Social Determinants of Health Linked to Congestive Heart Failure Deaths

Congestive heart failure (CHF) combined with social determinants of health (SDOH) is associated with a higher mortality rate, a study published in Scientific Reports found.¹

Although researchers have established links between both CHF and SDOH and increased and earlier mortality, the combined effects weren’t well understood until a recent study sought to assess their combined influence. CHF is the leading cause of death worldwide and affects nearly 6.7 million US adults and is projected to surpass 8 million by 2023. It is also one of the major contributors to cardiovascular disease (CVD), which impacts over 17 million adults and accounts for 900,000 annual deaths in the US alone.²

Social determinants of health combined with heart failure increase the risk of mortality. | Image Credit - lovelyday12 - stock.adobe.com

SDOH are also recognized as a non-medical driver of cardiovascular outcomes. Defined by the World Health Organization, SDOH can be categorized into 5 groups: economic stability, education, healthcare access and quality, neighborhood environment, and social and community context. The study showed that amongst patients with CHF, more than half had high SDOH burdens, and after a median follow-up of 81 years, both CHF and high SDOH were associated with an increase in all-cause and CVD mortality.¹

“Patients with CHF burdened by poverty, limited education, or poor healthcare access are less able to obtain consistent care and adhere to complex heart failure management,” the authors wrote. “Furthermore, lacking social support can exacerbate these challenges—low health literacy, social isolation, and substandard care access have all been implicated in persistently high heart failure mortality in disadvantaged groups.”

Researchers analyzed data from the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2018. The total sample size consisted of 38,947 participants, which excluded those who were under 18 years old, missing CHF information, with incomplete SDOH data, or missing covariate or mortality information. 

The SDOH assessment used 8 self-reporting indicators, which included employment status, family poverty-income ratio, food security, education level, health insurance coverage, home ownership, and marital status. Each indicator was either marked favorable (0) or unfavorable (1), and the cumulative score was calculated by summing all dichotomized indicators, which was then labeled as low burden (SDOH ≤ 2) or high burden (SDOH > 2).

Covariates included demographic characteristics like age, sex, and race; lifestyle factors (smoking status, drinking status, and physical activity); and clinical parameters (body mass index [BMI], hypertension, diabetes mellitus, and hyperlipidemia). Amongst the 38,497 participants, 51.88% (20,110) were female, 68.4% (17,240) were non-Hispanic White, 11.17% (8335) were Black, 5.05% (3264) were Hispanic, and 15.38% (10,098) were Other.

Amongst the total participants, 3.4% (1252) had CHF, and of those with CHF, 64% had a high SDOH burden. These individuals were more likely to be female (55.7%), Black (20.4%), and have a higher prevalence of diabetes, hypertension, hyperlipidemia, smoking, heavy drinking, higher BMI, and lower physical activity.

Individuals with both CHF and a high burden of unfavorable SDOH had the highest mortality risk. When compared with those without CHF and low SDOH, this group exhibited a 3.47-fold increased risk of all-cause mortality (HR, 3.47; 95% CI, 2.88-4.19) and a 5.27-fold increased risk of cardiovascular mortality (HR, 5.27; 95% CI, 3.91-7.10).

“Our findings highlight a significant joint impact, demonstrating that patients experiencing both CHF and a high SDOH burden are particularly vulnerable, with substantially amplified mortality risks,” the study author explained. “This synergy was most pronounced in vulnerable subgroups—those under 65 years old, with coexistent hypertension, lacking employment, without routine healthcare access, or with low education.”

While the results of the study aligned with prior research that socioeconomic status is linked to poor heart failure outcomes, there was an unexpected finding observed in patients with CHF and high SDOH burden known as the “obesity paradox.” The theory attributes better long-term outcomes in traditionally high-risk patients to targeted social and healthcare interventions. Another hypothesis supports the idea that CHF patients facing socioeconomic hardships affecting healthcare may survive longer due to a stronger support system over time, known as the “Hispanic paradox.”

Furthermore, the study limitations included selection bias, as those excluded due to missing data may have been more socially disadvantaged, thus potentially biasing results towards healthier individuals. Additionally, changes in employment, insurance, or support networks over time were not assessed, which may have led to misclassifications.

“Clinicians should recognize socially disadvantaged CHF patients as high-risk and prioritize integrated care that includes both medical and social support,” the study author wrote. “At the policy level, efforts to reduce structural barriers—through improved access, coverage, and community resources—are essential. Addressing social risk is not only a matter of equity but also a necessary step toward reducing preventable mortality and improving heart failure outcomes.”

References

1. Tang X, Li C, Shen J. Joint association of social determinants of health and congestive heart failure with mortality in U.S. adults. Sci Rep. 2025;15(1):25300. doi:10.1038/s41598-025-10735-2
2. Kazi DS, Elkind MSV, Deutsch A, et al. Forecasting the economic burden of cardiovascular disease and stroke in the United States through 2050: a presidential advisory from the American Heart Association. Circulation. 2024;150(4):e89-e101. doi:10.1161/CIR.0000000000001258