Excluding deprivation from heart disease risk is jeopardising thousands of lives

[By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease. Heart 2005; online first]

Leaving deprivation out of standard risk assessments for heart disease is potentially denying life saving preventive treatment to those who need it most, reveals research published ahead of print in Heart.

A person’s estimated chances of developing heart disease, and being allocated “primary preventive” treatment, is currently calculated using the standard risk factors of smoking, blood pressure, cholesterol, age, sex, and diabetes. These are typically pulled together in the internationally used Framingham Risk Score.

Deprivation is excluded, despite known links between poverty and poor health, because definitions of deprivation vary so much, making international standardisation difficult.

The authors, from the Cardiovascular Epidemiology Unit at the University of Dundee, tracked the progress of 13,000 healthy Scottish men and women over a period of 10 years to March 1997, recording deaths and episodes of hospital treatment. All the participants were aged between 30 and 74 at the start of the study,

A new deprivation score – the Scottish Index of Multiple Deprivation (SIMD) – covering 31 indicators from income to access to services, based on areas of residence, was applied retrospectively to the data.

Using the SIMD, the authors compared “observed risk” of death/illness from heart disease with “expected risk”, estimated using the Framingham score.

Expected risk showed a modest difference between the most and least deprived sectors of the study population, while observed risk revealed a very steep difference, which was fivefold in women.

As in other recent studies using the Framingham score, observed risk was lower than expected overall. But the most deprived 20% determined by the SIMD had twice the ratio of observed to expected risk of that in the least deprived 20%.

In other words, the Framingham score would allocate them only half as much primary preventive treatment in proportion to their future level of disease.

The authors estimate that being in the most deprived 20% rather than the least deprived 20% is broadly equivalent to being 10 years older or having diabetes. And they call for guidelines on primary prevention to be adjusted to take account of deprivation.

Current standards for risk assessment will widen health inequalities between social groups, by discriminating against the most needy, so potentially jeopardising thousands of lives, they claim.