Tang Xiaoman, Li Can, Shen Jian
Department of Cardiovascular Medicine, Cardiovascular Research Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Cardiovascular Medicine, Chongqing Medical University, Chongqing, China.
Sci Rep. 2025 Jul 13;15(1):25300. doi: 10.1038/s41598-025-10735-2.
Congestive heart failure (CHF) and social determinants of health (SDoH) are each associated with increased mortality risk, but their combined effects are not well understood. This study investigated the joint association of CHF and cumulative SDoH burden with all-cause and cardiovascular disease (CVD) mortality. Data were obtained from 38,937 U.S. adults aged ≥ 18 years participating in the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2018. CHF was identified by self-reported physician diagnosis. Eight SDoH indicators across five domains were assessed and categorized into low (≤ 2) or high (> 2) burden. Cox proportional hazards models estimated the independent and joint associations of CHF and SDoH with mortality. Restricted cubic spline (RCS) models assessed non-linear associations. Subgroup and sensitivity analyses were performed, and Kaplan-Meier (KM) curves illustrated survival. Among 38,937 participants (mean age 47.1 years; 51.9% female), 3.4% had CHF and 54.0% had high SDoH burden. During a median follow-up of 8.1 years, 4,730 all-cause deaths and 1,224 CVD deaths were recorded. CHF was associated with elevated all-cause (HR = 2.31, 95% CI: 2.03-2.62) and CVD mortality (HR = 3.52, 95% CI: 2.90-4.26). High SDoH burden also increased the risk of all-cause (HR = 1.84, 95% CI: 1.69-1.99) and CVD mortality (HR = 1.92, 95% CI: 1.62-2.28). The highest risks were observed among individuals with both CHF and high SDoH burden (HR = 3.47 and 5.27, respectively). RCS analysis demonstrated significant non-linear, dose-response relationships (p for nonlinearity < 0.001). Joint risks were particularly elevated in younger adults (< 65 years), those with hypertension, and individuals lacking routine healthcare. Sensitivity analyses confirmed the robustness of findings. CHF and high SDoH burden are independently and jointly associated with increased mortality. Addressing both clinical and social risk factors is essential to reduce disparities and improve cardiovascular outcomes.
充血性心力衰竭（CHF）和健康的社会决定因素（SDoH）均与死亡风险增加相关，但它们的联合作用尚不清楚。本研究调查了CHF与累积SDoH负担对全因死亡率和心血管疾病（CVD）死亡率的联合关联。数据来自2003年至2018年参与美国国家健康与营养检查调查（NHANES）的38937名年龄≥18岁的美国成年人。CHF通过自我报告的医生诊断确定。评估了五个领域的八个SDoH指标，并将其分为低负担（≤2）或高负担（>2）。Cox比例风险模型估计了CHF和SDoH与死亡率的独立和联合关联。受限立方样条（RCS）模型评估了非线性关联。进行了亚组分析和敏感性分析，Kaplan-Meier（KM）曲线显示了生存率。在38937名参与者中（平均年龄47.1岁；51.9%为女性），3.4%患有CHF，54.0%有高SDoH负担。在中位随访8.1年期间，记录了4730例全因死亡和1224例CVD死亡。CHF与全因死亡率升高（HR = 2.31，95%CI：2.03 - 2.62）和CVD死亡率升高（HR = 3.52，95%CI：2.90 - 4.26）相关。高SDoH负担也增加了全因死亡率（HR = 1.84，95%CI：1.69 - 1.99）和CVD死亡率（HR = 1.92，95%CI：1.62 - 2.28）的风险。在同时患有CHF和高SDoH负担的个体中观察到最高风险（分别为HR = 3.47和5.27）。RCS分析显示了显著的非线性剂量反应关系（非线性p<0.001）。在年轻成年人（<65岁）、患有高血压的人群以及缺乏常规医疗保健的个体中，联合风险尤其升高。敏感性分析证实了研究结果的稳健性。CHF和高SDoH负担与死亡率增加独立且联合相关。解决临床和社会风险因素对于减少差异和改善心血管结局至关重要。
