Lidia Redondo-Bravo1, Juan Miguel Fernández-Alvira2, Juan Górriz3, José María Mendiguren4, Javier Sanz5, Leticia Fernández-Friera6, José Manuel García-Ruiz7, Antonio Fernández-Ortiz8, Borja Ibáñez9, Héctor Bueno10, Valentín Fuster11. 1. Preventive Medicine and Public Health Department, Hospital Universitario La Paz, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain. 2. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain. 3. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Cardiology Department, Hospital de Getafe, Getafe, Spain. 4. Banco de Santander, Madrid, Spain. 5. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Icahn School of Medicine at Mount Sinai, New York, New York. 6. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Hospitales de Madrid, Madrid, Spain. 7. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; ISPA-Hospital Universitario Central de Asturias, Oviedo, Spain. 8. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; Cardiology Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain. 9. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; IIS-Fundacion Jiménez Díaz Hospital, Madrid, Spain. 10. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Imas12, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain. Electronic address: hector.bueno@cnic.es. 11. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address: vfuster@cnic.es.
Abstract
BACKGROUND: Socioeconomic status (SES)-education, income level, and occupation-is associated with cardiovascular risk. OBJECTIVES: This study aimed to investigate the association between SES and subclinical atherosclerosis and the potential mechanisms involved. METHODS: SES, lifestyle habits (smoking, dietary patterns, physical activity, and hours of sleep), traditional risk factors, and subclinical atherosclerosis extent were prospectively assessed in 4,025 individuals aged 40 to 54 years without known cardiovascular disease enrolled in the PESA (Progression of Early Subclinical Atherosclerosis) study. After factors associated with atherosclerosis were identified, a multiple mediation model was created to quantify the effect of SES on subclinical atherosclerosis as explained by lifestyle behaviors. RESULTS: Although education level was significantly associated with the presence of atherosclerosis, no differences were found according to income level in this population. Participants with lower education presented with a higher risk of generalized atherosclerosis than those with higher education (odds ratio: 1.46; 95% confidence interval: 1.15 to 1.85; p = 0.002). Lifestyle behaviors associated with both education level and atherosclerosis extent were: smoking status, number of cigarettes/day, and dietary pattern, which explained 70.5% of the effect of SES on atherosclerosis. Of these, tobacco habit (smoking status 35% and number of cigarettes/day 32%) accounted for most of the explained differences between groups, whereas dietary pattern did not remain a significant mediator in the multiple mediation model. CONCLUSIONS: Despite the relative economic homogeneity of the cohort, lower education level is associated with increased subclinical atherosclerosis, mainly mediated by the higher and more frequent tobacco consumption. Smoking cessation programs are still needed, particularly in populations with lower education level.
BACKGROUND: Socioeconomic status (SES)-education, income level, and occupation-is associated with cardiovascular risk. OBJECTIVES: This study aimed to investigate the association between SES and subclinical atherosclerosis and the potential mechanisms involved. METHODS: SES, lifestyle habits (smoking, dietary patterns, physical activity, and hours of sleep), traditional risk factors, and subclinical atherosclerosis extent were prospectively assessed in 4,025 individuals aged 40 to 54 years without known cardiovascular disease enrolled in the PESA (Progression of Early Subclinical Atherosclerosis) study. After factors associated with atherosclerosis were identified, a multiple mediation model was created to quantify the effect of SES on subclinical atherosclerosis as explained by lifestyle behaviors. RESULTS: Although education level was significantly associated with the presence of atherosclerosis, no differences were found according to income level in this population. Participants with lower education presented with a higher risk of generalized atherosclerosis than those with higher education (odds ratio: 1.46; 95% confidence interval: 1.15 to 1.85; p = 0.002). Lifestyle behaviors associated with both education level and atherosclerosis extent were: smoking status, number of cigarettes/day, and dietary pattern, which explained 70.5% of the effect of SES on atherosclerosis. Of these, tobacco habit (smoking status 35% and number of cigarettes/day 32%) accounted for most of the explained differences between groups, whereas dietary pattern did not remain a significant mediator in the multiple mediation model. CONCLUSIONS: Despite the relative economic homogeneity of the cohort, lower education level is associated with increased subclinical atherosclerosis, mainly mediated by the higher and more frequent tobacco consumption. Smoking cessation programs are still needed, particularly in populations with lower education level.