Fornari et al. BMC Public Health 2010, 10:574 http://www.biomedcentral.com/1471-2458/10/574 R E S E A R C H A R T I C L E Open Access Social status and cardiovascular disease: a Mediterranean case. Results from the Italian Progetto CUORE cohort study Carla Fornari1, Chiara Donfrancesco2, Michele A Riva1, Luigi Palmieri2, Salvatore Panico3, Diego Vanuzzo4, Marco M Ferrario5, Lorenza Pilotto4, Simona Giampaoli2, Giancarlo Cesana1* Abstract Background: Social factors could offer useful information for planning prevention strategy for cardiovascular diseases. This analysis aims to explore the relationship between education, marital status and major cardiovascular risk factors and to evaluate the role of social status indicators in predicting cardiovascular events and deaths in several Italian cohorts. Methods: The population is representative of Italy, where the incidence of the disease is low. Data from the Progetto CUORE, a prospective study of cohorts enrolled between 1983-1997, were used; 7520 men and 13127 women aged 35-69 years free of previous cardiovascular events and followed for an average of 11 years. Educational level and marital status were used as the main indicators of social status. Results: About 70% of the studied population had a low or medium level of education (less than high school) and more than 80% was married or cohabitating. There was an inverse relationship between educational level and major cardiovascular risk factors in both genders. Significantly higher major cardiovascular risk factors were detected in married or cohabitating women, with the exception of smoking. Cardiovascular risk score was lower in married or cohabitating men. No relationship between incidence of cardiac events and the two social status indicators was observed. Cardiovascular case-fatality was significantly higher in men who were not married and not cohabitating (HR 3.20, 95%CI: 2.21-4.64). The higher cardiovascular risk observed in those with a low level of education deserves careful attention even if during the follow-up it did not seem to determine an increase of cardiac events. Conclusions: Preventive interventions on cardiovascular risk should be addressed mostly to people with less education. Cardiovascular risk score and case-fatality resulted higher in men living alone while cardiovascular factors were higher in women married or cohabitating. Such gender differences seem peculiar of our population and require further research on unexpected cultural and behavioural influences. Background In several studies social status, defined through various variables - education, occupation, income, etc - taken alone or together, were inversely associated with cardio- vascular disease (CVD ) [1,2]. In Italy this relationship has been reported in the North [3,4] and in the Centre of the country [5,6], but not in the South. * Correspondence: giancarlo.cesana@unimib.it 1Research Centre on Public Health, Department of Clinical and Preventive Medicine, University of Milano-Bicocca, Monza, Italy Full list of author information is available at the end of the article Among the most important indicators of social status are education and marital status. Higher educational levels resulted protective against all causes of mortality [1] and circulatory events [7]. Various studies reported an inverse gradient in incidence and mortality for cor- onary and stroke events by educational level [8-11]. The lower cardiovascular risk in people with a higher level of education is usually explained as a result of the role that education plays in understanding and achieving healthy lifestyles. © 2010 Fornari et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.