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Original Investigation
October 9, 2019

Longitudinal Associations Between Income Changes and Incident Cardiovascular Disease: The Atherosclerosis Risk in Communities Study

Author Affiliations
  • 1Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
  • 4Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5University of Minnesota School of Public Health, Minneapolis
  • 6University of North Carolina Gillings School of Global Public Health, Chapel Hill
  • 7University of Kentucky College of Public Health, Lexington
  • 8School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Israel
  • 9Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Cardiol. Published online October 9, 2019. doi:10.1001/jamacardio.2019.3788
Key Points

Question  What is the association between bidirectional income change and cardiovascular disease?

Findings  In this cohort study of middle-aged, community-dwelling adults, a more than 50% income drop was significantly associated with higher risk of incident cardiovascular disease, while a more than 50% income rise was significantly associated with lower risk of incident cardiovascular disease, over a 17-year follow-up.

Meaning  A negative income change is associated with higher risk of incident cardiovascular disease, while a positive income change is associated with lower risk of incident cardiovascular disease.

Abstract

Importance  Higher income is associated with lower incident cardiovascular disease (CVD). However, there is limited research on the association between changes in income and incident CVD.

Objective  To examine the association between change in household income and subsequent risk of CVD.

Design, Setting, and Participants  The Atherosclerosis Risk In Communities (ARIC) study is an ongoing, prospective cohort of 15 792 community-dwelling men and women, of mostly black or white race, from 4 centers in the United States (Jackson, Mississippi; Washington County, Maryland; suburbs of Minneapolis, Minnesota; and Forsyth County, North Carolina), beginning in 1987. For our analysis, participants were followed up until December 31, 2016.

Exposures  Participants were categorized based on whether their household income dropped by more than 50% (income drop), remained unchanged/changed less than 50% (income unchanged), or increased by more than 50% (income rise) over a mean (SD) period of approximately 6 (0.3) years between ARIC visit 1 (1987-1989) and visit 3 (1993-1995).

Main Outcomes and Measures  Our primary outcome was incidence of CVD after ARIC visit 3, including myocardial infarction (MI), fatal coronary heart disease, heart failure (HF), or stroke during a mean (SD) of 17 (7) years. Analyses were adjusted for sociodemographic variables, health behaviors, and CVD biomarkers.

Results  Of the 8989 included participants (mean [SD] age at enrollment was 53 [6] years, 1820 participants were black [20%], and 3835 participants were men [43%]), 900 participants (10%) experienced an income drop, 6284 participants (70%) had incomes that remained relatively unchanged, and 1805 participants (20%) experienced an income rise. After full adjustment, those with an income drop experienced significantly higher risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 1.17; 95% CI, 1.03-1.32). Those with an income rise experienced significantly lower risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 0.86; 95% CI, 0.77-0.96).

Conclusions and Relevance  Income drop over 6 years was associated with higher risk of subsequent incident CVD over 17 years, while income rise over 6 years was associated with lower risk of subsequent incident CVD over 17 years. Health professionals should have greater awareness of the influence of income change on the health of their patients.

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