cardiovascular disease inequalities: causes and consequences

2009

European Society of Cardiology

&European Heart Network

Cardiovascular disease risk factorsCardiovascular disease risk factors CVD InequalitiesCVD InequalitiesCauses, ConsequencesCauses, Consequences && ChallengesChallenges

European Society of Cardiology

& European Heart Network

Simon CapewellSimon CapewellProfessor of Clinical EpidemiologyProfessor of Clinical Epidemiology LIVERPOOL UNIVERSITYLIVERPOOL UNIVERSITY UKUK

Madrid, 18Madrid, 18thth February 2010February 2010 TThanks:hanks: Susanne Logstrup, Sophie OSusanne Logstrup, Sophie O’’KellKelly,y, MuriMuri elel

MioulMiouleet, Lars Rt, Lars Rydydeen, Ilarn, Ilaria Lia Leggeri,eggeri, Robin Ireland,Robin Ireland, PPhhilip Jamilip Jameses,, MM aartinrtin OO ’’Flaherty,Flaherty, JulJuliia Critca Critchley,hley, RosalindRosalind RaiRai nne, Hie, Hilarlary Graham,y Graham, MadMadddy Bajeky Bajekaal,l, MargaretMargaret WhWh iteheiteheaad, Peterd, Peter WhWh iinncupcup,, EarEarll FF ord,ord, PedrPedroo MarquesMarques--Vidal, Sarah Wild,Vidal, Sarah Wild, Ann CapewellAnn Capewell

Cardiovascular disease risk factorsCardiovascular disease risk factors CVD InequalitiesCVD InequalitiesCauses, consequences & challengesCauses, consequences & challenges

THIS TALKTHIS TALK Big inequalities CVDBig inequalities CVD burdenburden of diseasedisease

Big inequalities in CVD risk factorsBig inequalities in CVD risk factors

Choices for CVD prevention:Choices for CVD prevention: ⇑⇓⇑⇓ InequalitiesInequalities

WHOWHO

CommissionCommission

onon

SocialSocial

DeterminantsDeterminants

of Healthof Health

20082008

Life expectancy at birth (men) Glasgow, Scotland (deprived suburb) 54Glasgow, Scotland (deprived suburb) 54

IndiaIndia 6161 PhilippinesPhilippines 6565 LithuaniaLithuania 6666

PolandPoland 7171

MexicoMexico 7272

CubaCuba 7575

USUS 7575

UKUK 7676

WHO Commission on Social Determinants of Health 2008

Life expectancy at birth (men) Glasgow, Scotland (deprived suburb)Glasgow, Scotland (deprived suburb) 5454 IndiaIndia 6161 PhilippinesPhilippines 6565 LithuaniaLithuania 6666

PolandPoland 7171

MexicoMexico 7272

CubaCuba 7575

USUS 7575

UKUK 7676

Glasgow, Scotland (affluent suburb)Glasgow, Scotland (affluent suburb) 8282

WHO Commission on Social Determinants of Health 2008

WHO Commission onWHO Commission on Social Determinants of HealthSocial Determinants of Health

ThreeThree overarchingoverarching recommendationsrecommendations

• Improve conditions of daily life

• Tackle the inequitable distribution ofpower, money & resources

• Measure & understand the problemand assess the impact of action

http://www.euro.who.int/socialdeterminants/publications/publications




• Tackle the inequitable distribution of power, money & resources

• Measure & understand the problem andassess the impact of action


Poverty rates before & after income transfers (direct tax & welfare benefits) EU & USA 2000

Smeeding 2005

H Graham 2009

Poverty rates before & after income transfers

(direct tax & welfare benefits) EU & USA 2000

40

30

20

10

0

US UK Sweden

Smeeding 2005before after H Graham 2009




• Tackle the inequitable distribution ofpower, money & resources

• Measure & understand the problem & assess the impact of action


Cardiovascular disease (CVD) risk factors CVD InequalitiesCauses, consequences & choices

Big inequalitiesBig inequalities inin CVDCVD burdenburden ofof diseasedisease

Inequalities in CVDInequalities in CVD

disease burdendisease burden

Poverty (Deprivation)Poverty (Deprivation)

DeprivationDeprivation & Heart Attack IncidenceHeart Attack Incidence

(patients(patients agedaged <65<65 Scotland 1990Scotland 1990--2000)2000)

2525

HospitalHospital admissionsadmissions Deaths by 30 daysDeaths by 30 days

55 PrePre--hospitalhospital

deathsdeaths00 (Deprived)(Deprived)(Affluent)(Affluent)

even

t rat

e pe

r 100

0ev

ent r

ate

per 1

000 2020

1515

1010

11 22 33 44 55

deprivation quintiledeprivation quintile MacIntyre et al BMJ 2000



AgeAge

MenMen && WomenWomen

CVD Patients: AGECVD Patients: AGE UK 2006

1

10

100

1000

10000

<34 35-44 45-54 55 -64 65-74 75-84 85+

MEN

Mortality rate/100,000 (log scale)

AGE (years)

CVD Patients:CVD Patients: SEXSEX & AGEAGE 10000

1000

Mortality rate/100,000

(log scale)

100

10

1

<34 35-44 45-54 55 -64 65-74 75-84 85+

UK 2006

MEN WOMEN

AGE(years)



GeographyGeography

North/South

Inequalities in

CVD

www.heartstats.org

SDR per 100000

Cardiovascular mortality (up to 65 years) in the WHO European RegionBig CVD inequalities across Europe

< 300 < 240 < 180 < 120 0 - 60 No data

Most recent data

….the main contributor to a 20 year difference in life expectancy across EU



TrendsTrends

Most Deprived

Inequality ratio = 1.9 Most Affluent

Inequality ratio = 1.7

EUROPE Total mortality INEQUALITIES (inequality ratios)

INEQUALITIES increased between 1980s and 1990s in many EU countries

Mackenbach et al. IJE 2003 32:830

Cardiovascular disease (CVD) risk factorsCardiovascular disease (CVD) risk factors

CVD InequalitiesCVD InequalitiesCauses, consequences & choicesCauses, consequences & choices

THIS TALKTHIS TALK

Big inequalitiesBig inequalities in CVD disease burdenin CVD disease burden

Big inequalitiesBig inequalities inin CVD risk factorsCVD risk factors

Choices for CVD preventionChoices for CVD prevention

CVD risk factorsCVD risk factors

MODIFIABLEMODIFIABLE


17.5

Five year CHD death ratesFive year CHD death rates inin

British menBritish men aged 35aged 35--6464 (British Regional Heart Study)

10.8

10

6

1111

66 44

22

Smokers NON-Smokers

High Cholesterol

Low Cholesterol

17

12

20

15

10

5

High Low High Low BP BP BP Blood Pressure

CVD causation pathways

Upstream

risk factors

Downstream

Risk factors


Upstream

risk factors

Downstream Risk factors

Smoking Blood Pressure Lipids Diabetes

CVD events

BMI


Upstream

risk factors

Diet Activity


CVD events Downstream

Risk factors

Obesity


Diet Obesity Activity


CVD events

Deprivation

Downstream risk factors

Upstream risk factors

GRADIENTS INGRADIENTS IN


GRADIENTS INGRADIENTS IN CVD risk factorsCVD risk factors

SMOKINGSMOKING

Smoking

Place &

Social Class

60

20

30

40

50

Trends in Cigarette smoking among womenAffluent & Deprived groups Britain, 1958-2000

Affluent

Deprived

0

10

1958 1978 1998

w omen-professional w omen-unsk manual Goddard 2008

Graham 2009

Socio-economic inequalities

• Five fold social gradients in premature CVD mortality rates

• Mostly explained by gradients in smoking & diet

& other pathways [stress, adrenaline etc]

Nigel Unwin

AffluentAffluent

DeprivedDeprived


Diet Obesity Activity


CVD RISK

Deprivation

Downstream risk factors

Upstream risk factors

Higher CVD risk in deprived groupsHigher CVD risk in deprived groupsProportion of men exceeding 10% risk of CVD death within one decProportion of men exceeding 10% risk of CVD death within one decade (Qrisk database)ade (Qrisk database)

Hippisley-Cox Heart 2007 Quintiles of the Townsend score DeprivedAffluent



THIS TALKTHIS TALK

Big inequalitiesBig inequalities in CVDin CVD

Big inequalities in CVD risk factorsBig inequalities in CVD risk factors

Choices for CVD preventionChoices for CVD prevention

CVD process:CVD process: in anin an individualindividual 100%100%

SurvivalSurvival

0%0% BirthBirth YouthYouth Middle AgeMiddle Age AgeAge (years)(years) ⇒⇒

Capewell et al 2009

AtheromaAtheromaArteryArtery ThrombosisThrombosis

NNaattuurraall CCoouurrssee ooff CCVVDD


SurvivalSurvival


Capewell et al 2009




SurvivalSurvival

First StrokeFirst Stroke oror Heart AttackHeart Attack


Capewell et al 2009




SurvivalSurvival

First StrokeFirst Stroke oror

NO SymptomsNO Symptoms Heart AttackHeart Attack

SymptomsSymptoms

SuddenSudden DeathDeath TypicalTypical Lucky (common) declinedecline

0%0% YouthYouthBirthBirth Middle AgeMiddle Age AgeAge (years)(years) ⇒⇒

Capewell et al 2009



SurvivalSurvival

First StrokeFirst Stroke oror

NO SymptomsNO Symptoms Heart AttackHeart Attack

SymptomsSymptoms Health servicesHealth servicesSecondary prevention

SuddenSudden DeathDeath TypicalTypical

declinedecline Lucky

(common) 0%0%

YouthYouthBirthBirth Middle AgeMiddle Age AgeAge (years)(years) ⇒⇒

Capewell et al 2009



SurvivalSurvival


Health servicesHealth services

Lucky

0%0% YouthYouthBirthBirth Middle AgeMiddle Age AgeAge (years)(years) ⇒⇒

SuddenSudden DeathDeath (common)

TypicalTypical declinedecline

NO SymptomsNO Symptoms

SymptomsSymptoms

PrimaryPrimary PreventionPrevention

Secondary prevention

DiseaseDisease PromotionPromotion

Capewell et al 2009

CVDCVD PreventionPrevention in ain a POPULATIONPOPULATION 100%100%

SurvivalSurvival


0%0%

70706060 AgeAge (years)(years) 8080 Natural Course of CVDNatural Course of CVD

AdvertisingAdvertising


Capewell et al 2009



SurvivalSurvival


0%0%

70706060 AgeAge (years)(years) 8080 MoreMore advertisingadvertising


Capewell et al 2009


SurvivalSurvival

DELAYED First StrokeDELAYED First Stroke Heart AttackHeart Attack

0%0%

70706060 AgeAge (years)(years) 8080 Natural Course of CVDNatural Course of CVD

AdvertisingAdvertising EgEg ⇑ tobacco controltobacco control

EFFECTIVEEFFECTIVE PrimaryPrimary PreventionPrevention oror

Capewell et al 2009


CVDCVD PreventionPrevention in ain a POPULATIONPOPULATION

EFFECTIVEEFFECTIVE PrimaryPrimary PreventionPrevention

HEALTHHEALTH PROTECTIONPROTECTION100%100% Eg byEg by tobaccotobacco oror saltsalt

legislationlegislationSurvivalSurvival

First StrokeFirst Stroke oror HeartHeart AttackAttack PREVENTEDPREVENTED

0%0% 70706060 AgeAge (years)(years) 8080

Capewell et al 2009

CVD prevention strategiesCVD prevention strategies •• High Risk Individual ApproachHigh Risk Individual Approach •• PopulationPopulation--based Approachbased Approach

CVD prevention approachesCVD prevention approaches

Prevalence %

30

Blood PressureBlood Pressure distribution in thedistribution in the populationpopulation

20

10

0

110110 130130120120 160160 Systolic BPSystolic BP

CVD prevention:CVD prevention: High risk individual approachHigh risk individual approach

Prevalence %

30

20

10

0


SBP >140SBP >140 mmHgmmHg


CVD prevention:CVD prevention: High risk individual approachHigh risk individual approach

Prevalence %

30

20

10

0


BP >140BP >140 mmHgmmHg

MedicationsMedications


PopulationPopulation--based CVD prevention strategybased CVD prevention strategy

Prevalence %

30

20

10

0

ShiftingShifting BloodBlood Pressure distributionPressure distribution


PopulationPopulation--based CVD prevention strategybased CVD prevention strategy

Prevalence %

30

Fewer BP >140Fewer BP >140 mmHgmmHg20

Less treatmentsLess treatments 10

0

ShiftingShifting BloodBlood Pressure distributionPressure distribution


WholeWhole--population approach forpopulation approach forpreventing CVD: successfulpreventing CVD: successful policiespolicies ––Farmers subsidies to stop dairy &Farmers subsidies to stop dairy &

beef , startbeef , start fruit & berry productionfruit & berry production (Finland)(Finland)

––Support food reformulationSupport food reformulation (All)(All)

WholeWhole--population approach forpopulation approach forpreventing CVD: successfulpreventing CVD: successful policiespolicies ––Farmers subsidies to stop dairy &Farmers subsidies to stop dairy &

beef , startbeef , start fruit & berry productionfruit & berry production (Finland)(Finland)

––Support food reformulationSupport food reformulation (All)(All)

––Banning transfatsBanning transfats (Denmark)(Denmark)

––Halving dietary saltHalving dietary salt (Finland)(Finland)

–– PromotingPromoting smokesmoke--freefree public spacespublic spaces (Ireland, UK ,Italy(Ireland, UK ,Italy etc))

Ireland: modelling reductions inIreland: modelling reductions in cardiovascular risk factorscardiovascular risk factors

Primary PreventionPrimary Prevention

Population Approach

⇓ Risk Factors in everyone

Versus

High Risk strategy

using statin & blood pressure medications

BMC Public Health 2007 7 117

Population secular BP

trends

TreatingHigh Risk

Blood Blood PressurePressure

CHD prevention in Ireland 1985-2000:

Population v. High Risk Strategies

Deaths prevented or postponed (Sensitivity analysis )

C h o l e s t e r o l

Population diet

change

High Risk

Statins

Diet change

in CHD

patients

BMC Public Health 2007 7 117

BMC Public Health. 2007; 7:117.

CHD prevention in Ireland 1985-2000:

Population v. High Risk Strategies

Deaths prevented or postponed (Sensitivity analysis )

High Risk TreatingPopulation

Statins Highsecular BP Population Diet trends Risk

diet changechange in BloodBlood

CHD patients PressurePressure

C h o l e s t e r o l BMC Public Health 2007 7 117

NICE Programme Development Group:NICE Programme Development Group: CVD prevention in populationsCVD prevention in populations

Will CVD preventionWill CVD preventionwidenwiden healthhealth inequalities?inequalities?

Simon CapewellSimon Capewell 2525th June 2009th June 2009

TheThe UK high risk approachUK high risk approach forfor preventing CVDpreventing CVD

UKUK Department of Health programme:Department of Health programme: NHS Health ChecksNHS Health Checks

TheThe UK high risk approachUK high risk approach forfor preventing CVDpreventing CVD

UKUK Department of Health programme:Department of Health programme: NHS Health ChecksNHS Health Checks –– All adults aged 40+All adults aged 40+ screenedscreened for CVD riskfor CVD risk –– If 20%+ risk CVD event in the nextIf 20%+ risk CVD event in the next

ten years, treat with:ten years, treat with:

•• lifestyle advice pluslifestyle advice plus •• tablets to reduce cholesterol & blood pressuretablets to reduce cholesterol & blood pressure

Evidence thatEvidence that high risk approachhigh risk approach may increase social inequalitiesmay increase social inequalities

Tudor HartTudor Hart’’ss ““Inverse Care LawInverse Care Law””

TugwellTugwell’’ss ““staircase effectstaircase effect””

J Tudor Hart . The inverJ Tudor Hart . The inverse care law. Lancet 1971;se care law. Lancet 1971; 1;1; 405.405. PP TugTugwwell; Bell; BMJ 20MJ 2006;06; 3333 2; 32; 35588


Tudor HartTudor Hart’’ss ““Inverse Care LawInverse Care Law””

•• The availability of good medical care tends toThe availability of good medical care tends to varyvary inverselyinversely with actual needwith actual need

TugwellTugwell’’ss ““staircase effectstaircase effect””Disadvantage can occur at every stage:Disadvantage can occur at every stage: –– Health beliefs, health behaviour,Health beliefs, health behaviour, presentationpresentation participation, persistence or adherenceparticipation, persistence or adherence

J Tudor Hart . The inverJ Tudor Hart . The inverse care law. Lancet 1971;se care law. Lancet 1971; 1;1; 405.405. PP TugTugwwell; Bell; BMJ 20MJ 2006;06; 3333 2; 32; 35588


PrescribingPrescribing gradientsgradients

Long term adherenceLong term adherence

Smoking cessationSmoking cessation

Nutrition interventions in individualsNutrition interventions in individuals

Oldroyd J. JECH 2008; 62:Oldroyd J. JECH 2008; 62:573. Thomsen R W,573. Thomsen R W, Br J Clin Pharm. 200Br J Clin Pharm. 2005; 60;534;5; 60;534;

Ashworth, M, QJof Amb CareAshworth, M, QJof Amb Care Management: 2008; 31; 220;Management: 2008; 31; 220;

VrijeVrijens B, BMJ 200ns B, BMJ 2008;338;336:16:1111144;; Morisky D.Morisky D. Clin HypertensionClin Hypertension 2008; 10; 3482008; 10; 348

JJoohnell K BMhnell K BMC PublicC Public HealtHealt hh 2005,2005, 5:5: 1717 Chaudhry HJ. Current Ather.Chaudhry HJ. Current Ather.

Rep 2008; 10; 19;Rep 2008; 10; 19; BoucBouchard MH, Br J Clin Pharmacol. 2007hard MH, Br J Clin Pharmacol. 2007 63(6)63(6): 69: 6988

Evidence thatEvidence that whole POPULATIONwhole POPULATION CVDCVD preventionprevention reducesreduces social inequalitiessocial inequalities

Kivimaki, MarmotKivimaki, Marmot et alet al Lancet 2008

15 year risk of CHD death15 year risk of CHD death •• calculated in British men aged 55calculated in British men aged 55 •• quantified the benefits of decreasing riskquantified the benefits of decreasing risk

factors uniformly across populationfactors uniformly across population [systolic blood pressure ⇓10mmHg total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ]

Evidence thatEvidence that whole POPULATIONwhole POPULATION CVDCVD preventionprevention reducesreduces social inequalitiessocial inequalities

Kivimaki, MarmotKivimaki, Marmot et alet al Lancet 2008

15 year risk of CHD death15 year risk of CHD death •• calculated in British men aged 55calculated in British men aged 55 •• quantified the benefits of decreasing riskquantified the benefits of decreasing risk

factors uniformly across populationfactors uniformly across population [systolic blood pressure ⇓10mmHg total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ]

•• WouldWould reducereduce thethe absoluteabsolute mortality gapmortality gapbetween affluent & deprived bybetween affluent & deprived by ≈≈70%70%

Evidence thatEvidence that whole POPULATIONwhole POPULATION CVDCVD preventionprevention reducesreduces social inequalitiessocial inequalities Diet interventionsDiet interventions •• Folic acid fortification of cerealsFolic acid fortification of cereals (USA population1996)(USA population1996)

DoDowdwd IJIJE 2008E 2008; 37; 37(5(5):):10105959

Evidence thatEvidence that whole POPULATIONwhole POPULATION CVDCVD preventionprevention reducesreduces social inequalitiessocial inequalities Diet interventionsDiet interventions Folic acid fortification of cerealsFolic acid fortification of cereals (USA population1996)(USA population1996)

Blood folate levels: Social gradientsBlood folate levels: Social gradients ⇓⇓⇓⇓ ≈≈ 70%70%

DoDowdwd IJIJE 2008E 2008; 37; 37(5(5):):10105959

Evidence thatEvidence that whole POPULATIONwhole POPULATION CVDCVD preventionprevention reducesreduces social inequalitiessocial inequalities SmokingSmoking•• cigarettecigarette price increasesprice increases more effective inmore effective in

TowTownnsensendd BMJ 1994;BMJ 1994; 309; 923309; 923deprived groupsdeprived groups ““increase inincrease in tobacco pricetobacco price may have the potentialmay have the potential

to reduce smoking related health inequalitiesto reduce smoking related health inequalities””

Main MetaMain Meta--analysis. Banalysis. BMMC Public Health 2008; 8; 178C Public Health 2008; 8; 178

CVD preventionCVD prevention & health inequalities& health inequalities VERDICTVERDICT

♥High Risk Strategies to screen & treat individuals typically widen social inequalities

CVD preventionCVD prevention & health inequalities& health inequalities VERDICTVERDICT

♥High Risk Strategies to screen & treat individuals typically widen social inequalities ♥Population wide policy interventions

usually narrow the inequalities gap

CVD population preventionCVD population prevention

⇒⇒ €€ COST SAVINGSCOST SAVINGS

CVD populationCVD population--wide preventionwide prevention

⇒⇒ €€ COST SAVINGSCOST SAVINGS

•• USAUSA Trust for AmericaTrust for America’’s Healths Health •• AustraliaAustralia AbelsonAbelson •• UKUK Wanless ReportWanless Report 20042004

(save(save €€ 4040 billion)billion) NICE GuidanceNICE Guidance 20102010 [Draft][Draft]

(save(save €€ 55 billionbillion –– €€1010 billionbillion))



Social InequalitiesSocial Inequalities

in CVDin CVD treatmentstreatments??

Deprived patients get less treatment Those who need most care get least care

Deprived patients get less treatment

Those who need most care get least care –– Management & drugsManagement & drugs (Roland 2009)(Roland 2009)

–– Referral from primary careReferral from primary care (Dixon; McBride & Raine)(Dixon; McBride & Raine)

–– UnderUnder--useuse ofof diagnosticsdiagnostics (H(Hippislippisley Cey Coox)x)

–– Less RevascularizationLess Revascularization BJGP 2000; 50: 449;BJGP 2000; 50: 449; BMJ 1997;BMJ 1997; 314: 257314: 257

–– Less rehabilitationLess rehabilitation

Deprived patients get less treatment

OLD patients get less treatment

WOMEN get less treatment



CVD Inequalities in UKCVD Inequalities in UK

HowHow bigbig are theare the inequalitiesinequalities inin YOURYOUR country??country??

CVD prevention in EUCVD prevention in EUWHATWHAT WE HAVE ACHIEVEDWE HAVE ACHIEVED •• European Heart Health CharterEuropean Heart Health Charter ((EHHC)EHHC)

•• Spanish Presidency Declaration 2002Spanish Presidency Declaration 2002

•• Council Conclusions 2004Council Conclusions 2004

CVD prevention in EUCVD prevention in EUWHATWHAT WE HAVE ACHIEVEDWE HAVE ACHIEVED •• European Heart Health Charter (European Heart Health Charter (EHHC)EHHC) •• Spanish Presidency Declaration 2002Spanish Presidency Declaration 2002 •• Council Conclusions 2004Council Conclusions 2004

WHATWHAT WE CAN DO NOWWE CAN DO NOW •• ⇑⇑ Tobacco ControlTobacco Control [[&& price]price] •• ⇑⇑ fruitfruit && vegetable consumptionvegetable consumption •• ⇓⇓ meatmeat && dairydairy [& HELP climate change][& HELP climate change] •• BanBan junk food advertisingjunk food advertising •• BanBan trans fatstrans fats

Cardiovascular disease risk factorsCardiovascular disease risk factors CVD InequalitiesCVD InequalitiesCauses, consequences & challengesCauses, consequences & challenges

CONCLUSIONSCONCLUSIONS Big CVD inequalitiesBig CVD inequalities burdenburden of diseasedisease

-- Social, Age, Sex, Place, EthnicitySocial, Age, Sex, Place, Ethnicity

Big inequalities in CVDBig inequalities in CVD risk factorsrisk factors

-- SmokingSmoking & DietDiet (Blood Pressure & Cholesterol)

Cardiovascular disease risk factorsCardiovascular disease risk factors CVD InequalitiesCVD InequalitiesCauses, consequences & choicesCauses, consequences & choices

CONCLUSIONSCONCLUSIONS Big CVD inequalitiesBig CVD inequalities burdenburden of diseasedisease

-- Social, Age, Sex, Place, EthnicitySocial, Age, Sex, Place, Ethnicity Big inequalities in CVDBig inequalities in CVD risk factorsrisk factors

-- SmokingSmoking & DietDiet (BP & Cholesterol)

Choices forChoices for CVD preventionCVD prevention:: --Individual approachIndividual approach ⇑⇑CVD InequalitiesCVD Inequalities⇑⇑

--Population approachPopulation approach ⇓⇓CVD InequalitiesCVD Inequalities⇓⇓

cardiovascular disease inequalities: causes and consequences

Health & Medicine

health inequalities

inequalities inequalities

risk cvd event

cvd risk factors choices

uk high risk approach

high risk strategiesdeaths

high risk approachmay

populationswill cvd