Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Original Article

Volume 16, Number 3, June 2025, pages 189-196

Complex Interactions of Social Determinants of Health on Survival Outcomes in Hispanic Patients With Pulmonary Arterial Hypertension in a US-Mexican Border City

Figure 1. Kaplan-Meier analysis of overall survival according to insurance (a) and insurance type (b). (a) Survival probabilities for patients with and without insurance. (b) Survival rates based on insurance type. A P-value of less than 0.01 highlights a statistically significant difference among the groups.

Figure 2. Kaplan-Meier analysis of overall survival according to employment status (a) and latent risk group (b). (a) Survival probabilities for patients based on employment status. (b) Survival probabilities based on latent risk group. A P-value of less than 0.01 indicates a statistically significant difference among the groups.

**Table 1.** Baseline Characteristics in the Entire Cohort and by Death Status
Factor	All patients	Alive	Death	P-value
Data are presented as mean (SD), except for gender and language (%). P-values for continuous variables were calculated using the t-test for time to worsening and age, and the Chi-square test for gender, language, marital status, insurance, employment, and religion. *Statistically significant. CHD: congenital health disease; CO: cardiac output; CTD: connective tissue disease; IPAH: idiopathic pulmonary arterial hypertension; mPAP: mean pulmonary pressure; N: total number of participants; SD: standard deviation; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.
N	158	121	37
Time to worsening (years), mean (SD)	3.75 (2.01)	4.28 (1.86)	2.01 (1.46)	< 0.001*
Age, mean (SD)	57.65 (15.46)	57.96 (15.79)	56.65 (14.55)	0.66
Gender				0.55
Female	112 (71.8%)	84 (70.6%)	28 (75.7%)
Male	44 (28.2%)	35 (29.4%)	9 (24.3%)
PAH etiology
IPAH	51%	47%	49%	0.251
CTD	23%	24%	29%
CHD	17%	23%	15%
Others	9%	6%	7%
Language				0.79
English	91 (57.6%)	69 (57.0%)	22 (59.5%)
Spanish	67 (42.4%)	52 (43.0%)	15 (40.5%)
Marital status				0.083
Married	53 (33.5%)	45 (37.2%)	8 (21.6%)
Separated	16 (10.1%)	9 (7.4%)	7 (18.9%)
Divorced	11 (7%)	7 (5.8%)	4 (10.8%)
Widowed	17 (10.8%)	15 (12.4%)	2 (5.4%)
Life partner	2 (1.3%)	1 (0.8%)	1 (2.7%)
Insurance				< 0.001*
Insured	121 (76.6%)	101 (83.5%)	20 (54.1%)
No insurance	37 (23.4%)	20 (16.5%)	17 (45.9%)
Employment				0.83
Employed	70 (44.3%)	52 (43.0%)	18 (48.6%)
No employment	52 (32.9%)	41 (33.9%)	11 (29.7%)
Retired	36 (22.8%)	28 (23.1%)	8 (21.6%)
Religion				0.33
Religious	132 (83.5%)	103 (85.1%)	29 (78.4%)
Not religious	26 (16.5%)	18 (14.9%)	8 (21.6%)
6MWD, mean (SD)	362.20 (107.32)	385.86 (97.32)	284.81 (103.06)	< 0.001
WHO-FC				< 0.001
1	9 (5.7%)	8 (6.6%)	1 (2.7%)
2	27 (17.1%)	27 (22.3%)	0 (0.0%)
3	101 (63.9%)	79 (65.3%)	22 (59.5%)
4	21 (13.3%)	7 (5.8%)	14 (37.8%)
mPAP, mean (SD)	43.25 (12.74)	41.97 (12.56)	47.45 (12.61)	0.021
CO, mean (SD)	3.85 (1.73)	4.06 (1.67)	3.18 (1.76)	0.007

Table 1. Baseline Characteristics in the Entire Cohort and by Death Status

Factor

All patients

Alive

Death

P-value

Data are presented as mean (SD), except for gender and language (%). P-values for continuous variables were calculated using the t-test for time to worsening and age, and the Chi-square test for gender, language, marital status, insurance, employment, and religion. *Statistically significant. CHD: congenital health disease; CO: cardiac output; CTD: connective tissue disease; IPAH: idiopathic pulmonary arterial hypertension; mPAP: mean pulmonary pressure; N: total number of participants; SD: standard deviation; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.

158

121

Time to worsening (years), mean (SD)

3.75 (2.01)

4.28 (1.86)

2.01 (1.46)

< 0.001*

Age, mean (SD)

57.65 (15.46)

57.96 (15.79)

56.65 (14.55)

0.66

Gender

0.55

Female

112 (71.8%)

84 (70.6%)

28 (75.7%)

Male

44 (28.2%)

35 (29.4%)

9 (24.3%)

PAH etiology

IPAH

51%

47%

49%

0.251

CTD

23%

24%

29%

CHD

17%

23%

15%

Others

Language

0.79

English

91 (57.6%)

69 (57.0%)

22 (59.5%)

Spanish

67 (42.4%)

52 (43.0%)

15 (40.5%)

Marital status

0.083

Married

53 (33.5%)

45 (37.2%)

8 (21.6%)

Separated

16 (10.1%)

9 (7.4%)

7 (18.9%)

Divorced

11 (7%)

7 (5.8%)

4 (10.8%)

Widowed

17 (10.8%)

15 (12.4%)

2 (5.4%)

Life partner

2 (1.3%)

1 (0.8%)

1 (2.7%)

Insurance

< 0.001*

Insured

121 (76.6%)

101 (83.5%)

20 (54.1%)

No insurance

37 (23.4%)

20 (16.5%)

17 (45.9%)

Employment

0.83

Employed

70 (44.3%)

52 (43.0%)

18 (48.6%)

No employment

52 (32.9%)

41 (33.9%)

11 (29.7%)

Retired

36 (22.8%)

28 (23.1%)

8 (21.6%)

Religion

0.33

Religious

132 (83.5%)

103 (85.1%)

29 (78.4%)

Not religious

26 (16.5%)

18 (14.9%)

8 (21.6%)

6MWD, mean (SD)

362.20 (107.32)

385.86 (97.32)

284.81 (103.06)

< 0.001

WHO-FC

< 0.001

9 (5.7%)

8 (6.6%)

1 (2.7%)

27 (17.1%)

27 (22.3%)

0 (0.0%)

101 (63.9%)

79 (65.3%)

22 (59.5%)

21 (13.3%)

7 (5.8%)

14 (37.8%)

mPAP, mean (SD)

43.25 (12.74)

41.97 (12.56)

47.45 (12.61)

0.021

CO, mean (SD)

3.85 (1.73)

4.06 (1.67)

3.18 (1.76)

0.007

**Table 2.** Unadjusted Association of Each Factor With Overall Survival
Covariates	HR	95% CI	P-value
Unadjusted and adjusted association factors are presented as HR with 95% CI and P-value. P-values were derived from Cox proportional hazards regression. *Statistically significant. Age: participant age; Gender: male versus female; Language: Spanish versus English; Marital status: living alone versus in a relationship; Insurance: no insurance versus insured; Employment: no employment versus employed; Religious affiliation: religious versus non-religious; WHO-FC: > 2 vs. ≤ 2; mPAP, CO, and 6MWD. CI: confidence interval; CO: cardiac output; HR: hazard ratio; mPAP: mean pulmonary pressure; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.
Age	0.994	0.974 - 1.014	0.568
Gender - male	0.833	0.393 - 1.766	0.634
Language - Spanish	0.926	0.480 - 1.785	0.818
Marital - living alone	1.736	0.819 - 3.679	0.15
Insurance - no insurance	2.922	1.530 - 5.579	0.001*
Employment - no	1.232	0.647 - 2.349	0.525
Religion - not religious	1.591	0.727 - 3.482	0.245
WHO-FC > 2 vs. ≤ 2	12.351	1.693 - 90.116	0.013
6MWD	0.992	0.989 - 0.995	< 0.001*
mPAP	1.028	1.004 - 1.053	0.02
CO	0.706	0.551 - 0.904	0.006

Table 2. Unadjusted Association of Each Factor With Overall Survival

Covariates

95% CI

P-value

Unadjusted and adjusted association factors are presented as HR with 95% CI and P-value. P-values were derived from Cox proportional hazards regression. *Statistically significant. Age: participant age; Gender: male versus female; Language: Spanish versus English; Marital status: living alone versus in a relationship; Insurance: no insurance versus insured; Employment: no employment versus employed; Religious affiliation: religious versus non-religious; WHO-FC: > 2 vs. ≤ 2; mPAP, CO, and 6MWD. CI: confidence interval; CO: cardiac output; HR: hazard ratio; mPAP: mean pulmonary pressure; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.

Age

0.994

0.974 - 1.014

0.568

Gender - male

0.833

0.393 - 1.766

0.634

Language - Spanish

0.926

0.480 - 1.785

0.818

Marital - living alone

1.736

0.819 - 3.679

0.15

Insurance - no insurance

2.922

1.530 - 5.579

0.001*

Employment - no

1.232

0.647 - 2.349

0.525

Religion - not religious

1.591

0.727 - 3.482

0.245

WHO-FC > 2 vs. ≤ 2

12.351

1.693 - 90.116

0.013

6MWD

0.992

0.989 - 0.995

< 0.001*

mPAP

1.028

1.004 - 1.053

0.02

0.706

0.551 - 0.904

0.006

**Table 3.** Adjusted Association of Each Factor With Overall Survival
	Adjusted model 1	Adjusted model 2
Adjusted model 1 was based on the entire follow-up data whereas adjusted model 2 was based on follow-up data limited to 5 years. Data are presented as HR with 95% CI and P-value. P-values were derived from Cox proportional hazards regression. *Statistically significant. Age: participant age; Gender: male versus female; Language: Spanish versus English; Marital status: living alone versus in a relationship; Insurance: no insurance versus insured; Employment: no employment versus employed; Religion: not religious versus religious; WHO-FC: > 2 vs. ≤ 2; mPAP, CO, and 6MWD. CI: confidence interval; CO: cardiac output; HR: hazard ratio; mPAP: mean pulmonary pressure; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.
Employment - no	1.83	0.93 - 3.60	0.078	2.99	1.42 - 6.30	0.004
CO	0.73	0.58 - 0.92	0.007
mPAP	1.03	1.00 - 1.06	0.022	1.02	1.00 - 1.05	0.102
WHO-FC ≥ 3	10.26	1.40 - 74.94	0.022	11.27	1.47 - 86.66	0.02
6MWD	0.99	0.99 - 0.99	< 0.001	0.99	0.99 - 1.00	< 0.001*
Insurance - no				2.17	1.05 - 4.49	0.037

Table 3. Adjusted Association of Each Factor With Overall Survival

Adjusted model 1

Adjusted model 2

95% CI

P-value

95% CI

P-value

Adjusted model 1 was based on the entire follow-up data whereas adjusted model 2 was based on follow-up data limited to 5 years. Data are presented as HR with 95% CI and P-value. P-values were derived from Cox proportional hazards regression. *Statistically significant. Age: participant age; Gender: male versus female; Language: Spanish versus English; Marital status: living alone versus in a relationship; Insurance: no insurance versus insured; Employment: no employment versus employed; Religion: not religious versus religious; WHO-FC: > 2 vs. ≤ 2; mPAP, CO, and 6MWD. CI: confidence interval; CO: cardiac output; HR: hazard ratio; mPAP: mean pulmonary pressure; 6MWD: six-minute walk distance; WHO-FC: World Health Organization Functional Classification.

Employment - no

1.83

0.93 - 3.60

0.078

2.99

1.42 - 6.30

0.004

0.73

0.58 - 0.92

0.007

mPAP

1.03

1.00 - 1.06

0.022

1.02

1.00 - 1.05

0.102

WHO-FC ≥ 3

10.26

1.40 - 74.94

0.022

11.27

1.47 - 86.66

0.02

6MWD

0.99

0.99 - 0.99

< 0.001

0.99

0.99 - 1.00

< 0.001*

Insurance - no

2.17

1.05 - 4.49

0.037