Diez-Roux A V, Nieto F J, Tyroler H A, Crum L D, Szklo M
Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
Am J Epidemiol. 1995 May 15;141(10):960-72. doi: 10.1093/oxfordjournals.aje.a117363.
The cross-sectional associations of social class indicators with coronary heart disease prevalence and subclinical atherosclerosis were investigated among 15,800 persons from four US communities between 1987 and 1989. Among persons without clinical atherosclerotic disease, ultrasound-determined intimal-medial wall thickening of the carotid arteries was used as an indicator of subclinical atherosclerosis. Odds ratios for coronary heart disease prevalence and mean differences in carotid wall thickness were investigated before and after adjustment for cardiovascular risk factors. After adjustment for age and gender, the lowest income category was associated with a threefold increase in coronary heart disease odds compared with the highest category (for whites, odds ratio (OR) = 3.4, 95% confidence interval (CI) 1.8-6.6; for blacks, OR = 3.2, 95% CI 2.2-4.8). Odds ratios increased linearly with decreasing income (p < 0.0001). Low education was also associated with increased odds of coronary heart disease after adjustment for age and gender, but the association was stronger in whites than in blacks (lowest category vs. highest: for whites, OR = 3.8, 95% CI 2.5-5.9; for blacks, OR = 1.7, 95% CI 0.9-3.1). Similar patterns were found for subclinical atherosclerosis: Carotid wall thickness increased with decreasing income and education, but trends by education were clearer in whites than in blacks. Lower occupational categories were also associated with increased coronary heart disease prevalence odds and increased carotid wall thickness. After adjustment for risk factors, associations with clinical coronary heart disease persisted but associations with carotid wall thickness disappeared, suggesting that factors related to the clinical expression of lesions may vary by social class. The process of atherogenesis and its clinical expression are patterned by social class, emphasizing the need to address social inequalities in the prevention of cardiovascular disease.
1987年至1989年间，在来自美国四个社区的15,800人中，研究了社会阶层指标与冠心病患病率和亚临床动脉粥样硬化之间的横断面关联。在无临床动脉粥样硬化疾病的人群中，超声测定的颈动脉内膜中层增厚用作亚临床动脉粥样硬化的指标。在对心血管危险因素进行调整前后，研究了冠心病患病率的比值比和颈动脉壁厚度的平均差异。调整年龄和性别后，与最高收入类别相比，最低收入类别患冠心病的几率增加了两倍（白人的比值比（OR）= 3.4，95%置信区间（CI）1.8 - 6.6；黑人的OR = 3.2，95% CI 2.2 - 4.8）。比值比随收入降低呈线性增加（p < 0.0001）。调整年龄和性别后，低教育水平也与冠心病几率增加相关，但白人中的关联比黑人更强（最低类别与最高类别相比：白人的OR = 3.8，95% CI 2.5 - 5.9；黑人的OR = 1.7，95% CI 0.9 - 3.1）。亚临床动脉粥样硬化也发现了类似模式：颈动脉壁厚度随收入和教育程度降低而增加，但教育程度的趋势在白人中比在黑人中更明显。较低的职业类别也与冠心病患病率几率增加和颈动脉壁厚度增加相关。调整危险因素后，与临床冠心病的关联仍然存在，但与颈动脉壁厚度的关联消失，这表明与病变临床表现相关的因素可能因社会阶层而异。动脉粥样硬化的发生过程及其临床表现因社会阶层而异，强调在预防心血管疾病中解决社会不平等问题的必要性。
