Temporal trends in socioeconomic disparity in clinical outcomes for patients with acute coronary syndrome

AIMS

Socioeconomic factors are well-established determinants of clinical outcomes among patients with acute coronary syndrome (ACS) although quality of care has improved the last decades. This study aims to investigate 20-years temporal trends of socioeconomic disparity in 1-year incidence of major adverse cardiac events (MACE) among ACS patients in Denmark.

METHODS

This population-based cohort study included all incident ACS patients in the Danish National Patient Registry during 1998-2017. Socioeconomic disparity was assessed by income and educational level. Patients were followed 1-year for MACE; defined as all-cause mortality, recurrent ACS, revascularization, stroke, or cardiac arrest. Adjusted MACE incidence rates (aIR) and hazard rate ratios (aHR) were computed with 95 % confidence intervals (CI) for five-year-periods. Changes in trends were examined from interaction analyses between the HR for five-year-periods and income and education, respectively.

RESULTS

The study included 220,887 patients with first-time ACS. The incidence of MACE decreased within all income and education levels. In 1998-2002 the MACE aIR among patients with low income was 885[95%CI:863-907] versus 733[711-756]/1000-person-year among those with high income (aHR: 1.19[95%CI:1.15-1.23]). The aIRs decreased to 506[489-522] and 405[388-423]/1000-person-year, respectively, in 2013-2017 (aHR: 1.23[1.17-1.29]). The aIRs of MACE decreased correspondingly within all educational levels from 1998 to 2002 to 2013-2017. However, the socioeconomic disparity according to the interaction analyses persisted both according to income and educational level.

CONCLUSION

Although 1-year clinical outcomes following ACS has improved substantially over the last decades, socioeconomic disparity persisted both according to income and education level.

Social, Geographical and Income Inequality as Demonstrated by the Coronary Calcium Score: An Ecological Study in Sydney, Australia

BACKGROUND

The coronary calcium score is a non-invasive biomarker of coronary artery disease. The concept of "arterial age" transforms the coronary calcium score to an expected age based on the degree of coronary atherosclerosis. This study aimed to investigate the relationship of socioeconomic status with the burden of coronary artery disease within Sydney, Australia.

METHODS

This was an ecological study at the postcode level of patients aged 45 and above who had completed a CT coronary calcium scan within New South Wales (NSW), Australia from January 2012 to December 2020. Arterial age difference was calculated as arterial age minus chronological age. Socioeconomic data was obtained for median income, Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) score and median property price. Linear regression was used for analysis.

RESULTS

There were 17,102 patients across 325 postcodes within NSW, comprising 9129 males with a median arterial age difference of 7 years and 7972 females with -9 years. Income, IRSAD score and property price each had an inverse relationship with arterial age difference (p-values < 0.05).

CONCLUSIONS

Income, socioeconomic status and local property prices are significantly correlated with premature coronary aging. Healthcare resource allocation and prevention should target the inequalities identified to reduce the burden of coronary artery disease.

Linalool attenuated ischemic injury in PC12 cells through inhibition of caspase-3 and caspase-9 during apoptosis

Numerous studies have indicated the pharmacological properties of linalool, a volatile terpene alcohol found in many flowers and spice plants, including anti-nociceptive, anti-inflammatory, and neuroprotective activities. The aim of this study was to explore the mechanisms of neuroprotection provided by (±) linalool and its enantiomer, (R)-(-) linalool against oxygen, and glucose deprivation/reoxygenation (OGD/R) in PC12 cells. PC12 cells were treated with (±) linalool and (R)-(-) linalool before exposure to OGD/R condition. Cell viability, reactive oxygen species (ROS) production, malondialdehyde (MDA) level, DNA damage, and the levels of proteins related to apoptosis were evaluated using MTT, comet assay, and western blot analysis, respectively. IC₅₀ values for the PC12 cells incubated with (±) linalool and (R)-(-) linalool were 2700 and 2600 μM after 14 h, as well as 5440 and 3040 μM after 18 h, respectively. Survival of the ischemic cells pre-incubated with (±) linalool and (R)-(-) linalool (100 μM of both) increased compared to the cells subjected to the OGD/R alone (p < .001). ROS and MDA formation were also decreased following incubation with (±) linalool and (R)-(-) linalool compared to the OGD/R group (p < .01). In the same way, pre-treatment with (±) linalool and (R)-(-) linalool significantly reduced OGD/R-induced DNA injury compared to that seen in OGD/R group (p < .001). (±) Linalool and (R)-(-) linalool also restored Bax/Bcl-2 ratio and cleaved caspase-3 and caspase-9 (p < .001, p < .01) following ischemic injury. The neuroprotective effect of linalool against ischemic insult might be mediated by alleviation of oxidative stress and apoptosis.

Socioeconomic Disparities in Health Care Consumption: Using the 2018-China Family Panel Studies

The existing research on residents’ health care consumption mostly covers medical care consumption and seldom regards residents’ health care consumption as an independent research object. This article takes residents’ healthcare consumption as the research object and aims to explore the impact of socioeconomic status on healthcare consumption and its mechanisms. The data of this study came from the 2018-China Family Panel Studies (CFPS). The binary probit regression model and the Tobit model explored the impact mechanism of residents’ income, education, occupation, and physical activity on health care consumption decision-making and health care expenditure, respectively. The research results showed that, from the perspective of the direct influence mechanism, residents’ work income (0.029, p < 0.01) and education level (811.149, p < 0.01) had a significant positive impact on health care consumption. Residents whose occupations (−99.697, p < 0.01) tend to be more skilled and also have higher health care consumption. From the perspective of the mediating mechanism, residents’ physical exercise duration had a significant positive impact on their participation in healthcare consumption (0.005, p < 0.01) but had a weaker impact on healthcare consumption expenditure (21.678, p < 0.1). In general, socioeconomic status represented by income, education, and occupation had a significant positive impact on residents’ health care consumption. The duration of physical exercise also played an important mediating role.

An egalitarian society? Widening inequalities in premature mortality from non-communicable diseases in Australia, 2006-16

BACKGROUND

The recent slowdown in life expectancy increase in Australia has occurred concurrently with widening socioeconomic and geographical inequalities in all-cause mortality risk. We analysed whether, and to what extent, mortality inequalities among specific non-communicable diseases (NCDs) in Australia at ages 35-74 years widened during 2006-16.

METHODS

Registered deaths that occurred during 2006-16 in Australia were analysed. Inequalities were measured by area socioeconomic quintile [ranging from Q1 (lowest) to Q5 (highest)] and remoteness (major cities, inner regional, outer regional/remote/very remote). Age-standardized death rates (ASDR) for 35-74 years were calculated and smoothed over time.

RESULTS

NCD mortality inequalities by area socioeconomic quintile widened; the ratio of Q1 to Q5 ASDR for males increased from 1.96 [95% confidence interval (CI) 1.91-2.01] in 2011 to 2.08 (2.03-2.13) in 2016, and for females from 1.78 (1.73-1.84) to 1.96 (1.90-2.02). Moreover, Q1 NCD ASDRs did not clearly decline from 2011 to 2016. CVD mortality inequalities were wider than for all NCDs. There were particularly large increases in smoking-related mortality inequalities. In 2016, mortality inequalities were especially high for chronic respiratory diseases, alcohol-related causes and diabetes. NCD mortality rates outside major cities were higher than within major cities, and these differences widened during 2006-16. Higher mortality rates in inner regional areas than in major cities were explained by socioeconomic factors.

CONCLUSIONS

Widening of inequalities in premature mortality rates is a major public health issue in Australia in the context of slowing mortality decline. Inequalities are partly explained by major risk factors for CVDs and NCDs: being overweight or obese, lack of exercise, poor diet and smoking. There is a need for urgent policy responses that consider socioeconomic disadvantage.

Socioeconomic status predicts the risk of stroke death: A systematic review and meta-analysis

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Low socioeconomic status influence on the risk of stroke mortality.

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Low income and ocuption for stroke mortality is higher than education.

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The heterogeneity of the study was mainly from different SES indicator.

Low socioeconomic status appears to be an independent risk factor for stroke mortality in epidemiology studies, but there has been no systematic assessment of this association. We performed a systematic review and meta-analysis evaluating the association between low socioeconomic status and stroke mortality. A systematic review of MEDLINE, EMBASE, and Web of Science for cohort studies that reported low socioeconomic status and stroke mortality was conducted from inception until July 2017. Research information, adjusted risk ratio (RR) estimates and 95% confidence intervals (Cls) were extracted. Estimates were pooled using a random-effects model. Heterogeneity was examined using the Q statistic and I². Twenty-seven prospective cohort studies (471,354,852 subjects; 429,886 deaths) assessing stroke mortality with low socioeconomic status were identified. Compared with the highest socioeconomic status, overall RR of stroke mortality was 1.39 (95% CI, 1.31–1.48) for those with the lowest after adjustment for confounding factors, but there was substantial heterogeneity between studies (I² = 89.9%, P = 0.001). Significant relationships were observed between risk of stroke mortality and the lowest education (RR = 1.21, 95% CI 1.11–1.33; I² = 70.9%, P < 0.001), income (RR = 1.54, 95% CI 1.30–1.82; I² = 91.6%, P < 0.001), occupation (RR = 1.54, 95% CI 1.35–1.75; I² = 78.3%, P < 0.001), composite socioeconomic status (RR = 1.37, 95% CI 1.25–1.51; I² = 69.5%, P = 0.001). After subgroup analysis, it was found that the heterogeneity of each SES indicator mainly came from the follow-up time, study population, stroke type, study area. Patients with low socioeconomic status had a higher risk of stroke mortality. The heterogeneity of income and occupation is larger, and the education and composite SES is smaller.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study

OBJECTIVE

To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions.

DESIGN

A population-based register study.

SETTING

Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013.

PARTICIPANTS

All deaths of Finnish inhabitants aged 25-74.

OUTCOME MEASURES

Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences.

RESULTS

Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women.

CONCLUSIONS

The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

Dexmedetomidine protects against oxygen-glucose deprivation/reoxygenation injury-induced apoptosis via the p38 MAPK/ERK signalling pathway

Objective

To investigate the protective effects of dexmedetomidine (DEX) in oxygen-glucose deprivation/reoxygenation (OGD/R) injury, which is involved in a number of ischaemic diseases.

Methods

An in vitro OGD/R injury model was generated using mouse Neuro 2A neuroblastoma (N2A) cells. Different concentrations of DEX were administrated to OGD/R cells. CV-65 was used to inhibit p38 microtubule associated protein kinase/extracellular signal-regulated kinases (MAPK/ERK) signalling. Cell proliferation, cell cycle, apoptosis, and the levels of proteins related to p38 MAPK/ERK signalling and apoptosis were evaluated using Cell Counting Kit-8, flow cytometry, TdT-UTP nick end labelling and Western blot analysis, respectively.

Results

DEX treatment of OGD/R cells promoted cell survival and attenuated OGD/R-induced cell apoptosis. It also activated the p38 MAPK/ERK signalling pathway, increased the levels of Bcl-2, and decreased the levels of Bax and cleaved caspase-3. Treatment with the p38 MAPK/ERK inhibitor CV-65 inhibited the activation of p38 MAPK/ERK and abrogated the DEX-induced effects on cell survival and apoptosis.

Conclusions

DEX protects N2A cells from OGD/R-induced apoptosis via the activation of the p38 MAPK/ERK signalling pathway. DEX might be an effective agent for the treatment of ischaemic diseases.

Standardised mortality rate for cerebrovascular diseases in the Slovak Republic from 1996 to 2013 in the context of income inequalities and its international comparison

Non-communicable diseases represent one of the greatest challenges for health policymakers. The main objective of this study is to analyse the development of standardised mortality rates for cerebrovascular disease, which is one of the most common causes of deaths, in relation to income inequality in individual regions of the Slovak Republic. Direct standardisation was applied using data from the Slovak mortality database, covering the time period from 1996 to 2013. The standardised mortality rate declined by 4.23% in the Slovak Republic. However, since 1996, the rate has been higher by almost 33% in men than in women. Standardised mortality rates were lower in the northern part of the Slovak Republic than in the southern part. The regression models demonstrated an impact of the observed income-related dimensions on these rates. The income quintile ratio and Gini coefficient appeared to be the most influencing variables. The results of the analysis highlight valuable baseline information for creating new support programmes aimed at eliminating health inequalities in relation to health and social policy.

Educational inequality in cardiovascular diseases: a sibling approach

AIMS

Educational inequality in diseases in the circulatory system (here termed cardiovascular disease) is well documented but may be confounded by early life factors. The aim of this observational study was to examine whether the associations between education and all cardiovascular diseases, ischaemic heart disease and stroke, respectively, were explained by family factors shared by siblings.

METHODS

The study population included all individuals born in Denmark between 1950 and 1979 who had at least one full sibling born in the same period. Using Cox regression, data were analysed in conventional cohort and within-sibship analyses in which the association was examined within siblings discordant on education. Assuming that attenuation of associations in the within-sibship as compared with the cohort analyses would indicate confounding from factors shared within families.

RESULTS

A lower educational status was associated with a higher risk of cardiovascular disease, ischaemic heart disease and stroke. All associations attenuated in the within-sibship analyses, in particular in the analyses on ischaemic heart disease before age 45 years. For instance, in the cohort analyses, the hazard rate of ischaemic heart disease among women less than 45 years who had a primary school education was 94% (hazard ratio 1.94 (1.78-2.12) higher than among those with a vocational education, while it attenuated to 51% (hazard ratio 1.51 (1.34-1.71)) in the within-sibship analysis.

CONCLUSIONS

Confounding from factors shared by siblings explained the associations between education and the cardiovascular disease outcomes but to varying degrees. This should be taken into account when planning interventions aimed at reducing educational inequalities in the development of cardiovascular disease, ischaemic heart disease and stroke.

Stroke incidence, prevalence and mortality in women worldwide

BACKGROUND

The study of sex differences on stroke incidence, prevalence and mortality is an emerging field of stroke epidemiology and care.

AIMS

This study sought to determine the information available on stroke epidemiology in women worldwide and possible sex differences in stroke epidemiology, and, if so, describe the nature of these differences and whether they are consistent across countries/groups of countries.

SUMMARY

We searched the available literature in English published between 1 January 2008 and 5 May 2015. Out of 17.789 papers only 56 peer-reviewed papers (29 community-based studies, 17 retrospective studies, 6 reviews, and 4 cross-sectional studies) have been included in the study. This review adopted the epidemiologic transition theory, which classifies countries into four stages according to their levels of industrialization and economy. For the first and second stages, reliable registries and health certification are lacking, and therefore our sought after data were very limited.In the third stage, specifically for Eastern Europe (post-socialist countries), the burden from stroke in women was on the rise, while in the fourth stage, despite an aging population, decreases in stroke incidence, prevalence and mortality have been observed, even in subjects older than 80 years for both sexes. However, regarding studies of US populations, these trends for women were less pronounced for African Americans, and Hispanics as well as Indians. This suggests a "gender-gap" regarding access to treatment and care.In conclusion, identifying the presence of differing global burden between the sexes will allow us to better understand how to prevent, treat, and manage both men and women.

Socioeconomic variation in incidence of primary and secondary major cardiovascular disease events: an Australian population-based prospective cohort study

BACKGROUND

Cardiovascular disease (CVD) disproportionately affects disadvantaged people, but reliable quantitative evidence on socioeconomic variation in CVD incidence in Australia is lacking. This study aimed to quantify socioeconomic variation in rates of primary and secondary CVD events in mid-age and older Australians.

METHODS

Baseline data (2006-2009) from the 45 and Up Study, an Australian cohort involving 267,153 men and women aged ≥ 45, were linked to hospital and death data (to December 2013). Outcomes comprised first event - death or hospital admission - for major CVD combined, as well as myocardial infarction and stroke, in those with and without prior CVD (secondary and primary events, respectively). Cox regression estimated hazard ratios (HRs) for each outcome in relation to education (and income and area-level disadvantage), separately by age group (45-64, 65-79, and ≥ 80 years), adjusting for age and sex, and additional sociodemographic factors.

RESULTS

There were 18,207 primary major CVD events over 1,144,845 years of follow-up (15.9/1000 person-years), and 20,048 secondary events over 260,357 years (77.0/1000 person-years). For both primary and secondary events, incidence increased with decreasing education, with the absolute difference between education groups largest for secondary events. Age-sex adjusted hazard ratios were highest in the 45-64 years group: for major CVDs, HR (no qualifications vs university degree) = 1.62 (95% CI: 1.49-1.77) for primary events, and HR = 1.49 (1.34-1.65) for secondary events; myocardial infarction HR = 2.31 (1.87-2.85) and HR = 2.57 (1.90-3.47) respectively; stroke HR = 1.48 (1.16-1.87) and HR = 1.97 (1.42-2.74) respectively. Similar but attenuated results were seen in older age groups, and with income. For area-level disadvantage, CVD gradients were weak and non-significant in older people (> 64 years).

CONCLUSIONS

Individual-level data are important for quantifying socioeconomic variation in CVD incidence, which is shown to be substantial among both those with and without prior CVD. Findings reinforce the opportunity for, and importance of, primary and secondary prevention and treatment in reducing socioeconomic variation in CVD and consequently the overall burden of CVD morbidity and mortality in Australia.

A comparison of age-standardised event rates for acute and chronic coronary heart disease in metropolitan and regional/remote Victoria: a retrospective cohort study

Background

Acute and chronic coronary heart disease (CHD) pose different burdens on health-care services and require different prevention and treatment strategies. Trends in acute and chronic CHD event rates can guide service implementation. This study evaluated changes in acute and chronic CHD event rates in metropolitan and regional/remote Victoria.

Methods

Victorian hospital admitted episodes with a principal diagnosis of acute CHD or chronic CHD were identified from 2005 to 2012. Acute and chronic CHD age-standardised event rates were calculated in metropolitan and regional/remote Victoria. Poisson log-link linear regression was used to estimate annual change in acute and chronic CHD event rates.

Results

Acute CHD age-standardised event rates decreased annually by 2.9 % (95 % CI, −4.3 to −1.4 %) in metropolitan Victoria and 1.7 % (95 % CI, −3.2 to −0.1 %) in regional/remote Victoria. In comparison, chronic CHD age-standardised event rates increased annually by 4.8 % (95 % CI, +3.0 to +6.5 %) in metropolitan Victoria and 3.1 % (95 % CI, +1.3 to +4.9 %) in regional/remote Victoria. On average, age-standardised event rates for regional/remote Victoria were 30.3 % (95 % CI, 23.5 to 37.2 %) higher for acute CHD and 55.3 % (95 % CI, 47.1 to 63.5 %) higher for chronic CHD compared to metropolitan Victoria from 2005 to 2012.

Conclusion

Annual decreases in acute CHD age-standardised event rates might reflect improvements in primary prevention, while annual increases in chronic CHD age-standardised event rates suggest a need to improve secondary prevention strategies. Consistently higher acute and chronic CHD age-standardised event rates were evident in regional/remote Victoria compared to metropolitan Victoria from 2005 to 2012.

Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996-2011

Background

It is not clear the relationship between stroke mortality trends and socioeconomic inequalities in low- and middle-income countries.

Aims

We compared differences of trends in stroke mortality by socioeconomic status in the city of Sao Paulo, Brazil.

Methods

We analyzed the intra-urban distribution of stroke death rates from 1996 to 2011 for persons aged 35-74 years old according to income using joinpoint regression.

Results

We confirmed 77 848 stroke deaths in the period, 51-4% of them among persons aged 35-74 years old. For all areas, there was parallelism between genders, and the average annual percent changes combined was -5.2 (-5.7 to -4.6) from 1996 to 2005 and -30 (-4.3 to -1.7) from 2005 to 2011. The full period average annual percent changes of age-adjusted rates between persons living in the high- and low-income area were, respectively, -5.4 and -4.2 ( P = 0.002) for men and -5.9 vs.-4.9 ( P = 0.017) for women. Differences in the risk of stroke between the high- and low-income areas increased more than twofold in the period in both genders.

Conclusions

The risk of stroke death is decreasing in all regions, but the faster decline in mortality rates in the wealthiest area contributes to further greater inequalities.

Population trends and inequalities in incidence and short-term outcome of acute myocardial infarction between 1998 and 2007

OBJECTIVE

We studied time trends in acute myocardial infarction (AMI) incidence, including out-of-hospital mortality proportions and hospitalized case-fatality rates. In addition, we compared AMI trends by age, gender and socioeconomic status.

METHODS

We linked the national Dutch hospital discharge register with the cause of death register to identify first AMI in patients ≥ 35 years between 1998 and 2007. Events were categorized in three groups: 178,322 hospitalized non-fatal, 43,210 hospitalized fatal within 28 days, and 75,520 out-of-hospital fatal AMI events. Time trends were analyzed using Joinpoint and Poisson regression.

RESULTS

Since 1998, age-standardized AMI incidence rates decreased from 620 to 380 per 100,000 in 2007 in men and from 323 to 210 per 100,000 in 2007 in women. Out-of-hospital mortality decreased from 24.3% of AMI in 1998 to 20.6% in 2007 in men and from 33.0% to 28.9% in women. Hospitalized case-fatality declined from 2003 onwards. The annual percentage change in incidence was larger in men than women (-4.9% vs. -4.2%, P<0.001). Furthermore, the decline in AMI incidence was smaller in young (35-54 years: -3.8%) and very old (≥ 85 years: -2.6%) men and women compared to middle-aged individuals (55-84 years: -5.3%, P<0.001). Smaller declines in AMI rates were observed in deprived socioeconomic quintiles Q5 and Q4 relative to the most affluent quintile Q1 (P=0.002 and P=0.015).

CONCLUSIONS

Substantial improvements were observed in incidence, out-of-hospital mortality and short-term case-fatality after AMI in the Netherlands. Young and female groups tend to fall behind, and socioeconomic inequalities in AMI incidence persisted and have not narrowed.