While middle-aged people in prosperous areas of the U.S. have become less likely to die of cardiovascular diseases like heart attacks and strokes, the progress has not extended to residents of less well-off regions, according to new research by researchers from the University of Pennsylvania and Harvard University. 

The paper, using data from 2010 to 2017 as the U.S. underwent a lagging and unequal recovery from the Great Recession, sheds light on the phenomenon of declining life expectancy, which has fallen in recent years following nearly a century of consistent progress. 

“Changes in economic prosperity were significantly associated with changes in mortality rates,” said lead author Sameed Khatana, an instructor in the Division of Cardiovascular Medicine at the University of Pennsylvania’s Perelman School of Medicine. “This was a very troubling trend and it hasn’t been explored fully in the literature so far.” 

To measure economic prosperity, the researchers used a metric called the Distressed Communities Index, which creates a score from 0 to 100 for each county based on Census Bureau data, using factors such as education, poverty, housing occupancy and employment. 

A 10-point increase in a typical U.S. county’s prosperity score between 2010 and 2017 was associated with a 0.4% lower cardiovascular mortality rate among adults aged 40 to 64 — a statistically significant change, according to the researchers. 

“The gap in the mortality rate between the most prosperous and least prosperous counties widened further,” said Khatana. 

The effect of income on cardiovascular mortality is well-documented, with residents of poorer areas having more difficulty accessing health care and healthy foods. However, this study is among the first to quantify how economic changes affect that disparity. 

“I think it’s quite easy for any physician to see that a lot of the things that determine their patients' health and outcomes are beyond the medications we’re prescribing in the clinic,” Khatana said. 

During the recovery from the Great Recession, upper-income households in the U.S. saw their median incomes significantly increase at a much greater rate than middle and lower-income households. Regions like the Rust Belt that were more exposed to the downsides of globalization were especially hard-hit.

This coincided with rise in what Princeton University economists Anne Case and Angus Deaton have called “deaths of despair” — an epidemic of suicides, drug overdoses and alcoholism causing hundreds of thousands of deaths per year, especially among low-income white people. 

For some researchers, such deaths are seen as a leading cause of the overall decline in life expectancy in the U.S. 

But Khatana believes that changes in cardiovascular disease, which kills about 655,000 Americans each year, could actually be a larger contributor to the decline in U.S. life expectancy than suicides, drug overdoses and alcoholism. 

“It’s not just the so-called 'deaths of despair' that are linked to economic trends,” he said. 

Research into deaths of despair has also generally focused on white people, but the changes in cardiovascular disease are affecting Americans of all ethnic backgrounds, the researchers found. 

“This relationship was not just for the white population,” said Khatana. 

As U.S. lawmakers debate what may become the largest economic relief package in U.S. history, Khatana believes they should be aware that unequal economic recoveries can have health consequences for decades. He said that he found it “striking” that economic events from 2007 and 2008 were still associated with health outcomes a decade later. 

“Economic trends can have lasting impacts that can go on for years and perhaps even longer,” he said. “It’s important to keep in mind that the impact could be seen for a long time to come.” 

Khatana’s interest in the relationship between economic inequality and cardiovascular deaths came from working as a cardiologist with lower-income patients in Philadelphia and observing that they had a more difficult time obtaining medications and healthy food, he said. 

He came up with the idea for the study in the summer of 2019 as he was following political conversations around economic inequality and medical data showing an uptick in cardiovascular deaths.

Khatana wrote the paper alongside University of Pennsylvania colleagues Atheendar Venkataraman, Ashwin Nathan, Elias Dayoub, Lauren Eberly, Nandita Mitra and Peter Groeneveld, as well as Dhruv Kazi, Robert Yeh and S.V. Subramanian of Harvard. 

That group included doctors, public health experts, statisticians and health economists. 

“It’s helpful to have people who are from several different disciplines,” Khatana said. 

In the future, Khatana said he’s interested in seeing whether the alarming trends his group identified can be reversed. 

“The next question is: Will interventions that improve the economic prosperity of an area lead to improvements in cardiovascular health and outcomes?” he said. 

The paper, titled “Association Between County-Level Change in Economic Prosperity and Change in Cardiovascular Mortality Among Middle-aged US Adults,” was published by the JAMA Network in February 2021. The authors are Sameed Khatana Atheendar Venkataraman, Ashwin Nathan, Elias Dayoub, Lauren Eberly, Nandita Mitra and Peter Groeneveld of the University of Pennsylvania, as well as Dhruv Kazi, Robert Yeh and S.V. Subramanian of Harvard University. Khatana was lead author.