Educational class inequalities in the incidence of coronary heart disease in Europe

Giovanni Veronesi, Marco M Ferrario, Martin Bobak, Lloyd E Chambless, Veikko Salomaa, Stefan Soderberg, Andrzej Pajak, Torben Jørgensen, Philippe Amouyel, Dominique Arveiler, Wojciech Drygas, Jean Ferrieres, Simona Giampaoli, Frank Kee, Licia Iacoviello, Sofia Malyutina, Annette Peters, Abdonas Tamosiunas, Hugh Tunstall-Pedoe, Giancarlo Cesana

Research output: Contribution to journalArticlepeer-review

32 Citations (Scopus)


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.

Original languageEnglish
Pages (from-to)958-65
Number of pages8
JournalHeart (British Cardiac Society)
Issue number12
Early online date05 Feb 2016
Publication statusPublished - 15 Jun 2016


  • Journal Article

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