Abstract
BACKGROUND: Financial strain has been linked to adverse cardiovascular outcomes, yet whether this association persists beyond objective socioeconomic resources remains unclear. We examined associations of financial strain with incident heart disease and all-cause mortality among US adults aged 50 years or older. METHODS: Prospective cohort study using the Health and Retirement Study (2006-2022). Among 7219 participants completing the Psychosocial Leave-Behind Questionnaire, the exposure was ongoing financial strain (high vs low/none). Incident heart disease was assessed among 4956 participants without baseline cardiovascular disease using cause-specific Cox and Fine-Gray models. All-cause mortality was modeled using sequential Cox regression. RESULTS: Among 7219 participants (mean [SD] age, 67.5 [10.6] years; 58.6% female), 1423 (19.7%) reported high financial strain. Financial strain was associated with incident heart disease (cause-specific HR, 1.18; 95% CI, 1.02-1.37; P = .03; 1310 events), corroborated by Fine-Gray models (SHR, 1.16; 95% CI, 1.00-1.34). For all-cause mortality (3466 deaths), financial strain was associated after demographic and clinical adjustment (HR, 1.17; 95% CI, 1.07-1.28) but attenuated after further adjustment for income and wealth (HR, 1.10; 95% CI, 1.00-1.20; P = .051). The mortality association differed by age (interaction P = .001): HR, 1.25 (95% CI, 1.03-1.52) for adults younger than 65 years versus HR, 1.04 (95% CI, 0.94-1.16) for those 65 or older. CONCLUSIONS: Financial strain was associated with incident heart disease independent of socioeconomic resources. The mortality association was attenuated by income and wealth adjustment but remained elevated among preretirement adults. Financial strain may be a clinically accessible marker of cardiovascular risk among working-age adults.