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Educational class inequalities in the incidence of coronary heart disease in Europe
  1. Giovanni Veronesi1,
  2. Marco M Ferrario1,
  3. Kari Kuulasmaa2,
  4. Martin Bobak3,
  5. Lloyd E Chambless4,
  6. Veikko Salomaa2,
  7. Stefan Soderberg5,
  8. Andrzej Pajak6,
  9. Torben Jørgensen7,8,9,
  10. Philippe Amouyel10,
  11. Dominique Arveiler11,
  12. Wojciech Drygas12,
  13. Jean Ferrieres13,
  14. Simona Giampaoli14,
  15. Frank Kee15,
  16. Licia Iacoviello16,
  17. Sofia Malyutina17,
  18. Annette Peters18,
  19. Abdonas Tamosiunas19,
  20. Hugh Tunstall-Pedoe20,
  21. Giancarlo Cesana21
  1. 1Centro Ricerche EPIMED—Epidemiologia e Medicina Preventiva, Università degli Studi dell'Insubria, Varese, Italy
  2. 2THL-National Institute for Health and Welfare, Helsinki, Finland
  3. 3Research Department of Epidemiology and Public Health, University College London, London, UK
  4. 4Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  5. 5Department of Public Health and Clinical Medicine, Cardiology and Heart Centre, Umeå University, Umeå, Sweden
  6. 6Department of Epidemiology and Population Studies, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
  7. 7Research Centre for Prevention and Health, Capital Region of Denmark, Denmark
  8. 8Department of Public Health, Faculty of Medical Science, University of Copenhagen, Copenhagen, Denmark
  9. 9Faculty of Medicine, Aalborg University, Denmark
  10. 10Department of Epidemiology & Public Health, Pasteur Institute of Lille, Lille, France
  11. 11Department of Epidemiology and Public Health, University of Strasbourg, Strasbourg, France
  12. 12Department of Epidemiology, CVD Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
  13. 13Department of Cardiology, Toulouse University School of Medicine, Toulouse, France
  14. 14Istituto Superiore di Sanità, Rome, Italy
  15. 15UKCRC Centre of Excellence for Public Health Research, Queen's University Belfast, Belfast, UK
  16. 16Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
  17. 17The Institute of Internal and Preventive Medicine, Siberian Branch of Russian Academy of Medical Sciences, Novosibirsk, Russian Federation
  18. 18Helmholtz Zentrum München—German Research Center for Environmental Health, Neuherberg, Germany
  19. 19Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
  20. 20Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee, UK
  21. 21Centro Studi e Ricerche in Sanità Pubblica (CESP), Università degli Studi di Milano-Bicocca, Monza, Italy
  1. Correspondence to Professor Marco M Ferrario, Centro Ricerche EPIMED—Epidemiologia e Medicina Preventiva, Dipartimento di Medicina Clinica e Sperimentale, Università degli studi dell'Insubria, Via O. Rossi, 9, Varese 21100, Italy; marco.ferrario{at}


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.

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