Association of Social Determinants of Health With Long-Term Mortality in Decompensated Heart Failure

Background: Decompensated heart failure (DHF) remains associated with high in-hospital mortality (8–17%) and substantial post-discharge mortality (15–20% at 90 days). Although social determinants of health (SDH) have been linked to short-term adverse outcomes, their impact on long-term survival in DHF, particularly in Brazilian urban settings, is not well defined. Objectives: To evaluate the association between SDH and in-hospital and long-term mortality in patients hospitalized for DHF and managed with standardized protocols at private tertiary centers serving populations with marked social inequalities. Methods: In this retrospective analysis of a prospective cohort, 1,023 consecutive patients admitted with DHF between 2011 and 2021 at two private tertiary centers in Rio de Janeiro were included. The centers are located in areas with contrasting municipal Human Development Index and serve populations with different socioeconomic status, one predominantly caring for lower socioeconomic status patients. All patients were treated according to standardized institutional protocols. Survival analyses used Kaplan–Meier curves, Fine–Gray competing risk models, survival trees, and multivariable Cox regression with variable selection via the Elastic Net, adopting a two-sided alpha of 5%. Results: In-hospital mortality was 10.8%, and post-discharge mortality reached 64.1% over a median follow-up of 6.5 years (interquartile range [IQR] 3.8–9.1). In the multivariable Cox model, SDH were independently associated with lower survival. Brown/Black ethnicity (hazard ratio [HR] 1.44, 95% confidence interval [CI] 1.12–1.86, P = 0.005), admission to the tertiary center serving a lower socioeconomic status population (HR 2.43, 95% CI 2.06–2.86, P < 0.001), and older age (HR 1.02 per year, 95% CI 1.02–1.03, P < 0.001) showed stronger adjusted hazard ratios than several traditional clinical variables. Conclusions: In Brazilian urban settings, SDH are powerful predictors of long-term mortality in patients hospitalized for DHF, exceeding the prognostic impact of conventional clinical factors. Incorporating SDH into risk prediction models may improve identification of high-risk patients and support more equitable allocation of cardiovascular care.