Cardiovascular disease inequalities: causes and consequences. Capewell S. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).

1. Cardiovascular disease risk factors
factors
CVD Inequalities
Causes, Consequences & Challenges
Challenges
Simon Capewell
Professor of Clinical Epidemiology
LIVERPOOL UNIVERSITY UK
Madrid, 18th February 2010
Thanks: Susanne Logstrup, Sophie O’Kelly,Muri el
Muri
Mioulet, Lars Ryden, Ilaria Leggeri, Robin Ireland,
Philip James,M artinO ’Flaherty, Julia Critchley,
M O
RosalindRai ne, Hilary Graham, Maddy Bajekal,
Rai
MargaretWh itehead, PeterWh incup, EarlFFord, Pedro
Wh Wh
Marques-Vidal, Sarah Wild, Ann Capewell
European Society
European Society
of Cardiology
of Cardiology
&
&
European Heart Network
European Heart Network 2009

2. Cardiovascular disease risk factors
factors
CVD Inequalities
Causes, consequences & challenges
challenges
THIS TALK
Big inequalities CVD burden of disease
disease
Big inequalities in CVD risk factors
Choices for CVD prevention: ⇑⇓ Inequalities
Inequalities

3. WHO
Commission
on
Social
Determinants
of Health
Health
2008
2008

4. Life expectancy at birth (men)
Glasgow, Scotland (deprived suburb) 54
54
India 61
61
Philippines 65
65
Lithuania 66
66
Poland 71
71
Mexico 72
72
Cuba 75
75
US 75
75
UK 76
76
WHO Commission on Social Determinants of Health 2008

5. Life expectancy at birth (men)
Glasgow, Scotland (deprived suburb) 54
54
India 61
61
Philippines 65
65
Lithuania 66
66
Poland 71
71
Mexico 72
72
Cuba 75
75
US 75
75
UK 76
76
Glasgow, Scotland (affluent suburb) 82
82
WHO Commission on Social Determinants of Health 2008

7. WHO Commission on
Social Determinants of Health
Health
Three overarching recommendations
recommendations
• Improve conditions of daily life
• Tackle the inequitable distribution of
power, money & resources
• Measure & understand the problem
and assess the impact of action
http://www.euro.who.int/socialdeterminants/publications/publications

8. WHO Commission on
Social Determinants of Health
Health
Three overarching recommendations
recommendations
• Improve conditions of daily life
• Tackle the inequitable distribution of
power, money & resources
• Measure & understand the problem and
assess the impact of action
http://www.euro.who.int/socialdeterminants/publications/publications

9. Poverty rates before & after income transfers
(direct tax & welfare benefits) EU & USA 2000
Smeeding 2005
H Graham 2009

10. Poverty rates before & after income transfers
(direct tax & welfare benefits) EU & USA 2000
40
30
20
10
0
US UK Sweden
Smeeding 2005
before
after
H Graham 2009

11. WHO Commission on
Social Determinants of Health
Health
Three overarching recommendations
recommendations
• Improve conditions of daily life
• Tackle the inequitable distribution of
power, money & resources
• Measure & understand the problem
& assess the impact of action
http://www.euro.who.int/socialdeterminants/publications/publications

12. Cardiovascular disease (CVD) risk factors
CVD Inequalities
Causes, consequences & choices
Big inequalities in CVD burden of disease
disease

13. Inequalities in CVD
disease burden
burden
Poverty (Deprivation)
(Deprivation)

14. Deprivation & Heart Attack Incidence
(patients aged <65 Scotland 1990-2000)
25
20
20
event rate per 1000
15
15 Hospital
10
10
admissions
Deaths by 30 days
5 Pre-hospital
0
deaths
deaths
(Affluent) 1 2 3 4 5 (Deprived)
deprivation quintile
MacIntyre et al BMJ 2000

15. Inequalities in CVD
disease burden
burden
Age
Men & Women
Women

16. CVD Patients: AGE UK 2006
10000
1000
Mor tality rate/100,000
(log scale)
100
MEN
10
1
<34 35-44 45-54 55
-64 65-74 75-84 85+ AGE (years)

17. CVD Patients: SEX & AGE UK 2006
10000
1000
Mor tality rate/100,000
(log scale)
100
MEN
10
WOMEN
1
<34 35-44 45-54 55
-64 65-74 75-84 85+
AGE (years)

18. Inequalities in CVD
disease burden
burden
Geography
Geography

19. North/South
Inequalities in
CVD
www.heartstats.org

20. Big CVD inequalitiesyears) in the WHO European Region
Cardiovascular mortality (up to 65
across Europe
< 300
< 240
< 180
< 120
Most recent data 0 - 60
No data
SDR per 100000
….the main contributor to a 20 year difference in life expectancy across EU

21. Inequalities in CVD
disease burden
burden
Trends
Trends

22. Most Deprived
Inequality ratio =
1.9
Most Affluent
Inequality ratio =
1.7

23. EUROPE
Total mortality INEQUALITIES (inequality ratios)
INEQUALITIES increased between 1980s and
1990s in many EU countries
Mackenbach et al. IJE 2003 32:830

24. Cardiovascular disease (CVD) risk factors
factors
CVD Inequalities
Causes, consequences & choices
THIS TALK
Big inequalities in CVD disease burden
Big inequalities in CVD risk factors
factors
Choices for CVD prevention

25. CVD risk factors
factors

26. MODIFIABLE
MODIFIABLE
CVD risk factors
factors

27. Five year CHD death rates in
in
British men aged 35-64
64
(British Regional Heart Study)
20
17
15 Smokers
NON-Smokers
12
10
1117.5 10
10.8 6
5 6
High Cholesterol
4
2 Low Cholesterol
High Low High Low
BP BP BP Blood Pressure

28. CVD causation pathways
Upstream
risk factors
Downstream
Risk factors

29. CVD causation pathways
Upstream
risk factors
Blood
Smoking Lipids Diabetes
Pressure
Downstream
CVD events Risk factors

30. CVD causation pathways
Upstream
risk factors
Diet BMI
Obesity Activity
Blood
Smoking Lipids Diabetes
Pressure
Downstream
CVD events Risk factors

31. CVD causation pathways
Deprivation Upstream
risk factors
Diet Obesity Activity
Blood
Smoking Lipids Diabetes
Pressure
Downstream
CVD events risk factors

32. GRADIENTS IN
CVD risk factors
factors

33. GRADIENTS IN
CVD risk factors
factors
SMOKING
SMOKING

34. Smoking
Place &
Social Class

35. Trends in Cigarette smoking among women
60
Affluent & Deprived groups Britain, 1958-2000
50
40
Deprived
30
20
Affluent
10
0
1958 1978 1998
Goddard 2008
w omen-professional w omen-unsk manual Graham 2009

36. Socio-economic inequalities
• Five fold social gradients in
premature CVD mortality rates
• Mostly explained by gradients in
smoking & diet
& other pathways [stress, adrenaline etc]

37. Nigel Unwin

38. Deprived
Affluent

39. CVD causation pathways
Deprivation Upstream
risk factors
Diet Obesity Activity
Blood
Smoking Lipids Diabetes
Pressure
Downstream
CVD RISK risk factors

40. Higher CVD risk in deprived groups
Proportion of men exceeding 10% risk of CVD death within one decade (Qrisk database)
Affluent Quintiles of the Townsend score Deprived
Hippisley-Cox Heart 2007

41. Cardiovascular disease (CVD) risk factors
factors
CVD Inequalities
Causes, consequences & choices
THIS TALK
Big inequalities in CVD
Big inequalities in CVD risk factors
Choices for CVD prevention

42. CVD process: in an individual
100%
Survival
0%
Birth Youth Middle Age Age (years) ⇒
Artery Atheroma Thrombosis
Capewell et al 2009

43. CVD process: in an individual
100%
Natural Cou
rse of CVD
Survival
0%
Birth Youth Middle Age Age (years) ⇒
Artery Atheroma Thrombosis
Capewell et al 2009

44. CVD process: in an individual
100%
Natural Cou
rse of CVD
Survival
First Stroke or
Heart Attack
0%
Birth Youth Middle Age Age (years) ⇒
Artery Atheroma Thrombosis
Capewell et al 2009

45. CVD process: in an individual
100%
Natural Cou
rse of CVD
Survival
First Stroke or
or
NO Symptoms Heart Attack
Attack
Symptoms
Sudden
Death Typical Lucky
(common) decline
0%
Birth Youth Middle Age Age (years) ⇒
Capewell et al 2009

46. CVD process: in an individual
100%
Natural Cou
rse of CVD
Survival
First Stroke or
or
NO Symptoms Heart Attack
Attack
Symptoms
Secondary prevention Health services
Sudden
Death Typical Lucky
(common) decline
0%
Birth Youth Middle Age Age (years) ⇒
Capewell et al 2009

47. CVD process: in an individual
100%
Natural Cou
rse of CVD Disease
Promotion
Survival
Primary
Prevention First Stroke or
NO Symptoms Heart Attack
Symptoms
Secondary prevention Health services
Sudden
Death Typical Lucky
(common) decline
0%
Birth Youth Middle Age Age (years) ⇒
Capewell et al 2009

48. CVD Prevention in a POPULATION
100%
Natural Cou
rse of CVD Advertising
Survival
Primary
Prevention
First Stroke or
Heart Attack
0%
0%
60 70 Age (years) 80
80
Capewell et al 2009

49. CVD Prevention in a POPULATION
100%
Natural Cou
rse of CVD More
advertising
Survival
Primary
Prevention First Stroke or
Heart Attack
0%
0%
60 70 Age (years) 80
80
Capewell et al 2009

50. CVD Prevention in a POPULATION
100%
Natural Cou
rse of CVD
Advertising
Eg ⇑ tobacco control
Survival EFFECTIVE
Primary DELAYED First Stroke
Prevention or Heart Attack
0%
0%
60 70 Age (years) 80
80
Capewell et al 2009

51. CVD Prevention in a POPULATION
100% HEALTH PROTECTION
Natural Cou Eg by tobacco or salt
rse of CVD
legislation
Survival EFFECTIVE
Primary First Stroke or Heart
Prevention Attack PREVENTED
0%
60 70 Age (years) 80
Capewell et al 2009

52. CVD prevention strategies
strategies
• High Risk Individual Approach
• Population-based Approach

53. CVD prevention approaches
approaches
Prevalence
%
Blood Pressure
distribution in the
30 population
20
10
0
110 120 130 Systolic BP 160
160

54. CVD prevention: High risk individual approach
Prevalence
%
Blood Pressure
distribution in the
30 population
20
SBP >140 mmHg
10
0
110 120 130 Systolic BP 160
160

55. CVD prevention: High risk individual approach
Prevalence
%
Blood Pressure
distribution in the
30 population
20
BP >140 mmHg
Medications
10
0
110 120 130 Systolic BP 160
160

56. Population-based CVD prevention strategy
strategy
Prevalence
%
Shifting Blood
Pressure distribution
30
20
10
0
110 120 130 Systolic BP 160
160

57. Population-based CVD prevention strategy
strategy
Prevalence
%
Shifting Blood
Pressure distribution
30
20
10
0
110 120 130 Systolic BP 160
160

58. Population-based CVD prevention strategy
strategy
Prevalence
%
Shifting Blood
Pressure distribution
30
20
Fewer BP >140 mmHg
Less treatments
10
0
110 120 130 Systolic BP 160
160

59. Whole-population approach for
preventing CVD: successful policies
– Farmers subsidies to stop dairy &
beef , start fruit & berry production (Finland)
– Support food reformulation (All)

60. Whole-population approach for
preventing CVD: successful policies
– Farmers subsidies to stop dairy &
beef , start fruit & berry production (Finland)
– Support food reformulation (All)
– Banning transfats (Denmark)
– Halving dietary salt (Finland)
– Promoting smoke-free public spaces
(Ireland, UK ,Italy etc)

61. Ireland: modelling reductions in
in
cardiovascular risk factors
factors
Primary Prevention
Population Approach
⇓ Risk Factors in everyone
Versus
High Risk strategy
using statin & blood pressure medications
BMC Public Health 2007 7 117

62. CHD prevention in Ireland 1985-2000:
Population v. High Risk Strategies
Deaths prevented or postponed (Sensitivity analysis )
BMC Public Health.
High 2007; 7:117.
Risk Population Treating
Statins secular BP High
Population trends Risk
Diet
diet change
change in Blood
CHD
patients Pressure
Cholesterol
BMC Public Health 2007 7 117

63. CHD prevention in Ireland 1985-2000:
Population v. High Risk Strategies
Deaths prevented or postponed (Sensitivity analysis )
High
Risk Population Treating
Statins secular BP High
Population trends Risk
Diet
diet change
change in Blood
CHD
patients Pressure
Cholesterol
BMC Public Health 2007 7 117

64. NICE Programme Development Group:
CVD prevention in populations
Will CVD prevention
widen health inequalities?
Simon Capewell
25th June 2009

65. The UK high risk approach
for preventing CVD
UK Department of Health programme:
programme:
NHS Health Checks

66. The UK high risk approach
for preventing CVD
UK Department of Health programme:
NHS Health Checks
– All adults aged 40+ screened for CVD risk
– If 20%+ risk CVD event in the next
ten years, treat with:
with:
• lifestyle advice plus
• tablets to reduce cholesterol & blood pressure

67. Evidence that high risk approach
may increase social inequalities
Tudor Hart’s “Inverse Care Law”
Tugwell’s “staircase effect”
J Tudor Hart . The inverse care law. Lancet 1971;1; 405. P Tugwell; BMJ 2006;33 2; 358
inverse 1; Tugw BMJ 2006; 33 35

68. Evidence that high risk approach
may increase social inequalities
Tudor Hart’s “Inverse Care Law”
• The availability of good medical care tends to
vary inversely with actual need
Tugwell’s “staircase effect”
Disadvantage can occur at every stage:
– Health beliefs, health behaviour, presentation
participation, persistence or adherence
J Tudor Hart . The inverse care law. Lancet 1971;1; 405. P Tugwell; BMJ 2006;33 2; 358
inverse 1; Tugw BMJ 2006; 33 35

69. Evidence that high risk approach
may increase social inequalities
Prescribing gradients
Long term adherence
Smoking cessation
Nutrition interventions in individuals
individuals
Oldroyd J. JECH 2008; 62:573. Thomsen R W, Br J Clin Pharm. 2005; 60;534;
62:573. 2005;
Ashworth, M, QJof Amb Care Management: 2008; 31; 220;
220;
Vrijens B, BMJ 2008;336:1114; Morisky D. Clin Hypertension 2008; 10; 348
Vrijens 2008;336:11 348
Johnell K BMC PublicHealt h2005, 5: 17
BMC Healt 2005, 5: Chaudhry HJ. Current Ather.
Ather.
Rep 2008; 10; 19; Bouchard MH, Br J Clin Pharmacol. 2007 63(6): 698
Bouchard 63(6): 698

70. Evidence that whole POPULATION CVD
prevention reduces social inequalities
Kivimaki, Marmot et al Lancet 2008
15 year risk of CHD death
• calculated in British men aged 55
• quantified the benefits of decreasing risk
factors uniformly across population
[systolic blood pressure ⇓10mmHg
total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ]

71. Evidence that whole POPULATION CVD
prevention reduces social inequalities
Kivimaki, Marmot et al Lancet 2008
15 year risk of CHD death
• calculated in British men aged 55
• quantified the benefits of decreasing risk
factors uniformly across population
[systolic blood pressure ⇓10mmHg
total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ]
• Would reduce the absolute mortality gap
between affluent & deprived by ≈70%

72. Evidence that whole POPULATION CVD
prevention reduces social inequalities
Diet interventions
• Folic acid fortification of cereals (USA population1996)
Dowd IJE 2008; 37(5):1059
Dowd IJE 2008; 37(5):1059

73. Evidence that whole POPULATION CVD
prevention reduces social inequalities
Diet interventions
Folic acid fortification of cereals (USA population1996)
Blood folate levels: Social gradients ⇓⇓ ≈ 70%
Dowd IJE 2008; 37(5):1059
Dowd IJE 2008; 37(5):1059

74. Evidence that whole POPULATION CVD
prevention reduces social inequalities
Smoking
• cigarette price increases more effective in
deprived groups TownsendBMJ 1994; 309; 923
Town send BMJ 1994; 309; 923
“increase in tobacco price may have the potential
potential
to reduce smoking related health inequalities”
Main Meta-analysis. BMC Public Health 2008; 8; 178
Meta- BM

75. CVD prevention
& health inequalities
VERDICT
♥ High Risk Strategies
toscreen & treat individuals
typically widen social inequalities

76. CVD prevention
& health inequalities
VERDICT
♥ High Risk Strategies
toscreen & treat individuals
typically widen social inequalities
♥ Population wide policy interventions
usually narrow the inequalities gap

77. CVD population prevention
prevention
⇒ € COST SAVINGS

78. CVD population-wide prevention
prevention
⇒ € COST SAVINGS
SAVINGS
• USA Trust for America’s Health
• Australia Abelson
• UK Wanless Report 2004
(save € 40 billion)
NICE Guidance 2010 [Draft]
(save € 5 billion – €10 billion)

79. Cardiovascular disease (CVD) risk factors
factors
CVD Inequalities
Causes, consequences & choices
Social Inequalities
in CVD treatments?

80. Deprived patients get less treatment
Those who need most care get least care

81. Deprived patients get less treatment
Those who need most care get least care
– Management & drugs (Roland 2009)
– Referral from primary care (Dixon; McBride & Raine)
– Under-use of diagnostics (Hippisley Cox)
– Less Revascularization BJGP 2000; 50: 449; BMJ 1997;
314: 257
– Less rehabilitation

82. Deprived patients get less treatment
OLD patients get less treatment
WOMEN get less treatment

83. Cardiovascular disease (CVD) risk factors
factors
CVD Inequalities
Causes, consequences & choices
CVD Inequalities in UK
UK
How big are the inequalities
in YOUR country??

84. CVD prevention in EU
WHAT WE HAVE ACHIEVED
• European Heart Health Charter (EHHC)
EHHC)
• Spanish Presidency Declaration 2002
2002
• Council Conclusions 2004

85. CVD prevention in EU
EU
WHAT WE HAVE ACHIEVED
• European Heart Health Charter (EHHC)
• Spanish Presidency Declaration 2002
• Council Conclusions 2004
WHAT WE CAN DO NOW
• ⇑ Tobacco Control [& price]
• ⇑ fruit & vegetable consumption
• ⇓ meat & dairy [& HELP climate change]
• Ban junk food advertising
• Ban trans fats

86. Cardiovascular disease risk factors
CVD Inequalities
Causes, consequences & challenges
CONCLUSIONS
Big CVD inequalities burden of disease
- Social, Age, Sex, Place, Ethnicity
Ethnicity
Big inequalities in CVD risk factors
- Smoking & Diet (Blood Pressure & Cholesterol)

87. Cardiovascular disease risk factors
CVD Inequalities
Causes, consequences & choices
CONCLUSIONS
Big CVD inequalities burden of disease
- Social, Age, Sex, Place, Ethnicity
Big inequalities in CVD risk factors
- Smoking & Diet (BP & Cholesterol)
Choices for CVD prevention:
-Individual approach ⇑CVD Inequalities⇑
-Population approach ⇓CVD Inequalities⇓