Research articleNeighborhood Socioeconomic Status and Leisure-Time Physical Activity After Myocardial Infarction: A Longitudinal Study
Introduction
Although low SES has been widely recognized as a risk factor for cardiovascular disease (CVD),1, 2 recent evidence has pointed to the detrimental effects of neighborhood deprivation above and beyond individual SES factors. Area-level SES is independently associated with CVD incidence and outcome, as demonstrated in the general population3, 4, 5 and in post–myocardial infarction (post-MI) patients.6, 7, 8 A prospective cohort study demonstrated elevated rates of ischemic stroke, cardiac mortality, and all-cause mortality in post-MI patients from deprived neighborhoods, even after controlling for MI severity, traditional risk factors, and multiple individual SES measures.8, 9 However, the mechanisms for these associations remain speculative.10, 11
Epidemiologic evidence has revealed a clear association between engagement in leisure-time physical activity (LTPA) and both primary and secondary CVD prevention in different settings.12, 13, 14, 15, 16 A recent study showed that regularly active MI survivors had approximately 50% reduced risk of mortality compared with inactive patients, independent of activity patterns prior to MI.17 Despite this clear advantage, only 18% of these patients were regularly active during 13 years of follow-up.17
Although several studies have examined the association between neighborhood deprivation and reduced physical activity,18, 19, 20, 21, 22, 23 they were mostly based on cross-sectional analyses of healthy populations and their results were conflicting and potentially subject to confounding because of insufficient adjustment for individual SES and clinical variables. Using a geographically defined community cohort of MI patients followed up longitudinally, the current study examined whether area of residence predicts long-term trajectory of LTPA. The study benefits from comprehensive socioeconomic and clinical data, long-term follow-up, and repeated measures of LTPA—a substantial advantage because physical activity patterns often vary with time.24 The primary hypothesis was that neighborhood SES would be associated with engagement in LTPA after MI above and beyond individual SES characteristics and clinical covariates.
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Study Design and Sample
The Israel Study of First Acute Myocardial Infarction is a longitudinal, prospective cohort study investigating the role of sociodemographic, medical, and psychosocial variables in long-term clinical outcomes in patients hospitalized with MI. Details of the study methods have been previously reported.8, 9, 25 Briefly, 1626 consecutive patients aged ≤65 years were admitted to the eight medical centers in central Israel with first MI between February 15, 1992, and February 15, 1993. Ninety-five
Results
A total of 1410 patients discharged from hospital after first MI were included in the study analysis. The mean age of participants was 53.8 (SD=8.3) years and 19% were women. Engagement in LTPA after MI was low, with point prevalence rates ranging from 33% to 37% for inactivity and from 19% to 27% for irregular activity throughout follow-up. Baseline patient characteristics across neighborhood SES tertiles are shown in Table 1. Residence in a poorer neighborhood was associated with pre-MI
Discussion
In this post-MI cohort, participants from disadvantaged neighborhoods were less likely to be engaged in LTPA in the decade following MI than participants from wealthier neighborhoods. This association was strongest in the first 5 years following MI. Neighborhood SES was a powerful predictor of LTPA levels, remaining so after extensive adjustment for individual SES and baseline clinical profile. LTPA may represent an intermediate mechanism between neighborhood SES and post-MI outcome. Indeed,
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