1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie, Kardiologie I Mainz, Deutschland; 2Universitätsmedizin der Johannes Gutenberg-Universität Mainz Labor für Molekulare Kardiologie Mainz, Deutschland; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Präventive Kardiologie und Medizinische Prävention Mainz, Deutschland; 4Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland
Introduction
Socioeconomic status (SES) is defined as an individual’s position relative to other members of a society regarding education, occupation, and income. There is robust evidence for socioeconomic inequalities in cardiovascular health. Many studies have investigated SES and health outcomes in countries (e.g. United States) where healthcare access is directly related to occupation and income. Germany has universal healthcare access and thus investigation of the relationship between social disadvantage and cardiovascular disease (CVD) outcomes in this setting can help disentangle healthcare access as a confounder.
Methods
Cross-sectional (N=15,010, aged 35 to 74 years, baseline investigation period 2007 to 2012) and longitudinal data (5- and 10-year follow-up from 2012 to 2022) from the Gutenberg Health Study were used to investigate the association between individual socioeconomic status (SES, measured via a validated questionnaire) and cardiovascular disease (CVD, composite of atrial fibrillation, coronary artery disease, myocardial infarction, stroke, chronic heart failure, peripheral artery disease, and/or venous thromboembolism) risk and mortality.
Results
Subjects with prevalent CVD had a lower SES sum score, as well as lower education, occupation, and household net-income scores (all P<0.0001). Logistic regression analysis showed that a low SES (vs. high, defined by validated cut-offs) was associated with 19% higher odds of prevalent CVD (odds ratio (OR) 1.19, 95% CI 1.01; 1.40) in the fully adjusted model. At 5-year follow-up, low SES was associated with both increased cardiovascular (hazard ratio (HR) 5.36, 2.24; 12.82) and all-cause mortality (HR 2.23, 1.51; 3.31). At 10-year follow-up, low SES was associated with a 68% higher risk of incident CVD (OR 1.68, 1.12; 2.47) as well as 86% higher all-cause mortality (HR 1.86, 1.55; 2.24). In general, the education and occupation scores were stronger related to risk of CVD and death than the household net-income score. Low SES was estimated to account for 451.45 disability-adjusted life years per 1,000 people (years lived with disability 373.41/1000 and years of life lost 78.03/1000) and an incidence rate of 11 CVD cases and 3.47 CVD deaths per 1000 people per year. The population attributable fraction for CVD incidence after 5 years were 4% due to low SES.
Conclusion
Despite universal healthcare access, cumulative social disadvantage remains associated with higher risk of CVD and mortality. Dimensions of education and occupation, but not household net-income, are associated with outcomes of interest.