Including Socioeconomic Status in Coronary Heart Disease Risk Estimation

University of Rochester, Rochester, New York, United States
The Annals of Family Medicine (Impact Factor: 5.43). 09/2010; 8(5):447-53. DOI: 10.1370/afm.1167
Source: PubMed

ABSTRACT Socioeconomic status (SES) predicts coronary heart disease independently of the Framingham risk-scoring factors included in cholesterol treatment guidelines, possibly resulting in undertreatment of lower SES persons. We examined whether hybrid SES measures (based on area measures of income and individual education) address this bias and derived an approach to incorporating SES information into treatment guidelines.
The Atherosclerosis Risk in Communities study data (initiated in 1987 with a 10-year follow-up of 15,495 adults aged 45 to 64 years in 4 southern and midwestern communities) were used to assess the calibration bias of 4 Cox models predicting 10-year coronary heart disease risk: Framingham risk score alone, and Framingham risk score plus SES using an individual-based measure (income less than 150% federal poverty level or less then 12 years of schooling), and 2 hybrid SES measures substituting area-based income measures (block group or zip code median incomes of less than 25th national percentiles) for the individual income component. Revised cholesterol treatment thresholds based on SES risk were also derived.
Use of either the block group hybrid or individual-based SES measures eliminated the significant SES bias observed using Framingham risk score alone. Cholesterol treatment guideline thresholds of 10% and 20% coronary heart disease risk (based on the Framingham risk score) were reduced to 6% and 13% for those with low SES.
Using patient income based on block group and individual education minimizes the SES bias in Framingham risk scoring and suggests more aggressive cholesterol treatment thresholds for low-SES persons.

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Available from: Daniel J Tancredi, Sep 26, 2015
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    • "Another methodological weakness of the study is that the calcium score as the measure of the arterial atherosclerotic burden is only a surrogate parameter, albeit an objectively measurable parameter, for cardiovascular morbidity and mortality. Socioeconomic aspects were not taken into consideration, although they have a known effect, on oral health (24,25) and atherosclerosis (26,27). The inverse correlation between restorative measures and atherosclerosis could ultimately be at least partially based on the fact that patients who particularly value dental care also placed particular value on the prevention of caries and periodontitis. "
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    ABSTRACT: Previous studies have suggested that marginal periodontitis is a risk factor for developing atherosclerosis. The objective of this study was to determine whether caries may also be associated with atherosclerosis. The computed tomography data sets of 292 consecutive patients, 137 women and 155 men with a mean age of 54.1±17.3 years, were analyzed. Caries were quantified based on the number of decayed surfaces of all the teeth, and periodontitis was quantified on the basis of the horizontal bone loss in the jaw. The presence of chronic apical periodontitis (CAP) was assessed, and the aortic atherosclerotic burden was quantified using a calcium scoring method. The patients with <1 caries surfaces/tooth had a lower atherosclerotic burden (0.13±0.61 mL) than patients with ≥1 caries surfaces/tooth. The atherosclerotic burden was greater in patients with a higher number of lesions with pulpal involvement and more teeth with chronic apical periodontitis. In the logistical regression models, age (Wald 49.3), number of caries per tooth (Wald 26.4), periodontitis (Wald 8.6), and male gender (Wald 11) were found to be independent risk factors for atherosclerosis. In the linear regression analyses, age and the number of decayed surfaces per tooth were identified as influencing factors associated with a higher atherosclerotic burden, and the number of restorations per tooth was associated with a lower atherosclerotic burden. Dental caries, pulpal caries, and chronic apical periodontitis are associated positively, while restorations are associated inversely, with aortic atherosclerotic burden. Prospective studies are required to confirm these observations and answer the question of possible causality.
    Clinics (São Paulo, Brazil) 07/2013; 68(7):946-53. DOI:10.6061/clinics/2013(07)10 · 1.19 Impact Factor
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    • "FRS ≥ 10%, including age, total cholesterol, smoking, high density lipoprotein (HDL)-cholesterol, and systolic blood pressure (SBP) were known to evaluate the risk of CVD incidence within 10 years. A prospective study showed that higher SES reduced the risks of FRS ≥ 10% and FRS ≥ 20% by 6% and 13%, respectively.14) In the Framingham cohort, lower SES was reported to increase the risk of CVD by 1.82 (adjusted 1.29) times.15) "
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    ABSTRACT: The purpose of this study was to examine the association of metabolic syndrome (MS) coronary heart disease (CHD) with socioeconomic status (SES). The participants were 2,170 (631 men and 1,539 women), aged over 40 years who had visited for health screening from April to December in 2009. We classified them into three SES levels according to their education and income levels. MS was defined using the criteria of modified National Cholesterol Education Program Adult Treatment Panel III and CHD risk was defined using Framingham risk score (FRS) ≥ 10%. High, middle, and low SES were 12.0%, 73.7%, and 14.3%, respectively. The prevalence of MS was 18.1%. For high, middle, and low SES, after adjusted covariates (age, drinking, smoking, and exercise), odds ratios for MS in men were 1.0, 1.41 (confidence interval [CI], 0.83 to 2.38; P > 0.05), and 1.50 (CI, 0.69 to 3.27; P > 0.05), respectively and in women were 1.0, 1.74 (CI, 1.05 to 3.18; P < 0.05), and 2.81 (CI, 1.46 to 2.43; P < 0.05), respectively. The prevalence of FRS ≥ 10% was 33.5% (adjusted covariates were drinking, smoking, and exercise) and odds ratios for FRS ≥ 10% in men were 1.0, 2.86 (CI, 1.35 to 6.08; P < 0.001), and 3.12 (CI, 1.94 to 5.00; P < 0.001), respectively and in women were 1.0, 3.24 (CI, 1.71 to 6.12; P < 0.001), and 8.80 (CI, 4.50 to 17.23; P < 0.001), respectively. There was an inverse relationship between SES and FRS ≥ 10% risk in men, and an inverse relationship between SES and both risk of MS and FRS ≥ 10% in women.
    Korean Journal of Family Medicine 03/2013; 34(2):131-8. DOI:10.4082/kjfm.2013.34.2.131
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    • "We previously reported that adding a measure of SES to CHD risk assessment based on Framingham risk scoring also improves model calibration (i.e. corrects under estimation of risk) for low SES persons [1,10]. This finding suggests that consideration of SES in the context of clinical decision making for cholesterol treatment may help address SES disparities in coronary heart disease [11]. "
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    ABSTRACT: Socioeconomic status (SES) predicts coronary heart disease independently of the traditional risk factors included in the Framingham risk score. However, it is unknown whether changes in Framingham risk score variables over time explain the association between SES and coronary heart disease. We examined this question given its relevance to risk assessment in clinical decision making. The Atherosclerosis Risk in Communities study data (initiated in 1987 with 10-years follow-up of 15,495 adults aged 45-64 years in four Southern and Mid-Western communities) were used. SES was assessed at baseline, dichotomized as low SES (defined as low education and/or low income) or not. The time dependent variables - smoking, total and high density lipoprotein cholesterol, systolic blood pressure and use of blood pressure lowering medication - were assessed every three years. Ten-year incidence of coronary heart disease was based on EKG and cardiac enzyme criteria, or adjudicated death certificate data. Cox survival analyses examined the contribution of SES to heart disease risk independent of baseline Framingham risk score, without and with further adjustment for the time dependent variables. Adjusting for baseline Framingham risk score, low SES was associated with an increased coronary heart disease risk (hazard ratio [HR] = 1.53; 95% Confidence Interval [CI], 1.27 to 1.85). After further adjustment for the time dependent variables, the SES effect remained significant (HR = 1.44; 95% CI, 1.19 to 1.74). Using Framingham Risk Score alone under estimated the coronary heart disease risk in low SES persons. This bias was not eliminated by subsequent changes in Framingham risk score variables.
    BMC Cardiovascular Disorders 06/2011; 11(1):28. DOI:10.1186/1471-2261-11-28 · 1.88 Impact Factor
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