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Anand VV, Zhe ELC, Chin YH, Goh RSJ, Lin C, Kueh MTW, Chong B, Kong G, Tay PWL, Dalakoti M, Muthiah M, Dimitriadis GK, Wang JW, Mehta A, Foo R, Tse G, Figtree GA, Loh PH, Chan MY, Mamas MA, Chew NWS. Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices. Int J Cardiol 2023:S0167-5273(23)00597-1. [PMID: 37116760 DOI: 10.1016/j.ijcard.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/26/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes. METHODS Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index. RESULTS A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001). CONCLUSION Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity. REGISTRATION AND PROTOCOL The current study was registered with PROSPERO, ID: CRD42022334482.
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Affiliation(s)
- Vickram Vijay Anand
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ethan Lee Cheng Zhe
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Yip Han Chin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Rachel Sze Jen Goh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Chaoxing Lin
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Martin Tze Wah Kueh
- Royal College of Surgeons in Ireland and University College Dublin Malaysia Campus, Malaysia
| | - Bryan Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Gwyneth Kong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Mayank Dalakoti
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Georgios K Dimitriadis
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK; Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Jiong-Wei Wang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Surgery, Cardiovascular Research Institute (CVRI), National University of Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anurag Mehta
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University Pauley Heart Centre, Richmond, VA, USA
| | - Roger Foo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; Kent and Medway Medical School, Kent, Canterbury CT2 7NT, UK
| | - Gemma A Figtree
- Northern Clinical School, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Poay Huan Loh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Y Chan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Institute of Population Health, University of Manchester, UK
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore.
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Kjærulff TM, Bihrmann K, Zhao J, Exeter D, Gislason G, Larsen ML, Ersbøll AK. Acute myocardial infarction: Does survival depend on geographical location and social background? Eur J Prev Cardiol 2019; 26:1828-1839. [PMID: 31126196 DOI: 10.1177/2047487319852680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS This study described the interplay between geographical and social inequalities in survival after incident acute myocardial infarction (AMI) and examined whether geographical variation in survival exists when accounting for sociodemographic characteristics of the patients and their neighbourhood. METHODS Ringmap visualization and generalized linear models were performed to study post-AMI mortality. Three individual-level analyses were conducted: immediate case fatality, mortality between days 1 and 28 after admission and 365-day survival among patients who survived 28 days after admission. RESULTS In total, 99,013 incident AMI cases were registered between 2005 and 2014 in Denmark. Survival after AMI tended to correlate with sociodemographic indicators at the municipality level. In individual-level models, geographical inequality in immediate case fatality was observed with high mortality in northern parts of Jutland after accounting for sociodemographic characteristics. In contrast, no geographical variation in survival was observed among patients who survived 28 days. In all three analyses, odds and rates of mortality were higher among patients with low educational level (odds ratio (OR) (95% credible intervals) of 1.20 (1.12-1.29), OR of 1.12 (1.01-1.24) and mortality rate ratio of 1.45 (1.30-1.61)) and low income (OR of 1.24 (1.15-1.33), OR of 1.33 (1.20-1.48) and mortality rate ratio of 1.25 (1.13-1.38)). CONCLUSION Marked geographical inequality was observed in immediate case fatality. However, no geographically unequal distribution of survival was found among patients who survived 28 days after AMI. Results additionally showed social inequality in survival following AMI.
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Affiliation(s)
- Thora Majlund Kjærulff
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Kristine Bihrmann
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Jinfeng Zhao
- Department of Population Health, Auckland University, New Zealand
| | - Daniel Exeter
- Department of Population Health, Auckland University, New Zealand
| | - Gunnar Gislason
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Department of Cardiology, The Cardiovascular Research Centre, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Annette Kjær Ersbøll
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Abbasi SH, De Leon AP, Kassaian SE, Karimi A, Sundin Ö, Jalali A, Soares J, Macassa G. Socioeconomic Status and in-hospital Mortality of Acute Coronary Syndrome: Can Education and Occupation Serve as Preventive Measures? Int J Prev Med 2015; 6:36. [PMID: 25984286 PMCID: PMC4427988 DOI: 10.4103/2008-7802.156266] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background: Socioeconomic status (SES) can greatly affect the clinical outcome of medical problems. We sought to assess the in-hospital mortality of patients with the acute coronary syndrome (ACS) according to their SES. Methods: All patients admitted to Tehran Heart Center due to 1st-time ACS between March 2004 and August 2011 were assessed. The patients who were illiterate/lowly educated (≤5 years attained education) and were unemployed were considered low-SES patients and those who were employed and had high educational levels (>5 years attained education) were regarded as high-SES patients. Demographic, clinical, paraclinical, and in-hospital medical progress data were recorded. Death during the course of hospitalization was considered the end point, and the impact of SES on in-hospital mortality was evaluated. Results: A total of 6246 hospitalized patients (3290 low SES and 2956 high SES) were included (mean age = 60.3 ± 12.1 years, male = 2772 [44.4%]). Among them, 79 (1.26%) patients died. Univariable analysis showed a significantly higher mortality rate in the low-SES group (1.9% vs. 0.6%; P < 0.001). After adjustment for possible cofounders, SES still showed a significant effect on the in-hospital mortality of the ACS patients in that the high-SES patients had a lower in-hospital mortality rate (odds ratio: 0.304, 95% confidence interval: 0.094–0.980; P = 0.046). Conclusions: This study found that patients with low SES were at a higher risk of in-hospital mortality due to the ACS. Furthermore, the results suggest the need for increased availability of jobs as well as improved levels of education as preventive measures to curb the unfolding deaths owing to coronary artery syndrome.
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Affiliation(s)
- Seyed Hesameddin Abbasi
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran ; Department of Heart, Family Health Research Center, Iranian Petroleum Health Research Institute, Tehran, Iran
| | - Antonio Ponce De Leon
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ; Department o de Epidemiologia, Instituto de Medicina Social, Universidade do Estado de Rio de Janeiro, Brazil
| | - Seyed Ebrahim Kassaian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbasali Karimi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Örjan Sundin
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Joaquim Soares
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Gloria Macassa
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ; Department of Occupational and Public Health Sciences University of Gävle, Gävle, Sweden
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Kim JH, Jeong MH, Park IH, Choi JS, Rhee JA, Lee DH, Park SH, Kim IS, Jeong HC, Cho JY, Jang SY, Lee KH, Park KH, Sim DS, Kim KH, Hong YJ, Park HW, Kim JH, Ahn Y, Cho JG, Park JC. The association of socioeconomic status with three-year clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. J Korean Med Sci 2014; 29:536-43. [PMID: 24753701 PMCID: PMC3991797 DOI: 10.3346/jkms.2014.29.4.536] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 02/03/2014] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 ± 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.
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Affiliation(s)
- Jeong Hun Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - In Hyae Park
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Jin Soo Choi
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Ae Rhee
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Doo Hwan Lee
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Soo Hwan Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - In Soo Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hae Chang Jeong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Soo Young Jang
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ki hong Lee
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Keun-Ho Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
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Kirchberger I, Meisinger C, Golüke H, Heier M, Kuch B, Peters A, Quinones PA, von Scheidt W, Mielck A. Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry. Int J Equity Health 2014; 13:19. [PMID: 24552463 PMCID: PMC3940020 DOI: 10.1186/1475-9276-13-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 02/07/2014] [Indexed: 11/10/2022] Open
Abstract
Background Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI. Methods The sample consisted of 2,575 men and 844 women, aged 28–74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality. Results During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05–1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02–2.41, p = 0.039). Conclusions Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.
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Affiliation(s)
- Inge Kirchberger
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr, 2, Augsburg D-86156, Germany.
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Foraker RE, Patel MD, Whitsel EA, Suchindran CM, Heiss G, Rose KM. Neighborhood socioeconomic disparities and 1-year case fatality after incident myocardial infarction: the Atherosclerosis Risk in Communities (ARIC) Community Surveillance (1992-2002). Am Heart J 2013; 165:102-7. [PMID: 23237140 DOI: 10.1016/j.ahj.2012.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 10/15/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Declines in case fatality post-myocardial infarction (MI) have been observed over the past 3 decades. Few studies report socioeconomic disparities in survival post-MI. METHODS We assessed 1-year case fatality among 9,116 incident MI patients included in the Atherosclerosis Risk in Communities community surveillance from 1992 to 2002. Addresses of hospitalized MI patients were geocoded by a commercial vendor and linked to year 2000 United States Census tract-level neighborhood income (nINC) data. We estimated case fatality odds ratios and 95% CIs with a multinomial logistic model to quantify the association between nINC tertile and case fatality, comparing short- (within 28 days) and long-term (29-365 days) case fatality to no death 1 year post-MI. RESULTS Overall, 1-year age-adjusted case fatality rates were highest among MI patients living in low-nINC areas, followed by medium- and high-nINC areas, respectively. We found significant odds ratio modification by race (P < .10) and formed race-nINC strata with high-nINC whites as the referent group. In multivariable models adjusting for age, gender, study community, and year of MI, low-nINC whites and low- and medium-nINC blacks had higher short-term case fatality than high-nINC whites. Low- and medium-nINC blacks had higher long-term case fatality compared with high-nINC whites. CONCLUSIONS Differences in short- and long-term case fatality by neighborhood socioeconomic factors have not been systematically studied in the United States. Surveillance efforts can be expanded to incorporate measures of the neighborhood context to examine these associations over time.
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Affiliation(s)
- Randi E Foraker
- Division of Epidemiology, The Ohio State University, Columbus, OH 43210, USA.
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The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study. Eur J Epidemiol 2012; 27:605-13. [PMID: 22669358 PMCID: PMC3444695 DOI: 10.1007/s10654-012-9700-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/21/2012] [Indexed: 02/06/2023]
Abstract
We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.
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Montaye M, Bingham A, Arveiler D, Ruidavets JB, Ducimetière P, Haas B, Ferrières J, Amouyel P, Dallongeville J. Interregional differences in the clinical, biological and electrical characteristics of first acute coronary events in France: results from the MONICA registries. Eur J Prev Cardiol 2012; 20:275-82. [PMID: 22345698 DOI: 10.1177/2047487312438983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In France, there is a large north-to-south, decreasing gradient in case fatality rates of hospitalized patients for an acute coronary event. This gradient may be explained by differences in the presenting patients' clinical, biological and electrocardiographic characteristics. GOAL To compare the characteristics of patients hospitalized for an acute episode of coronary insufficiency in three regions of France with contrasting fatality rates. METHODS We assessed all men and women (aged 35-74 years) covered by the MONICA registries in three geographical areas (north, east and south-west France) and hospitalized in 2006 for a first acute coronary event. The symptoms, electrocardiogram features, left ventricular ejection fraction (LVEF) and troponin levels were systematically transcribed from medical files. Vital status was followed up for one year. RESULTS Fatality rates at 28 days and 1 year were higher in the north (7% and 12%, respectively) than in the east (5% and 7%) and in the south-west (2% and 5%). Major symptoms (such as cardiac arrest, acute pulmonary oedema and cardiac shock), altered LVEF and ST+ myocardial infarction (STEMI) were more frequent in the north than in the south-west (all p < 0.0001) - pointing to marked inter-regional differences in the presentation of acute coronary syndromes (ACSs). In multivariate analyses, age, major symptoms, altered LVEF and STEMI remained strongly associated with 28-day lethality, whereas the relationship with geographical area was attenuated. Similar results were observed for 1-year outcomes. CONCLUSIONS The clinical, biological and electrocardiographic presentations of hospitalized incident ACSs differ from one region of France to another. These differences explain (at least in part) the 28-day and 1-year decreasing case fatality gradient in hospitalized patients from northern France to south-western France.
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Affiliation(s)
- Michèle Montaye
- Laboratoire d'épidémiologie et de santé publique, Inserm U744, Institut Pasteur de Lille, Université Lille Nord de France, Lille, France
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Ohrlander T, Merlo J, Ohlsson H, Sonesson B, Acosta S. Socioeconomic position, comorbidity, and mortality in aortic aneurysms: a 13-year prospective cohort study. Ann Vasc Surg 2011; 26:312-21. [PMID: 22079461 DOI: 10.1016/j.avsg.2011.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 01/31/2011] [Accepted: 08/03/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register. METHODS We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA. RESULTS We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA. CONCLUSIONS Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.
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Affiliation(s)
- Tomas Ohrlander
- Vascular Center Malmö-Lund, Malmö University Hospital, Malmö, Sweden
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Income-related inequity in initiation of evidence-based therapies among patients with acute myocardial infarction. J Gen Intern Med 2011; 26:1329-35. [PMID: 21751053 PMCID: PMC3208463 DOI: 10.1007/s11606-011-1799-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 06/13/2011] [Accepted: 06/20/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Previous research has shown a socioeconomic status (SES) gradient in the receipt of cardiac services following acute myocardial infarction (AMI), but much less is known about SES and the use of secondary preventive medicines following AMI. OBJECTIVES To examine the role of income in initiation of treatment with ACE-inhibitors, beta-blockers and statins in the 120 days following discharge from hospital for first AMI. DESIGN A cross-sectional study with a population-based cohort. PARTICIPANTS First-time AMI patients between age 40 and 100 discharged alive from the hospital and surviving at least 120 days following discharge between January 1, 1999 and September 3, 2006. MAIN MEASURES Binary variables indicating whether the patient had filled at least one prescription for each of the medicines of interest. KEY RESULTS Our results reveal a significant and positive income gradient with initiation of the guideline-recommended medicines among male AMI patients. Men in the third income quintile and above were significantly more likely to initiate treatment with any of the medicines than those in the first quintile, with those in the fifth income quintile having 37%, 50% and 71% higher odds of initiating ACE-inhibitors, beta-blockers and statins, respectively, than men in the lowest income quintile [OR = 1.37 95% CI (1.24, 1.51); OR = 1.50 95% CI (1.35, 1.68); and OR = 1.71 95% CI (1.53, 190)]. The gradient was not present among women, although women in the fifth income quintile were more likely to initiate beta-blockers and statins than women in the lowest income quintile [OR = 1.25 95% CI (1.06, 1.47) and OR = 1.32 95% CI (1.12, 1.54)]. CONCLUSIONS There were inequities in treatment following AMI in the form of a clear and often significant gradient between income and initiation of evidence-based pharmacologic therapies among male patients. This gradient persisted despite significant changes in coverage levels for the costs of these medicines.
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Donyavi T, Naieni KH, Nedjat S, Vahdaninia M, Najafi M, Montazeri A. Socioeconomic status and mortality after acute myocardial infarction: a study from Iran. Int J Equity Health 2011; 10:9. [PMID: 21299888 PMCID: PMC3042926 DOI: 10.1186/1475-9276-10-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 02/07/2011] [Indexed: 11/28/2022] Open
Abstract
Background Studies have shown an inverse relationship between socioeconomic status (SES) and mortality due to coronary heart disease (CHD). Little is known about this association in Iran. This study aimed to investigate whether mortality after myocardial infarction (MI) varies by SES. Methods In a retrospective study, 1283 MI patients who hospitalized in Tehran Heart Center from March 2005 to March 2006 were followed up in March 2008. Demographic, clinical and SES data were collected from case records and by telephone interviews. Multiple logistic regression analysis was performed to estimate the predictive effect of socioeconomic factors on outcome. Results In all 664 patients were studied. Of these, 500 patients were alive and 164 were dead due to MI (64 died at hospital and 100 died at home). The results of regression analysis showed that in addition to treatment (OR = 9.52, 95%CI 4.84-18.7), having diabetes (OR = 1.78, 95% CI 1.12-2.81) or hyperlipidemia (OR = 1.82, 95% CI 1.14-2.90), socioeconomic variables including living area in square per person (lowest level vs. upper level OR = 4.92, 95% CI 2.11-11.4), unemployment (OR = 3.50, 95% CI 1.50-8.13) and education (OR for illiterate patients = 2.51, 95% CI 1.00-6.31) were the most significant contributing factors to increased mortality after MI. Conclusion Although the findings should be interpreted with caution, the study results indicated that socioeconomic variables were significant contributing factors to increased mortality after myocardial infarction. The underlying role of socioeconomic status on increased mortality after MI deserves further investigation.
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Affiliation(s)
- Tahereh Donyavi
- Department of Mental Health, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran.
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Gerward S, Tydén P, Engström G, Hedblad B. Marital status and occupation in relation to short-term case fatality after a first coronary event--a population based cohort. BMC Public Health 2010; 10:235. [PMID: 20459706 PMCID: PMC2874781 DOI: 10.1186/1471-2458-10-235] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 05/10/2010] [Indexed: 11/13/2022] Open
Abstract
Background Although marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors. Methods Population-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years. Results A total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender. Conclusions In this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.
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Affiliation(s)
- Sofia Gerward
- Department of Clinical Sciences in Malmö, Cardiovascular Epidemiology, Skåne University Hospital, Malmö, Sweden.
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The effect of early life factors on 28 day case fatality after acute myocardial infarction. Scand J Public Health 2009; 37:720-7. [DOI: 10.1177/1403494809344445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims: To study the association of size at birth and social circumstances at birth with 28 day case fatality of acute myocardial infarction (AMI). Methods: Based on 1,776 first cases of AMI occurring in Uppsala Birth Cohort (men and women born 1915—1929) between 1964 and 2002. Data on circumstances at birth retrieved from archived obstetric records; data on social characteristics in adulthood, hospitalizations, and date of death obtained through linkage to Censuses, Hospital Discharge Register, and Cause of Death Register. Results: We found a U-shaped association between standardized birth weight and case fatality of AMI in men (p = 0.045 for age and period adjusted quadratic trend over quintiles of standardized birth weight) that was driven by cases of AMI occurring during the early years of follow-up. We found no association between standardized birth weight and case fatality of AMI in women. There was a statistically non-significant inverse association of AMI case fatality with social class at birth as well as with social class and household income in adulthood in the cohort. Marital status was a strong determinant of case fatality in men. Conclusions: Standardized birth weight for gestational age was associated with case fatality of AMI in men. Social class at birth was weakly inversely associated with case fatality of AMI in the cohort.
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Agabiti N, Cesaroni G, Picciotto S, Bisanti L, Caranci N, Costa G, Forastiere F, Marinacci C, Pandolfi P, Russo A, Perucci CA. The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery. J Epidemiol Community Health 2009; 62:882-9. [PMID: 18791046 PMCID: PMC2602741 DOI: 10.1136/jech.2007.067470] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Understanding the mechanism by which both patient- and hospital level factors act in generating disparities has important implications for clinicians and policy-makers. Objective: To measure the association between socioeconomic position (SEP) and postoperative complications after major elective cardiovascular procedures. Design: Multicity hospital-based study. Subjects: Using Hospital Discharge Registries (ICD-9-CM codes), 19 310 patients were identified undergoing five cardiovascular operations (coronary artery bypass grafting (CABG), valve replacement, carotid endarterectomy, major vascular bypass, repair of unruptured abdominal aorta aneurysm (AAA repair)) in four Italian cities, 1997–2000. Measures: For each patient, a five-level median income index by census block of residence was calculated. In-hospital 30-day mortality, cardiovascular complications (CCs) and non-cardiovascular complications (NCCs) were the outcomes. Odds ratios (ORs) were estimated with multilevel logistic regression adjusting for city of residence, gender, age and comorbidities taking into account hospital and individual dependencies. Main results: In-hospital 30-day mortality varied by type of surgery (CABG 3.7%, valve replacement 5.7%, carotid endarterectomy 0.9%, major vascular bypass 8.8%, AAA repair 4.0%). Disadvantaged people were more likely to die after CABG (lowest vs highest income OR 1.93, p trend 0.023). For other surgeries, the relationship between SEP and mortality was less clear. For cardiac surgery, SEP differences in mortality were higher for publicly funded patients in low-volume hospitals (lowest vs highest income OR 3.90, p trend 0.039) than for privately funded patients (OR 1.46, p trend 0.444); however, the difference in the SEP gradients was not statistically significant. Conclusions: Disadvantaged people seem particularly vulnerable to mortality after cardiovascular surgery. Efforts are needed to identify structural factors that may enlarge SEP disparities within hospitals.
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Affiliation(s)
- N Agabiti
- Department of Epidemiology, Local Health Authority Rome E, Via di S Costanza 53, 00198 Rome, Italy.
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Rosvall M, Gerward S, Engström G, Hedblad B. Income and short-term case fatality after myocardial infarction in the whole middle-aged population of Malmö, Sweden. Eur J Public Health 2008; 18:533-8. [PMID: 18621776 DOI: 10.1093/eurpub/ckn059] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are no previous studies investigating when and where those who die pre-hospitally after an AMI paid their last visit to medical care. METHODS AND RESULTS Incidence of AMI, pre-hospital and 28-day case fatality rates were monitored over 13 years of follow-up, in relation to sex-specific quartiles of annual income in all inhabitants aged 40-64 years in Malmö, Sweden. Both incidence and short-term case fatality were inversely related to income. In all, 60-70% of all deaths within 28 days after the AMI were pre-hospital deaths. As compared with the lowest income group, the highest income group had lower odds of pre-hospital death with an age- and time-to-event-adjusted odds ratio of 0.5 (95% CI 0.4-0.8) for men and 0.3 (95% CI 0.1-0.6) for women. On the other hand, while 72% of those in the lowest two income groups had paid a visit to the medical services during the three months before death, only 59% had done so in the two highest income groups (P < 0.05). CONCLUSIONS Poor socioeconomic circumstances increase the risk of pre-hospital death after an AMI. Of the pre-hospital deaths, the proportion who had visited the medical services during the 3 months preceding their AMI was higher among those from lower income groups. However, many of those suffering a pre-hospital death had visited clinics that normally do not treat coronary symptoms. If more patients were identified at an earlier stage this might increase the number of patients reaching hospital alive.
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Affiliation(s)
- Maria Rosvall
- Department of Clinical Sciences, Social Epidemiology, Lund University, Malmö University Hospital, Malmö, Sweden.
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Georgiades A, Janszky I, Blom M, László KD, Ahnve S. Financial strain predicts recurrent events among women with coronary artery disease. Int J Cardiol 2008; 135:175-83. [PMID: 18619689 DOI: 10.1016/j.ijcard.2008.03.093] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 12/14/2007] [Accepted: 03/29/2008] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although a number of epidemiological studies have found an association between socioeconomic status (SES) indices such as income and education and coronary morbidity and mortality, few have looked at health consequences arising from actually experiencing financial shortcomings. The objective of the present study was to examine whether financial strain predicts recurrent coronary artery disease (CAD) events among women with established CAD. METHODS Two hundred two women (mean age 62+/-9 years) hospitalized for an acute coronary event were followed over a period of 3.5 years. Demographic, socioeconomic, lifestyle-related, psychosocial and biological characteristics were obtained by means of questionnaires and clinical examination. Data on recurrent cardiac events were collected from the Swedish discharge and death registers. RESULTS Women experiencing financial strain over the past year had an increased risk for recurrent events, i.e. the combination of all-cause mortality, new acute myocardial infarction and unstable angina pectoris during the follow-up with an unadjusted hazard ratio (HR) of 3.2 (95% CI 1.6-6.6), and a HR of 2.76 (95% CI 1.02-7.50) after controlling for education, household income, age, cohabiting status, inclusion diagnosis and rehabilitation therapy. Adjustment for potential mediators, i.e. psychosocial factors, lipids, diabetes mellitus, smoking, body-mass index, blood pressure, physical activity, alcohol consumption, participation in other cardiac rehabilitation programs did not alter the results significantly. CONCLUSIONS Financial strain was a predictor for recurrent events among women with CAD, independently of commonly used SES indicators such as education and household income. Future studies will have to explore the mechanism behind this association.
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Affiliation(s)
- Anastasia Georgiades
- Preventive Medicine, Department of Public Health Sciences, Karolinska Institutet and Center of Public Health, Stockholm County Council, Stockholm, Sweden
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Janzon E, Engström G, Hedblad B, Berglund G, Janzon L. Smoking as a determinant of the geographical pattern of cardiac events among women in an urban population. Scand J Public Health 2007; 35:272-7. [PMID: 17530549 DOI: 10.1080/14034940601011735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Smoking is the major risk factor for cardiac events in younger women and is most common in groups with the least favourable socioeconomic circumstances. OBJECTIVE To assess to what extent geographical differences in the female incidence of myocardial infarction in the city of Malmö in Sweden can be accounted for by smoking and to what extent intra-urban variances of smoking are related to socioeconomic circumstances. METHOD Area specific prevalences of smokers is based on a sample of 17,319 women, aged 45-73 years. A comprehensive score was used to rank the 17 residential areas in terms of socioeconomic circumstances. Incidence of myocardial infarction and death is based on official statistics 1989-97. RESULTS The area-specific prevalence of female smokers, which ranged from 17.5 to 32.5%, was inversely related to the socioeconomic score in 45- to 54 and 55- to 64-year-olds, r = -0.65 (p<0.05) and -0.59 (p<0.05). No correlation was found for women above 65 years of age. The annual age-adjusted incidence of cardiac events in the residential areas, which ranged from 151 to 414 per 100,000 person years, was strongly related to the prevalence of smokers, r = 0.75 (p<0.001). CONCLUSION Between 50% and 60% of the intra-urban variance of the female incidence of myocardial infarction was accounted for by smoking in this urban population. The geographical pattern of smoking was strongly related to inferior socioeconomic circumstances.
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Affiliation(s)
- Ellis Janzon
- Department of Health and Society, Malmö University, Malmö, Sweden.
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Pilote L, Dasgupta K, Guru V, Humphries KH, McGrath J, Norris C, Rabi D, Tremblay J, Alamian A, Barnett T, Cox J, Ghali WA, Grace S, Hamet P, Ho T, Kirkland S, Lambert M, Libersan D, O'Loughlin J, Paradis G, Petrovich M, Tagalakis V. A comprehensive view of sex-specific issues related to cardiovascular disease. CMAJ 2007; 176:S1-44. [PMID: 17353516 PMCID: PMC1817670 DOI: 10.1503/cmaj.051455] [Citation(s) in RCA: 292] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.
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Affiliation(s)
- Louise Pilote
- Division of Internal Medicine, The McGill University Health Centre Research Institute, McGill University, Montréal, Que.
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