Socioeconomic environment and recurrent coronary events after initial myocardial infarction

Avshalom Koren, David M. Steinberg, Yaacov Drory, Yariv Gerber*, Yeheskiel Kishon, Michael Kriwisky, Yoseph Rosenman, Goldbourt Uri Goldbourt, Hod Hanoch Hod, Kaplinsky Eliezer Kaplinsky, Eldar Michael Eldar, Shapira Itzhak Shapira, Pines Amos Pines, Drory Margalit Drory, Roth Arie Roth, Laniado Shlomo Laniado, Keren Gad Keren, Daniel David, Morton Leibowitz, Hana PausnerZvi Schlesinger, Zvi Vered, Battler Alexander Battler, Solodky Alejandro Solodky, Sclarovsky Samuel Sclarovsky, Zehavi Izhar Zehavi, Marom-Klibansky Rachel Marom-Klibansky, Ron Leor

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Purpose: Longitudinal data linking area-level socioeconomic status (SES) to repeated acute coronary syndrome (ACS) events are limited. Using multiple failure-time data, we examined the association between neighborhood SES and ACS in a community-based cohort of myocardial infarction (MI) survivors. Methods: Consecutive patients aged 65 years or younger discharged from eight hospitals in central Israel after first MI in 1992-1993 were followed through 2005. Recurrent MI and unstable angina pectoris (UAP) leading to hospitalization were recorded. Neighborhood SES was assessed through a composite census-derived index developed by the Israel Central Bureau of Statistics. Different variance-corrected proportional hazards models were used to account for multiple recurrent events: Andersen-Gill, Wei-Lin-Weissfeld (WLW), and Prentice-Williams-Peterson. Results: During follow-up, 531 recurrent MIs and 1584 UAP episodes occurred among 1164 patients. Adjusting for known prognostic factors and individual SES using the Andersen-Gill model, higher estimated hazards were associated with poor neighborhood SES (hazard ratio, 1.55; 95% confidence interval [CI], 1.13-2.14 for recurrent MI; and hazard ratio, 1.48; 95% CI, 1.22-1.79 for UAP; in the 5th vs. 95th percentiles). The WLW and Prentice-Williams-Peterson models yielded similar results. When the two outcomes were combined, the WLW-derived hazard ratio was 1.64 (95% CI, 1.39-1.93). Conclusions: MI survivors living in a deprived neighborhood are at higher risk of repeated hospital admissions because of ACS. Secondary prevention initiatives should incorporate multilevel approaches to increase effectiveness and reduce geographic health disparities.

Original languageEnglish
Pages (from-to)541-546
Number of pages6
JournalAnnals of Epidemiology
Issue number8
StatePublished - Aug 2012


FundersFunder number
Environment and Health Fund, Jerusalem, IsraelRGA 0904
Israel National Institute for Health Policy and Health Services Researchr/89/2008


    • Acute coronary syndromes
    • Cohort studies
    • Multiple failure-time data analysis
    • Myocardial infarction
    • Neighborhood socioeconomic status
    • Survival analysis


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