Persistent Social Patterning of Cardiovascular Risk

Abstract

There is abundant evidence that cardiovascular disease is strongly patterned by socioeconomic position.1 Contrary to the stereotypical image of the wealthy but stressed executive who dies of a heart attack, people in the lowest socioeconomic strata, whether defined by income, education, or occupation, are consistently at greater risk of cardiovascular disease, at least in industrialized countries. Interestingly, the increased risk is not limited to the very poor but appears to decrease in quite a remarkable graded fashion, as socioeconomic resources increase.2,3 This graded relationship, which is observed for virtually all indicators of socioeconomic position, is striking given the crudeness with which social factors are usually measured in epidemiological and clinical studies, and the fact that these factors are necessarily very distal to the biological processes that lead to the development of atherosclerosis and the precipitation of clinical events. The strength and persistence of these patterns suggest a pervasive influence of social context on the body and on the cardiovascular system in particular. However, like many things that we are used to seeing over and over again, with time they become invisible and their significance is forgotten. See p 3063 In this issue of Circulation , Tonne et al4 report a graded, inverse association between neighborhood deprivation and long-term survival after an acute myocardial infarction (AMI). Although there have been numerous reports of the socioeconomic patterning of cardiovascular mortality, few have investigated whether these mortality differences result from differences in the incidence of disease or from differences in survival of individuals after a clinical event. A great strength of the article by Tonne et al is the large sample size of relatively well-characterized events with complete follow-up information. A limitation discussed by the authors is exclusion of sudden deaths and in-hospital deaths. The most likely scenario is that …