Shishehbor Mehdi H, Litaker David, Pothier Claire E, Lauer Michael S
Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
JAMA. 2006 Feb 15;295(7):784-92. doi: 10.1001/jama.295.7.784.
Lower socioeconomic status (SES) confers heightened cardiovascular risk and mortality, although the mediating pathways are unclear.
To evaluate the extent to which exercise physiologic characteristics account for the association between lower SES and mortality.
DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 30 043 consecutive patients living in 7 counties in northeast Ohio referred between 1990 and 2002 for symptom-limited stress testing for evaluation of known or suspected coronary artery disease. Follow-up for mortality continued through February 2004.
Estimated functional capacity in metabolic equivalents and heart rate recovery, physiologic characteristics that are determined directly from exercise; testing and all-cause mortality during a median follow-up of 6.5 years.
Multivariable models adjusting for demographics, insurance status, smoking status, and clinical confounders demonstrated a strong association between a composite SES score based on census block data and functional capacity (adjusted odds ratio comparing 25th with 75th percentile values, 1.72; 95% confidence interval [CI], 1.56-1.89; P<.001) as well as heart rate recovery (adjusted odds ratio comparing 25th with 75th percentile values, 1.18; 95% CI, 1.07-1.30; P<.001). There were 2174 deaths, with mortality risk increasing from 5% to 10% as SES decreased by quartile (P<.001). Cox proportional hazards models that included all confounding variables except exercise physiologic characteristics demonstrated increased mortality as SES decreased (adjusted hazard ratio comparing 25th with 75th percentile values, 1.32; 95% CI, 1.22-1.42; P<.001). After further adding functional capacity and heart rate recovery, the magnitude of this relationship was reduced (comparing 25th with 75th percentile values; adjusted hazard ratio, 1.17; 95% CI, 1.08-1.26; P<.001), with these variables explaining 47% of the association.
Impaired functional capacity and abnormal heart rate recovery were strongly associated with lower SES and accounted for a major proportion of the correlation between SES and mortality. Efforts to modify these clinical features among patients with low SES may narrow disparities in mortality.
社会经济地位（SES）较低会增加心血管疾病风险和死亡率，但其介导途径尚不清楚。
评估运动生理特征在多大程度上解释了较低SES与死亡率之间的关联。
设计、地点和参与者：对1990年至2002年间因症状受限的运动试验被转诊至俄亥俄州东北部7个县的30043例连续患者进行前瞻性队列研究，以评估已知或疑似冠状动脉疾病。对死亡率的随访持续至2004年2月。
以代谢当量和心率恢复来估计功能能力，这些生理特征直接由运动测试确定；以及在中位随访6.5年期间的全因死亡率。
对人口统计学、保险状况、吸烟状况和临床混杂因素进行调整的多变量模型显示，基于普查街区数据的综合SES评分与功能能力之间存在强关联（比较第25百分位数与第75百分位数的调整优势比为1.72；95%置信区间[CI]为1.56 - 1.89；P <.001），以及与心率恢复之间存在关联（比较第25百分位数与第75百分位数的调整优势比为1.18；95% CI为1.07 - 1.30；P <.001）。共有2174例死亡，随着SES按四分位数降低，死亡风险从5%增加到10%（P <.001）。Cox比例风险模型纳入了除运动生理特征外的所有混杂变量，结果显示随着SES降低死亡率增加（比较第25百分位数与第75百分位数的调整风险比为1.32；95% CI为1.22 - 1.42；P <.001）。在进一步纳入功能能力和心率恢复后，这种关系的强度降低（比较第25百分位数与第75百分位数；调整风险比为1.17；95% CI为1.08 - 1.26；P <.001），这些变量解释了47%的关联。
功能能力受损和心率恢复异常与较低的SES密切相关，并占SES与死亡率之间相关性的很大比例。改善SES较低患者的这些临床特征的努力可能会缩小死亡率差距。
