-Torres N, Seguin RA, et al. Improving heart health among Black/African American women using civic engagement: a pilot study. BMC Public Health. 2017;17(1):112.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Medicine Io. America's Uninsured crisis: consequences for health and health care. Washington, DC: The National Academies Press; 2009. 237 p

  65. Institute of Medicine Committee on Health Insurance S, Its C. America’s uninsured crisis: consequences for health and health care. Washington (DC): National Academies Press (US) Copyright 2009 by the National Academy of Sciences. All rights reserved.; 2009.

  66. Fowler-Brown A, Corbie-Smith G, Garrett J, Lurie N. Risk of cardiovascular events and death--does insurance matter? J Gen Intern Med. 2007;22(4):502–7.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Khera R, Valero-Elizondo J, Das SR, Virani SS, Kash BA, de Lemos JA, et al. Cost-related medication nonadherence in adults with atherosclerotic cardiovascular disease in the United States, 2013 to 2017. Circulation. 2019;140(25):2067–75.

    Article  PubMed  Google Scholar 

  68. Buchmueller TC, Grumbach K, Kronick R, Kahn JG. The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature. Med Care Res Rev. 2005;62(1):3–30.

    Article  PubMed  Google Scholar 

  69. McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Impact of Medicare coverage on basic clinical services for previously uninsured adults. Jama. 2003;290(6):757–64.

    Article  PubMed  Google Scholar 

  70. Majerol M, Newkirk V, Garfield R. The uninsured: a primer–key facts about health insurance and the uninsured in America. The Kaiser Commission on Medicaid and the Uninsured. 2015:1–21.

  71. Garfield R, Orgera K, Damico A. The uninsured and the ACA: a primer-key facts about health insurance and the uninsured amidst changes to the affordable care act. Kaiser Family Foundation. 2019;25.

  72. Health UDO. Services H. Disparities in healthcare quality among racial and ethnic minority groups [Fact sheet]. Washington, DC: Centers for Disease Control and Prevention; 2011.

    Google Scholar 

  73. Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60(1):4–10.e2.

    Article  PubMed  Google Scholar 

  74. Cunningham P, May J. Medicaid patients increasingly concentrated among physicians. Track Rep. 2006;16:1–5.

    Google Scholar 

  75. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976–93.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit Racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60–76.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Silverio A, Cavallo P, De Rosa R, Galasso G. Big health data and cardiovascular diseases: a challenge for research, an opportunity for clinical care. Front Med (Lausanne). 2019;6:36.

    Article  Google Scholar 

  78. Finding TF. Clinical decision support systems recommended to prevent cardiovascular disease. Am J Prev Med. 2015;49(5):796–9.

    Article  Google Scholar 

  79. McPadden J, Durant TJS, Bunch DR, Coppi A, Price N, Rodgerson K, et al. Health care and precision medicine research: analysis of a scalable data science platform. J Med Internet Res. 2019;21(4):e13043.

    Article  PubMed  PubMed Central  Google Scholar 

  80. •• Palacio A, Mansi R, Seo D, Suarez M, Garay S, Medina H, et al. Social determinants of health score: does it help identify those at higher cardiovascular risk? Am J Manag Care. 2020;26(10):e312–e8 In this unique study, the authors created an aggregate SDOH score, based on presence/absence of multiple individual SDOH, and tested its association with traditional CVD risk factors. Despite limited SDOH data, the authors demonstrated that such a score can help identify individuals at high risk of CVD.

    Article  PubMed  Google Scholar 

  81. SDOH Data and Analytics [Available from:

  82. Gajardo AIJ, Henríquez F, Llancaqueo M. Big data, social determinants of coronary heart disease and barriers for data access. Eur J Prev Cardiol. 2020;2047487320922366.

  83. Weintraub WS. Role of Big data in cardiovascular research. J Am Heart Assoc. 2019;8(14):e012791.

    Article  PubMed  PubMed Central  Google Scholar 

  84. Kent J. Sharing SDOH data for improved population health management [Available from:

Download references



Conflicts of Interest

Dr Virani reports grants from the Department of Veterans Affairs, World Heart Federation, and Tahir and Jooma Family and honorarium from the American College of Cardiology (Associate Editor for Innovations, and serves as a member of the steering committee for the PALM (Patient and Provider Assessment of Lipid Management) Registry at Duke Clinical Research Institute (no financial remuneration).

Dr. Nasir reports being on advisory board for Amgen, Esperion, and Novartis and is supported by Katz Academy of Translational Science.

Dr. Blaha reports grants from NIH, FDA, AHA, and Aetna; grants and personal fees from Amgen and Novo Nordisk; and personal fees from Bayer, Novartis, Sanofi, Regeneron, Akcea, 89Bio, Kowa, and Inozyme, outside the submitted work.

The other authors had no disclosures to report.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Khurram Nasir.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Topical Collection on Reviews and New Research Implications

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jilani, M.H., Javed, Z., Yahya, T. et al. Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity. Curr Atheroscler Rep 23, 55 (2021).

Download citation

  • Accepted:

  • Published:

  • DOI: