Financial Toxicity and Coronary Heart Disease: A Dual-Level Cross-Sectional and Spatial Analysis of Adults in the United States, 2022-2024.

Introduction  Coronary heart disease (CHD) remains a leading cause of mortality in the United States. While traditional risk factors are well established, the structural impact of financial toxicity, defined as the inability to afford medical care, on cardiovascular outcomes is undercharacterized in nationally representative populations. Methods  A dual-level analysis was conducted. At the individual level, a pooled cross-sectional analysis using 2022-2024 Behavioral Risk Factor Surveillance System (BRFSS) data (N=1,336,111) was performed to calculate prevalence ORs. At the macro level, a Bayesian spatial hierarchical model using the Besag-York-Mollié (BYM) specification was implemented to evaluate the geographic association between state-level financial toxicity and CHD mortality. Results  Individual-level analysis revealed that financial toxicity was strongly associated with premature CHD, corresponding to more than three-fold higher odds of CHD among adults aged 25-44 years (OR=3.38; 95% CI: 2.78-4.12). At the macro level, structural financial toxicity and state uninsured rates were highly collinear (r=0.88). State-level multivariable modeling (R²=0.42) identified age-adjusted CHD prevalence as the dominant predictor of mortality. Furthermore, Bayesian spatial modeling (BYM) confirmed financial toxicity as a credible, independent correlate of cardiovascular mortality (β=2.51; 94% highest-density interval (HDI): 0.65-4.39), with pronounced residual geographic risk clustering in the Midwest and Mid-Atlantic regions. Conclusions  Financial toxicity is a critical structural correlate of premature cardiovascular disease and regional mortality. Improving population-level cardiovascular outcomes requires integrating structural competence and financial screening into primary care, alongside addressing state-level healthcare policy gaps.