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Summary

This chapter discusses the social determinants of cardiovascular disease (CVD) that operate at the population level. Although every individual is affected by the society in which they live, some are more burdened than others by social and economic disadvantages, which in turn can result in health disparities. The major social determinants of health include socioeconomic status, race/ethnicity, sex, the environment, and access to care. Whilst on a global level, CVD is considered a disease of affluence, a contrasting gradient of CVD prevalence exists within developed societies (see accompanying Hurst’s Central Illustration); thus, as countries develop economically, the disadvantaged socioeconomic position progressively becomes a systematic risk factor for CVD. Racial and ethnic minority populations are disproportionally burdened with cardiovascular risk factors and CVD; socioeconomic status explains some portion of observed health disparities, but does not account for all of it. Scientific evidence also shows that, compared with men, women receive less treatment for both cardiovascular risk factors and CVD, and have increased mortality after myocardial infarction. The environment in which an individual lives impacts on cardiovascular health: lack of social relationships, living in disadvantaged neighborhoods, and work stress are all associated with increased risk of CVD. Finally, reduced access to care is also associated with increased CVD risk. Policy initiatives are critical to improving health outcomes and reducing health disparities.

eFig 107-01

Population and social determinants of the prevalence of cardiovascular disease (CVD). Socioeconomic status is one of the most studied and important social determinants of health. Whilst the poorest regions of the world still see relatively low rates of CVD, regions within developing countries that are marked by increasing wealth and adoption of the ‘Western’ lifestyle have seen rapid rises in rates of CVD. However, a gradient of CVD prevalence also exists within societies; early in the transition to a ‘Western’ lifestyle, individuals with high socioeconomic status are the first to adopt a lifestyle that promotes the development of cardiovascular risk factors and CVD, but late in the transition these individuals are the first to reduce behavioral risk factors and experience a decline in CVD. Race/ethnicity, sex, an individual’s environment, and access to care all also impact significantly on CVD risk.

INTRODUCTION

Cardiovascular disease (CVD) is the number one cause of death around the globe, now accounting for about one in three deaths.1 More than 80% of these CVD deaths take place in low- and middle-income countries.2 Although mortality from CVD in the United States has been declining since the 1970s, heart disease is still the leading cause of death in America as well, accounting for approximately 31.3% of deaths in 2011.3 The US decline in CVD mortality has been attributed to advances in prevention, diagnosis, and treatment. However, if current trends prevail, the prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030....

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