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Women with lower socioeconomic status at higher risk for CHD, CVD than men
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Among adults with low socioeconomic status, the risk for CHD and CVD was significantly higher in women than in men, according to new data.
“To date, there has been no systematic synthesis of the literature comparing sex differences in the relationship between markers of [socioeconomic status] and CVD,” Kathryn Backholer, PhD, of the School of Health and Social Development at Deakin University in Victoria, Australia, and colleagues wrote. “We, therefore, conducted a systematic review and meta-analysis to ascertain the most reliable estimate of the sex differences in the [RRs] of socioeconomic status on the risk of incident CHD, stroke and CVD in the general population.”
The researchers analyzed 116 cohorts, including 22 million individuals (35% women), from Asia (n = 22), Europe (n = 75), North America (n = 7) and Australasia (n = 12). More than 1 million CVD events were documented.
Across the studies, socioeconomic status was determined by educational attainment, area-level deprivation, occupation or income.
Sex differences
For CHD, when the lowest level of education was compared with the highest, the pooled age-adjusted RR for women was 1.66 (95% CI, 1.46-1.88) vs. 1.3 (95% CI, 1.15-1.48) for men. The pooled RRs remained significantly different for women vs. men when adjusting for CVD risk factors.
Women with the lowest level of education were a higher risk for CHD compared with men with the same level of education (age-adjusted RR = 1.24; 95% CI, 1.09-1.41). The risk remained significant after adjustments for CVD risk factors (RR = 1.34; 95% CI, 1.09-1.63).
When socioeconomic status was measured by area deprivation, occupation or income, the pooled age-adjusted RRs and multivariable-adjusted RRs were similar to those for education attainment.
The analysis of risk for CVD was similar to CHD. The pooled age-adjusted RR for lowest education vs. highest was 1.66 (95% CI, 1.43-1.92) in women and 1.42 (95% CI, 1.35-1.63) in men. Additionally, the pooled age-adjusted RR for CVD for women compared with men with the same level of education was 1.18 (95% CI, 1.03-1.36). Similar risks were found when using other measures of socioeconomic status.
For stroke, when the lowest level of education was compared with the highest, the pooled age-adjusted RR for women was 1.34 (95% CI, 1.07-1.69) vs. 1.53 (95% CI, 1.27-1.86) for men. However, there were no significant differences between the sexes among those with the same level of education (age-adjusted RR = 0.93; 95% CI, 0.72-1.18; multivariable-adjusted RR = 0.79; 95% CI, 0.53-1.19).
“The mechanisms underpinning this excess [CV] risk conferred by low [socioeconomic status] in women, compared with men, remain speculative, but they are unlikely to be governed solely by sex differences in major risk factors for two reasons,” the researchers wrote. “First, adjustment for conventional CVD risk factors (for both the pooled analyses and when comparing age- and CVD risk factor-adjusted analyses and within the [individual participant data] studies) did not remove the excess [CV] risk associated with education in women. Second, these risk factors also impact on stroke risk for which there was no evidence of a sex difference.”
Prevention strategies
The researchers recommended developing prevention strategies that consider the differences in risk for CVD and CHD in women of lower socioeconomic status.
“Men and women have a similar lifetime risk of heart disease. However, women, on average, develop heart disease 5 to 10 years later in life than men. This advantage is smaller among women with a lower socioeconomic status,” Sanne A. E. Peters, PhD, research fellow at The George Institute for Global Health, University of Oxford, said in a press release. “We need to examine why this is happening and make sure women are able to access lifesaving treatment.” – by Cassie Homer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Monique R. Robinson, MD, PhD
The authors provide an interesting signal that lower socioeconomic status, defined mainly by education level, is associated with higher CV risk, with women appearing to carry a disproportionately higher burden. This was a large-scale analysis and there is strength in the large numbers of events and people involved. One caution is that the pooling of data from heterogenous populations makes generalization on sex-specific differences challenging. For example, the various cultural mores that might not have been captured by the studies included in the meta-analysis could be more relevant than educational level.
The study certainly brings more spotlight on the potential disparities in CV risk that exist between men and women of lower educational level — and this is a good thing. Exposing differences, and the root causes for these, will allow for more equitable health care delivery and improve CV outcomes for all.
This research provides a good launching pad for a deeper dive into the causes of different health care outcomes between men and women. Regional studies exploring why women or those with less education might be more at risk for CVD will better guide how health care providers interact with and appropriately support specific populations of people.
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