Subclinical coronary atherosclerosis is more pronounced in men and women with lower socio-economic status: associations in a population-based study Coronary atherosclerosis and social status
Restricted accessResearch articleFirst published online August, 2007
Subclinical coronary atherosclerosis is more pronounced in men and women with lower socio-economic status: associations in a population-based study Coronary atherosclerosis and social status
Social inequalities of manifest coronary heart diseases are well documented in modern societies. Less evidence is available on subclinical atherosclerotic disease despite the opportunity to investigate processes underlying this association. Therefore, we examined the relationship between coronary artery calcification as a sign of subclinical coronary atherosclerosis, socio-economic status and established cardiovascular risk factors in a healthy population.
Design
Cross-sectional.
Methods
In a population-based sample of 4487 men and women coronary artery calcification was assessed by electron beam computed tomography quantified by the Agatston score. Socio-economic status was assessed by two indicators, education and income. First, we investigated associations between the social measures and calcification. Second, we assessed the influence of cardiovascular risk factors on this association.
Results
After adjustment for age, men with 10 and less years of formal education had a 70% increase in calcification score compared with men with high education. The respective increase for women was 80%. For income the association was weaker (among men 20% higher for the lowest compared with the highest quartile; and among women 50% higher, respectively). Consecutive adjustment for cardiovascular risk factors significantly attenuated the observed association of socio-economic status with calcification.
Conclusions
Social inequalities in coronary heart diseases seem to influence signs of subclinical coronary atherosclerosis as measured by coronary artery calcification. Importantly, cumulation of major cardiovascular risk factors in lower socio-economic groups accounted for a substantial part of this association.
KaplanGAKeilJE.Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation1993; 88:1973–1998.
2.
MackenbachJPBosVAndersonOCardanoMCostaGHardingS. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol2003; 32:830–837.
3.
MarmotMBartleyM.Social class and coronary heart disease. In: StansfeldSMarmotM, editors. Stress and the heart. London: BMJ Books; 2002. pp. 2002–5.
4.
Department of Health.Independent inquiry into inequalities in health: report (Acheson Report). London: The Stationairy Office; 1998 [electronic document: http://www.archive.official-documents.co.uk/].
5.
LynchJKaplanGACohenRDTuomilethoJSalonenJT.Do cardiovascular risk factors explain the relation between socioeconomic status, risk of all-cause mortality, cardiovascular mortality, and acute myocardial infarction? Am J Epidemiol1996; 15:934–942.
6.
SiegristJMarmotM.Social inequalities in health: new evidence and policy implications. Oxford: Oxford University Press; 2006. pp. 2006–1.
7.
AradYGoodmanKRothMNewsteinDGuerciA.Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events. J Am Coll Cardiol2005; 46:158–165.
8.
LamonteMJFitzgeraldSJChurchTSBarlowCERadfordNBLevineBD. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol2005; 162:421–429.
9.
SchmermundADenktasAERumbergerJAChristianTFSheedyPFBaileyKR. Independent and incremental value of coronary artery calcium for predicting the extent of angiographic coronary artery disease: comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll Cardiol1999; 34:777–786.
10.
BildDEFolsomARLoweLPKiefeCWestfallAOZhengZJ. Prevalence and correlates of coronary calcification in black and white young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Arterioscler Thromb Vasc Biol2001; 21:852–857.
11.
ColhounHMRubensMBUnderwoodSRFullerJH.Cross sectional study of differences in coronary artery calcification by socioeconomic status. BMJ2000; 321:1262–1263.
12.
GalloLCMatthewsKAKullerLHSutton-TyrrellKEdmundowiczD.Educational attainment and coronary and aortic calcification in postmenopausal women. Psychosom Med2001; 63:925–935.
13.
KopWJBermanDSGransarHWongNDMiranda-PeatsRWhiteMD. Social network and coronary artery calcification in asymptomatic individuals. Psychosom Med2005; 67:343–352.
14.
DiezRoux AVDetranoRJacksonSJacobsDRSchreinerPJSheaS. Acculturation and socioeconomic position as predictors of coronary calcification in a multiethnic sample. Circulation2005; 112: 1557–1565.
15.
O'RourkeRABrundageBHFroelicherVFGreenlandPGrundySMHachamovitchR. American College of Cardiology/American Heart Association Expert Consensus Document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation2000; 102:126–140.
16.
GeyerSPeterR.Income, occupational position, qualification and health inequalities-competing risks? Comparing indicators of social status. J Epidemiol Community Health2000; 54:299–305.
17.
SchmermundAMöhlenkampSStangAGrönemeyerDSeibelRHircheH. Assessment of clinically silent atherosclerotic disease and established and novel risk factors for predicting myocardial infarction and cardiac death in healthy middle-aged subjects: rationale and design of the Heinz Nixdorf Recall Study. Am Heart J2002; 144:212–218.
18.
StangAMoebusSDraganoNBeckEMöhlenkampSSchmermundA. Baseline recruitment and analyses of nonresponse of the Heinz Nixdorf Recall Study: identifiability of phone numbers as the major determinant of response. Eur J Epidemiol2005; 20:489–496.
19.
SchmermundAMohlenkampSBerenbeinSPumpHMoebusSRoggenbuckU. Population-based assessment of subclinical coronary atherosclerosis using electron-beam computed tomography. Atherosclerosis2006; 185:177–182.
20.
AgatstonASJanowitzWRHildnerFJZusmerNRViamonteMDetranoR.Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol1990; 15:827–832.
21.
UNESCO.International standard classification of education. ISCED 1997. Paris: UNESCO; 1997.
22.
BurnhamKAndersonDR.Model selection and multimodel inference a practical information-theoretic approach. 2 ed.New York: Springer; 2005.
23.
NorrisCMGhaliWASaundersLDBrantRGalbraithDFarisP. Ordinal regression model and the linear regression model were superior to the logistic regression models. J Clin Epidemiol2006; 59:448–456.
24.
Diez-RouxAVNietoFJTyrolerHACrumLDSzkloM.Social inequalities and atherosclerosis. The atherosclerosis risk in communities study. Am J Epidemiol1995; 141:960–972.
25.
Din-DziethamRLiaoDDiez-RouxANietoFJPatonCHowardG. Association of educational achievement with pulsatile arterial diameter change of the common carotid artery: the Atherosclerosis Risk in Communities Study, 1987-1992. Am J Epidemiol2005; 152:617–627.
26.
BartleyMSackerAFirthDFitzpatrickR.Understanding social variation in cardiovascular risk factors in women and men: the advantage of theoretically based measures. Soc Sci Med1999; 49:831–845.
27.
Ben-ShlomoYKuhD.A life course approach to chronic disease epidemiology. Int J Epidemiol2002; 31:285–293.
28.
KaufmanJSMaclehoseRFKaufmanS.A further critique of the analytic strategy of adjusting for covariates to identify biologic mediation. Epidemiol Perspect Innov2004; 1:4.
29.
AradYSpadaroLAGoodmanKNewsteinD.Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol2000; 36:1253–1260.
30.
GreenlandPLaBreeLAzenSPDohertyTMDetranoRC.Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA2004; 291:210–215.
31.
PletcherMJTiceJAPignoneMBrownerWS.Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis. Arch Int Med2004; 164:1285–1292.
32.
SchmermundAErbelR.Unstable coronary plaque and its relation to coronary calcium. Circulation2001; 104:1682–1687.
33.
TaylorAJBindemanJFeuersteinICaoFBrazaitisMO'MalleyPG.Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors mean three-year outcomes in the prospective Army Coronary Calcium Project. J Am Coll Cardiol2005; 46:807–814.
34.
KaplanGAKeilJE.Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation1993; 88:1973–1998.
35.
MackenbachJPBosVAndersonOCardanoMCostaGHardingS. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol2003; 32:830–837.
36.
MarmotMBartleyM.Social class and coronary heart disease. In: StansfeldSMarmotM, editors. Stress and the heart. London: BMJ Books; 2002. pp. 2002–5.
37.
Department of Health.Independent inquiry into inequalities in health: report (Acheson Report). London: The Stationairy Office; 1998 [electronic document: http://www.archive.official-documents.co.uk/].
38.
LynchJKaplanGACohenRDTuomilethoJSalonenJT.Do cardiovascular risk factors explain the relation between socioeconomic status, risk of all-cause mortality, cardiovascular mortality, and acute myocardial infarction? Am J Epidemiol1996; 15:934–942.
39.
SiegristJMarmotM.Social inequalities in health: new evidence and policy implications. Oxford: Oxford University Press; 2006. pp. 2006–1.
40.
AradYGoodmanKRothMNewsteinDGuerciA.Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events. J Am Coll Cardiol2005; 46:158–165.
41.
LamonteMJFitzgeraldSJChurchTSBarlowCERadfordNBLevineBD. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol2005; 162:421–429.
42.
SchmermundADenktasAERumbergerJAChristianTFSheedyPFBaileyKR. Independent and incremental value of coronary artery calcium for predicting the extent of angiographic coronary artery disease: comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll Cardiol1999; 34:777–786.
43.
BildDEFolsomARLoweLPKiefeCWestfallAOZhengZJ. Prevalence and correlates of coronary calcification in black and white young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Arterioscler Thromb Vasc Biol2001; 21:852–857.
44.
ColhounHMRubensMBUnderwoodSRFullerJH.Cross sectional study of differences in coronary artery calcification by socioeconomic status. BMJ2000; 321:1262–1263.
45.
GalloLCMatthewsKAKullerLHSutton-TyrrellKEdmundowiczD.Educational attainment and coronary and aortic calcification in postmenopausal women. Psychosom Med2001; 63:925–935.
46.
KopWJBermanDSGransarHWongNDMiranda-PeatsRWhiteMD. Social network and coronary artery calcification in asymptomatic individuals. Psychosom Med2005; 67:343–352.
47.
DiezRoux AVDetranoRJacksonSJacobsDRSchreinerPJSheaS. Acculturation and socioeconomic position as predictors of coronary calcification in a multiethnic sample. Circulation2005; 112: 1557–1565.
48.
O'RourkeRABrundageBHFroelicherVFGreenlandPGrundySMHachamovitchR. American College of Cardiology/American Heart Association Expert Consensus Document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation2000; 102:126–140.
49.
GeyerSPeterR.Income, occupational position, qualification and health inequalities-competing risks? Comparing indicators of social status. J Epidemiol Community Health2000; 54:299–305.
50.
SchmermundAMöhlenkampSStangAGrönemeyerDSeibelRHircheH. Assessment of clinically silent atherosclerotic disease and established and novel risk factors for predicting myocardial infarction and cardiac death in healthy middle-aged subjects: rationale and design of the Heinz Nixdorf Recall Study. Am Heart J2002; 144:212–218.
51.
StangAMoebusSDraganoNBeckEMöhlenkampSSchmermundA. Baseline recruitment and analyses of nonresponse of the Heinz Nixdorf Recall Study: identifiability of phone numbers as the major determinant of response. Eur J Epidemiol2005; 20:489–496.
52.
SchmermundAMohlenkampSBerenbeinSPumpHMoebusSRoggenbuckU. Population-based assessment of subclinical coronary atherosclerosis using electron-beam computed tomography. Atherosclerosis2006; 185:177–182.
53.
AgatstonASJanowitzWRHildnerFJZusmerNRViamonteMDetranoR.Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol1990; 15:827–832.
54.
UNESCO.International standard classification of education. ISCED 1997. Paris: UNESCO; 1997.
55.
BurnhamKAndersonDR.Model selection and multimodel inference a practical information-theoretic approach. 2 ed.New York: Springer; 2005.
56.
NorrisCMGhaliWASaundersLDBrantRGalbraithDFarisP. Ordinal regression model and the linear regression model were superior to the logistic regression models. J Clin Epidemiol2006; 59:448–456.
57.
Diez-RouxAVNietoFJTyrolerHACrumLDSzkloM.Social inequalities and atherosclerosis. The atherosclerosis risk in communities study. Am J Epidemiol1995; 141:960–972.
58.
Din-DziethamRLiaoDDiez-RouxANietoFJPatonCHowardG. Association of educational achievement with pulsatile arterial diameter change of the common carotid artery: the Atherosclerosis Risk in Communities Study, 1987-1992. Am J Epidemiol2005; 152:617–627.
59.
BartleyMSackerAFirthDFitzpatrickR.Understanding social variation in cardiovascular risk factors in women and men: the advantage of theoretically based measures. Soc Sci Med1999; 49:831–845.
60.
Ben-ShlomoYKuhD.A life course approach to chronic disease epidemiology. Int J Epidemiol2002; 31:285–293.
61.
KaufmanJSMaclehoseRFKaufmanS.A further critique of the analytic strategy of adjusting for covariates to identify biologic mediation. Epidemiol Perspect Innov2004; 1:4.
62.
AradYSpadaroLAGoodmanKNewsteinD.Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol2000; 36:1253–1260.
63.
GreenlandPLaBreeLAzenSPDohertyTMDetranoRC.Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA2004; 291:210–215.
64.
PletcherMJTiceJAPignoneMBrownerWS.Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis. Arch Int Med2004; 164:1285–1292.
65.
SchmermundAErbelR.Unstable coronary plaque and its relation to coronary calcium. Circulation2001; 104:1682–1687.
66.
TaylorAJBindemanJFeuersteinICaoFBrazaitisMO'MalleyPG.Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors mean three-year outcomes in the prospective Army Coronary Calcium Project. J Am Coll Cardiol2005; 46:807–814.
