Cardiovascular disease is down among the wealthy—but what about everyone else?

Cardiovascular disease (CVD) rates are shrinking steadily among the richest people in the United States, according to a new study published in JAMA Network Open. For the rest of the country, however, that isn’t necessarily the case.

The study’s authors explored data from the National Health and Nutrition Examination Survey collected from 1999 to 2016. Nearly 45,000 people were included in the analysis, and the 20% wealthiest participants were compared with the other 80%.

To provide some context, the authors examined some financial data from 2018. The mean annual income for the wealthiest Americans, for instance, was approximately $234,000 per household and $111,379 per earner. For the other 80%, the mean annual income was $54,053 per household and $45,258 per earner.

“In addition, the richest people have access to a number of other demographic assets that distinguish them from the rest of the population,” wrote lead author Salma M. Abdalla, MBBS, MPH, Boston University School of Public Health, and colleagues. “For example, most people in the highest income group are married (77%) and more than two-thirds (67%) have a college degree or higher educational level. Conversely, a smaller proportion of people in the remainder of the population are married (41%) and fewer than one-third (28%) have a college degree or higher educational level.”

After completing their analysis, Abdalla et al. noted that the age-standardized prevalence of CVD dropped for the country’s top earners from 1999 to 2016 in a number of areas. The prevalence of angina dropped from 3.4% to 0.3%, for example, while heart attacks fell from 3.2% to 1.4%. Also, congestive heart failure (CHF) dropped from 1.2% to 0.5%, and stroke was down slightly from 1.1% to 1%.

Among the other 80% of the population, the prevalence of angina (3.3% vs. 2.6%) and heart attack (4% vs. 3.6%) did drop—but not nearly as much as among wealthier Americans. CHF and stroke, however, saw increases during that same time period, with CHF rising from 2.6% to 2.8% and stroke rising from 2.9% to 3.2%.

“This cross-sectional study found substantial and increasing disparities in CVD between people with the most resources and the remainder of the U.S. population,” the authors wrote. “Over the past two decades, decreases in CVD prevalence primarily occurred in the highest-resources group, whereas the prevalence among the remainder of the population declined at a much lower rate, stayed the same, or increased, depending on the specific cardiovascular condition. Moreover, the largest disparities in CVD were in conditions associated with high out-of-pocket and health care expenditures.”

The researchers highlighted the importance of their findings, noting that serious work is needed—and on multiple levels—to help improve healthcare of all Americans, not just the nation’s top earners.

“A substantially different architecture of inequality, one that points to other solutions, is needed,” they concluded. “Policy and public health efforts should be directed to mitigate the consequences of these inequality dynamics.”

Click here for the full analysis.