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Disparities in heart disease among British civil servants are not due to cardiac care differences

Low social position and South Asian ethnicity are both associated with increased risk of dying from coronary heart disease. Such potential health care disparities have stimulated calls in both the United States and the United Kingdom for remedial action. However, a recent study did not find a connection between either socioeconomic position or ethnicity with receipt of cardiac procedures or drugs. The study was supported in part by the Agency for Healthcare Research and Quality (HS06516).

Michael Marmot, M.B.B.S., M.P.H., Ph.D., and colleagues at the University College London Medical School prospectively studied 10,308 British civil servants (by employment grade), aged 35-55 at baseline (1985-1988) for over 15 years in the Whitehall II study. They compared the subjects' need for cardiac care (presence of angina, heart attack, and coronary risk factors) with receipt of care: exercise electrocardiography, coronary angiography, coronary revascularization procedures, and cardiac preventive medications (aspirin, beta-blockers, lipid lowering agents, or angiotensin converting enzyme inhibitors).

The researchers found no evidence that low social position (defined by employment grade) or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need. After adjustment for age, men in low employment grades had 66 percent higher incidence of angina and heart attack than men in high employment grades, and South Asian men (who were also less likely to be in a high employment grade) had a 95 percent higher incidence than white men. However, after adjustment for clinical need, social position showed no association with the use of cardiac procedures or secondary prevention drugs.

South Asian subjects were more likely than white participants to undergo cardiac procedures and to be taking more secondary prevention drugs, even after adjustment for clinical need. It may be that South Asian patients and their doctors are responding to widely held perceptions that these patients have an increased risk of heart disease with corresponding lower thresholds of action.

For details, see "Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study," by Annie Britton, Martin Shipley, Dr. Marmot, and Harry Hemingway, in the July 2004 British Medical Journal 329, pp. 318-323.

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