Does Socioeconomic Status Influence the Risk of Subclinical Atherosclerosis? A Mediation Model

Lidia Redondo-Bravo, Juan Miguel Fernández-Alvira, Juan Górriz, José María Mendiguren, Javier Sanz, Leticia Fernández-Friera, José Manuel García-Ruiz, Antonio Fernández-Ortiz, Borja Ibáñez, Héctor Bueno, Valentín Fuster

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16 Scopus citations


Background: Socioeconomic status (SES)—education, income level, and occupation—is associated with cardiovascular risk. Objectives: This study aimed to investigate the association between SES and subclinical atherosclerosis and the potential mechanisms involved. Methods: SES, lifestyle habits (smoking, dietary patterns, physical activity, and hours of sleep), traditional risk factors, and subclinical atherosclerosis extent were prospectively assessed in 4,025 individuals aged 40 to 54 years without known cardiovascular disease enrolled in the PESA (Progression of Early Subclinical Atherosclerosis) study. After factors associated with atherosclerosis were identified, a multiple mediation model was created to quantify the effect of SES on subclinical atherosclerosis as explained by lifestyle behaviors. Results: Although education level was significantly associated with the presence of atherosclerosis, no differences were found according to income level in this population. Participants with lower education presented with a higher risk of generalized atherosclerosis than those with higher education (odds ratio: 1.46; 95% confidence interval: 1.15 to 1.85; p = 0.002). Lifestyle behaviors associated with both education level and atherosclerosis extent were: smoking status, number of cigarettes/day, and dietary pattern, which explained 70.5% of the effect of SES on atherosclerosis. Of these, tobacco habit (smoking status 35% and number of cigarettes/day 32%) accounted for most of the explained differences between groups, whereas dietary pattern did not remain a significant mediator in the multiple mediation model. Conclusions: Despite the relative economic homogeneity of the cohort, lower education level is associated with increased subclinical atherosclerosis, mainly mediated by the higher and more frequent tobacco consumption. Smoking cessation programs are still needed, particularly in populations with lower education level.

Original languageEnglish
Pages (from-to)526-535
Number of pages10
JournalJournal of the American College of Cardiology
Issue number4
StatePublished - 30 Jul 2019


  • atherosclerosis
  • education
  • mediation model
  • smoking
  • socioeconomic status


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