In exploring the relationship between cardiovascular disease and SES, the impact in utero of direct maternal deprivation53 and adverse child and adolescent living conditions have been explored as potential etiologies. Similarly occupational risks,55 educational bias, and genetic predisposition or selection have been examined. None of these effects have to date been examined specifically in relation to CHF.
Examining the remaining, as yet unproven contributions to the excess SES mortality in CHF is crucial. Risk factors are important, but to isolate these from a more global approach to coronary heart disease prevention seems futile. Key areas for future research in primary care should include:
Observing the effects of SES on health care providers’ behavior regarding diagnostic thresholds, treatments offered, and referral patterns (both elective and acutely) toward patients with CHF.
Examination of the equity of access to secondary care and to relevant investigations, such as echocardiography in communities from different socioeconomic groups.
Exploration of the behavior of patients with CHF in terms of consulting patterns and triggers, compliance, and the role of social stress.
Examination of the support available in the community to patients with CHF and perceptions of this support.
A more holistic approach to the problems of social deprivation and CHF, as outlined above, is necessary to inform future intervention strategies aimed at reducing the excess mortality from CHF. Simply pursuing the traditional approach of targeting risk factors, though important, will miss significant opportunities for intervention.
The authors would like to thank Professor Simon Capewell for his constructive advice during the writing of this paper.