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Original research
Association of household income and adverse outcomes in patients with atrial fibrillation
  1. Anna Rose LaRosa1,
  2. J'Neka Claxton2,
  3. Wesley T O'Neal3,
  4. Pamela L Lutsey4,
  5. Lin Y Chen5,
  6. Lindsay Bengtson6,
  7. Alanna M Chamberlain7,
  8. Alvaro Alonso8,
  9. Jared W Magnani9
  1. 1 Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  2. 2 Department of Epidemiology, Emory University, Atlanta, Georgia, USA
  3. 3 Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
  4. 4 Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
  5. 5 Cardiovascular Division, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
  6. 6 Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, Minnesota, USA
  7. 7 Division of Epidemiology, Department of Health Research Sciences, Mayo Clinic, Rochester, Minnesota, USA
  8. 8 Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesotaa, USA
  9. 9 Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Jared W Magnani, University of Pittsburgh, Pittsburgh, PA 15260, USA; magnanij{at}


Background Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).

Objectives The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.

Methods We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40–$59 999; $60–$74 999; $75–$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).

Results Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.

Conclusions We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

  • atrial fibrillation
  • quality and outcomes of care

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  • Contributors AA and JWM conceived and designed the primary aim and method of this study. JC, LB, WTO, PLL, LYC and AMC designed and implemented data collection. AA, JWM, JC and ARL analysed the data. JWM and ARL drafted the manuscript. JWM and AA supervised the project. AA and PLL obtained funding. All authors critically reviewed and developed the final manuscript.

  • Funding Research reported in this publication was supported by the National Institutes of Health's National Heart, Lung and Blood Institute award numbers R01HL122200 and R01HL143010. This work was supported by Grant 2015084 from the Doris Duke Charitable Foundation, New York, New York, and by American Heart Association grant 16EIA26410001.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests Disclosures: LB is an employee of Optum. There are no other author disclosures.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Analysis was conducted at Emory University with the approval of the Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data employed in this analysis are not publicly available as they belong to Optum Cliniformatics. The data may be obtained by appropriate request and cost.

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