Social Vulnerability Linked to Premature Cardiovascular Deaths

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The counties in the United States with more social vulnerabilities had higher premature mortality related to cardiovascular diseases, such as heart disease, stroke, high blood pressure, and heart failure.

Americans who live in counties considered “socially vulnerable” have higher rates of premature death from cardiovascular diseases (CVDs) like heart disease, stroke, high blood pressure, and heart failure, according to a study published in Circulation, the flagship journal of the American Heart Association.

While it is well known that smoking, high cholesterol, and high blood pressure are factors leading to premature death from CVD, there is growing evidence in a number of conditions and disease states that social determinants of health also have a role in premature deaths, noted the authors.

“There is compelling research suggesting that social factors—apart from medical conditions—play a more important role in health than previously thought,” study author Khurram Nasir, MD, MPH, MSc, chief of cardiovascular prevention and wellness at Houston Methodist DeBakey Heart and Vascular Center and codirector of the Center for Outcomes Research at Houston Methodist, said in a statement.

The authors performed a cross-sectional study linking county-level CDC/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (ATSDR SVI) data with county-level CDC WONDER (Wide-Ranging Online data for Epidemiological Research) mortality data. There are 4 components of SVI—socioeconomic status, household composition and disability, minority states and language, and housing type and transportation—and the authors calculated scores for them and the overall SVI using 15 social attributes.

Counties were divided into 4 groups, with the first quartile being least vulnerable (0 to 0.25) and the fourth quartile being most vulnerable (0.75 to 1.00). They then evaluated rates of death in each quartile among young adults (18-44 years) and middle-aged adults (45-64 years).

They found that the age-adjusted CVD mortality rate per 100,000 person-years was 47.0 across counties. Compared with counties in the first quartile, counties in the fourth quartile had significantly higher mortality for CVD (rate ratio [RR], 1.84; 95% CI, 1.43-2.36), ischemic heart disease (RR, 1.52; 95% CI, 1.09-2.13), hypertension (RR, 2.71; 95% CI, 1.54-4.75), and heart failure (RR, 3.38; 95% CI, 1.32-8.61).

The authors also found:

  • The southwestern and southeastern United States had the largest concentration of counties with socially vulnerable households resulting in higher death rates.
  • Counties in the fourth quartile of social vulnerability had an average 84% greater risk of premature death from CVD compared with counties in the first quartile.
  • Counties in the fourth quartile had nearly 3.4 times the risk of death from heart failure and more than 2.7 times the risk of death from high blood pressure.
  • Non-Hispanic Black adults in the fourth quartile had double the risk of heart failure–related death compared with Black adults in the first quartile.

Overall, the relative risks varied considerably by demographic characteristics. For instance, rural counties with more social vulnerability had a 2- to 5-fold higher risk of premature death from CVD, heart disease, stroke, high blood pressure, and heart failure.

The authors noted that the growing burden of premature CVD can be curbed through the use of focused public health interventions.

“There is an urgent need for everyone to realize the importance of these social risks and their potential impact on health, as well as for health systems and doctors to ensure that we incorporate these assessments into our routine care. This will allow us to develop more tailored interventions, such as supporting cost-related barriers via community resources, addressing transportation barriers and other relevant social risks can be developed,” Nasir said. “As the link between social risk and health outcomes is more clearly defined and detailed, future policy and practice models should ensure appropriate resources are allocated to address excessive risk in socially vulnerable communities.”


Khan SU, Javed Z, Lone AN, et al. Social vulnerability and premature cardiovascular mortality among US counties, 2014 to 2018. Circulation. 2021;144(16):1272-1279. doi:10.1161/CIRCULATIONAHA.121.054516