Cardiovascular diseases (CVD) continue to be the leading cause of death and disability worldwide, representing 30% of all deaths.1 The impact of the main risk factors (smoking, hypertension, dyslipidemia, and diabetes mellitus [DM]) on this public health issue is well known. It has been estimated that 972 million people suffer from hypertension2 and 366 million from DM.3 The World Health Organization estimates that dyslipidemia is associated with more than half of all cases of ischemic heart disease and more than 4 million deaths per year.4 It is well known that the elderly population has a higher incidence of CVD and a worse prognosis.5 The population aged 65 and older in the United States has more than doubled, from 35 million in 2000 to 71 million in 2030, while the worldwide population aged 65 and older is projected to increase from 420 million to 973 million during 2000-2030.6 Although researchers are increasingly interested in the study of multimorbidity and related determinants in this age group, this population is usually underrepresented in clinical trials.7,8 Socioeconomic or demographic factors are among the many factors that have been associated with unequal access to health care services, which can produce inequalities in the diagnosis, treatment, and management of CVD risk factors.9,10 Low socioeconomic status (SES) is directly related to a higher risk of CVD.11,12 In a previous study carried out in patients with established coronary heart disease, we found no inequalities in cardiovascular prevention related to SES in Spain's health care system, which provides free, universal coverage.13 The present study aimed to assess the relationship between SES and health inequalities for CVD prevention treatment in patients at high cardiovascular risk who have not yet developed CVD, within the context of a universal, free health care system.

A total of 7447 patients were included. Mean age was 67.0 (6.2) and 57.5% of the participants were women. Only 7.2% of the participants had attained a university education. At baseline, 81.2% (N=6041) of participants had hypertension; 47.7% (N=3553) DM, and 71.0% (N=5285) dyslipidemia.

Among participants with hypertension, 81.4% (n=4922) received antihypertensive drugs; 66.5% of diabetic patients (n=2362) were prescribed insulin or oral antidiabetic agents, and 59.3% of patients with dyslipidemia (n=3132) received lipid-lowering therapy.

Participants in the lower educational level group were more frequently women, older, obese, less physically active, and had a lower adherence to the Mediterranean diet. Participants with a higher educational level were more often smokers and consumed more alcohol. Both the prevalence of DM and the proportion having 3 cardiovascular risk factors were higher in the lower educational level group (Table 1).

Participants with hypertension, DM, and a low educational level had more probability of receiving antihypertensive and lipid-lowering therapy. Participants with a low educational level and at least 2 cardiovascular risk factors were more likely to be treated (P=.063). In participants with dyslipidemia and in those with either 1 or 3cardiovascular risk factors, we observed no relationship between receiving treatment and educational level (Table 2).

Multivariate analysis did not show any relationship between treatment received and educational level (Table 3). Only participants with a middle educational level were less likely to be treated for hypertension (P=.049).

When the analysis was stratified by sex (Table 4), we observed that men with the lowest educational level had a 35% lower probability of receiving treatment for their hypertension than did participants at the highest level (odds ratio [OR]=0.65 [95%CI, 0.46-0.92]).No socioeconomic differences were observed for the other cardiovascular risk factors (DM, dyslipidemia) studied.

Figure presents the adjusted OR (95%CI) for receiving treatment for each of the cardiovascular risks factors. Table 5 shows the probability of receiving treatment depending on number of cardiovascular risk factors.

Figure.

Adjusted odds ratios for all participant characteristics of receiving treatment, for each cardiovascular risk factor. A: hypertension. B: diabetes. C: dyslipidemia. Squares represent odds ratios of receiving pharmacological treatment. Horizontal lines indicate 95% confidence intervals. Vertical lines signify odds ratio=1. The following were the reference categories for the variables tested in different models: educational attainment, high level; sex, men; body weight, normal weight. Reference categories for lifestyle were non-smoking, high adherence to Mediterranean diet, physically active, and low alcohol intake, and for cardiovascular risk: no hypertension, no diabetes, and no dyslipidemia. 95%CI, 95% confidence interval; MedD, Mediterranean diet; OR, odds ratio.

(0.3MB).

Our study found no overall differences related to SES in the pharmacological treatment prescribed for primary cardiovascular prevention in an elderly population with high cardiovascular risk. Educational level was selected as an indicator of SES because it remains unchanged throughout life, influencing the adoption of lifestyles and the related health outcomes.20 The greater proportion of women and of older participants with the lowest educational levels may be due to the particular historical situation of Spain. University access was limited until the last third of the 20th century, especially for women.21 Higher tobacco and alcohol consumption observed at the upper educational levels in our sample is consistent with other studies in Spain, and is likely due to historical cultural patterns in this age group; these patterns are changing in younger populations.22 The lower physical activity, less healthy dietary patterns, higher prevalence of DM and obesity, and larger number of cardiovascular risk factors observed in participants with lower educational levels also agrees with previous studies from Spain and other countries.23–26

Only a few studies have analyzed inequalities in preventive cardiovascular treatment depending on SES. with controversial results that vary depending on the country and population studied.27,28 Results of the present study concur with our previous analysis of a general population aged 34 to 75 years, in which we did not observe differences related to SES in preventive treatment for CVD.29 Reasons for such homogeneity could be that patients with CVD are more highly monitored or, as has been shown in other studies,30 that men with lower SES received less treatment for their hypertension because they use primary care services less often than women.

Although the health of a population is not only determined by use of health services, the type of coverage may contribute to SES-related health inequalities in CVD prevention (eg, access to medical services at different levels).9,10,31 Health care systems based on strong primary care models could be more effective in reducing inequalities for socioeconomically disadvantaged people because resources are better distributed according to population needs.32 The day-to-day tasks of primary care include the provision of specific care for patients with chronic diseases through the implementation of systematic preventive programs. In the Spanish health care system, patients can visit their general practitioner as often as needed, and during the study period most retired people did not pay for their prescriptions (a “copayment” was imple-mented in July 2012). We did not find inequalities in preventive treatment based on SES in the elderly population studied, probably due to the higher utilization of primary care services by the population with lower educational levels, as reported by other studies.33,34

Our study did not find that socioeconomic differences affected the treatment received for primary cardiovascular prevention in elderly patients in the context of a universal health care system based on a primary care model.

This project has been funded by the Spanish Ministry of Health (Instituto de Salud Carlos III, Fondo de Investigaciones Sanitarias) projects PI051839, PI070240, PI070954, G03/140, RD06/0045 FEDER (Fondo Europeo de Desarrollo Regional) and CIBERobn (an initiative of Instituto de Salud Carlos III, Spain), and by the Patrimonio Comunal Olivarero, California Walnut Commission, Borges, La Morella Nuts, and Hojiblanca, which donated virgin olive oil and mixed nuts. Agencia Canaria de Investigación, Innovación y Sociedad de la Información-EU FEDER (PI 2007/050). None of these companies played or will play any role in the design, collection, analysis, or interpretation of the data or in the decision to submit manuscripts for publication.

Dr. Estruch reports receiving lecture fees from FIVIN (Fundación para la Investigación del Vino y Nutrición) and serving on its scientific advisory board; receiving research grants from the Fundación Cerveza y Salud and serving on its scientific advisory board; and receiving lecturer fees from Sanofi-Aventis Laboratories. Dr. Salas-Salvadó reports receiving research funding from the International Nut and Dried Fruit Council, serving on its scientific advisory board, and receiving consultancy fees from Danone. Dr. Serra-Majem reports serving on the scientific advisory board of Fundación Dieta Mediterránea and Fundación Cerveza y Salud. No other co-authors have reported any potential conflict of interest relevant to this article.