Education and risk for acute myocardial infarction in 52 high, middle and low-income countries: INTERHEART case-control study

Approaches to Comparing the Impact of Socioeconomic Disadvantage on Acute Myocardial Infarction Care Within and Across Countries: A Scoping Review

BACKGROUND

Understanding how cardiovascular disease treatment and outcomes differ for socioeconomically disadvantaged patients across countries may reveal insights into the impact of countries' policy initiatives on health equity. However, methods of undertaking these studies are poorly characterized.

METHODS

We performed a scoping review to identify studies describing between-country comparisons of socioeconomic inequalities in the care of acute myocardial infarction (AMI). We sought to determine the extent to which such comparisons have been conducted, the methodologies used, and outcomes assessed. We searched Medline from January 1, 2013 to September 30, 2023 for peer-reviewed English-language publications. Studies were included if they stratified patients by a measure of socioeconomic disadvantage (eg, race, ethnicity, income, education, occupation, immigrant status) and made comparisons between 2 or more countries.

RESULTS

Our search yielded 4861 articles focused on patients with AMI, of which 7 met our inclusion criteria. Common individual-level proxies for disadvantage were self-reported income or education. In contrast, we found no cross-country comparisons focused on other measures of disadvantage such as race and ethnicity. There was marked heterogeneity in methods and thresholds used to define socioeconomic disadvantage at the individual level. All included studies found that patients with higher income and higher educational attainment had improved AMI outcomes.

CONCLUSIONS

Between-country comparisons of socioeconomic disparities in AMI outcomes are scarce and heterogeneous, but all identified studies relied on metrics of disadvantage including income and education that could be uniformly measured across countries. We found no articles addressing other types of inequities, likely because of significant methodologic challenges.

Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

Association between socio-economic status and estimated atherosclerotic cardiovascular disease risk: results from a middle-aged population-based study

OBJECTIVES

The association between cardiovascular disease (CVD) risk and socio-economic status (SES) remains poorly studied. The purpose of this study was to investigate the relationship between SES and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among the general UK Biobank population.

STUDY DESIGN

This was a population-based study.

METHODS

Among 311,928 volunteers (47.7% men) of the UK Biobank population, SES was assessed by a questionnaire, and ASCVD risk was calculated using pooled cohort equation models. Associations between SES and ASCVD risk were estimated using multiple gender-specific regressions.

RESULTS

The findings from this study showed that men had higher estimated 10-year ASCVD risk than women (8.6% vs 2.7%; P < 0.001), higher education level (38.3% vs 36.2%; P < 0.001), higher income level (31.0% vs 25.1%; P < 0.001), higher levels of employment (65.4% vs 60.5%; P < 0.001) and higher scores of Townsend deprivation (P < 0.001). Using the multiple logistic regression model, a decreased 10-year ASCVD risk in men was associated with high income level (odds ratio [OR] = 0.64 [95% confidence interval {CI} 0.61-0.68]; P < 0.001), high educational level (OR = 0.71 [95% CI 0.68-0.74]; P < 0.001), higher Townsend deprivation quintile (OR = 0.81 [95% CI 0.78-0.85]; P < 0.001) and employed status (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001). The same results were observed in women, with high income level (OR = 0.68 [95% CI 0.55-0.68]; P < 0.001), high educational level (OR = 0.87 [95% CI 0.82-0.93]; P < 0.001), higher Townsend deprivation quintile (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001) and employed status (OR = 0.53 [95% CI 0.45-0.63]; P < 0.001) being associated with a lower 10-year ASCVD risk. When considering the false discovery rate logworth analysis, SES factors presented a similar contribution to CVD risk as lifestyle factors.

CONCLUSIONS

Health policies should consider the SES factors identified in this study, in addition to traditional risk factors, when designing prevention campaigns for CVD. Further research is required to improve the ASCVD risk prediction models among different SES variables.

Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome

Objective

To describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS).

Patients and Methods

Participants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI).

Results

Of the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (P interaction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (P interaction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (P interaction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; P comparison=.003).

Conclusion

In this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS.

Impact of Lifestyle and Socioeconomic Position on the Association Between Non-steroidal Anti-inflammatory Drug Use and Major Adverse Cardiovascular Events: A Case-Crossover Study

INTRODUCTION

It is unknown whether the cardiovascular risks associated with non-steroidal anti-inflammatory drug (NSAID) use differ according to lifestyle and socioeconomic position.

OBJECTIVE

We examined the association between NSAID use and major adverse cardiovascular events (MACE) within subgroups defined by lifestyle and socioeconomic position.

METHODS

We conducted a case-crossover study of all adult first-time respondents to the Danish National Health Surveys of 2010, 2013, or 2017, without previous cardiovascular disease, who experienced a MACE from survey completion through 2020. We used a Mantel-Haenszel method to obtain odds ratios (ORs) of the association between NSAID use (ibuprofen, naproxen, or diclofenac) and MACE (myocardial infarction, ischemic stroke, heart failure, or all-cause death). We identified NSAID use and MACE via nationwide Danish health registries. We stratified the analyses by body mass index, smoking status, alcohol consumption, physical activity level, marital status, education, income, and employment.

RESULTS

Compared with non-use, the OR of MACE was 1.34 (95% confidence interval: 1.23-1.46) for ibuprofen, 1.48 (1.04-2.43) for naproxen, and 2.18 (1.72-2.78) for diclofenac. When comparing NSAID use with non-use or the individual NSAIDs with each other, we observed no notable heterogeneity in the ORs within subgroups of lifestyle and socioeconomic position for any NSAID. Compared with ibuprofen, diclofenac was associated with increased risk of MACE in several subgroups with high cardiovascular risk, e.g., individuals with overweight (OR 1.52, 1.01-2.39) and smokers (OR 1.54, 0.96-2.46).

CONCLUSIONS

The relative increase in cardiovascular risk associated with NSAID use was not modified by lifestyle or socioeconomic position.

Impact of lifestyle and socioeconomic position on use of non-steroidal anti-inflammatory drugs: A population-based cohort study

PURPOSE

Lifestyle and socioeconomic position may confound the link between non-steroidal anti-inflammatory drugs (NSAIDs) and cardiovascular events, if associated with NSAID use. We examined this association.

METHODS

We conducted a cohort study of all adult first-time responders to the Danish National Health Surveys of 2010, 2013, or 2017 without an NSAID prescription within 3 months before survey completion (n = 407 395). Study exposures were weight, smoking status, alcohol consumption, binge drinking frequency, physical activity level, marital status, highest achieved level of education, income, and employment status. We used a Cox model to compute hazard ratios of time to first redemption of an NSAID prescription and a cumulative odds model to compute odds ratios (ORs) of redeeming one additional NSAID prescription in the year after survey completion.

RESULTS

Total follow-up time was 1 931 902 years. The odds of redeeming one additional NSAID prescription in the year after survey completion varied within all categories of lifestyle and socioeconomic position. The largest ORs were observed within categories of weight (1.70, 95% CI: 1.65-1.74 for obesity vs. normal weight), smoking status (1.24, 95% CI: 1.21-1.27 for current vs. never use), and education (1.44, 95% CI: 1.39-1.49 for primary or other vs. university or higher education). The Cox model showed consistent results.

CONCLUSIONS

Markers of unhealthy lifestyle and low socioeconomic position were associated with initiation and prolonged NSAID use. Consideration of lifestyle and socioeconomic markers as potential confounders in NSAID studies is therefore recommended.

The magnitude and importance of perceived health dimensions define effective tailor-made health-promoting interventions per targeted socioeconomic group

Recent insights and developments on health and society urge a critical look at the positive relationship between socioeconomic status (SES) and health. We challenge the notions that it is sufficient to distinguish only between two groups of SES (low and high) and that only overall health is taken into account. A new grouping of SES was developed based on both income and education, resulting in six SES groups. Health was defined in terms of a new positive health concept, operationalized into six health dimensions generating a measure of total general health (TGH). Next, six socioeconomic and demographic determinants of health were included. Linear regression, T-tests and one-way ANOVA were applied to investigate the relationships in a Dutch sample. A subjective way to measure health was applied: self-rated health (SRH). As a result, four out of six dimensions of health determined TGH: bodily functions, daily functioning, quality of life, and social and societal participation. Three out of six socioeconomic and demographic determinants impacted TGH: housing situation, age, and difficulties meeting financial obligations. While this is the general picture for the entire sample, there were interesting similarities and differences between the six SES groups. The similarities lie in the positive impact of the evaluation of bodily functions and daily functioning on TGH in all SES groups. The other dimensions affected TGH in some groups, and some dimensions only in one SES group. None of the socioeconomic and demographic determinants affected TGH in all SES groups. New insights on health inequalities are provided. It is concluded, first that the well-known positive relationship between SES and health is confirmed in this study. Second, further refining the health concept into six dimensions provides more detailed insights on which dimensions impact health the most. The subjective approach applied offers more refined information to better understand which health issues really matter to people. This yields new insights to develop tailor-made interventions aimed at increasing healthy behaviour in specific societal groups.

The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes

PURPOSE

Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR.

METHODS

This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate.

RESULTS

Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables.

CONCLUSIONS

Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

Socioeconomic Disparities in Hypertension by Levels of Green Space Availability: A Cross-Sectional Study in Philadelphia, PA

Green spaces have been proposed as equigenic factors, potentially mitigating health disparities. We used data from the 3887 participants residing in Philadelphia who participated in the Public Health Management Corporation’s Southeastern Pennsylvania Household Health Survey in 2014–2015 to assess whether socioeconomic disparities in hypertension are modified by availability of neighborhood-level green spaces. Socioeconomic status (SES) was measured using individual-level education and neighborhood-level median household income. Green space availability was measured using surrounding percent tree canopy cover, mean normalized difference vegetation index (NDVI), and proximity to nearest park. Using logistic regression models adjusted for age, sex, and race/ethnicity, we found that adults with higher educational attainment had significantly lower levels of hypertension (OR = 0.63, 0.57, and 0.36 for high school, some college, and college graduates, respectively, as compared to those with less than high school education), and this pattern was similar for median household income (higher prevalence in lower income areas). We found no significant interaction between education and percent tree canopy cover (p = 0.83), meaning that educational disparities in hypertension were similar across all levels of green space availability. These results held when using mean NDVI or distance to nearest park as availability measures, or when considering neighborhood-level median household income as the socioeconomic measure, although the specific patterns and significance of interactions varied by exposure and modifier. While socioeconomic disparities in hypertension are strong for adults residing in Philadelphia, green spaces did not seem to modify them.

Paediatric Hypertension in Africa: A Systematic Review and Meta-Analysis

BACKGROUND

The burden of cardiovascular disease (CVD) and hypertension is rapidly increasing in low- and middle-income countries. This is evident not only in adults, but also in children. Recent estimates of prevalence in children are lacking, particularly in Africa. As such, we conducted a systematic review and meta-analysis to provide updated estimates of paediatric hypertension in Africa.

METHODS

We searched PubMed and EBSCO to identify articles published from January 2017 to November 2020. Studies were assessed for quality. We combined results for meta-analyses using a random effects model (Freeman-Tukey arcsine transformation). Heterogeneity was quantified using the I² statistic.

FINDINGS

In the narrative synthesis of 53 studies, publication bias was low for 28, moderate for 24, and high for one study. Hypertension prevalence ranged substantially (0·2%-38·9%). Meta-analysis included 41 studies resulting in data on 52918 participants aged 3 to 19 years from ten countries. The pooled prevalence for hypertension (systolic/diastolic BP≥95th percentile) was 7·45% (95%CI 5·30-9·92, I²=98.96%), elevated blood pressure (BP, systolic/diastolic BP≥90th percentile and <95th percentile) 11·38% (95%CI 7·94-15·33, I²=98.97%) and combined hypertension/elevated BP 21·74% (95%CI 15·5-28·69, I²=99.48%). Participants categorized as overweight/with obesity had a higher prevalence of hypertension (18·5% [95%CI 10·2-28·5]) than those categorized as underweight/normal (1·0% [95%CI 0·1-2·6], 4·8% [95%CI 2·9-7·1], p<0·001). There were significant differences in hypertension prevalence when comparing BP measurement methods and classification guidelines.

INTERPRETATION

Compared to a previous systematic review conducted in 2017, this study suggests a continued increase in prevalence of paediatric hypertension in Africa, and highlights the potential role of increasing overweight/obesity.

FUNDING

This research was funded in part by the Wellcome Trust [Grant number:214082/Z/18/Z]. LJW and SAN are supported by the DSI-NRF Centre of Human Development at the University of the Witwatersrand.

Fatigue, Depression, Cardiovascular Risk, and Self-Rated Health: Comparing a Community Sample of Adults to Those With a History of Myocardial Infarction

This cross-sectional descriptive study was designed to compare fatigue, depression, cardiovascular risk, and self-rated health in community dwelling adults (CDA) without a history of myocardial infarction (MI) compared to adults who had experienced an MI 3 to 7 years ago. A convenience sample (n = 40) of CDA completed: demographic health form, Revised Piper Fatigue Scale, and CES-D. Age-matched controls (n = 40) were randomly selected from the Recurrence of Myocardial Infarction (ROMI) study. Most (N = 80) were White (66%) with a mean age of 58.3 (SD = 11.5; range 21-83). The ROMI group reported more diabetes, hypercholesterolemia, obesity, and hypertension, and had higher fatigue (t(61) = 4.51, p < .001). No differences were noted in depression scores (p = .952). Higher fatigue and depression scores were correlated with poorer self-rated health: r = .544 (p < .001) and r = .295 (p = .008).

Mental Health as a Mediator of the Association Between Educational Inequality and Cardiovascular Disease: A Mendelian Randomization Study

Background

Education is inversely associated with cardiovascular disease (CVD). Several mediators of this have been established; however, a proportion of the protective effect remains unaccounted for. Mental health is a proposed mediator, but current evidence is mixed and subject to bias from confounding factors and reverse causation. Mendelian randomization is an instrumental variable technique that uses genetic proxies for exposures and mediators to reduce such bias.

Methods and Results

We performed logistic regression and 2‐step Mendelian randomization analyses using UK Biobank data and genetic summary statistics to investigate whether educational attainment affects risk of mental health disorders. We then performed mediation analyses to explore whether mental health disorders mediate the association between educational attainment and cardiovascular risk. Higher levels of educational attainment were associated with reduced depression, anxiety, and CVD in observational analyses (odds ratio [OR], 0.79 [95% CI, 0.77–0.81], 0.76 [95% CI, 0.73–0.79], and 0.75 [95% CI, 0.74–0.76], respectively), and Mendelian randomization analyses provided evidence of causality (OR, 0.72 [95% CI, 0.67–0.77], 0.50 [95% CI, 0.42–0.59], and 0.62 [95% CI, 0.58–0.66], respectively). Both anxiety and depression were associated with CVD in observational analyses (OR, 1.63 [95% CI, 1.49–1.79] and 1.70 [95% CI, 1.59–1.82], respectively) but only depression showed evidence of causality in the Mendelian randomization analyses (OR, 1.09; 95% CI, 1.03–1.15). An estimated 2% of the total protective effect of education on CVD was mediated by depression.

Conclusions

Higher levels of educational attainment protect against mental health disorders, and reduced depression accounts for a small proportion of the total protective effect of education on CVD.

Cardiorespiratory Fitness in Occupational Groups-Trends over 20 Years and Future Forecasts

BACKGROUND

Reports have indicated a negative trend in cardiorespiratory fitness (CRF) in the general population. However, trends in relation to different occupational groups are missing. Therefore, the aim of our study was to examine the trends in CRF during the last 20 years, and to provide a prognosis of future trends in CRF, in different occupational groups of Swedish workers.

METHODS

Data from 516,122 health profile assessments performed between 2001 to 2020 were included. CRF was assessed as maximal oxygen consumption and was estimated from a submaximal cycling test. Analyses include CRF as a weighted average, standardized proportions with low CRF (<32 mL/min/kg), adjusted annual change in CRF, and forecasting of future trends in CRF.

RESULTS

There was a decrease in CRF over the study period, with the largest decrease in both absolute and relative CRF seen for individuals working in administrative and customer service (-10.1% and -9.4%) and mechanical manufacturing (-6.5% and -7.8%) occupations. The greatest annual decrease was seen in transport occupations (-1.62 mL/min/kg, 95% CI -0.190 to -0.134). Men and younger individuals had in generally a more pronounced decrease in CRF. The proportion with a low CRF increased, with the greatest increase noted for blue-collar and low-skilled occupations (range: +19% to +27% relative change). The forecast analyses predicted a continuing downward trend of CRF.

CONCLUSION

CRF has declined in most occupational groups in Sweden over the last two decades, with a more pronounced decline in blue-collar and low-skilled occupational groups.

Fresh vegetable and fruit consumption and carotid atherosclerosis in high-cardiovascular-risk population: a cross-sectional study in Jiangsu, China

This study aimed to investigate the association of vegetable and fruit consumption with carotid plaque (CP) and carotid intima-media thickness (CIMT), two predictors of carotid atherosclerosis, within urban and rural adults at high risk of developing cardiovascular diseases (CVDs) in regional China. A total of 11,392 adults at high CVD risk were identified from general population of 71,511 in this cross-sectional study, conducted between November of 2015 and May of 2016 in the Jiangsu Province. Among these 11,392 high risk participants, CP prevalence was 36.7%. The independent variables, vegetable and fruit intake frequency, were assessed by a food frequency questionnaire. The outcome variables, CIMT and CP, were measured by ultrasound examination. The ANCOVA analysis showed no association between CIMT values and vegetable and fruit intake frequencies. Multivariate logistic regression models were introduced to examine the association between vegetable and fruit intake and CP. After adjustment for potential confounders, the odds ratios (ORs) for participants who occasionally and daily consumed vegetable to experience any CP were 0.67 (95%CI: 0.58-0.78) and 0.70 (95%CI: 0.62-0.79), respectively, compared with those rarely consumed vegetable. While the adjusted ORs were 0.77 (95%CI: 0.64-0.92) and 0.80 (95%CI: 0.68-0.94), separately, for occasional and daily vegetable consumers to develop single CP relative to their counterparts who rarely consumed any vegetables. However, no significant association between fruit consumption and CP was observed. Among the Chinese population at high CVD risk, consumption of fresh vegetables was negatively associated with the risk of developing carotid plaque.

The Association of Structural Inequities and Race With Out-of-Hospital Sudden Death During the COVID-19 Pandemic

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Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in Prospective Urban and Rural Epidemiology study: prospective cohort study

OBJECTIVE

To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study.

DESIGN

Prospective cohort study.

SETTING

PURE study in 21 countries.

PARTICIPANTS

148 858 participants with median follow-up of 9.5 years.

EXPOSURES

Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.

MAIN OUTCOME MEASURE

Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre.

RESULTS

Analyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes.

CONCLUSION

High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.

Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil

BACKGROUND

It has been suggested that cardiovascular disease exhibits a 'social cross-over', from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.

METHODS

We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).

RESULTS

In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.

CONCLUSIONS

Our results do not support a 'social crossover' in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.

The Association of Neighborhood Medical Facilities with Aging in Place and Risk of Incident Myocardial Infarction

Objectives: Aging in place (residential stability) is a desirable means of aging where adults remain in their homes, even when facing challenges that impair their capacity for self-care. Residential stability, especially following acute health challenges, depends on individual and community factors, possibly including proximity to medical facilities. Methods: We explored the association between the density of medical facilities around homes with risk of incident myocardial infarction (MI) and with aging in place following incident MI. Results: Densities of neighborhood pharmacies were not associated with aging in place or time to MI. High densities of neighborhood clinical care facilities were significantly associated with decreased residential stability. Discussion: The lack of significant associations between medical facility exposures and MI-related outcomes, coupled with prior findings, casts doubt on their salience and may indicate that other neighborhood features are more strongly associated with these outcomes.

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.

Social Factors, Sex, and Mortality Risk After Coronary Artery Bypass Grafting: A Population-Based Cohort Study

Background Little is known of the impact of social factors on mortality after coronary artery bypass grafting ( CABG ). We explored sex- and age-specific associations between mortality risk after CABG and marital status, income, and education. Methods and Results This population-based register study included 110 742 CABG patients (21.3% women) from the SWEDEHEART registry (Swedish Web-system for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies) operated 1992 to 2015. Cox regression models were used to study the relation between social factors and all-cause mortality. Never having been married compared with being married/cohabiting was associated with a higher risk in women than in men (hazard ratio 1.32, 95% CI 1.20-1.44) versus 1.17 (1.13-1.22), P=0.030 between sex. The lowest income quintile, compared with the highest, was associated with higher risk in men than in women (hazard ratio 1.44 [1.38-1.51] versus 1.25 [1.14-1.38], P=0.0036). Lowest education level was associated with higher risk without sex difference (hazard ratio 1.15 [1.11-1.19] versus 1.25 [1.16-1.35], P=0.75). For unmarried women aged 60 years at surgery with low income and low education, mortality 10 years after surgery was 18%, compared with 11% in married women with high income and higher education level. The median life expectancy was 4.8 years shorter. Corresponding figures for 60-year-old men were 21% versus 12% mortality risk at 10 years and 5.0 years shorter life expectancy. Conclusions There are strong associations between social factors and mortality risk after CABG in both men and women. These results emphasize the importance of developing and implementing secondary prevention strategies for CABG patients with disadvantages in social factors.

Post-transplantation plasma malondialdehyde is associated with cardiovascular mortality in renal transplant recipients: a prospective cohort study

BACKGROUND

In renal transplant recipients (RTRs), cardiovascular mortality is the most common cause of long-term renal graft loss. Oxidative stress (OS) has been associated with cardiovascular disease and is known to be enhanced in RTRs. We aimed to prospectively investigate whether the concentration of the OS biomarker malondialdehyde (MDA) is associated with long-term risk of cardiovascular mortality in a large cohort of RTRs.

METHODS

The plasma MDA concentration was measured using the thiobarbituric acid reaction assay in 604 extensively phenotyped RTRs with a functioning allograft for ≥1 year. The association between MDA and cardiovascular mortality was assessed using Cox proportional hazard regression analyses in the overall cohort and within subgroups according to significant effect modifiers.

RESULTS

Median circulating MDA concentration at baseline was 5.38 [interquartile range (IQR) 4.31-6.45] μmol/L. During a follow-up period of 6.4 (IQR 5.6-6.8) years, 110 (18%) RTRs died, with 40% of deaths due to cardiovascular causes. MDA concentration was significantly associated with the risk for cardiovascular mortality {hazard ratio [HR] 1.31 [95% confidence interval (CI) 1.03-1.67] per 1-SD increment}, independent of adjustment for potential confounders, including renal function, immunosuppressive therapy, smoking status and blood pressure. The association between MDA concentration and the risk for cardiovascular mortality was stronger in RTRs with relatively lower plasma ascorbic acid concentrations [≤42.5 µmol/L; HR 1.79 (95% CI 1.30-2.48) per 1-SD increment] or relatively lower estimated glomerular filtration rates [≤45 mL/min/1.73 m2; HR 2.09 (95% CI 1.45-3.00) per 1-SD increment].

CONCLUSIONS

Circulating MDA concentration is independently associated with long-term risk for cardiovascular mortality, particularly in RTRs with relatively lower ascorbic acid concentrations or renal function. Further studies are warranted to elucidate whether OS-targeted interventions could decrease cardiovascular mortality in RTRs.

Active commuting in Swedish workers between 1998 and 2015-Trends, characteristics, and cardiovascular disease risk

Background

Trend analyses of active commuting and potential variations in trends and association with cardiovascular disease (CVD) risk within subgroups are unknown.

Objectives

To (a) describe trends in active commuting between 1998 and 2015 and (b) to study the association between different amounts of active commuting and the incidence risk of CVD in a large sample of Swedish workers, and analyses of potential variations across subgroups of socio‐demographics, physical activity, and BMI.

Methods

A total of 318 309 participants (47% women, 18‐74 years) who participated in a nationwide occupational health service screening between 1998 and 2015 were included. Commuting habits were self‐reported, and data on first‐time CVD events were derived from national registers.

Results

Self‐reported passive commuters decreased between 1998 and 2015 (64% to 56%), transferring to an increase in mainly moderate/high‐dose active commuters (12% to 19%). Changes were seen in all subgroups. The characteristics and lifestyle habits of the typical passive and active commuter changed little over the study period. Low‐ and moderate/high‐dose active commuters had significantly decreased risks for a first time CVD during follow‐up. This was accentuated in men, middle‐aged, and in participants with light physical work situations, irregular exercise habits, being overweight/obese, and with low fitness.

Conclusion

Increases in active commuting were observed between 1998 and 2015, however still leaving a majority who do not actively commute. As active commuting, regardless dose, is associated with a lower CVD risk, encouraging more people to actively commute may provide an easily accessible and time‐efficient possibility to increase physical activity and health in the general population.

Myocardial infarction and death findings from a 22-year follow-up of a cohort of 980 employed Swedish men

OBJECTIVES

In this article, we present death and myocardial infarction (MI) incidences over 22 years in relation to possible risk factors and their explanatory value.

STUDY DESIGN

In 1993, 980 middle-aged Swedish men in an automotive industry were surveyed at a health checkup as part of the Renault-Volvo Coeur project. The Swedish cohort was revisited in 2015.

METHODS

In 2015, incident MIs were identified using postal questionnaires, hospital records, and the Swedish national MI and death registers. The statistical results were given as odds ratios (ORs) and pseudo-R² (PR²), showing the proportion of variation in risk explained by logistic models.

RESULTS

One hundred and four deaths (4.6 per 1000 person-years) and 89 first MIs (4.2 per 1000 person-years) were identified. The Framingham risk index showed the strongest association with MI (OR = 23; 95% confidence interval [CI] = 5.42, 96.9), comparing the fifth quintile with the first. The all-cause death showed an OR of 3.2 (95% CI = 1.65, 6.08), with a suggested U-shape over quintiles. The percentages of PR² for MI and death were 8.8% and 6.6%, respectively. All risk factors together explained 22% of the variation in risk of MI. Comparing mortality in men living alone with those married yielded an OR of 3.78, which was found to be statistically significant. The corresponding OR for MI was not significant.

CONCLUSIONS

Traditional risk factors were confirmed but explained a modest proportion of the risk variation.

Association of smoking with coronary artery disease in Nepalese populations: a case control study

There are well-known traditional risk factors for coronary artery disease (CAD). Among them, smoking is one of the most prominent and modifiable risk factors. This study aims to determine the magnitude of smoking as a risk factor for CAD in the Nepalese population. A hospital-based age- and sex-matched case-control study was carried out with a total of 612 respondents. Bivariate analysis showed that the risk of developing CAD in ex-smokers and current smokers was higher (odds ratio (OR): 1.81 (confidence interval (CI): 1.21-2.7) and OR: 5.2 (CI: 3.4-7.97)), with p-values less than 0.004 and <0.00001, respectively, compared to the risk in never smokers. From stratified socio-demographic, cardio-metabolic, behavioural and psychosocial risk factor analysis, smoking was found to be associated with CAD in almost all subgroups. In the subsequent multivariate analysis, adjustment for socio-demographic, cardio-metabolic and psychosocial risk factors showed a steady increase in risk. However, further adjustment for behavioural risk factors (alcohol use and physical activity) showed that the risk was attenuated by 59% in current smokers. After adjusting for the covariates, current smokers and ex-smokers had an increased risk of CAD (OR: 6.64, 95% CI: 3.64-12.12, p < 0.00001; OR: 1.89, 95% CI: 1.08-3.31, p < 0.012, respectively) compared with non-smokers. In conclusion, smoking was found to increase the risk of CAD in the Nepalese population.

Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study

BACKGROUND

Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status-wealth and education-differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management.

METHODS

In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family.

FINDINGS

Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96-1·58) for high-income countries, 1·59 (1·42-1·78) in middle-income countries, and 2·23 (1·79-2·77) in low-income countries (p_interaction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14-1·98) for high-income countries, 1·80 (1·58-2·06) in middle-income countries, and 2·76 (2·29-3·31) in low-income countries (p_interaction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (p_interaction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries.

INTERPRETATION

Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education.

FUNDING

Full funding sources are listed at the end of the paper (see Acknowledgments).

Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a randomized controlled trial sub-study

BACKGROUND

The objective of this study was to analyze the impact of two forms of secondary preventive follow-up on the association between education level and levels of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) after stroke/transient ischemic attack (TIA).

METHODS

We included a population-based cohort of 771 stroke and TIA patients randomly assigned (1:1) to secondary preventive follow-up within primary health care (control) or nurse-led, telephone-based follow-up (intervention) between January 1, 2010, and December 31, 2013, as part of the NAILED (nurse-based age-independent intervention to limit evolution of disease) stroke risk factor trial. We compared BP and LDL-C levels 12 months after hospital discharge in relation to education level (low, ≤10 years; high, >10 years) separately for the intervention and control groups.

RESULTS

Among controls, systolic BP (SBP) decreased only among the highly educated (-2.5 mm Hg, 95% confidence interval (CI) -0.2 to -4.8), whereas LDL-C increased in the low-education group (0.2 mmol/L, 95% CI 0.1 to 0.3). At 12 months, controls with low education not more than 70 years of age had higher SBP than controls of the same age with high education (5.8 mm Hg, 95% CI 1.0 to 10.6). In contrast, SBP in the intervention group decreased similarly regardless of education level, LDL-C decreased among those with low education (-0.3 mmol/L, 95% CI -0.2 to -0.4) and, in the subgroup not more than 70 years old, low-educated participants had lower LDL-C at 12 months than those with high education (0.3 mmol/L, 95% CI 0.1 to 0.5).

CONCLUSIONS

Nurse-led, telephone-based secondary preventive follow-up led to comparable improvements in BP across education groups, while routine follow-up disfavored those with low education.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN23868518 , June 19, 2012 - Retrospectively registered.

Association between education and major adverse cardiac events among patients with acute coronary syndrome in the Arabian Gulf

Introduction

The objective of this study was to evaluate the association between education and major adverse cardiac events in patients with acute coronary syndrome (ACS) in the Arabian Gulf.

Methods

Data were analysed from 3874 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013. Education was defined as any type of formal training from primary school and above. MACE included stroke/transient ischaemic attack (TIA), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons.

Results

The overall mean age was 60±13 years and 67% (n=2579) were men. A total of 53% (n=2039) of the patients had some form of school education. Adjusting for demographic and clinical characteristics as well as socioeconomic measures (insurance type and employment), at 12-month follow-up, educated patients were significantly less likely to have had MACE (adjusted OR (aOR): 0.55; 95% CI 0.44 to 0.68; p<0.001) than those with no formal education. The lower rate of events was also consistent across all MACE components: stroke/TIA (aOR: 0.56; 95% CI 0.33 to 0.94; p=0.030), MI (aOR: 0.58; 95% CI 0.38 to 0.86; p=0.008), all-cause mortality (aOR: 0.58; 95% CI 0.39 to 0.87; p=0.009) and readmissions for cardiac reasons (aOR: 0.61; 95% CI 0.48 to 0.77; p<0.001). MACE outcomes were consistent across men and women and across countries.

Conclusions

Education was associated with lower MACE events in patients with ACS in the Arabian Gulf. Interventions promoting healthy lifestyles and management of clinical risk factors for patients with low health literacy are urgently required.

Decline in cardiorespiratory fitness in the Swedish working force between 1995 and 2017

Background

Long‐term trend analyses of cardiorespiratory fitness (VO₂max) in the general population are limited.

Objectives

To describe trends in VO₂max from 1995 to 2017 in the Swedish working force and to study developments across categories of sex, age, education, and geographic regions.

Methods

A total of 354 277 participants (44% women, 18‐74 years) who participated in a nationwide occupational health service screening between 1995 and 2017 were included. Changes in standardized mean values of absolute (L/min) and relative (mL/min/kg) VO₂max, and the proportion with low (<32) relative VO₂max are reported. VO₂max was estimated using a submaximal cycle test.

Results

Absolute VO₂max decreased by −6.7% (−0.19 L/min) in the total population. Relative VO₂max decreased by −10.8% (−4.2 mL/min/kg) with approximately one‐third explained by a simultaneous increase in body mass. Decreases in absolute fitness were more pronounced in men vs women (8.7% vs 5.3%), in younger vs older (6.5% vs 2.3%), in short (11.4%) vs long (4.5%) education, and in rural vs urban regions (6.5% vs 3.5%), all P < 0.001. The proportions with low VO₂max increased from 27% to 46% (P < 0.001).

Conclusion

Between 1995 and 2017, there was a steady and pronounced decline in mean cardiorespiratory fitness in Swedish adults. Male gender, young age, short education, and living in a rural area were predictive of greater reductions. The proportion with low cardiorespiratory fitness almost doubled. Given the strong associations between cardiorespiratory fitness and multiple morbidities and mortality, preventing further decreases is a clear public health priority, especially for vulnerable groups.

The contribution of health behaviors to socioeconomic inequalities in health: A systematic review

Unhealthy behaviors and their social patterning have been frequently proposed as factors mediating socioeconomic differences in health. However, a clear quantification of the contribution of health behaviors to the socioeconomic gradient in health is lacking. This study systematically reviews the role of health behaviors in explaining socioeconomic inequalities in health. Published studies were identified by a systematic review of PubMed, Embase and Web-of-Science. Four health behaviors were considered: smoking, alcohol consumption, physical activity and diet. We restricted health outcomes to cardiometabolic disorders and mortality. To allow comparison between studies, the contribution of health behaviors, or the part of the socioeconomic gradient in health that is explained by health behaviors, was recalculated in all studies according to the absolute scale difference method. We identified 114 articles on socioeconomic position, health behaviors and cardiometabolic disorders or mortality from electronic databases and articles reference lists. Lower socioeconomic position was associated with an increased risk of all-cause mortality and cardiometabolic disorders, this gradient was explained by health behaviors to varying degrees (minimum contribution -43%; maximum contribution 261%). Health behaviors explained a larger proportion of the SEP-health gradient in studies conducted in North America and Northern Europe, in studies examining all-cause mortality and cardiovascular disease, among men, in younger individuals, and in longitudinal studies, when compared to other settings. Of the four behaviors examined, smoking contributed the most to social inequalities in health, with a median contribution of 19%. Health behaviors contribute to the socioeconomic gradient in cardiometabolic disease and mortality, but this contribution varies according to population and study characteristics. Nevertheless, our results should encourage the implementation of interventions targeting health behaviors, as they may reduce socioeconomic inequalities in health and increase population health.

Neighborhood Socioeconomic Disadvantage and Care After Myocardial Infarction in the National Cardiovascular Data Registry

Background:

Patients living in disadvantaged neighborhoods are at high risk for adverse outcomes after acute myocardial infarction (MI). Whether residential socioeconomic status (SES) is associated with quality of in-hospital care among patients presenting with MI is unclear.

Methods and Results:

Multivariable logistic regression was used to examine the relationship between SES, quality of care, and in-hospital cardiovascular outcomes among patients with MI from diverse SES neighborhoods from July 2008 to December 2013, at 586 participating hospitals in the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines quality improvement program. Patients were categorized according to which SES summary measure group they resided in through linkage with US census block data. Outcomes were in-hospital mortality and major adverse cardiovascular events. Quality of MI care was assessed with the defect-free care measure that delineates the proportion of eligible patients who received all acute and discharge guideline-recommended therapies. Among 390 692 patients, there was a substantially longer median arrival-to-angiography time in lower SES neighborhoods (lowest 8.0 hours, low 5.5 hours, medium 4.8 hours, high 4.5 hours, highest 3.4 hours; P <0.0001), and a higher proportion of ST-segment–elevation myocardial infarction patients treated with fibrinolysis (lowest 23.1%, low 20.2%, medium 18.0%, high 14.2%, highest 5.9%; P <0.0001). However, after adjustment for clinical risk factors, insurance status, and hospital characteristics, socioeconomic disadvantage was not associated with lower rates of guideline-recommended defect-free acute care. Patients presenting from more disadvantaged neighborhoods had a progressively higher independent risk of in-hospital mortality ( P global =0.03) and major bleeding ( P global <0.001), along with lower quality of discharge care.

Conclusions:

In this national registry of MI, patients living in the most disadvantaged neighborhoods received equitable in-hospital care compared with advantaged neighborhoods. However, they experienced substantial delays in receiving angiography. Furthermore, patients living in disadvantaged neighborhoods remain at higher risk of adverse in-hospital outcomes after MI, including mortality. These observations suggest there are further opportunities for improvement in acute and discharge MI care.

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Burden of hypertension in The Gambia: evidence from a national World Health Organization (WHO) STEP survey

BACKGROUND

Non-communicable diseases are increasing in sub-Saharan Africa and are estimated to account for 32% of adult deaths in The Gambia. Worldwide, prevalence of hypertension is highest in the African region (46%) and a very high proportion is undiagnosed. This study examined diagnosed and undiagnosed hypertension in The Gambian adult population.

METHODS

Data were collected in 2010 from a nationally representative random sample of 4111 adults aged 25-64 years, using the World Health Organization STEPwise cross-sectional survey methods. Analyses were restricted to non-pregnant participants with three valid blood pressure measurements (n = 3573). We conducted gender-stratified univariate and multivariate regression analyses to identify the strongest sociodemographic, behavioural and biological risk factors associated with hypertension.

RESULTS

Almost one-third of adults were hypertensive; a high proportion were undiagnosed, particularly among men (86% of men vs 71% of women with hypertension, P < 0.001). Rural and semi-urban residents and overweight/obese persons had increased odds of hypertension. Compared with urban residents, participants from one of the most rural regions had higher odds of hypertension among both men [adjusted odds ratio (AOR) 3.2; 95% CI: 1.6-6.4] and women (AOR 2.5; 95% CI: 1.3-4.6). Other factors strongly associated with hypertension in multivariate analyses were age, smoking, physical inactivity and ethnicity.

CONCLUSIONS

Rural and semi-urban residence were strongly associated with hypertension, contrary to what has been found in similar studies in sub-Saharan Africa. Intervention to reduce the burden of hypertension in The Gambia could be further targeted towards rural areas.

Socioeconomic Status and Cardiovascular Disease: an Update

PURPOSE OF REVIEW

The aim of this paper is to summarize the recent and relevant evidence linking socioeconomic status (SES) to cardiovascular disease (CVD) and cardiovascular risk factors (CVRFs).

RECENT FINDINGS

In high-income countries (HICs), the evidence continues to expand, with meta-analyses of large longitudinal cohort studies consistently confirming the inverse association between SES and several CVD and CVRFs. The evidence remains limited in low-income and middle-income countries (LMICs), where most of the evidence originates from cross-sectional studies of varying quality and external validity; the available evidence indicates that the association between SES and CVD and CVRFs depends on the socioeconomic development context and the stage in the demographic, epidemiological, and nutrition transition of the population. The recent evidence confirms that SES is strongly inversely associated with CVD and CVRFs in HICs. However, there remains a need for more research to better understand the way socioeconomic circumstances become embodied in early life and throughout the life course to affect cardiovascular risk in adult and later life. In LMICs, the evidence remains scarce; thus, there is an urgent need for large longitudinal studies to disaggregate CVD and CVRFs by socioeconomic indicators, particularly as these countries already suffer the greatest burden of CVD.

Two tales of cardiovascular risksmiddle-aged women living in Sweden and Scotland: a cross-sectional comparative study

OBJECTIVES

To compare cardiovascular risk factors as well as rates of cardiovascular diseases in middle-aged women from urban areas in Scotland and Sweden.

DESIGN

Comparative cross-sectional study.

SETTING

Data from the general population in urban areas of Scotland and the general population in two major Swedish cities in southeast Sweden, south of Stockholm.

PARTICIPANTS

Comparable data of middle-aged women (40-65 years) from the Scottish Health Survey (n=6250) and the Swedish QWIN study (n=741) were merged together into a new dataset (n=6991 participants).

MAIN OUTCOME MEASURE

We compared middle-aged women in urban areas in Sweden and Scotland regarding risk factors for cardiovascular disease (CVD), CVD diagnosis, anthropometrics, psychological distress and lifestyle.

RESULTS

In almost all measurements, there were significant differences between the countries, favouring the Swedish women. Scottish women demonstrated a higher frequency of alcohol consumption, smoking, obesity, low vegetable consumption, a sedentary lifestyle and also more psychological distress. For doctor-diagnosed coronary heart disease, there were also significant differences, with a higher prevalence among the Scottish women.

CONCLUSIONS

This is one of the first studies that clearly shows that Scottish middle-aged women are particularly affected by a worse profile of CVD risks. The profound differences in CVD risk and outcome frequency in the two populations are likely to have arisen from differences in the two groups of women's social, cultural, political and economic environments.

Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine

Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

Does education lower allostatic load? A co-twin control study

Many studies have found that education is associated with better health, but the causal basis of this association is unclear. The current study used a co-twin control design to examine if differences in years of education within twin pairs predict allostatic load. The strength of this design is that it controls for genetic and other familial confounds shared between twins. The sample consisted of 381 twins (with 292 twins from 146 complete pairs; mean age=57; 61% female) who participated in the biomarker project of the Midlife Development in the United States (MIDUS) study. Individual-level analyses showed a significant, negative association between years of education and allostatic load, but this association was explained entirely by familial influences shared between twins. The results of this study suggest that schooling does not itself protect against allostatic load.

Greater decreases in cholesterol levels among individuals with high cardiovascular risk than among the general population: the northern Sweden MONICA study 1994 to 2014

AIM

Decreasing cholesterol levels in Western populations is the main reason for decreasing mortality due to coronary heart disease. Our aim was to analyze trends in cholesterol levels in the population during a period of 20 years in relation to previous cardiovascular disease (CVD), other cardiovascular risk factors, and socioeconomic status.

METHODS AND RESULTS

A total of 4546 women and 4349 men aged 25-74 years participated in five population-based surveys in the Northern Sweden MONICA Study between 1994 and 2014 (participation rate 76.8-62.5%). Total cholesterol levels decreased from 6.2 mmol/L (95% confidence interval, CI, 6.1-6.2) in 1994 to 5.5 mmol/L (CI 5.4-5.5) in 2014. The decrease was more pronounced in elderly vs. younger participants (1.0 vs. 0.5 mmol/L). In 2014, participants with previous CVD, diabetes, or hypertension had lower cholesterol levels than the general population, whereas their levels were higher or similar to the general population in 1994. The use of lipid-lowering drugs increased markedly and was used by 14.3% in 2014. Previously described differences in cholesterol levels between participants with obesity and normal weight, and between those with and without university education, diminished, or vanished over time.

CONCLUSION

Cholesterol levels decreased by 0.7 mmol/L over 20 years with no sign of abating. The improvement occurred in all age and gender groups but more prominently among those at high risk of ischaemic heart disease.

Physical activity pattern, cardiorespiratory fitness, and socioeconomic status in the SCAPIS pilot trial - A cross-sectional study

Living in a low socioeconomic status (SES) area is associated with an increased risk of cardiovascular events and all-cause mortality. Previous studies have suggested a socioeconomic gradient in daily physical activity (PA), but have mainly relied on self-reported data, and individual rather than residential area SES. This study aimed to investigate the relationships between residential area SES, PA pattern, compliance with PA-recommendations and fitness in a Swedish middle-aged population, using objective measurements. We included 948 individuals from the SCAPIS pilot study (Gothenburg, Sweden, 2012, stratified for SES, 49% women, median age: 58 years), in three low and three high SES districts. Accelerometer data were summarized into intensity-specific categories: sedentary (SED), low (LIPA), and medium-to-vigorous PA (MVPA). Fitness was estimated by submaximal ergometer testing. Participants of low SES areas had a more adverse cardiovascular disease risk factor profile (smoking: 20% vs. 6%; diabetes: 9% vs. 3%; hypertension: 38% vs. 25%; obesity: 31% vs. 13%), and less frequently reached 150 min of MVPA per week (67% vs. 77%, odds ratio [OR] = 0.61; 95% confidence interval [95% CI] = 0.46–0.82), from 10-minute bouts (19% vs. 31%, OR = 0.53, 95% CI = 0.39–0.72). Individuals in low SES areas showed lower PA levels (mean cpm: 320 vs. 348) and daily average MVPA (29.9 vs. 35.5 min), and 12% lower fitness (25.1 vs. 28.5 mL × min^− 1 × kg^− 1) than did those in high SES areas. Reduced PA and fitness levels may contribute to social inequalities in health, and should be a target for improved public health in low SES areas.

•

We studied physical activity pattern and fitness between socioeconomic (SES) areas.

•

Low SES residents showed lower mean physical activity levels and 12% lower fitness.

•

Rates of adherence to physical activity guidelines were lower in low SES areas.

Fresh Fruit Consumption and Major Cardiovascular Disease in China

BACKGROUND

In Western populations, a higher level of fruit consumption has been associated with a lower risk of cardiovascular disease, but little is known about such associations in China, where the consumption level is low and rates of stroke are high.

METHODS

Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline. Cox regression yielded adjusted hazard ratios relating fresh fruit consumption to disease rates.

RESULTS

Overall, 18.0% of participants reported consuming fresh fruit daily. As compared with participants who never or rarely consumed fresh fruit (the "nonconsumption" category), those who ate fresh fruit daily had lower systolic blood pressure (by 4.0 mm Hg) and blood glucose levels (by 0.5 mmol per liter [9.0 mg per deciliter]) (P<0.001 for trend for both comparisons). The adjusted hazard ratios for daily consumption versus nonconsumption were 0.60 (95% confidence interval [CI], 0.54 to 0.67) for cardiovascular death, and 0.66 (95% CI, 0.58 to 0.75), 0.75 (95% CI, 0.72 to 0.79), and 0.64 (95% CI, 0.56 to 0.74), respectively, for incident major coronary events, ischemic stroke, and hemorrhagic stroke. There was a strong log-linear dose-response relationship between the incidence of each outcome and the amount of fresh fruit consumed. These associations were similar across the 10 study regions and in subgroups of participants defined by baseline characteristics.

CONCLUSIONS

Among Chinese adults, a higher level of fruit consumption was associated with lower blood pressure and blood glucose levels and, largely independent of these and other dietary and nondietary factors, with significantly lower risks of major cardiovascular diseases. (Funded by the Wellcome Trust and others.).

Educational class inequalities in the incidence of coronary heart disease in Europe

OBJECTIVE

To estimate the burden of social inequalities in coronary heart disease (CHD) and to identify their major determinants in 15 European populations.

METHODS

The MORGAM (MOnica Risk, Genetics, Archiving and Monograph) study comprised 49 cohorts of middle-aged European adults free of CHD (110 928 individuals) recruited mostly in the mid-1980s and 1990s, with comparable assessment of baseline risk and follow-up procedures. We derived three educational classes accounting for birth cohorts and used regression-based inequality measures of absolute differences in CHD rates and HRs (ie, Relative Index of Inequality, RII) for the least versus the most educated individuals.

RESULTS

N=6522 first CHD events occurred during a median follow-up of 12 years. Educational class inequalities accounted for 343 and 170 additional CHD events per 100 000 person-years in the least educated men and women compared with the most educated, respectively. These figures corresponded to 48% and 71% of the average event rates in each gender group. Inequalities in CHD mortality were mainly driven by incidence in the Nordic countries, Scotland and Lithuania, and by 28-day case-fatality in the remaining central/South European populations. The pooled RIIs were 1.6 (95% CI 1.4 to 1.8) in men and 2.0 (1.7 to 2.4) in women, consistently across population. Risk factors accounted for a third of inequalities in CHD incidence; smoking was the major mediator in men, and High-Density-Lipoprotein (HDL) cholesterol in women.

CONCLUSIONS

Social inequalities in CHD are still widespread in Europe. Since the major determinants of inequalities followed geographical and gender-specific patterns, European-level interventions should be tailored across different European regions.

Acute Stress Decreases but Chronic Stress Increases Myocardial Sensitivity to Ischemic Injury in Rodents

Cardiovascular disease (CVD) is the largest cause of mortality worldwide, and stress is a significant contributor to the development of CVD. The relationship between acute and chronic stress and CVD is well evidenced. Acute stress can lead to arrhythmias and ischemic injury. However, recent evidence in rodent models suggests that acute stress can decrease sensitivity to myocardial ischemia-reperfusion injury (IRI). Conversely, chronic stress is arrhythmogenic and increases sensitivity to myocardial IRI. Few studies have examined the impact of validated animal models of stress-related psychological disorders on the ischemic heart. This review examines the work that has been completed using rat models to study the effects of stress on myocardial sensitivity to ischemic injury. Utilization of animal models of stress-related psychological disorders is critical in the prevention and treatment of cardiovascular disorders in patients experiencing stress-related psychiatric conditions.

Disentangling the relative importance of different socioeconomic resources for myocardial infarction incidence and survival: a longitudinal study of over 300,000 Finnish adults

BACKGROUND

Lower socioeconomic position (SEP) is associated with an increased risk of myocardial infarction (MI) incidence and mortality, but the relative importance of different socioeconomic resources at different stages of the disease remains unclear.

METHODS

A nationally representative register-based sample of 40- to 60-year-old Finnish men and women in 1995 (n= 302 885) were followed up for MI incidence and mortality in 1996-2007. We compared the effects of education, occupation, income and wealth on first MI incidence, first-day and long-term fatality. Cox's proportional hazards regression and logistic regression models were estimated adjusting for SEP covariates simultaneously to assess independent effects.

RESULTS

Fully adjusted models showed greatest relative inequalities of MI incidence by wealth in both sexes, with an increased risk also associated with manual occupations. Education was a significant predictor of incidence in men. Low income was associated with a greater risk of death on the day of MI incidence [odds ratio (OR) = 1.40 in men and 1.95 in women when comparing lowest and highest income quintiles], and in men, with long-term fatality [hazard ratio (HR) = 1.74]. Wealth contributed to inequalities in first-day fatality in men and in long-term fatality in both sexes.

CONCLUSION

The results show that different socioeconomic resources have diverse effects on the disease process and add new evidence on the significant association of wealth with heart disease onset and fatality. Targeting those with the least resources could improve survival in MI patients and help reduce social inequalities in coronary heart disease mortality.

Socio-Economic Differences in Cardiovascular Health: Findings from a Cross-Sectional Study in a Middle-Income Country

BACKGROUND

A relatively consistent body of literature, mainly from high-income countries, supports an inverse association between socio-economic status (SES) and risk of cardiovascular disease (CVD). Data from low- and middle-income countries are scarce. This study explores SES differences in cardiovascular health (CVH) in the Republic of Srpska (RS), Bosnia and Herzegovina, a middle-income country.

METHODS

We collected information on SES (education, employment status and household's relative economic status, i.e. household wealth) and the 7 ideal CVH components (smoking status, body mass index, physical activity, diet, blood pressure, total cholesterol, and fasting blood glucose) among 3601 participants 25 years of age and older, from the 2010 National Health Survey in the RS. Based on the sum of all 7 CVH components an overall CVH score (CVHS) was calculated ranging from 0 (all CVH components at poor levels) to 14 (all CVH components at ideal levels). To assess the differences between groups the chi-square test, t-test and ANOVA were used where appropriate. The association between SES and CVHS was analysed with multivariate linear regression analyses. The dependent variable was CVHS, while independent variables were educational level, employment status and wealth index.

RESULTS

According to multiple linear regression analysis CVHS was independently associated with education attainment and employment status. Participants with higher educational attainment and those economically active had higher CVHS (b = 0.57; CI = 0.29-0.85 and b = 0.27; CI = 0.10-0.44 respectively) after adjustment for sex, age group, type of settlement, and marital status. We failed to find any statistically significant difference between the wealth index and CVHS.

CONCLUSION

This study presents the novel information, since CVHS generated from the individual CVH components was not compared by socio-economic status till now. Our finding that the higher overall CVHS was independently associated with a higher education attainment and those economically active supports the importance of reducing socio-economic inequalities in CVH in RS.

Mother's education and the risk of preterm and small for gestational age birth: a DRIVERS meta-analysis of 12 European cohorts

BACKGROUND

A healthy start to life is a major priority in efforts to reduce health inequalities across Europe, with important implications for the health of future generations. There is limited combined evidence on inequalities in health among newborns across a range of European countries.

METHODS

Prospective cohort data of 75 296 newborns from 12 European countries were used. Maternal education, preterm and small for gestational age births were determined at baseline along with covariate data. Regression models were estimated within each cohort and meta-analyses were conducted to compare and measure heterogeneity between cohorts.

RESULTS

Mother's education was linked to an appreciable risk of preterm and small for gestational age (SGA) births across 12 European countries. The excess risk of preterm births associated with low maternal education was 1.48 (1.29 to 1.69) and 1.84 (0.99 to 2.69) in relative and absolute terms (Relative/Slope Index of Inequality, RII/SII) for all cohorts combined. Similar effects were found for SGA births, but absolute inequalities were greater, with an SII score of 3.64 (1.74 to 5.54). Inequalities at birth were strong in the Netherlands, the UK, Sweden and Spain and marginal in other countries studied.

CONCLUSIONS

This study highlights the value of comparative cohort analysis to better understand the relationship between maternal education and markers of fetal growth in different settings across Europe.

Socioeconomic inequalities of cardiovascular risk factors among manufacturing employees in the Republic of Ireland: A cross-sectional study

Objectives: To explore socioeconomic differences in four cardiovascular disease risk factors (overweight/obesity, smoking, hypertension, height) among manufacturing employees in the Republic of Ireland (ROI). Methods: Cross-sectional analysis of 850 manufacturing employees aged 18–64 years. Education and job position served as socioeconomic indicators. Group-specific differences in prevalence were assessed with the Chi-squared test. Multivariate regression models were explored if education and job position were independent predictors of the CVD risk factors. Cochran–Armitage test for trend was used to assess the presence of a social gradient. Results: A social gradient was found across educational levels for smoking and height. Employees with the highest education were less likely to smoke compared to the least educated employees (OR 0.2, [95% CI 0.1–0.4]; p < 0.001). Lower educational attainment was associated with a reduction in mean height. Non-linear differences were found in both educational level and job position for obesity/overweight. Managers were more than twice as likely to be overweight or obese relative to those employees in the lowest job position (OR 2.4 [95% CI 1.3–4.6]; p = 0.008). Conclusion: Socioeconomic inequalities in height, smoking and overweight/obesity were highlighted within a sub-section of the working population in ROI.

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Exploring socioeconomic differences in four cardiovascular disease risk factors among manufacturing workers in Ireland.

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Cross-sectional study with 850 randomly selected employees aged 18–64 years.

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A social gradient was found across education levels for smoking and height.

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Employees with a higher education attainment were less likely to be hypertensive.

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Managers were more likely to be overweight or obese relative to the general working population.