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Socioeconomic inequalities in cardiovascular disease: a causal perspective

Nature Reviews Cardiology volume 21, pages 238–249 (2024)Cite this article

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Abstract

Socioeconomic inequalities in cardiovascular disease (CVD) persist in high-income countries despite marked overall declines in CVD-related morbidity and mortality. After decades of research, the field has struggled to unequivocally answer a crucial question: is the association between low socioeconomic position (SEP) and the development of CVD causal? We review relevant evidence from various study designs and disciplinary perspectives. Traditional observational, family-based and Mendelian randomization studies support the widely accepted view that low SEP causally influences CVD. However, results from quasi-experimental and experimental studies are both limited and equivocal. While more experimental and quasi-experimental studies are needed to aid causal understanding and inform policy, high-quality descriptive studies are also required to document inequalities, investigate their contextual dependence and consider SEP throughout the lifespan; no simple hierarchy of evidence exists for an exposure as complex as SEP. The COVID-19 pandemic illustrates the context-dependent nature of CVD inequalities, with the generation of potentially new causal pathways linking SEP and CVD. The linked goals of understanding the causal nature of SEP and CVD associations, their contextual dependence, and their remediation by policy interventions necessitate a detailed understanding of society, its change over time and the phenotypes of CVD. Interdisciplinary research is therefore key to advancing both causal understanding and policy translation.

Key points

  • Socioeconomic disparities in cardiovascular disease (CVD) remain an important public health challenge; however, the causal nature of this association remains elusive.

  • Understanding causality is crucial for the generation of robust evidence and to inform policy.

  • Evidence from traditional observational, family-based and Mendelian randomization studies supports the generally well-accepted view that low socioeconomic position (SEP) causally influences CVD.

  • Results from quasi-experimental and experimental studies are mixed and often null, with few available studies; more evidence is required to improve causal understanding and inform policy.

  • No simple hierarchy of evidence exists for an exposure as complex as SEP; each study design has value, and a need remains both for more evidence across each study design and for studies that triangulate across multiple designs.

  • High-quality descriptive studies remain valuable to document associations and examine their contextual dependence; for example, the COVID-19 pandemic might have altered causal processes linking SEP and CVD.

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Fig. 1: Hazard ratios associated with various risk factors for CVD death.
Fig. 2: SEP across the life course.
Fig. 3: Associations between socioeconomic position and cardiovascular disease can be generated by causal links or by confounding or reverse causation.
Fig. 4: Cardiovascular disease outcomes.
Fig. 5: Links between the COVID-19 pandemic, SEP and CVD.

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Acknowledgements

The authors thank the following individuals for helpful comments on an earlier version of this manuscript: George Davey Smith (University of Bristol, UK), Alice Goisis (University College London, UK) and Emilie Courtin (London School of Economics, UK).

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Authors and Affiliations

  1. Centre for Longitudinal Studies, Social Research Institute, IOE, UCL’s Faculty of Education and Society, University College London, London, UK

    David Bann & Liam Wright

  2. MRC Unit for Lifelong Health & Ageing at UCL, Department of Population Science and Experimental Medicine, Institute of Cardiovascular Science, Faculty of Population Health Science, University College London, London, UK

    Alun Hughes & Nish Chaturvedi

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Bann, D., Wright, L., Hughes, A. et al. Socioeconomic inequalities in cardiovascular disease: a causal perspective. Nat Rev Cardiol 21, 238–249 (2024). https://doi.org/10.1038/s41569-023-00941-8

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