Social class differences in secular trends in established coronary risk factors over 20 years: a cohort study of British men from 1978-80 to 1998-2000

Risk Factors, Presentation, and Outcome in Acute Stroke according to Social Position Indicators in Patients Hospitalised in a Referral Centre in Bogotá 2011-2019

INTRODUCTION

Treatment of stroke is time-dependent and it challenges patients' social and demographic context for timely consultation and effective access to reperfusion therapies.

OBJECTIVE

The objective of this study was to relate indicators of social position to cardiovascular risk factors, time of arrival, access to reperfusion therapy, and mortality in the setting of acute stroke.

METHODS

A retrospective analysis of patients with a diagnosis of ischaemic stroke in a referral hospital in Bogotá was performed. A simple random sample with a 5% margin of error and 95% confidence interval was selected. Patients were characterised according to educational level, place of origin, marital status, occupation, duration of symptoms before consultation, cardiovascular risk factors, access to reperfusion therapy, and mortality during hospitalisation.

RESULTS

558 patients were included with a slight predominance of women. Diagnosis of diabetes was more common in women and smoking in men (n = 68, 28.4% vs. n = 51, 15.9%; p = 0.0004). Rural origin was associated with higher prevalence of hypertension, diabetes, and dyslipidaemia (hypertension n = 45, 73.8% vs. n = 282, 57.4%; p = 0.007; diabetes n = 20, 33.3% vs. 109, 19.5%; p = 0.02; dyslipidaemia n = 19, 32.7% vs. n = 93, 18.9%; p = 0.02). Mortality was higher in rural patients (n = 8, 14.2% vs. n = 30, 6.1%; p = 0.03). Lower schooling was associated with higher frequency of hypertension and dyslipidaemia (hypertension n = 152, 76.0% vs. n = 94, 46.3%; p ≤ 0.0001; dyslipidaemia n = 56, 28% vs. n = 35, 17.0%; p = 0.009) as well as with late consultation (n = 30, 15% vs. n = 59, 28.7%; p = 0.0011) and lower probability of accessing reperfusion therapy (n = 12, 6% vs. n = 45, 22%; p ≤ 0.0001). Formal employment was associated with a visit to the emergency department in less than 3 h (n = 50, 25.2% vs. n = 58, 18%, p = 0.04 and a higher probability of accessing reperfusion therapy (n = 35, 17.6% vs. n = 33, 10.2%; p = 0.01). Finally, living in a household with a stratum higher than 3 was associated with a consultation before 3 h (n = 77, 25.5% vs. n = 39, 15.6%; p = 0.004) and a higher probability of reperfusion therapy (n = 57, 18.9% vs. n = 13, 5.2%; p ≤ 0.0001).

CONCLUSION

Indicators of socio-economic status are related to mortality, consultation time, and access to reperfusion therapy. Mortality and reperfusion therapy are inequitably distributed and, therefore, more attention needs to be directed to the cause of these disparities in order to reduce the access gap in the context of acute stroke in Bogotá.

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.

Social capital, mortality, cardiovascular events and cancer: a systematic review of prospective studies

BACKGROUND

Social capital is considered to be an important determinant of life expectancy and cardiovascular health. Evidence on the association between social capital and all-cause mortality, cardiovascular disease (CVD) and cancer was systematically reviewed.

METHODS

Prospective studies examining the association of social capital with these outcomes were systematically sought in Medline, Embase and PsycInfo, all from inception to 8 October 2012. We categorized the findings from studies according to seven dimensions of social capital, including social participation, social network, civic participation,social support, trust, norm of reciprocity and sense of community, and pooled the estimates across studies to obtain summary relative risks of the health outcomes for each social capital dimension. We excluded studies focusing on children, refugees or immigrants and studies conducted in the former Soviet Union.

RESULTS

Fourteen prospective studies were identified. The pooled estimates showed no association between most social capital dimensions and all-cause mortality, CVD or cancer. Limited evidence was found for association of increased mortality with social participation and civic participation when comparing the most extreme risk comparisons.

CONCLUSIONS

Evidence to support an association between social capital and health outcomes is limited. Lack of consensus on measurements for social capital hinders the comparability of studies and weakens the evidence base.

Are there any differences in education levels and changes of cardiovascular risk factors among urban and rural population: Isfahan Healthy Heart Program

BACKGROUND

This study aimed to find the influence of education level on the trends of changes of these risk factors among a great sample of Iranian population.

MATERIALS AND METHODS

This cross-sectional study is a secondary analysis of Isfahan Healthy Heart Program (IHHP). Blood samples were taken to determine the lipid levels including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), low levels of high-density lipoprotein cholesterol (HDL-C), and triglycerides. Education categorized based on training system in Iran as 1-5, 6-12, and more than 12 years training.

RESULTS

The prevalence of diabetes was higher among illiterate participants in both areas. Hypertension was more prevalent in illiterate subjects (2001; 44.0% and 2007; 46.3%) in intervention area (P < 0.001). Dyslipidemia was more prevalent among illiterate people (P < 0.001). In the intervention, illiterates have higher BMI in both 2001 and 2007 (P < 0.001). The prevalence of current smoking was the highest in education level range 6 to 12 years and was steadily decreased in higher education levels (P < 0.001). Subjects with 6-12 years of education have more unhealthy nutritional habits in both areas. In 2001, subjects with 12 years of education or more had more physical activity than other groups (P < 0.001), whereas, in 2007, subjects with 6-12 years of education were more active (P < 0.001).

CONCLUSION

Although the prevalence of diabetes, hypertension obesity, and dyslipidemia are more in illiterate subjects and prevalence of diabetes and hyperlipidemia was sharply decreased with education level, it seems that well educated participants have higher daily physically activity compared with those who have lower education without considering the place or residency.

Time trends in socioeconomic inequalities in cancer mortality: results from a 35 year prospective study in British men

Background

Socioeconomic inequalities in cancer mortality in Britain have been shown to be present in the 1990s and early 2000s. Little is known about on-going patterns in such inequalities in cancer mortality. We examined time trends in socioeconomic inequalities in cancer mortality in Britain between 1978 and 2013.

Methods

A socially representative cohort of 7489 British men with data on longest-held occupational social class, followed up for 35 years, in whom 1484 cancer deaths occurred.

Results

The hazard ratio for cancer mortality for manual vs. non-manual social classes remained unchanged; among men aged 50–59 years it was 1.62 (95%CI 1.17–2.24) between 1980–1990 and 1.65 (95%CI 1.14–2.40) between 1990–2000. The absolute difference (non-manual minus manual) in probability of surviving death from cancer to 70 years remained at 3% over the follow-up. The consistency of risks over time was similar for both smoking-related and non-smoking related cancer mortality.

Conclusion

Socioeconomic inequalities in cancer mortality in Britain remain unchanged over the last 35 years and need to be urgently addressed.

Age and gender differences in the social patterning of cardiovascular risk factors in Switzerland: the CoLaus study

OBJECTIVES

We examined the social distribution of a comprehensive range of cardiovascular risk factors (CVRF) in a Swiss population and assessed whether socioeconomic differences varied by age and gender.

METHODS

Participants were 2960 men and 3343 women aged 35-75 years from a population-based survey conducted in Lausanne, Switzerland (CoLaus study). Educational level was the indicator of socioeconomic status used in this study. Analyses were stratified by gender and age group (35-54 years; 55-75 years).

RESULTS

There were large educational differences in the prevalence of CVRF such as current smoking (Δ = absolute difference in prevalence between highest and lowest educational group:15.1%/12.6% in men/women aged 35-54 years), physical inactivity (Δ = 25.3%/22.7% in men/women aged 35-54 years), overweight and obesity (Δ = 14.6%/14.8% in men/women aged 55-75 years for obesity), hypertension (Δ = 16.7%/11.4% in men/women aged 55-75 years), dyslipidemia (Δ = 2.8%/6.2% in men/women aged 35-54 years for high LDL-cholesterol) and diabetes (Δ = 6.0%/2.6% in men/women aged 55-75 years). Educational inequalities in the distribution of CVRF were larger in women than in men for alcohol consumption, obesity, hypertension and dyslipidemia (p<0.05). Relative educational inequalities in CVRF tended to be greater among the younger (35-54 years) than among the older age group (55-75 years), particularly for behavioral CVRF and abdominal obesity among men and for physiological CVRF among women (p<0.05).

CONCLUSION

Large absolute differences in the prevalence of CVRF according to education categories were observed in this Swiss population. The socioeconomic gradient in CVRF tended to be larger in women and in younger persons.

Socioeconomic status and stroke: an updated review

BACKGROUND AND PURPOSE

Rates of stroke incidence and mortality vary across populations with important differences between socioeconomic groups worldwide. Knowledge of existing disparities in stroke risk is important for effective stroke prevention and management strategies. This review updates the evidence for associations between socioeconomic status and stroke. Summary of Review- Studies were identified with electronic searches of MEDLINE and EMBASE databases (January 2006 to July 2011) and reference lists from identified studies were searched manually. Articles reporting the association between any measure of socioeconomic status and stroke were included.

CONCLUSIONS

The impact of stroke as measured by disability-adjusted life-years lost and mortality rates is >3-fold higher in low-income compared with high- and middle-income countries. The number of stroke deaths is projected to increase by >30% in the next 20 years with the majority occurring in low-income countries. Higher incidence of stroke, stroke risk factors, and rates of stroke mortality are generally observed in low compared with high socioeconomic groups within and between populations worldwide. There is less available evidence of an association between socioeconomic status and stroke recurrence or temporal trends in inequalities. Those with a lower socioeconomic status have more severe deficits and are less likely to receive evidence-based stroke services, although the results are inconsistent. Poorer people within a population and poorer countries globally are most affected in terms of incidence and poor outcomes of stroke. Innovative prevention strategies targeting people in low socioeconomic groups are required along with effective measures to promote access to effective stroke interventions worldwide.

Persistent socioeconomic inequalities in cardiovascular risk factors in England over 1994-2008: a time-trend analysis of repeated cross-sectional data

BACKGROUND

Our aims were to determine the pace of change in cardiovascular risk factors by age, gender and socioeconomic groups from 1994 to 2008, and quantify the magnitude, direction and change in absolute and relative inequalities.

METHODS

Time trend analysis was used to measure change in absolute and relative inequalities in risk factors by gender and age (16-54, ≥ 55 years), using repeated cross-sectional data from the Health Survey for England 1994-2008. Seven risk factors were examined: smoking, obesity, diabetes, high blood pressure, raised cholesterol, consumption of five or more daily portions of fruit and vegetables, and physical activity. Socioeconomic group was measured using the Index of Multiple Deprivation 2007.

RESULTS

Between 1994 and 2008, the prevalence of smoking, high blood pressure and raised cholesterol decreased in most deprivation quintiles. However, obesity and diabetes increased. Increasing absolute inequalities were found in obesity in older men and women (p = 0.044 and p = 0.027 respectively), diabetes in young men and older women (p = 0.036 and p = 0.019 respectively), and physical activity in older women (p = 0.025). Relative inequality increased in high blood pressure in young women (p = 0.005). The prevalence of raised cholesterol showed widening absolute and relative inverse gradients from 1998 onwards in older men (p = 0.004 and p ≤ 0.001 respectively) and women (p ≤ 0.001 and p ≤ 0.001).

CONCLUSIONS

Favourable trends in smoking, blood pressure and cholesterol are consistent with falling coronary heart disease death rates. However, adverse trends in obesity and diabetes are likely to counteract some of these gains. Furthermore, little progress over the last 15 years has been made towards reducing inequalities. Implementation of known effective population based approaches in combination with interventions targeted at individuals/subgroups with poorer cardiovascular risk profiles are therefore recommended to reduce social inequalities.

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

RATIONALE, AIMS AND OBJECTIVES

Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline.

METHODS

We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total).

RESULTS

Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern.

CONCLUSION

Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.