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. 2025 Jul 1;8(7):e2518826.
doi: 10.1001/jamanetworkopen.2025.18826.

Marginalized Neighborhoods and Health Outcomes in Younger Myocardial Infarction Survivors

Leo E Akioyamen  1 , Atul Sivaswamy  2 , Olivia Haldenby  2 , Husam Abdel-Qadir  1   2   3   4   5 , Maneesh Sud  1   6 , David A Alter  1   2   3   4 , Clare L Atzema  1   2   3 , Peter C Austin  2   3 , Cynthia A Jackevicius  2   3   7 , Moira K Kapral  1   2   3   4 , Harlan M Krumholz  8   9   10 , Karen Tu  2   3   11   12 , Harindra C Wijeysundera  1   2   3   6 , Dennis T Ko  1   2   3   6
Affiliations

Marginalized Neighborhoods and Health Outcomes in Younger Myocardial Infarction Survivors

Leo E Akioyamen et al. JAMA Netw Open. .

Abstract

Importance: Neighborhood characteristics may be independently associated with survival after acute myocardial infarction (AMI).

Objective: To examine the association of living in a marginalized neighborhood with mortality and care for younger AMI survivors (aged <65 years) in a universal health care system.

Design, setting, and participants: Population-based retrospective cohort using clinical and administrative databases in Ontario, Canada. Participants were younger patients hospitalized for their first AMI who received invasive evaluation and survived to 7 days after discharge between April 1, 2010, and March 1, 2019. Statistical analysis was performed between May 27, 2022, and March 31, 2025.

Exposures: Neighborhood marginalization, a metric comprising material deprivation, residential instability, and dependency.

Main outcomes and measures: All-cause death, all-cause hospitalizations, and subsequent AMIs. Proportional hazards regression models were used to quantify the association of marginalization with outcomes over 3 years.

Results: Among 65 464 AMI patients (median age, 56 [IQR, 50-61] years; 22.9% female), increasing neighborhood marginalization was associated with higher rates of mortality beginning 30 days after discharge and persisting over time. At 3 years, mortality rates ranged from 2.2% in the least marginalized neighborhood quintile (Q1) to 5.2% in the most marginalized (Q5). Adjusted hazard ratios for mortality over 3 years of follow-up were significantly higher in patients from marginalized neighborhoods and ranged from 1.13 (95% CI, 0.95-1.35) in Q2 to 1.52 (95% CI, 1.29-1.80) in Q5. Over 1 year, differences were observed between Q1 and Q5 in visits to primary care physicians (Q1, 96.1%; Q5, 91.6%) and cardiologists (Q1, 88.0%; Q5, 75.7%), as well as diagnostic testing.

Conclusions and relevance: In this cohort study of younger AMI survivors with universal health care, living in marginalized neighborhoods was associated with adverse outcomes. The observed differences in health service utilization among marginalized patients warrant further investigation to better understand the underlying structural and systemic factors.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Abdel-Qadir reported personal fees from Amgen, personal fees from Jazz Pharmaceuticals, grants from the Government of Canada, grants from the Heart and Stroke Foundation of Canada, and grants from the Government of Ontario outside the submitted work. Dr Krumholz reported receiving options for Element Science and Identifeye and payments from F-Prime for advisory roles; being a cofounder and holding equity in Hugo Health, Refactor Health, and ENSIGHT-AI; and having research contracts through Yale University from Janssen, Kenvue, Novartis, and Pfizer. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cohort Creation
AMI indicates acute myocardial infarction; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention.
Figure 2.
Figure 2.. Adverse Events Within 1 Year of Index Acute Myocardial Infarction Hospitalization by Marginalization Quintile (Q)
Hazard ratios are relative to patients living in neighborhoods in the first quintile (least marginalized) and are adjusted for demographic characteristics, cardiac risk factors, disease severity on index presentation, comorbid diseases, and per capita concentration of cardiologists. AHR indicates adjusted hazard ratio; AMI indicates acute myocardial infarction.
Figure 3.
Figure 3.. Adverse Events Within 3 Years of Index Acute Myocardial Infarction Hospitalization by Marginalization Quintile (Q)
Hazard ratios are relative to patients living in neighborhoods in the first quintile (least marginalized) and are adjusted for demographic characteristics, cardiac risk factors, disease severity on index presentation, comorbid diseases, and per capita concentration of cardiologists. AHR indicates adjusted hazard ratio; AMI indicates acute myocardial infarction.
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