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Inequalities in cardiovascular disease mortality: the role of behavioural, physiological and social risk factors
  1. Alison Beauchamp1,
  2. Anna Peeters1,
  3. Rory Wolfe1,
  4. Gavin Turrell2,
  5. Linton R Harriss1,
  6. Graham G Giles1,3,4,
  7. Dallas R English3,4,
  8. John McNeil1,
  9. Dianna Magliano5,
  10. Stephen Harrap6,
  11. Danny Liew7,
  12. David Hunt8,
  13. Andrew Tonkin1
  1. 1Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
  2. 2School of Public Health, Queensland University of Technology, Brisbane, Australia
  3. 3Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia
  4. 4Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population Health, University of Melbourne, Melbourne, Australia
  5. 5International Diabetes Institute, Melbourne, Australia
  6. 6Department of Physiology, University of Melbourne, Melbourne, Australia
  7. 7Department of Medicine, University of Melbourne, Melbourne, Australia
  8. 8Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
  1. Correspondence to Dr Alison Beauchamp, Department of Epidemiology & Preventive Medicine, Monash University, Alfred Hospital, Melbourne 3004, Australia; alison.beauchamp{at}


Background While the relationship between socio-economic disadvantage and cardiovascular disease (CVD) is well established, the role that traditional cardiovascular risk factors play in this association remains unclear. The authors examined the association between education attainment and CVD mortality and the extent to which behavioural, social and physiological factors explained this relationship.

Methods Adults (n=38 355) aged 40–69 years living in Melbourne, Australia were recruited in 1990–1994. Subjects with baseline CVD risk factor data ascertained through questionnaire and physical measurement were followed for an average of 9.4 years with CVD deaths verified by review of medical records and autopsy reports.

Results CVD mortality was higher for those with primary education only, compared with those who had completed tertiary education, with an HR of 1.66 (95% CI 1.10 to 2.49) after adjustment for age, country of birth and gender. Those from the lowest educated group had a more adverse cardiovascular risk factor profile compared with the highest educated group, and adjustment for these risk factors reduced the HR to 1.18 (95% CI 0.78 to 1.77). In analysis of individual risk factors, smoking and waist circumference explained most of the difference in CVD mortality between the highest and lowest education groups.

Conclusions Most of the excess CVD mortality in lower socio-economic groups can be explained by known risk factors, particularly smoking and overweight. While targeting cardiovascular risk factors should not divert efforts from addressing the underlying determinants of health inequalities, it is essential that known risk factors are addressed effectively among lower socio-economic groups.

  • Epidemiology
  • cardiovascular disease
  • primary prevention
  • risk factors
  • socio-economic status
  • epidemiology me
  • heart disease
  • prevention PR
  • social inequalities

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  • Funding This work was supported by the National Health and Medical Research Council (NHMRC) (ID No 209057, 334032, 396414). Further infrastructure support was provided by The Cancer Council Victoria and Monash University. AB is a PhD scholar funded by the NHMRC (ID No 465352). GT is a Senior Research Fellow funded by the NHMRC (ID No 390109). AP is funded by a VicHealth Fellowship. Cohort recruitment was funded by VicHealth and The Cancer Council Victoria.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Cancer Council Victoria Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.