Midlife Changes in Wealth Appear to Impact Future CV Health

US adults who become more prosperous between age 50 and 64 have a lower risk of cardiovascular events after age 65 than those whose finances stay stable, according to new data. But the flip side is also true: people with a negative wealth trajectory face an increased CV risk.

The link between socioeconomic status and health outcomes is well established, particularly in cross-sectional studies, but there is less research looking into whether changes specifically in wealth are associated with cardiovascular health.

Senior author Muthiah Vaduganathan, MD (Brigham and Women’s Hospital Heart & Vascular Center, Boston, MA), told TCTMD the current study has two unique aspects: it incorporates principles from traditional economic analyses in which a person’s wealth is ranked against their peers and it considers multiple dimensions of wealth (income, nonhousing assets, and debt) rather than income alone.

The researchers hypothesized that “dynamic changes in wealth do forecast improved or worsening cardiovascular health status, and in many ways that was most seen with substantial wealth loss,” he said.

Where one starts out also predicts future cardiovascular risk, but the associations between adverse outcomes and changes in wealth remain significant even after taking into account a person’s baseline, Vaduganathan noted. “That suggests that, potentially, policies [aimed at] buffering large fluctuations—especially large losses—in wealth may actually influence subsequent cardiovascular health status.”

Health and Retirement Study

The analysis, published online June 30, 2021, in JAMA Cardiology, was led by Sara Machado, PhD (London School of Economics, England), and Andrew Sumarsono, MD (UT Southwestern Medical Center and Parkland Memorial Hospital, Dallas, TX). It included 5,579 US adults 50 and older (mean age 54.2 years; 55.2% women) with no history of CVD, stroke, hypertension, or diabetes who participated in the RAND Health and Retirement Study and were available for follow-up after age 65. Most of the participants self-reported as white (76.4%), with 11.7% non-Hispanic Black, 9.8% Hispanic, and 2.2% of another race/ethnicity.

Participants were divided into quintiles of wealth. In the bottom quintile, wealth ranged from -$581,447 to $7,460, and in the top group, it ranged from $327,064 to $22,661,450.

During a mean follow-up of 16.9 years, 24.0% of participants reported a primary endpoint event—CV death or nonfatal MI, heart failure, cardiac arrhythmia, or stroke—with a lower risk seen among people with higher initial wealth (adjusted HR per quintile 0.89; 95% CI 0.84-0.95).

Changes over time mattered, however. Compared with those whose wealth remained stable, people who moved up at least one quintile had a lower risk of CV events (adjusted HR 0.84; 95% CI 0.73-0.97), whereas those who dropped down had a greater risk (adjusted HR 1.15; 95% CI 1.00-1.32).

The findings were consistent across groups defined by race/ethnicity, but because most of the participants were white, “the study is unable to comment on the interplay among race, residential segregation, and wealth,” the researchers write.

Implications for Policy, Clinical Practice

The study, Vaduganathan said, was not designed to explore what’s driving the relationships between changes in wealth and cardiovascular outcomes. But prior research points to the possible contributions of excess stress, physical inactivity, and the reallocation of resources or time that would have gone to healthy behaviors in response to a sudden loss in wealth, he said. On the flip side, he and his colleagues note in their paper, an improvement in wealth status might improve outcomes by relieving stress and increasing healthy behaviors and leisure time.

Reverse causality also could be at play, Vaduganathan said, with declining CV health status leading to deteriorating finances. “This is a two-way relationship, and we do know that cardiovascular disease especially plays a large role in financial hardship and excess bills that can contribute to wealth deficits over time,” he explained.

Vaduganathan indicated that the study findings suggest an opportunity for clinicians to help address this link between wealth and health when speaking with their patients: “Individual clinicians can better incorporate these types of conversations about contextualizing what is happening in one’s life to understand how we can then perhaps tailor our recommendations, especially with respect to expensive medications or devices.”

Commenting for TCTMD, Ed Havranek, MD (University of Colorado Anschutz Medical Campus, Aurora), agreed, saying that “understanding your patients’ material circumstances becomes really important for how you take care of them.” Instead of just taking a medical history, doctors can cast a wider net to ask about what’s happening in a patient’s life. If there has been a job loss or a large expenditure, for instance, that patient might have to be watched more closely to ensure they return for required follow-up, Havranek said.

In terms of potential larger-scale solutions, Vaduganathan said policies that protect against large wealth losses—those related to extraordinary health or litigation bills, for instance—or debt forgiveness programs could have an impact. In addition, he said, the study “really does support improving opportunities for individuals to experience greater upward mobility—and so that’s improved educational access and ability to secure jobs, especially among low-wealth or low-income individuals.”

One of the more straightforward things that can be done on a societal level is to improve access to health insurance, which the Affordable Care Act did mostly by expanding Medicaid, Havranek said, noting that this made a difference in health outcomes. It’s important, he added, to make sure “that when people lose work or lose access to care in other ways, we have a way for them to mitigate that with Medicaid or what have you.”

Tackling Structural Racism

The researchers stress that structural racism needs to be addressed as part of any policy solution, noting that “opportunities to accrue and use wealth are closely tied with existing social structures. Greater wealth provides access to safer neighborhoods, higher-rated school districts, healthier restaurants, cleaner air, and more active recreation. Structural racism in the form of discriminatory housing and lending practices, biased policing and sentencing patterns, and implicit biases, combined with disparities in financial literacy, all represent barriers to equitable opportunity to build wealth.”

And that has led to a major gap in wealth between white and Black families in the United States, Machado et al indicate. “Thus, any new policy aimed at improving the financial health of adults must also target existing systemically racist policies that disproportionately prevent minorities from building and using wealth.”

The analysis showing no difference between changes in wealth and CV outcomes by race/ethnicity “says that the change in capability, the change in resource access, is really driven by wealth regardless of race so that one of the big social determinants of Black health inequity probably has to do with wealth,” Havranek said. “Thinking about that, doing something about that on a societal basis, might substantially improve health equity.”

The ongoing international conversation about social justice is important for society to keep having, Havranek continued. “Adding the health part of that to the discussion will be important,” he said.

Addressing the impact of wealth inequities across racial/ethnic groups can begin at the level of individual health systems, hospitals, and clinical practices, Havranek said. “We need to look at what we are doing to ignore the effect of wealth and education on health outcomes and how we can reduce barriers and improve care for people,” he argued, noting that research has shown that even once reaching the hospital, people living in poorer neighborhoods receive a lower level of care than others.

“As providers, we want to talk about and put some of the responsibility for this on society as a whole, on government policy as a whole,” he concluded. “But there is a role for looking in the mirror and saying, ‘What are we doing to perpetuate this within our own systems? What are we doing to not make this happen?’”