title: Combined effect of educational status and cardiovascular risk factors on the incidence of coronary heart disease and stroke in European cohorts: Implications for prevention.
abstract: Background The combined effect of social status and risk factors on the absolute risk of cardiovascular disease has been insufficiently investigated, but results provide guidance on who could benefit most through prevention. Methods We followed 77,918 cardiovascular disease-free individuals aged 35-74 years at baseline, from 38 cohorts covering Nordic and Baltic countries, the UK and Central Europe, for a median of 12 years. Using Fine-Gray models in a competing-risks framework we estimated the effect of the interaction of education with smoking, blood pressure and body weight on the cumulative risk of incident acute coronary heart disease and stroke. Results Compared with more educated smokers, the less educated had an added increase in absolute risk of cardiovascular disease of 3.1% (95% confidence interval + 0.1%, +6.2%) in men and of 1.5% (-1.9%, +5.0%) in women, consistent across smoking categories. Conversely, the interaction was negative for overweight: -2.6% (95% CI: -5.6%, +0.3%) and obese: -3.6% (-7.6%, +0.4%) men, suggesting that the more educated would benefit more from the same reduction in body weight. A weaker interaction was observed for body weight in women, and for blood pressure in both genders. Less educated men and women with a cluster of two or more risk factors had an added cardiovascular disease risk of 3.6% (+0.1%, +7.0%) and of 2.6% (-0.5%, +5.6%), respectively, compared with their more educated counterparts. Conclusions Socially disadvantaged subjects have more to gain from lifestyle and blood pressure modification, hopefully reducing both their risk and also social inequality in disease.
authors.affiliation: 1 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: 2 Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, UK.
authors.forename: Hugh
authors.initials: H
authors.lastname: Tunstall-Pedoe
authors.affiliation: 1 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: 3 UKCRC Centre of Excellence for Public Health Research, Queens University Belfast, UK.
authors.forename: Frank
authors.initials: F
authors.lastname: Kee
authors.affiliation: 4 THL-National Institute for Health and Welfare, Helsinki, Finland.
authors.forename: Kari
authors.initials: K
authors.lastname: Kuulasmaa
authors.affiliation: 5 Department of Biostatistics, University of North Carolina at Chapel Hill, USA.
authors.forename: Lloyd E
authors.initials: LE
authors.lastname: Chambless
authors.affiliation: 6 Department of Epidemiology & Public Health, Pasteur Institute of Lille, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Amouyel
authors.affiliation: 7 Department of Epidemiology and Public Health, EA 3430, FMTS, University of Strasbourg, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Arveiler
authors.affiliation: 8 Research Department of Epidemiology and Public Health, University College London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Bobak
authors.affiliation: 9 Department of Cardiology, Toulouse University School of Medicine, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Ferrieres
authors.affiliation: 10 Istituto Superiore di Sanità, Rome, Italy.
authors.forename: Simona
authors.initials: S
authors.lastname: Giampaoli
authors.affiliation: 11 Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark.|12 Department of Public Health, Faculty of Medical Science, University of Copenhagen, Denmark.|13 Faculty of Medicine, Aalborg University, Denmark.
authors.forename: Torben
authors.initials: T
authors.lastname: Jørgensen
authors.affiliation: 14 Helmholtz Zentrum München - German Research Centre for Environmental Health, Neuherberg, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Peters
authors.affiliation: 4 THL-National Institute for Health and Welfare, Helsinki, Finland.
authors.forename: Veikko
authors.initials: V
authors.lastname: Salomaa
authors.affiliation: 15 Department of Public Health and Clinical Medicine, Cardiology and Heart Centre, Umeå University, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Soderberg
authors.affiliation: 16 Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania.
authors.forename: Abdonas
authors.initials: A
authors.lastname: Tamosiunas
authors.affiliation: 17 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; D000368:Aged; D001794:Blood Pressure; D001835:Body Weight; D002318:Cardiovascular Diseases / Q000209:etiology*; D015331:Cohort Studies; D003327:Coronary Disease / Q000453:epidemiology*; D004522:Educational Status; D005060:Europe; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012907:Smoking; D020521:Stroke / Q000453:epidemiology*
keywords: Europe; Social inequalities; additive interaction; cardiovascular disease risk; competing risks; differential vulnerability