A socioeconomic gradient in coronary mortality is well established in developed countries, and is becoming increasingly apparent in low- and middle-income countries too.  Previously, it has not been clear to what extent the classical cardiovascular risk factors are responsible for this difference, nor indeed whether by treating them effectively it could be possible to balance out inequalities in cardiovascular disease.  Currently “best-practice” interventions can reduced systolic blood pressure by about 10mmHg, total cholesterol by 2mmol/L, blood glucose in pre-diabetics by 1mmol/L, and have halved the prevalence of non-insulin dependent diabetes mellitus in adults.

A prospective cohort of 17186 civil sevants in the UK (the Whitehall study) compared the potential reduction in excess coronary heart disease mortality in those of low versus high socioeconomic class (determined by employment grade) if best-practice interventions were successfully instigated, compared to the potential reduction if primordial prevention were possible (i.e the ability to lower risk factors to that of the majority of the population).

The 15-year absolute risk of death due to coronary heart disease per 100 men (standardised to age 55 years) was 11·0 for men in the low employment grade group and 7·5 for those in the high grade group. Using population-wide best-practice interventions would reduce coronary heart disease mortality by 57%, and the difference in mortality between socioeconomic groups by 69%. However, for primordial prevention, the corresponding reductions would be 73% and 86%, respectively.

This important paper demonstrates that proper implementation of our current best-practice interventions could go a long way towards reducing social inequalities in cardiovascular risk.  The challenge lies in finding the best way to deliver “best-practice intervention” to the appropriate sections of the population.

• Kivimäki M, Shipley MJ, Ferrie JE et al. Best-practice interventions to reduce socioeconomic inequalities of coronary heart disease mortality in UK: a prospective occupational cohort study. Lancet 2008; 372:1648-1654.
• Tobias M and Rodgers A. Can we eliminate inequalities in coronary disease? Absolutely. Lancet 2008; 372:1612-1613.