title: The contribution of educational class in improving accuracy of cardiovascular risk prediction across European regions: The MORGAM Project Cohort Component.
abstract: OBJECTIVE
  To assess whether educational class, an index of socioeconomic position, improves the accuracy of the SCORE cardiovascular disease (CVD) risk prediction equation.
  
  
  METHODS
  In a pooled analysis of 68 455 40-64-year-old men and women, free from coronary heart disease at baseline, from 47 prospective population-based cohorts from Nordic countries (Finland, Denmark, Sweden), the UK (Northern Ireland, Scotland), Central Europe (France, Germany, Italy) and Eastern Europe (Lithuania, Poland) and Russia, we assessed improvements in discrimination and in risk classification (net reclassification improvement (NRI)) when education was added to models including the SCORE risk equation.
  
  
  RESULTS
  The lowest educational class was associated with higher CVD mortality in men (pooled age-adjusted HR=1.64, 95% CI 1.42 to 1.90) and women (HR=1.31, 1.02 to 1.68). In men, the HRs ranged from 1.3 (Central Europe) to 2.1 (Eastern Europe and Russia). After adjustment for the SCORE risk, the association remained statistically significant overall, in the UK and Eastern Europe and Russia. Education significantly improved discrimination in all European regions and classification in Nordic countries (clinical NRI=5.3%) and in Eastern Europe and Russia (NRI=24.7%). In women, after SCORE risk adjustment, the association was not statistically significant, but the reduced number of deaths plays a major role, and the addition of education led to improvements in discrimination and classification in the Nordic countries only.
  
  
  CONCLUSIONS
  We recommend the inclusion of education in SCORE CVD risk equation in men, particularly in Nordic and East European countries, to improve social equity in primary prevention. Weaker evidence for women warrants the need for further investigations.
authors.affiliation: Dipartimento di Medicina Clinica e Sperimentale, Centro Ricerche EPIMED-Epidemiologia e Medicina Preventiva, Università degli Studi dell'Insubria, Varese, Italy.
authors.forename: Marco M
authors.initials: MM
authors.lastname: Ferrario
authors.affiliation: Dipartimento di Medicina Clinica e Sperimentale, Centro Ricerche EPIMED-Epidemiologia e Medicina Preventiva, Università degli Studi dell'Insubria, Varese, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Veronesi
authors.affiliation: Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Lloyd E
authors.initials: LE
authors.lastname: Chambless
authors.affiliation: Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee, UK.
authors.forename: Hugh
authors.initials: H
authors.lastname: Tunstall-Pedoe
authors.affiliation: Department of Chronic Disease Prevention, THL-National Institute for Health and Welfare, Helsinki, Finland.
authors.forename: Kari
authors.initials: K
authors.lastname: Kuulasmaa
authors.affiliation: Department of Chronic Disease Prevention, THL-National Institute for Health and Welfare, Helsinki, Finland.
authors.forename: Veikko
authors.initials: V
authors.lastname: Salomaa
authors.affiliation: Research Centre for Prevention and Health, Glostrup University Hospital, Glostrup, Denmark.
authors.forename: Anders
authors.initials: A
authors.lastname: Borglykke
authors.affiliation: Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
authors.forename: Nigel
authors.initials: N
authors.lastname: Hart
authors.affiliation: Department of Public Health and Clinical Medicine, Cardiology and Heart Centre, Umeå University, Umeå, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Söderberg
authors.affiliation: Centro Studi e Ricerche in Sanità Pubblica (CESP), Università degli Studi di Milano-Bicocca, Monza, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Cesana
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000517:prevention & control; D004522:Educational Status; D005060:Europe / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D010353:Patient Education as Topic / Q000592:standards*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment / Q000592:standards*; D012307:Risk Factors; D012959:Socioeconomic Factors; D015996:Survival Rate / Q000639:trends