Combined effect of educational status and cardiovascular risk factors on the incidence of coronary heart disease and stroke in European cohorts: Implications for prevention

Abstract

Background

The combined effect of social status and risk factors on the absolute risk of cardiovascular disease has been insufficiently investigated, but results provide guidance on who could benefit most through prevention.

Methods

We followed 77,918 cardiovascular disease-free individuals aged 35–74 years at baseline, from 38 cohorts covering Nordic and Baltic countries, the UK and Central Europe, for a median of 12 years. Using Fine–Gray models in a competing-risks framework we estimated the effect of the interaction of education with smoking, blood pressure and body weight on the cumulative risk of incident acute coronary heart disease and stroke.

Results

Compared with more educated smokers, the less educated had an added increase in absolute risk of cardiovascular disease of 3.1% (95% confidence interval + 0.1%, +6.2%) in men and of 1.5% (−1.9%, +5.0%) in women, consistent across smoking categories. Conversely, the interaction was negative for overweight: −2.6% (95% CI: −5.6%, +0.3%) and obese: −3.6% (−7.6%, +0.4%) men, suggesting that the more educated would benefit more from the same reduction in body weight. A weaker interaction was observed for body weight in women, and for blood pressure in both genders. Less educated men and women with a cluster of two or more risk factors had an added cardiovascular disease risk of 3.6% (+0.1%, +7.0%) and of 2.6% (−0.5%, +5.6%), respectively, compared with their more educated counterparts.

Conclusions

Socially disadvantaged subjects have more to gain from lifestyle and blood pressure modification, hopefully reducing both their risk and also social inequality in disease.

Keywords

Social inequalities cardiovascular disease risk differential vulnerability additive interaction competing risks Europe

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References

Manrique-Garcia

Sidorchuk

Hallqvist

et al.

Socioeconomic position and incidence of acute myocardial infarction: A meta-analysis. J Epidemiol Community Health 2011; 65: 301–309.

Addo

Ayerbe

Mohan

et al.

Socioeconomic status and stroke: An updated review. Stroke 2012; 43: 1186–1191.

Veronesi

Ferrario

Kuulasmaa

et al. for the MORGAM Project . Educational class inequalities in the incidence of coronary heart disease in Europe. Heart 2016; 102: 958–965.

Kerr

Slavin

Clark

et al.

Do vascular risk factors explain the association between socioeconomic status and stroke incidence: A meta-analysis. Cerebrovasc Dis 2011; 31: 57–63.

Nordahl

Lange

Osler

et al.

Education and cause-specific mortality: The mediating role of differential exposure and vulnerability to behavioral risk factors. Epidemiology 2014; 25: 389–396.

Rod

Lange

Andersen

et al.

Additive interaction in survival analysis: Use of the additive hazards model. Epidemiology 2012; 23: 733–737.

Nordahl

Osler

Frederiksen

et al.

Combined effects of socioeconomic position, smoking, and hypertension on risk of ischemic and hemorrhagic stroke. Stroke 2014; 45: 2582–2587.

van Walraven

McAlister

. Competing risk bias was common in Kaplan–Meier risk estimates published in prominent medical journals. J Clin Epidemiol 2016; 69: 170–173.e8.

Di Cesare

Khang

Asaria

et al. Lancet NCD Action Group . Inequalities in non-communicable diseases and effective responses. Lancet 2013; 381: 585–597.

10.

World Health Organization, Regional Office for Europe. Review of social determinants and the health divide in the WHO European Region: Final report. Updated reprint. Available at: https://www.instituteofhealthequity.org/projects/who-european-review/final-report (2014, accessed 13 January 2016).

11.

Evans

Salomaa

Kulathinal

et al.

MORGAM (an international pooling of cardiovascular cohorts). Int J Epidemiol 2005; 34: 21–27.

12.

Veronesi G, Ferrario MM, Chambless LE, et al.; for the MORGAM Project. Description and quality of baseline data: Marital status, education and occupation. Available at: http://www.ktl.fi/morgam/a/publications/qa/baseline/se_data/seqa.pdf (2008, accessed 13 January 2016).

13.

Karvanen

Veronesi

Kuulasmaa

. Defining thirds of schooling years in population studies. Eur J Epidemiol 2007; 22: 487–492.

14.

Fine

Gray

. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999; 94: 496–509.

15.

Malki

Koupil

Eloranta

et al.

Temporal trends in incidence of myocardial infarction and ischemic stroke by socioeconomic position in Sweden 1987–2010. PLoS One 2014; 9: e105279.

16.

Igland

Vollset

Nygård

et al.

Educational inequalities in acute myocardial infarction incidence in Norway: A nationwide cohort study. PLoS One 2014; 9: e106898.

17.

Ferrario

Veronesi

Chambless

et al.

MORGAM Project. The contribution of educational class in improving accuracy of cardiovascular risk prediction across European regions: The MORGAM Project Cohort Component. Heart 2014; 100: 1179–1187.

18.

Woodward

Brindle

Tunstall-Pedoe

SIGN group on risk estimation . Adding social deprivation and family history to cardiovascular risk assessment: The ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007; 93: 172–176.

19.

Mons

Müezzinler

Gellert

et al. CHANCES Consortium . Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: Meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium. BMJ 2015; 350: h1551.

20.

Hillier-Brown

Bambra

Cairns

et al.

A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults. Int J Obes 2014; 38: 1483–1490.

21.

Scholes

Bajekal

Love

et al.

Persistent socioeconomic inequalities in cardiovascular risk factors in England over 1994–2008: A time-trend analysis of repeated cross-sectional data. BMC Public Health 2012; 12: 129.

22.

Giampaoli

Palmieri

Donfrancesco

et al. for the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey Research Group . Cardiovascular health in Italy. Ten-year surveillance of cardiovascular diseases and risk factors: Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey 1998–2012. Eur J Prev Cardiol 2015; 22(Suppl. 2): 9–37.

23.

Harald

Salomaa

Jousilahti

et al.

Non-participation and mortality in different socioeconomic groups: The FINRISK population surveys in 1972-92. J Epidemiol Community Health 2007; 61: 449–454.

24.

Schwartz

Bellinger

Glass

. Exploring potential sources of differential vulnerability and susceptibility in risk from environmental hazards to expand the scope of risk assessment. Am J Public Health 2011; 101: S94–S100.

25.

Thurston

El Khoudary

Derby

et al.

Low socioeconomic status over 12 years and subclinical cardiovascular disease: the study of women's health across the nation. Stroke 2014; 45: 954–960.

26.

Galobardes

Shaw

Lawlor

et al.

Indicators of socioeconomic position (part 1). J Epidemiol Community Health 2006; 60: 7–12.

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