Using Social Risk to Guide Coronary Heart Disease (CHD) Preventive Treatment

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DESCRIPTION (provided by applicant): Disparities in coronary heart disease (CHD) mortality by socioeconomic status, race and ethnicity, have been extensively documented, but translating them into clinical practice to reduce CHD disparities has proven challenging. This project aims to address this need. Current CHD preventive recommendations, such as Adult Treatment Panel (ATP) III cholesterol treatment and aspirin prophylaxis guidelines, are based on assessment of global risk of CHD. Guidelines for treatment of blood pressure are also likely to incorporate global CHD risk assessment in the near future. However, with the exception of age and sex, key sociodemographic characteristics such as socioeconomic status, race and ethnicity, and marital status (referred to as social risk factors) are not used to estimate global risk despite evidence that they predict CHD risk independently of Framingham Risk Scoring (FRS). The broad aim of this project is to demonstrate that incorporation of social risk into global risk assessment and preventive treatment guidelines offers potential for reducing disparities in CHD. Toward this end, we propose the following specific aims: Aim 1: To develop and validate CHD prediction models that incorporates social risk. Aim 2: To assess the contribution of social risk to CHD risk independent of behavioral risk factors and CRP. Aim 3: To assess the impact of social risk on barriers to CHD preventive therapy. Aim 4: To assess the potential impact of ATP/FRS + social risk guidelines on CHD preventive therapy according to social risk. Aim 5 (exploratory): To assess the potential impact of implementation of ATP + social risk guidelines on social disparities in CHD risk. Aim 1 will be achieve through analysis of data from the Atherosclerosis Risk in Communities Study (ARIC). The prediction tool will be validated using data from the second National Health and Nutrition Study (NHANES II). Aim 2 will be examined using both ARIC and NHANES II data. Aims 3-5 will use NHANES 1988-1994 and 1999-2006 data. Specifically, global risk assessments that include social risk will be applied to these samples to estimate the impact on CHD preventive therapy eligibility. The final aim will simulate use of this tool to estimate impact on disparities. Use of this tool, and recognition of its underpinning paradigm, has implications beyond expanded eligibility for drug therapy among those at social risk. Implementation of such a global risk tool could ultimately help justify implementation of more intensive behavioral interventions focusing on diet, exercise, smoking cessation and medication adherence for those at highest social risk.