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Risk of major cardiovascular events according to educational level before and after the initial COVID-19 public lockdown: a nationwide study
  1. Julie Andersen1,
  2. Katrine Strandberg-Larsen2,
  3. Thomas Gerds1,3,
  4. Gunnar Gislason1,4,
  5. Christian Torp-Pedersen5,
  6. Paul Blanche3,4,
  7. Charlotte Andersson4,6,
  8. Lars Køber7,
  9. Emil Fosbøl7,
  10. Matthew Phelps1,
  11. Kristian Kragholm8,
  12. Mikkel Porsborg Andersen5,
  13. Lauge Østergaard7,
  14. Jawad Butt7,
  15. Morten Schou4
  1. 1Department of Cardiovascular Research, The Danish Heart Foundation, Copenhagen, Denmark
  2. 2Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  3. 3Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  4. 4Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
  5. 5Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
  6. 6Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston University, Boston, MA, USA
  7. 7Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
  8. 8Department of Cardiology, Unit of Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
  1. Correspondence to Julie Andersen, Research, Hjerteforeningen, 1120 Kobenhavn, Denmark; juliea{at}


Background During the COVID-19 pandemic, decreasing rates of hospitalisations for cardiovascular disease raised concerns for undertreatment, particularly for vulnerable groups. We investigated how the initial COVID-19 public lockdown, impacted the risk of being hospitalised with a major cardiovascular event (MCE: myocardial infarction/stroke/heart failure) according to educational level.

Methods We grouped all Danish residents according to educational attainment level (low, medium, high) and age (40–59, 60–69, ≥70 years). In each group, we used multiple logistic regression to derive the age-standardised and sex standardised risk of MCE hospitalisation in the initial COVID-19 lockdown-period (13 March 2020–3 May 2020) and in the corresponding calendar period in 2019. We calculated age-standardised and sex-standardised risks to investigate whether the COVID-19 lockdown had a differential effect on MCE incidence according to educational level.

Results In the period in 2019, 2700 Danish residents were hospitalised with MCE, compared with only 2290 during the lockdown. During lockdown, the risk of hospitalisation for MCE decreased among residents aged ≥70 with low education (risk difference (RD) −46.2 (−73.2; −19.2) per 100,000) or medium education (RD −23.2 (−50.8; 4.3) per 100 000), but not among residents with high education (RD 5.1 (−32.3; 42.5), per 100 000). The risk of hospitalisation for MCE did not decrease significantly for the younger age groups.

Conclusions The COVID-19 lockdown is associated with a reduced incidence for MCE, especially among low educated, elderly residents. This raises concern for undertreatment that without clinical awareness and action may widen the educational gap in cardiovascular morbidity and mortality.

  • health policy
  • public health
  • public health policy
  • social inequalities
  • socio-economic

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  • Contributors JA, KS-L, TG and MS contributed to the conception, design and analysis of the work. JA drafted the manuscript. All authors contributed to the acquisition or interpretation of data for the work, revised the manuscript and gave final approval.

  • Funding JA is supported by The Danish Heart Foundation, Grant Number:17-R116-A7610-22048.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement Data may be obtained from a third party and are not publicly available.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.