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Determinants of social inequalities in cardiovascular disease among Iranian patients
Mid Sweden University, Faculty of Human Sciences, Department of Health Sciences.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and objectives: Cardiovascular disease (CVD) is the single largest cause of mortality in the world. Similar to other health issues, CVD is generally affected either by individual risk factors, which may influence the risk for developing an illness or its complications, or by social indicators (social determinants of health). There is evidence from developed countries which shows that the so-called "upstream factors"—including social determinants such as political, social, spiritual, cultural, and economic factors—may affect the prevalence and incidence of CVD. Scarce evidence from studies in low- and middle-income countries also suggests that social factors may affect the distribution of CVD across population groups. However, there is a dearth of such data in Iran, where only a few small-sizedstudies have focused on the social determinants of health. Therefore, the present thesis sought to fill this gap by assessing the effects of socioeconomic status (SES) on the distribution of CVD and the relevant inequalities within the Iranian context.

Methods: This thesis is based on four studies, which used data from the Tehran Heart Center’s Databases. In Study I, a total of 44,820 patients who underwent coronary angiography at Tehran Heart Center between 2005 and 2010 were recruited. Then, their pre- and post-procedural data—including demographics, CVD risk factors, symptoms, and laboratory tests—were compared between men and women. In Study II, 6,246 patients with acutecoronary syndrome who were hospitalized between March 2004 and August 2011 were included and, based on their education and their employment status, were divided into high- and low-SES groups. Thereafter, the effect of SES on the in-hospital death of the patients was evaluated. In Study III, 20,165 patients with documented coronary artery disease who underwent coronary angiography at Tehran Heart Center were enrolled and CVD risk factors and severity (measured by the Gensini score) were assessed among the six major Iranian ethnic groups. In Study IV, 9,088 patients with acute coronary syndrome who were hospitalized at Tehran Heart Center between May 2007and June 2014 were recruited and the association between in-hospital death due to acute coronary syndrome and place of residence (rural/urban) was assessed using logistic regression adjusted for potential confounders.

Results: In this thesis, the data analyses were based on the hypothesis that there is a potential association between the different socioeconomic indicators and the selected cardiovascular outcomes. In Study I, among the recruited participant, 25,363 men and 11,995 women had coronary artery disease and the women not only were significantly older, less educated, and more overweight but also had higher blood levels of triglyceride, cholesterol, low-density lipoprotein, high-density lipoprotein, and fasting blood sugar than the men. Moreover, hypertension and diabetes mellitus showed the strongest association in the women with coronary artery disease (OR=3.45, 95% CI: 3.28to 3.61 and OR=2.37, 95% CI: 2.26 to 2.48, respectively). In addition, the frequency of post-procedural recommendations for non-invasive procedures was higher in the women than in the men (20.1% vs 18.6%; P<0.001). In StudyII, of the 6,246 recruited patients with acute coronary syndrome, 3,290individuals were considered low-SES and 2,956 high-SES individuals. In-hospital death occurred in 79 (1.26%) patients: 1.9% in the low-SES and 0.6% in the high-SES groups. After adjustment for the possible cofounders, our multivariate analysis demonstrated a significant effect of the patients’ SES on their in-hospital death and a lower in-hospital mortality rate was shown in the high-SES patients (OR=0.30, 95% CI: 0.09 to 0.98; P=0.046). In Study III, the Fars (8.7%) and Gilak (8.6%) ethnic groups had the highest frequency of having at least four simultaneous risk factors. Additionally, the mean Gensini score was lowest in the Lurs (67.5±52.8) and highest among the Gilaks (77.1±55.9). The multivariable regression analysis indicated that the Gilaks showed the worst CVD severity (β: 0.056, 95% CI: 0.009 to 0.102; P=0.018), followed by the Turks (β: 0.032, 95% CI: 0.005 to 0.059; P=0.020), and the lowest CVD severity, was detected in the Lurs (β: -0.087, 95% CI: -0.146 to -0.027;P=0.004). Study IV showed that while smoking (P=0.002), positive family history of coronary artery disease (P=0.003), higher body mass index (P=0.013),and hyperlipidemia (P=0.026) were more prevalent in the urban patients, the rural patients showed lower educational levels (P<0.001) and higher frequency of unemployment (P=0.009). Meanwhile, in-hospital death occurred in 135 (1.5%) patients: 125 (1.5%) urban and 10 (1.2%) rural. To adjust the effects of the possible confounders, we utilized the Firth regression model, which showed no significant difference regarding in-hospital death betweenthe rural and urban patients (OR=1.57, 95% CI: 0.376 to 7.450; P=0.585).

Conclusions: The aim of this thesis was to investigate the effects of social determinants (particularly SES) on CVD and its modifiable risk factors among Iranian patients. Results showed that medical treatment for CVD was more recommended (by treating physicians) to the women than the men, and the low-SES patients with acute coronary syndrome were more likely to die in the hospital than their high-SES counterparts. In addition, the thesis found heterogeneity in the distribution of the traditional risk factors for CVD as well as CVD severity in the major Iranian ethnic groups. Further, there were no differences concerning the in-hospital death rates due to acute coronary syndrome between the urban and rural patients after adjustment for the potential confounders.

Place, publisher, year, edition, pages
Sundsvall: Mid Sweden University , 2018. , p. 68
Series
Mid Sweden University doctoral thesis, ISSN 1652-893X ; 283
Keyword [en]
Iran, Social inequalities, Cardiovascular disease, Coronary artery disease, Acute coronary syndrome, Socioeconomic status, In-hospital mortality, Urban/rural residence
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:miun:diva-33612ISBN: 978-91-88527-55-4 (print)OAI: oai:DiVA.org:miun-33612DiVA, id: diva2:1205557
Public defence
2018-06-08, C326, Holmgatan 10, Sundsvall, 10:00 (English)
Opponent
Supervisors
Note

Vid tidpunkten för disputationen var följande delarbeten opublicerade: delarbete 4 inskickat.

At the time of the doctoral defence the following papers were unpublished: paper 4 submitted.

Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-05-15Bibliographically approved
List of papers
1. Gender Differences in the Risk of Coronary Artery Disease in Iran
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2012 (English)In: Iranian Journal of Public Health, ISSN 0304-4556, Vol. 41, no 3, p. 36-47Article in journal (Refereed) Published
Abstract [en]

Background: Given gender differences in the risk of coronary artery disease (CAD), the present study sought to investigate these dissimilarities amongst patients who underwent angiography at a major, tertiary heart hospital in Iran. Methods: Between 2005 and 2010, 44,820 patients who underwent coronary angiography were enrolled in a registry. Pre-procedural data such as demographics, CAD risk factors, presenting symptoms, and laboratory tests, as well as postprocedural data were collected. The data were, subsequently, compared between the men and women. Results: Out of the 44,820 patients (16,378 women), who underwent coronary angiography, 37,358 patients (11,995 women) had CAD. Amongst the CAD patients, the females were not only significantly older, less educated, and more overweight than were the males but also had higher levels of triglyceride, cholesterol, low-density lipoprotein, highdensity lipoprotein, and fasting blood sugar (P< 0.001). Of all the risk factors, hypertension and diabetes mellitus showed the strongest association in our female CAD patients (OR=3.45, 95%CI: 3.28-3.61 and OR=2.37, 95%CI: 2.26- 2.48, respectively). Acute coronary syndrome was more prevalent in the men (76.1% vs. 68.6%, P< 0.001), and chronic stable angina was more frequent in the females (31.4% vs. 23.9%, P< 0.001). With respect to post-procedural recommendations, the frequency of recommendations for non-invasive modalities was higher in the females (20.1% vs. 18.6%, P< 0.001). Conclusion: Hypertension and diabetes mellitus had the strongest association with CAD in our female patients. In the extensive CAD patients, medical treatment was recommended to the women more often.

Keyword
Coronary artery disease; Female; Iran; Male; Risk factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:miun:diva-16008 (URN)000302000900005 ()2-s2.0-84858437146 (Scopus ID)
Available from: 2012-05-23 Created: 2012-03-19 Last updated: 2018-05-14Bibliographically approved
2. Socioeconomic status and in hospital mortality of acute corony syndrome: Can education and occupation serves as preventive measures?
Open this publication in new window or tab >>Socioeconomic status and in hospital mortality of acute corony syndrome: Can education and occupation serves as preventive measures?
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2015 (English)In: International Journal of Preventive Medicine, ISSN 2008-7802, E-ISSN 2008-8213, Vol. 6, article id Art. no. 6:36Article in journal (Refereed) Published
Abstract [en]

Background: Socioeconomic status (SES) can greatly affect the clinical outcome of medical problems. We sought to assess the in‑hospital mortality of patients with the acute coronarysyndrome (ACS) according to their SES.

Methods: All patients admitted to Tehran Heart Center due to 1st‑time ACS between March 2004 and August 2011 were assessed. The patients who were illiterate/lowly educated (≤5 years attained education) and were unemployed were considered low‑SES patients and those who were employed and had high educational levels (>5 years attained education) were regarded as high‑SES patients. Demographic, clinical, paraclinical, and in‑hospital medical progress data were recorded. Death during the course of hospitalization was considered the end point, and the impact of SES on in‑hospital mortality was evaluated.

Results: A total of 6246 hospitalized patients (3290 low SES and 2956 high SES) were included (mean age = 60.3 ± 12.1 years, male = 2772 [44.4%]). Among them, 79 (1.26%) patients died. Univariable analysis showed a significantly higher mortality rate in the low‑SES group (1.9% vs. 0.6%; P < 0.001). After adjustment for possible cofounders, SES still showed a significant effect on the in‑hospital mortality of the ACS patients in that the high‑SES patients had a lower in‑hospital mortality rate (odds ratio: 0.304, 95% confidence interval: 0.094–0.980; P = 0.046).

Conclusions: This study found that patients with low SES were at a higher risk of in‑hospital mortality due to the ACS. Furthermore, the results suggest the need for increased availability of jobs as well as improved levels of education as preventive measures to curb the unfolding deaths owing to coronary artery syndrome.

Keyword
Coronary disease, education, mortality, occupation
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:miun:diva-24668 (URN)10.4103/2008-7802.156266 (DOI)2-s2.0-84930911813 (Scopus ID)
Available from: 2015-03-21 Created: 2015-03-21 Last updated: 2018-05-14Bibliographically approved
3. Ethnic differences in the risk factors and severity of coronary artery disease: a patient-based study in Iran
Open this publication in new window or tab >>Ethnic differences in the risk factors and severity of coronary artery disease: a patient-based study in Iran
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2017 (English)In: Journal of Racial and Ethnic Health Disparities, ISSN 2197-3792Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background Diverse ethnic groups may differ regarding

the risk factors and severity of coronary artery disease

(CAD). This study sought to assess the association between

ethnicity and CAD risk and severity in six major

Iranian ethnic groups.

Methods In this study, 20,165 documented coronary artery

disease patients who underwent coronary angiography

at a tertiary referral heart center were recruited. The

demographic, laboratory, clinical, and risk factor data of

all the patients were retrieved. The Gensini score (an

indicator of CAD severity) was calculated for all, and

the risk factors and severity of CAD were compared

between the ethnical groups, using adjusted standardized

residuals, Kruskal–Wallis test, and multivariable regression

analysis.

Results The mean age of the participants (14,131

[70.1%] men and 6034 [29.9%] women) was

60.7 ± 10.8 years. The Fars (8.7%) and Gilak (8.6%)

ethnic groups had the highest prevalence of ≥4 simultaneous

risk factors. The mean Gensini score was the

highest for the Gilaks (77.1 ± 55.9) and the lowest

among the Lors (67.5 ± 52.8). The multivariable regression

analysis showed that the Gilaks had the worst severity

(β 0.056, 95% CI 0.009 to 0.102; P = 0.018),

followed by the Torks (β 0.032, 95% CI 0.005 to 0.059;

P = 0.020). Meanwhile, the Lors showed the lowest

severity (β −0.087, 95% CI −0.146 to −0.027;

P = 0.004).

Conclusions This study found that there was heterogeneity in

CAD severity and a diverse distribution in its well-known

traditional risk factors among major Iranian ethnic groups.

Place, publisher, year, edition, pages
Springer Berlin/Heidelberg, 2017
Keyword
Health status disparities Ethnicity Coronary heart disease
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:miun:diva-31406 (URN)10.1007/s40615-017-0408-3 (DOI)
Available from: 2017-08-16 Created: 2017-08-16 Last updated: 2018-05-14Bibliographically approved
4. Mortality by acute Coronary syndrome in Iran: Does place of residence matter?
Open this publication in new window or tab >>Mortality by acute Coronary syndrome in Iran: Does place of residence matter?
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(English)In: Article in journal (Refereed) Submitted
National Category
Health Sciences
Identifiers
urn:nbn:se:miun:diva-33614 (URN)
Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-05-14Bibliographically approved

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