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Prognostic role of education levels after cardiac surgery and inhospital cardiac rehabilitation

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... In fact, health literacy was strongly associated with educational attainment that could represent the cultural background of health literacy; moreover, even educational attainment has been associated with higher cardiovascular risk, overall and cardiovascular mortality in both primary 9 and secondary cardiovascular prevention after cardiac rehabilitation. 10 Taken together, these findings raise a series of considerations. First, as societies grow more complex and people are increasingly bombarded with health information and misinformation, to become a health-literate person may represent a growing challenge that influences the cardiovascular outcome. ...
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Introduction Current cardiac telerehabilitation (CTR) interventions are insufficiently tailored to the preferences and competences of individual patients, which raises the question whether their implementation will increase overall participation and adherence to cardiac rehabilitation. However, research on patient-specific factors that influence participation and adoption of CTR interventions is scarce. Objective The aim of this study was to evaluate which patient-related characteristics influence participation in a novel CTR intervention in patients with coronary artery disease. Methods This prospective observational substudy of the SmartCare-CAD randomised controlled trial evaluated patient characteristics of study participants as proxy for participation in a CTR intervention. We compared demographic, geographic and health-related characteristics between trial participants and non-participants to determine which characteristics influenced trial participation. Results A total of 699 patients (300 participants and 399 non-participants; 84% male, mean age 64.3 ± 10.5 years) were included. Most of the non-participants refused participation because of insufficient technical skills or lack of interest in digital health (26%), or preferred centre-based cardiac rehabilitation (CR) (21%). Variables independently associated with non-participation included: higher age, lower educational level, shorter traveling distance, smoking, positive family history for cardiovascular disease, having undergone coronary artery bypass grafting; and a higher blood pressure, worse exercise capacity and higher risk of depression before the start of CR. Conclusion Participation in CTR is strongly influenced by demographic and health-related factors such as age, educational level, smoking status and both physical and mental functioning. CTR interventions should therefore be redesigned with the involvement of these currently underrepresented patient subgroups.
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With increasing socioeconomic disparity in cardiovascular risk factors, there is a need to assess the role of socioeconomic factors in chronic heart failure (CHF) and to what extent this is caused by modifiable risk factors. In a prospective cohort of 18 616 men and women without known myocardial infarction or CHF examined in 1976-78, 1981-83, 1991-94, and 2001-03 in the Copenhagen City Heart Study, we studied the effect of education on CHF incidence. During a median follow-up of 21 years (range 0-31), 2190 participants were admitted to hospital for CHF. Age-adjusted hazard ratio (HR) for intermediary (8-10 years) and high level of education (>10 years) with low (< 8 years) as reference was 0.69 (0.62-0.78) and 0.52 (0.43-0.63), respectively, with similar associations in men and women. After adjusting for updated cardiovascular risk factors, corresponding HRs were 0.75 (0.67-0.85) and 0.61 (0.50-0.73). In a random subset of the population examined with echocardiography in 2001-03 (n = 3589), education was associated with left ventricular (LV) hypertrophy, LV dilatation, reduced LV ejection fraction, and severe diastolic dysfunction (P for trend, all <0.05), whereas no association was found for mild diastolic dysfunction (P for trend, 0.61). With the exception of LV hypertrophy, significant associations persisted after adjustment for potential mediating factors. In this cohort study, the level of education was associated with cardiac dysfunction and predicted future hospital admission for CHF. Only a minor part of the excess risk was mediated through traditional cardiovascular risk factors. Strategies to reduce this inequality should be strengthened.
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The study objective was to describe the associations between socioeconomic status and (concurrence of) cardiovascular risk factors. The Netherlands Monitoring Project on Cardiovascular Risk Factors is a screening project that was carried out from 1987-1991 in three cities. Cross-sectional data were obtained on educational level and on the prevalence of smoking, alcohol intake, physical inactivity, obesity, hypertension, hypercholesterolaemia and low HDL-cholesterol. A total of 36 000 men and women, aged 20-59 years participated. For all risk factors, except alcohol intake, a significant inverse association was found with educational level. Concurrence of risk factors was more prevalent in lower educated groups than in higher educated groups, but not more than can be expected under the condition of independence of the risk factors (no clustering). In conclusion, in the lower educated groups the prevalence of individual risk factors and of concurrence of risk factors was higher than in the higher educated groups. Concurrence of risk factors can have a synergistic effect on the risk for cardiovascular disease. Therefore socioeconomic differences in risk factors may explain a greater part of the socioeconomic differences in cardiovascular morbidity and mortality than is generally assumed.
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Large social inequalities exist in risk of ischaemic heart disease (IHD) in Western populations; inequalities which are only little accounted for by established risk factors. We wished to find out if some newly identified cardiovascular risk factors in concert with established factors might contribute further to the explanation. A 6-year follow-up in the Copenhagen Male Study. Some 2974 males aged 53-75 years (mean 63) without overt cardiovascular disease were included in the study. Potential confounders included were: alcohol, physical activity, smoking, serum lipids, serum cotinine, serum selenium, lifetime occupational exposure to soldering fumes and organic solvents, body mass index, blood pressure, hypertension, use of sugar in hot beverages, use of diuretics, and Lewis phenotypes. During the 6-year follow-up period (1985/1986-1991), 184 men (6.2%) had a first IHD event. Compared to higher social classes (classes I, II and III), lower classes (classes IV and V) had a significantly (P < 0.05) increased risk of IHD; age-adjusted relative risk (RR) with 95% confidence limits was 1.44 (1.1-1.9), P = 0.02. After multivariate adjustment for age, blood pressure, serum lipids, physical activity, and smoking, the RR dropped to 1.38 (1.0-1.9), P = 0.05. Some newly identified risk factors were significantly associated with increased risk of IHD as well as with low social class: a low serum selenium concentration, a low level of leisure time physical activity in midlife, long-term exposure to soldering fumes, and abstention from or a low consumption of wine and strong spirits. After adjustment for these factors also, the RR dropped to 1.12 (P = 0.54). The results of this study suggest that potentially modifiable risk factors associated with lifestyle and working environment are strong mediators of social inequalities in risk of ischaemic heart disease.
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There is a well-established inverse relation between education and mortality from cardiovascular disease and cancer. The reasons for this are still in part unclear. We aimed to investigate whether differences in traditional vascular risk factors, adult height, physical activity, and biomarkers of fatty acid and antioxidant intake, could explain this association. In all, 2301 50-year-old men in Uppsala, Sweden (82% of the background population) were examined with regard to educational level, blood pressure, blood glucose, body mass index, serum lipids, smoking, body height, physical activity, serum beta carotene, alpha tocopherol, selenium, and serum fatty acids in cholesterol esters. Cause-specific mortality was registered 25 years later. Low education was associated with a higher rate of mortality from cardiovascular disease (crude relative risk [RR] = 1.67, 95% CI : 1.17-2.39), and from cancer (crude RR = 1.94, 95% CI : 1.21-3.10), compared to high educational attainment. Men with high education had an overall more beneficial risk factor profile concerning traditional cardiovascular risk factors, physical activity, and biomarkers of dietary intake of antioxidants and fat. After adjustment for all examined risk factors, the inverse gradient between education and cardiovascular mortality disappeared (RR in low education = 1.01. 95% CI : 0.67-1.52). Controlling for smoking, physical activity and dietary biomarkers explained less than half of the excess cancer mortality in the lower educational groups. Smoking (adjusted RR = 1.89, 95% CI : 1.37-2.61), and high proportions of palmitoleic acid in serum cholesterol esters (adjusted RR per 1 SD = 1.39, 95% CI : 1.07-1.82) predicted cancer mortality, independently of all other factors. There were no independent relations between serum antioxidants and mortality. These data indicate that modifiable lifestyle factors mediate the inverse gradient between education and death from cerebro- and cardiovascular disease. Smoking, physical activity and dietary factors explained half of the excess cancer mortality in lower educated groups. Further studies are needed to explore the proposed association between palmitoleic acid, a marker of high intake of animal and dairy fat, and cancer.
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Importance Estimates of lifetime risk may help raise awareness of the extent to which educational inequalities are associated with risk of cardiovascular disease (CVD). Objective To estimate lifetime risks of CVD according to categories of educational attainment. Design, Setting, and Participants Participants were followed from 1987 through December 31, 2013. All CVD events (coronary heart disease, heart failure, and stroke) were confirmed by physician review and International Classification of Diseases codes. A total of 13 948 whites and African Americans who were 45 to 64 years old and free of CVD at baseline were included from 4 US communities (Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and suburbs of Minneapolis, Minnesota). The data analysis was performed from June 7 to August 31, 2016. Exposures Educational attainment. Main Outcomes and Measures We used a life table approach to estimate lifetime risks of CVD from age 45 through 85 years according to educational attainment. We adjusted for competing risks of death from underlying causes other than CVD. Results The sample of 13 948 participants was 56% female and 27% African American. During 269 210 person-years of follow-up, we documented 4512 CVD events and 2401 non-CVD deaths. Educational attainment displayed an inverse dose-response relation with cumulative risk of CVD, which became evident in middle age, with the most striking gap between those not completing vs completing high school. In men, lifetime risks of CVD were 59.0% (95% CI, 54.0%-64.1%) for grade school, 52.5% (95% CI, 47.7%-56.8%) for high school education without graduation, 50.9% (95% CI, 47.3%-53.9%) for high school graduation, 47.2% (95% CI, 41.5%-52.5%) for vocational school, 46.4% (95% CI, 42.8%-49.6%) for college with or without graduation, and 42.2% (95% CI, 36.6%-47.0%) for graduate/professional school; in women, 50.8% (95% CI, 45.7%-55.8%), 49.3% (95% CI, 45.1%-53.1%), 36.3% (95% CI, 33.4%-39.1%), 32.2% (95% CI, 26.0%-37.3%), 32.8% (95% CI, 29.1%-35.9%), and 28.0% (95% CI, 21.9%-33.3%), respectively. Educational attainment was inversely associated with CVD even within categories of family income, income change, occupation, or parental educational level. Conclusions and Relevance More than 1 in 2 individuals with less than high school education had a lifetime CVD event. Educational attainment was inversely associated with the lifetime risk of CVD, regardless of other important socioeconomic characteristics. Our findings emphasize the need for further efforts to reduce CVD inequalities related to educational disparities.
Article
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.
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The purpose of this study was to ascertain way in which conventional risk factors, readiness to modify behaviour and to comply with recommended medication, and the effect of this medication were associated with education in patients with established coronary heart disease (CHD). The EUROASPIRE IV (EUROpean Action on Secondary Prevention by Intervention to Reduce Events) study was a cross-sectional survey undertaken in 24 European countries to ascertain how recommendations on secondary CHD prevention are being followed in clinical practice. Consecutive patients, men and women ≤80 years of age who had been hospitalized for an acute coronary syndrome or revascularization procedure, were identified retrospectively. Data were collected through an interview with examinations at least six months and no later than three years after hospitalization. A total of 7937 patients (1934 (24.37%) women) were evaluated. Patients with primary education were older, with a larger proportion of women. Control of risk factors, as defined by Joint European Societies 4 and 5 guidelines, was significantly better with higher education for current smoking (p = 0.001), overweight and obesity (p = 0.047 and p = 0.029, respectively), low physical activity (p < 0.001) and low high-density lipoprotein (HDL)-cholesterol (p = 0.011) in men, and for obesity (p = 0.005), high blood pressure (p < 0.005 and p < 0.001), low physical activity (p = 0.001), diabetes (p < 0.001) and low HDL-cholesterol (p = 0.023) in women. Patients with primary and secondary education were more often treated with diuretics and antidiabetic drugs. Better control of hypertension was achieved in patients with higher education. Particular risk communication and control are needed in secondary CHD prevention for patients with lower educational status. © The European Society of Cardiology 2015.
Article
An Institute of Medicine report titled U.S. Health in International Perspective: Shorter Lives, Poorer Health documents the decline in the health status of Americans relative to people in other high-income countries, concluding that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”1 The report blames many factors, “adverse economic and social conditions” among them. In an editorial in Science discussing the findings of the Institute of Medicine report, Bayer et al2 call for a national commission on health “to address the social causes that have put the USA last among comparable nations.” Although mortality from cardiovascular disease (CVD) in the United States has been on a linear decline since the 1970s, the burden remains high. It accounted for 31.9% of deaths in 2010.3 There is general agreement that the decline is the result, in equal measure, of advances in prevention and advances in treatment. These advances in turn rest on dramatic successes in efforts to understand the biology of CVD that began in the late 1940s.4,5 It has been assumed that the steady downward trend in mortality will continue into the future as further breakthroughs in biological science lead to further advances in prevention and treatment. This view of the future may not be warranted. The prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030.6 This change in the trajectory of cardiovascular burden is the result not only of an aging population but also of a dramatic rise over the past 25 years in obesity and the hypertension, diabetes mellitus, and physical inactivity that accompany weight gain. Although there is no consensus on the precise causes of the obesity epidemic, a dramatic change in the underlying biology of Americans is …
Article
Background There is a well-established inverse relation between education and mortality from cardiovascular disease and cancer. The reasons for this are still in part unclear. We aimed to investigate whether differences in traditional vascular risk factors, adult height, physical activity, and biomarkers of fatty acid and antioxidant intake, could explain this association. Methods In all, 2301 50-year-old men in Uppsala, Sweden (82% of the background population) were examined with regard to educational level, blood pressure, blood glucose, body mass index, serum lipids, smoking, body height, physical activity, serum beta carotene, alpha tocopherol, selenium, and serum fatty acids in cholesterol esters. Cause-specific mortality was registered 25 years later. Results Low education was associated with a higher rate of mortality from cardiovascular disease (crude relative risk [RR] = 1.67, 95% CI : 1.17–2.39), and from cancer (crude RR = 1.94, 95% CI : 1.21–3.10), compared to high educational attainment. Men with high education had an overall more beneficial risk factor profile concerning traditional cardiovascular risk factors, physical activity, and biomarkers of dietary intake of antioxidants and fat. After adjustment for all examined risk factors, the inverse gradient between education and cardiovascular mortality disappeared (RR in low education = 1.01. 95% CI : 0.67–1.52). Controlling for smoking, physical activity and dietary biomarkers explained less than half of the excess cancer mortality in the lower educational groups. Smoking (adjusted RR = 1.89, 95% CI : 1.37–2.61), and high proportions of palmitoleic acid in serum cholesterol esters (adjusted RR per 1 SD = 1.39, 95% CI : 1.07–1.82) predicted cancer mortality, independently of all other factors. There were no independent relations between serum antioxidants and mortality. Conclusions These data indicate that modifiable lifestyle factors mediate the inverse gradient between education and death from cerebro- and cardiovascular disease. Smoking, physical activity and dietary factors explained half of the excess cancer mortality in lower educated groups. Further studies are needed to explore the proposed association between palmitoleic acid, a marker of high intake of animal and dairy fat, and cancer.
Article
Despite recent declines in mortality, cardiovascular diseases are the leading cause of death in the United States today. It appears that many of the major risk factors for coronary disease have been identified. Researchers are still learning about different modifiable factors that may influence cardiovascular diseases. Socioeconomic status may provide a new focus. The principal measures of SES have been education, occupation, and income or combinations of these. Education has been the most frequent measure because it does not usually change (as occupation or income might) after young adulthood, information about education can be obtained easily, and it is unlikely that poor health in adulthood influences level of education. However, other measures of SES have merit, and the most informative strategy would incorporate multiple indicators of SES. A variety of psychosocial measures--for example, certain aspects of occupational status--may be important mediators of SES and disease. The hypothesis that high job strain may adversely affect health status has a rational basis and is supported by evidence from a limited number of studies. There is a considerable body of evidence for a relation between socioeconomic factors and all-cause mortality. These findings have been replicated repeatedly for 80 years across measures of socioeconomic level and in geographically diverse populations. During 40 years of study there has been a consistent inverse relation between cardiovascular disease, primarily coronary heart disease, and many of the indicators of SES. Evidence for this relation has been derived from prevalence, prospective, and retrospective cohort studies. Of particular importance to the hypothesis that SES is a risk factor for cardiovascular disease was the finding by several investigators that the patterns of association of SES with coronary disease had changed in men during the past 30 to 40 years and that SES has been associated with the decline of coronary mortality since the mid-1960s. However, the declines in coronary mortality of the last few decades have not affected all segments of society equally. There is some evidence that areas with the poorest socioenvironmental conditions experience later onset in the decline in cardiovascular mortality. A number of studies suggest that poor living conditions in childhood and adolescence contribute to increased risk of arteriosclerosis. Some of these studies have been criticized because of their nature, and others for inadequate control of confounding factors.(ABSTRACT TRUNCATED AT 400 WORDS)
Article
Reducing health disparities remains a major public health challenge in the United States. Having timely access to current data on disparities is important for policy and program development. Accordingly, we assessed the current magnitude of disparities in cardiovascular disease (CVD) and its risk factors in the United States. Using national surveys, we determined CVD and risk factor prevalence and indexes of morbidity, mortality, and overall quality of life in adults > or =18 years of age by race/ethnicity, sex, education level, socioeconomic status, and geographic location. Disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.2%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (47.3%). Hypertension prevalence was high among blacks (39.8%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women in both groups of educational status. Ischemic heart disease and stroke were inversely related to education, income, and poverty status. Hospitalization was greater in men for total heart disease and acute myocardial infarction but greater in women for congestive heart failure and stroke. Among Medicare enrollees, congestive heart failure hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for congestive heart failure and stroke were highest in the southeastern United States. Life expectancy remains higher in women than men and higher in whites than blacks by approximately 5 years. CVD mortality at all ages tended to be highest in blacks. Disparities in CVD and related risk factors remain pervasive. The data presented here can be invaluable for policy development and in the planning, implementation, and evaluation of interventions designed to eliminate health disparities.
Combined effect of educational status and cardiovascular risk factors on the incidence of coronary heart disease and stroke in European cohorts: implications for prevention
  • G Veronesi
  • H Tunstall-Pedoe
  • Ferrario
  • Mm