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Social Determinants of Health

The Case of the Impoverished Janitor

Bui, Simonetti, Benson, Malek and Anderson

Published 11/3/2014

A 52-year-old man presents to a neighborhood health center for evaluation of intermittent

chest pressure. His symptoms started 2 weeks ago, worsen with exertion, last 10-15 minutes

and are associated with shortness of breath and diaphoresis.  He has not seen a doctor in many years.  He takes no medications, has smoked 1 pack per day for the last 35 years, and denies alcohol or drug use.  He currently works as a janitor at a ballpark, and is usually unemployed for 4-5 months each year.  He lives in a rented apartment in a run-down part of town. He was adopted and is uncertain of his family medical history.  His physical examination reveals BP 160/96, P 74, BMI 39. Cardiopulmonary exam is normal.  1+ pedal edema is noted with good distal pulses.  ECG shows normal sinus rhythm without ST-T change. You are concerned that his chest pain is angina and would like to refer him for further evaluation.  

Which of the following risk factors for ischemic heart disease is not included in current risk calculators—Framingham or ASCVD pooled cohort?

  1. Age

  2. Lack of primary care

  3. Hypertension

  4. Smoking

  5. Low socioeconomic status

  6. Cholesterol levels

What mechanism or pathway could account for its role in cardiovascular diseases?  Would this change your management, and how?

Fast fact:

Low socioeconomic status, including living in low-income neighborhoods, is independently predictive of cardiovascular disease and all-cause mortality.  For individuals from low socioeconomic backgrounds defined as <12 years of education or <$12,000 annual income, Framingham scores underestimated CVD risk by 24%.  The effects of SES on ASCVD risk calculated with the ACC/AHA Pooled Cohort Equations has not been established.


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  • Singh, G.K. Area deprivation and widening inequalities in U.S. mortality, 1969–1998. Am J Public Health. 2003; 93: 1137–1143