{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,10,4]],"date-time":"2026-10-04T01:54:32Z","timestamp":1791078872771,"version":"4.1.0"},"posted":{"date-parts":[[2026,9,30]]},"group-title":"Cardiovascular Medicine","reference-count":25,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,9,30]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Cardiovascular prevention is organized around target metrics. Blood pressure, LDL cholesterol, and A1c define treatment targets, quality metrics, and, implicitly, who is considered safe. Yet a value below a cutoff is a correlative measurement, not an outcome. We tested whether social context recorded before the measurement separated subsequent cardiovascular events among people whose numbers already met the cutoff.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>In this retrospective cohort study, we analyzed All of Us participants without recorded cardiovascular disease and with low comorbidity in three separately indexed cohorts: systolic blood pressure (SBP), LDL cholesterol, and A1c. A preindex score combined household income, education, food security, physical activity, and ZIP-linked deprivation, standardized against a fixed pooled reference of 325,652 eligible people. Cox models adjusted for the measured biomarker value, its square, a score-by-biomarker term, medication exposure, and clinical covariates. The outcome was first myocardial infarction, ischemic stroke, or heart failure. A sensitivity analysis indexed participants at the first measurement after the score became computable and counted only events recorded in inpatient or emergency settings.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>The SBP, LDL, and A1c cohorts included 19,525, 16,578, and 18,539 participants with 144, 129, and 191 events. Each one-SD more favorable score was associated with lower hazard: HR 0.611 (95% CI 0.498\u20130.749), 0.631 (0.512\u20130.778), and 0.544 (0.457\u20130.648), respectively. Below each study cutoff (SBP &lt;140 mmHg, LDL &lt;100 mg\/dL, A1c &lt;8%), less favorable context had event rates of 3.39 versus 1.68, 7.16 versus 2.05, and 8.67 versus 2.34 per 1,000 person-years. In a one-year analysis restricted to 2019\u20132023 index dates, the corresponding adjusted HRs were 0.530, 0.336, and 0.365. In the sensitivity cohorts (54,338, 41,451, and 33,607 participants; 493, 288, and 316 events), HRs were 0.732 (0.657\u20130.815), 0.660 (0.573\u20130.761), and 0.631 (0.552\u20130.722).<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>A biomarker below the study cutoff did not identify a uniform, low-risk population. Social context recorded before the measurement separated cardiovascular events after adjustment for the measured value and clinical factors. Risk assessment that stops at the number misses this variation.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>What Is Known<\/jats:title>\n                  <jats:list list-type=\"bullet\">\n                    <jats:list-item>\n                      <jats:p>Social, economic, and neighborhood conditions shape cardiovascular risk factors and predict cardiovascular events.<\/jats:p>\n                    <\/jats:list-item>\n                    <jats:list-item>\n                      <jats:p>Blood pressure, LDL cholesterol, and A1c targets anchor prevention and quality measurement, yet trials of treating to those targets show modest absolute reductions in hard outcomes.<\/jats:p>\n                    <\/jats:list-item>\n                  <\/jats:list>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>What the Study Adds<\/jats:title>\n                  <jats:list list-type=\"bullet\">\n                    <jats:list-item>\n                      <jats:p>After adjustment for the measured biomarker itself, each SD of more favorable preindex social context was associated with a 37% to 46% lower hazard of myocardial infarction, ischemic stroke, or heart failure across SBP, LDL cholesterol, and A1c cohorts. The association persisted, at 27% to 37%, in sensitivity cohorts 1.8 to 2.8 times larger.<\/jats:p>\n                    <\/jats:list-item>\n                    <jats:list-item>\n                      <jats:p>Below each biomarker cutoff, less favorable context carried 2- to nearly 4-fold higher observed event rates.<\/jats:p>\n                    <\/jats:list-item>\n                    <jats:list-item>\n                      <jats:p>A value below a study cutoff identifies a biomarker category; recorded social context identifies variation in subsequent events within that category.<\/jats:p>\n                    <\/jats:list-item>\n                  <\/jats:list>\n                <\/jats:sec>","DOI":"10.64898\/2026.09.28.26364240","type":"posted-content","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T19:00:44Z","timestamp":1790794844000},"source":"Crossref","is-referenced-by-count":0,"title":["Preindex Social Context and Cardiovascular Events Across Blood Pressure, LDL 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