Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties.

Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES.

Design, setting, and participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations.

Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma.

Main outcomes and measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths.

Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES.

Conclusions and relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.

Conflict of Interest Disclosures: Dr Goldman reported receiving grants from the Agency for Health Care Policy and Research, Agency for Healthcare Research and Quality, and National Center for Health Services Research; Henry J. Kaiser Family Foundation; National Heart, Lung, and Blood Institute; Flight Attendant Medical Research Institute; Swanson Family Fund; Bristol-Myers Squibb; American College of Cardiology; and National Institutes of Health (NIH) during the conduct of the study as well as personal fees from Elsevier and Little, Brown outside the submitted work. All of the grants were awarded to institutions, not to Dr Goldman, and were used to develop, upgrade, and update the Cardiovascular Disease Policy Model. No other disclosures were reported.

• K08 HL132106/HL/NHLBI NIH HHS/United States
• R25 HD083136/HD/NICHD NIH HHS/United States
• UL1 TR001863/TR/NCATS NIH HHS/United States
• R01 HL081066/HL/NHLBI NIH HHS/United States
• K24 DK103992/DK/NIDDK NIH HHS/United States