Giovanni Veronesi1, Marco M Ferrario1, Kari Kuulasmaa2, Martin Bobak3, Lloyd E Chambless4, Veikko Salomaa2, Stefan Soderberg5, Andrzej Pajak6, Torben Jørgensen7, Philippe Amouyel8, Dominique Arveiler9, Wojciech Drygas10, Jean Ferrieres11, Simona Giampaoli12, Frank Kee13, Licia Iacoviello14, Sofia Malyutina15, Annette Peters16, Abdonas Tamosiunas17, Hugh Tunstall-Pedoe18, Giancarlo Cesana19. 1. Centro Ricerche EPIMED-Epidemiologia e Medicina Preventiva, Università degli Studi dell'Insubria, Varese, Italy. 2. THL-National Institute for Health and Welfare, Helsinki, Finland. 3. Research Department of Epidemiology and Public Health, University College London, London, UK. 4. Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. 5. Department of Public Health and Clinical Medicine, Cardiology and Heart Centre, Umeå University, Umeå, Sweden. 6. Department of Epidemiology and Population Studies, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland. 7. Research Centre for Prevention and Health, Capital Region of Denmark, Denmark Department of Public Health, Faculty of Medical Science, University of Copenhagen, Copenhagen, Denmark Faculty of Medicine, Aalborg University, Denmark. 8. Department of Epidemiology & Public Health, Pasteur Institute of Lille, Lille, France. 9. Department of Epidemiology and Public Health, University of Strasbourg, Strasbourg, France. 10. Department of Epidemiology, CVD Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland. 11. Department of Cardiology, Toulouse University School of Medicine, Toulouse, France. 12. Istituto Superiore di Sanità, Rome, Italy. 13. UKCRC Centre of Excellence for Public Health Research, Queen's University Belfast, Belfast, UK. 14. Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy. 15. The Institute of Internal and Preventive Medicine, Siberian Branch of Russian Academy of Medical Sciences, Novosibirsk, Russian Federation. 16. Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg, Germany. 17. Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania. 18. Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee, UK. 19. Centro Studi e Ricerche in Sanità Pubblica (CESP), Università degli Studi di Milano-Bicocca, Monza, Italy.
Abstract
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. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
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. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
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