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Lower socioeconomic status predicts higher mortality and morbidity in patients with heart failure
  1. Benedikt Schrage1,2,3,
  2. Lars H Lund1,
  3. Lina Benson1,
  4. Davide Stolfo1,4,
  5. Anna Ohlsson5,
  6. Ragnar Westerling5,
  7. Dirk Westermann2,3,
  8. Anna Strömberg6,
  9. Ulf Dahlström6,
  10. Frieder Braunschweig1,
  11. João Pedro Ferreira7,8,
  12. Gianluigi Savarese1
  1. 1 Department of Medicine, Karolinska Institute, Stockholm, Sweden
  2. 2 German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
  3. 3 Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
  4. 4 Cardiovascular Department, 'Ospedali Riuniti' and University of Trieste, Trieste, Italy
  5. 5 Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
  6. 6 Department of Medical and Health Science, Linköping University, Linköping, Sweden
  7. 7 Centre d’Investigations Cliniques Plurithématique 1433, Université de Lorraine and CHU de Nancy, INSERM UMR1116, Vandoeuvre-les-nancy, France
  8. 8 F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Vandoeuvre-les-Nancy, France
  1. Correspondence to Dr Gianluigi Savarese, Department of Medicine, Karolinska Institute, Stockholm 17176, Sweden; gianluigi.savarese{at}


Objective It is not fully understood whether and how socioeconomic status (SES) has a prognostic impact in patients with heart failure (HF). We assessed SES and its association with patient characteristics and outcomes in a contemporary and well-characterised HF cohort.

Methods Socioeconomic risk factors (SERF) were defined in the Swedish HF Registry based on income (low vs high according to the annual median value), education level (no degree/compulsory school vs university/secondary school) and living arrangement (living alone vs cohabitating).

Results Of 44 631 patients, 21% had no, 33% one, 30% two and 16% three SERF. Patient characteristics strongly and independently associated with lower SES were female sex and no specialist referral. Additional independent associations were older age, more severe HF, heavier comorbidity burden, use of diuretics and less use of HF devices. Lower SES was associated with higher risk of HF hospitalisation/mortality, and overall cardiovascular and non-cardiovascular events. These associations persisted after extensive adjustment for patient characteristics, treatments and care. The magnitude of the association increased linearly with the increasing number of coexistent SERF: HR (95% CI) 1.09 (1.05 to 1.13) for one, 1.16 (1.12 to 1.20) for two and 1.22 (1.18 to 1.28) for three SERF (p<0.01).

Conclusions In a contemporary and well-characterised HF cohort and after comprehensive adjustment for confounders, lower SES was linked with multiple factors such as less use of HF devices and age, but most strongly with female sex and lack of specialist referral; and associated with greater risk of morbidity/mortality.

  • heart failure

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  • Contributors BS and GS wrote the first draft of the manuscript. LHL, DS, AO, RW, DW, AS, UD, FB, LB and JPF edited and revised for important intellectual content. All the authors approved the submitted version of the manuscript.

  • Funding This study received support from the EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking BigData@Heart grant (n° 116074). BS is funded by the German Research Foundation.

  • Competing interests BS reports personal fees from AstraZeneca. GS reports grants and personal fees from Vifor, grants from Boehringer Ingelheim, personal fees from Societa' Prodotti Antibiotici, grants from MSD, grants and personal fees from AstraZeneca, grants from Pharmacosmos, grants from Boston Scientific, personal fees from Roche, personal fees from Servier, personal fees from Medtronic, personal fees from Cytokinetics, grants from Novartis, personal fees from Genesis. UD reports grants and honoraria/consultancies from AstraZeneca, Honoraria/consultancies from Novartis and Amgen and grants from Boehringer Ingelheim. AS reports honoraria from Novartis. DW reports honorary from AstraZeneca, Bayer, Berlin-Chemie and Novartis. LHL reports personal fees from Merck, personal fees from Sanofi, grants and personal fees from Vifor-Fresenius, grants and personal fees from AstraZeneca, grants and personal fees from Relypsa, personal fees from Bayer, grants from Boston Scientific, grants and personal fees from Novartis, personal fees from Pharmacosmos, personal fees from Abbott, grants and personal fees from Mundipharma, personal fees from Medscape, personal fees from Myokardia, grants and personal fees from Boehringer Ingelheim, outside the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval SwedeHF as well as this analysis were approved by a multisite ethics committee. The study was conducted in accordance with the Declaration of Helsinki. Individual patient consent was not required, but patients were informed of entry into the registry and allowed to opt out.

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

  • Data availability statement Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author, provided that data sharing is permitted by European Union General Data Protection Regulation regulations and appropriate ethics committees.