A global perspective on cardiovascular risk factor management in patients with CHD and different educational level: SURF CHD II
Authors: Marza Florensa A , Vaartjes I , Klipstein-Grobusch K , Graham I , Grobbee D E 
Published: November 2023

Abstract

Background
Clinical guidelines recommend that patients with established coronary heart disease (CHD) change health behaviors and use medication to control risk factors (RF), eventually reducing cardiovascular risk. Nevertheless, RF management in daily practice is challenging and RF control in secondary prevention remains suboptimal. Patients with low educational level tend to have higher cardiovascular risk. This association varies indifferent contexts, yet research on health inequalities in secondary prevention has focused mostly on high-income countries.

Purpose
To provide a global picture of health inequalities in RF management in secondary prevention of CHD, by assessing RF recording, target attainment, and treatment by educational level in patients from four world regions.

Methods
The Survey of Risk Factors in Coronary Heart Disease (SURF CHD) II is a clinical audit on RF management, undertaken in patients with CHD during routine outpatient visits. The survey is easy to perform, allowing its use in low-resource centers.
We studied RF recording (data availability), attainment of targets defined by guidelines, and treatment (medication and cardiac rehabilitation). RF included smoking, physical activity, waist circumference, blood pressure, LDL, non-HDL cholesterol, triglycerides, and Hba1c (among diabetics).
We reported the % of recording, target attainment and treatment in patients with primary/secondary schooling and in those with tertiary education. We assessed differences in RF management by educational level with logistic regression adjusted by age and sex, and stratified by region.

Results
13884 patients were enrolled in 29 countries in Europe (N=10255), South-East Asia (SEA) (N=2290), the Americas (N=779) and North Africa and Eastern Mediterranean (N=560). 47.0% of participants had tertiary education, 34.5% had secondary schooling, and 18.6% primary schooling.
RF recording ranged from 22.2% (waist circumference) to 93.0% (blood pressure); target attainment from 15.9% (waist circumference) to 76.9% (smoking). 50.5% participated in cardiac rehabilitation.
RF information was collected more often in highly educated patients for most RF in the Americas, and for blood pressure and HBa1c in SEA. BMI and waist circumference were more frequently registered among lower-educated participants in Europe and SEA.
Highly educated patients were more likely to meet RF targets for smoking in most regions, physical activity in Americas and Europe, LDL in SEA, and Non-HDL cholesterol and Hba1c in SEA and Americas regions. Patients with higher education participated more often in cardiac rehabilitation in all regions except SEA (Figure 1).

Conclusions
Health inequalities persist in secondary prevention of CHD: highly educated patients are generally more likely to have RF information recorded, have RF levels on target and attend cardiac rehabilitation. However, these associations present specific patterns by RF and region.