title: The Association between Educational Level and Cardiovascular and Cerebrovascular Diseases within the EPICOR Study: New Evidence for an Old Inequality Problem.
abstract: BACKGROUND
  A consistent association has been reported between low socioeconomic status (SES) and cardiovascular events (CE), whereas the association between SES and cerebrovascular events (CBVD) is less clear. The aim of this study was to investigate the association between SES (measured using education) and CE/CBVD in a cohort study, as well as to investigate lifestyle and clinical risk factors, to help to clarify the mechanisms by which SES influences CE/CBVD.
  
  
  METHODS
  We searched for diagnoses of CE and CBVD in the clinical records of 47,749 members of the EPICOR cohort (average follow-up time: 11 years). SES was determined by the relative index of inequality (RII).
  
  
  RESULTS
  A total of 1,156 CE and 468 CBVD were found in the clinical records. An increased risk of CE was observed in the crude Cox model for the third tertile of RII compared to the first tertile (hazard ratio [HR] = 1.39; 95% confidence interval [CI] 1.21-1.61). The increased risk persisted after adjustment for lifestyle risk factors (HR = 1.19; 95%CI 1.02-1.38), clinical risk factors (HR = 1.35; 95%CI 1.17-1.56), and after full adjustment (HR = 1.17; 95%CI 1.01-1.37). Structural equation model showed that lifestyle rather than clinical risk factors are involved in the mechanisms by which education influences CE. No significant association was found between education and CBVD. A strong relationship was observed between education and diabetes at baseline.
  
  
  CONCLUSIONS
  The most important burden of inequality in CE incidence in Italy is due to lifestyle risk factors.
authors.affiliation: Unit of Epidemiology, Regional Health Service, Grugliasco, Turin, Italy.|Unit of Cancer Epidemiology, University of Turin and Città della Salute e della Scienza Hospital, Turin, Italy.
authors.forename: Fulvio
authors.initials: F
authors.lastname: Ricceri
authors.affiliation: Unit of Cancer Epidemiology, University of Turin and Città della Salute e della Scienza Hospital, Turin, Italy.
authors.forename: Carlotta
authors.initials: C
authors.lastname: Sacerdote
authors.affiliation: Department of Mathematics, University of Turin, Turin, Italy.
authors.forename: Maria Teresa
authors.initials: MT
authors.lastname: Giraudo
authors.affiliation: Unit of Cancer Epidemiology, University of Turin and Città della Salute e della Scienza Hospital, Turin, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Fasanelli
authors.affiliation: Department of Mathematics, University of Turin, Turin, Italy.
authors.forename: Giulia
authors.initials: G
authors.lastname: Lenzo
authors.affiliation: Department of Mathematics, University of Turin, Turin, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Galli
authors.affiliation: Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
authors.forename: Sabina
authors.initials: S
authors.lastname: Sieri
authors.affiliation: Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Pala
authors.affiliation: Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute-ISPO, Florence, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Masala
authors.affiliation: Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute-ISPO, Florence, Italy.
authors.forename: Benedetta
authors.initials: B
authors.lastname: Bendinelli
authors.affiliation: Cancer Registry, Department of Prevention, ASP, Ragusa, Italy.
authors.forename: Rosario
authors.initials: R
authors.lastname: Tumino
authors.affiliation: Cancer Registry, Department of Prevention, ASP, Ragusa, Italy.
authors.forename: Graziella
authors.initials: G
authors.lastname: Frasca
authors.affiliation: Department of Physical and Mental Health and Prevention, Second University of Naples, Naples, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Chiodini
authors.affiliation: Department of Clinical and Experimental Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: Amalia
authors.initials: A
authors.lastname: Mattiello
authors.affiliation: Department of Clinical and Experimental Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Panico
mesh_terms: D002318:Cardiovascular Diseases / Q000453:epidemiology*; D002561:Cerebrovascular Disorders / Q000453:epidemiology*; D015331:Cohort Studies; D004522:Educational Status; D005260:Female; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008019:Life Style; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012959:Socioeconomic Factors