Future trends and inequalities in premature coronary deaths in England: Modelling study

Coronary heart disease (CHD) is a major cause of premature mortality, particularly in deprived groups. Might recent declines in overall mortality obscure different rates of decline among social strata, creating potentially misleading views on inequalities?

We used a Bayesian analysis of an age-period-cohort model for the English population. We projected age-specific premature CHD mortality (ages 35-74) by gender and area-based deprivation status for the period 2007-2035, using 1982-2006 as the input. Deprivation status was measured by Index of Multiple Deprivation quintiles, which aggregate seven types of deprivation, including health and income. We analysed inequality in premature CHD mortality. We investigated the annual changes in inequality and the contributions of changes in each IMDQ to the overall annual changes, using both absolute (probability) and relative (logit) scales. We quantified inequality using the statistical variance in the probability of premature death among deprivation quintiles.

The overall premature CHD mortality trends conceal marked heterogeneities. Our models predict more rapid declines in premature CHD mortality for the most affluent quintiles than for the most deprived (annualized rate of decline 2006-2025, 7.5% [95% Credible Interval 4.3-10.5%] versus 5.4% [2.2-8.7%] for men, and 6.3% [3.0-9.9%] versus 5.9% [1.5-10.8%] for women). For men, the posterior probability that the rate of decline is greater for the most affluent was 82%. Variance in premature CHD mortality across deprivation quintiles was projected to decrease by approximately 81% [28-95%] among men and by 89% [30-99%] among women. This decrease was particularly driven by the most deprived groups due to their higher premature death rates. However, relative inequality was projected to rise by 93% among men [81-125%] and rise by 13% [-25-58%] among women. These increases are also mostly influenced by the most deprived, reflecting their slower declines in premature deaths.

Overall, premature coronary death rates in England continue to decline steeply. Absolute inequalities are decreasing, reflecting declines in the high premature mortality in deprived groups. However, relative inequalities are projected to widen further, reflecting slower mortality declines in the most deprived groups. More aggressive and progressive prevention policies are urgently needed.