Identification and ranking of cardiovascular diseases risk factors with MICMAC managerial approach

Document Type : Original Article

Authors

1 Assistant Professor of Healthcare Services Management,School of Health, Jiroft University of Medical Sciences, Jiroft, Iran

2 PhD in Human Resource Management, Human Resource Manager, Shiraz University of Medical Sciences, Shiraz, Iran

3 Ph.D. Health Services Management, Student Research Committee, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran

4 4. Ph.D. Health Economics, Health Management and Economics Researcher Center, Iran University of Medical Sciences Tehran, Iran

5 Associate Professor, Health Human Resources Research Center, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran

6 Assistant professor, Tabriz Health Services Management Research Center. Tabriz University of Medical Sciences, Tabriz, Iran

Abstract

Introduction: Cardiovascular diseases are one of the most important causes of mortality worldwide, and their prevention needs recognition of the factors affecting its occurrence and prospective planning. The aim of this study was to identify and rank the risk factors of cardiovascular diseases using MICMAC managerial approach.
Methods: The present study was conducted in two phases. In the first phase, a comprehensive overview of cardiovascular disease risk factors was performed. In the second phase, the identified factors were ranked using MICMAC managerial approach.
Results: In the literature review, 16 cardiovascular diseases risk factors including stress, anxiety and depression, nutrition and an unhealthy diet, low physical activity, smoking and drug consumption, hypertension, high blood lipids, overweight and obesity, age, gender, diabetes, family history, alcohol consumption, air and noise pollution, socioeconomic status, ethnicity and race and genetic factors were identified. According to the MICMAC approach and direct effects, three factors including unhealthy diet, obesity, and socioeconomic status were ranked first to third, as the most influential risk factors of cardiovascular diseases, respectively.
Conclusion: According to the findings and focusing on the three factors of unhealthy diet, obesity and economic and social status, appropriate educational interventions, notification, and awareness raising among the community using the mass media are suggested.
 

Keywords


1. World Health Organization [internet]. Nonommunicable disease. WHO. [Cited 2017 Apr 17]. Available from: http://www.who.int/ mediacenter/factsheets/fs355/en.
2. Guallar E, Banegas JR, Blasco-Colmenares E, Jimenez FJ, Dallongeville J, Halcox JP, et al. Excess risk attributable to traditional cardiovascular risk factors in clinical practice settings across Europe - The EURIKA Study. BMC Public Health. 2011;11:704. doi: 10.1186/1471-2458-11-704.
3. Alwan A. Global status report on noncommunicable diseases Geneva: World Health Organization; 2011.
4. Mattu HS, Randeva HS. Role of adipokines in cardiovascular disease. J Endocrinol. 2013;216(1):T17-36. doi: 10.1530/JOE-12 0232.
5. Parsamehr M, Afshani A, Nikoo F. Relationship between anxiety and depression with quality of life after coronary artery bypass graft. Iran Journal of Nursing. 2015;28(93):106-17.
6. Kivimaki M, Kawachi I. Work Stress as a Risk Factor for Cardiovascular Disease. Curr Cardiol Rep. 2015;17(9):630. doi: 10.1007/s11886-015- 0630-8.
7. Yu S, Li K, Yang Y, Gu G, Ma L, Duan X. The relationship between occupational stress and cardiovascular disease risk factor. Zhonghua lao dong wei sheng zhi ye bing za zhi= Zhonghua laodong weisheng zhiyebing zazhi= Chinese journal of industrial hygiene and occupational diseases. 2003;21(1):12-5.
8. Kade G, Wierzbicki P, Kade E. Stress as a risk factor for cardiovascular disease. Polski merkuriusz lekarski: organ Polskiego Towarzystwa Lekarskiego. 2000;9(54):864-5.
9. Turk-Adawi K, Sarrafzadegan N, Fadhil I, Taubert K, Sadeghi M, Wenger NK, et al. Cardiovascular disease in the Eastern Mediterranean region: epidemiology and risk factor burden. Nat Rev Cardiol. 2018;15(2):106-19. doi: 10.1038/ nrcardio.2017.138.
10. Huffman JC, Celano CM, Beach SR, Motiwala SR, Januzzi JL. Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. Cardiovasc Psychiatry Neurol. 2013;2013:695925. doi: 10.1155/2013/695925.
11. Cohen BE, Edmondson D, Kronish IM. State of the Art Review: Depression, Stress, Anxiety, and Cardiovascular Disease. Am J Hypertens. 2015;28(11):1295-302. doi: 10.1093/ajh/hpv047.
12. Suls J, Bunde J. Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Psychol Bull. 2005;131(2):260-300. doi: 10.1037/0033-2909.131.2.260.
13. Fung TT, Rimm EB, Spiegelman D, Rifai N, Tofler GH, Willett WC, et al. Association between dietary patterns and plasma biomarkers of obesity and cardiovascular disease risk. Am J Clin Nutr. 2001;73(1):61-7. doi: 10.1093/ajcn/73.1.61.
14. Forman D, Bulwer BE. Cardiovascular disease: optimal approaches to risk factor modification of diet and lifestyle. Curr Treat Options Cardiovasc Med. 2006;8(1):47-57. doi: 10.1007/s11936-006- 0025-7.
15. Arauz A, Monge R, Munoz L, Rojas M. Diet as a risk factor for cardiovascular disease in residents of the metropolitan area, San Jose, Costa Rica. Archivos Latinoamericanos de Nutricion. 1991;41(3):350-62.
16. Frank GC, Berenson GS, Webber LS. Dietary studies and the relationship of diet to cardiovascular disease risk factor variables in 10-year-old children--The Bogalusa Heart Study. Am J Clin Nutr. 1978;31(2):328-40. doi: 10.1093/ ajcn/31.2.328.
17. McRae MP. Dietary Fiber Is Beneficial for the Prevention of Cardiovascular Disease: An Umbrella Review of Meta-analyses. J Chiropr Med. 2017;16(4):289-99. doi: 10.1016/j.jcm.2017.05.005.
18. Barker AR, Gracia-Marco L, Ruiz JR, Castillo MJ, Aparicio-Ugarriza R, Gonzalez-Gross M, et al. Physical activity, sedentary time, TV viewing, physical fitness and cardiovascular disease risk in adolescents: The HELENA study. Int J Cardiol. 2018;254:303-9. doi: 10.1016/j.ijcard.2017.11.080.
19. Hamer M, O’Donovan G, Murphy M. Physical Inactivity and the Economic and Health Burdens Due to Cardiovascular Disease: Exercise as Medicine. Adv Exp Med Biol. 2017;999:3-18. doi: 10.1007/978-981-10-4307-9_1.
20. Minneboo M, Lachman S, Snijder MB, Vehmeijer JT, Jorstad HT, Peters RJ. Risk factor control in secondary prevention of cardiovascular disease: results from the multi-ethnic HELIUS study. Neth Heart J. 2017;25(4):250-7. doi: 10.1007/ s12471-017-0956-5.
21. Erhardt L. Cigarette smoking: an undertreated risk factor for cardiovascular disease. Atherosclerosis. 2009;205(1):23-32. doi: 10.1016/j. atherosclerosis.2009.01.007.
22. Lubin JH, Couper D, Lutsey PL, Woodward M, Yatsuya H, Huxley RR. Risk of Cardiovascular Disease from Cumulative Cigarette Use and the Impact of Smoking Intensity. Epidemiology. 2016;27(3):395-404. doi: 10.1097/ EDE.0000000000000437.
23. Morris PB, Ference BA, Jahangir E, Feldman DN, Ryan JJ, Bahrami H, et al. Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology. J Am Coll Cardiol. 2015;66(12):1378-91. doi: 10.1016/j. jacc.2015.07.037.
24. Leone A. Relationship between cigarette smoking and other coronary risk factors in atherosclerosis: risk of cardiovascular disease and preventive measures. Curr Pharm Des. 2003;9(29):2417-23. doi: 10.2174/1381612033453802.
25. Wang J, Shi X, Ma C, Zheng H, Xiao J, Bian H, et al. Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: a systematic review and meta-analysis. J Hypertens. 2017;35(1):10-7. doi: 10.1097/HJH.0000000000001159.
26. Hadaegh F, Mohebi R, Khalili D, Hasheminia M, Sheikholeslami F, Azizi F. High normal blood pressure is an independent risk factor for cardiovascular disease among middle-aged but not in elderly populations: 9-year results of a population-based study. J Hum Hypertens. 2013;27(1):18-23. doi: 10.1038/jhh.2011.112.
27. Chen Z, Zhang M, Li Y, Zhao Z, Zhang X, Huang Z, et al. Study on relationship between prevalence or co-prevalence of risk factors for cardiovascular disease and blood pressure level in adults in China. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi. 2018;39(5):640-5.
28. Bundy JD, Li C, Stuchlik P, Bu X, Kelly TN, Mills KT, et al. Systolic Blood Pressure Reduction and Risk of Cardiovascular Disease and Mortality: A Systematic Review and Network Meta-analysis. JAMA Cardiol. 2017;2(7):775-81. doi: 10.1001/ jamacardio.2017.1421.
29. Ma W, Zhang B, Yang Y, Qi L, Meng L, Zhang Y, et al. Correlating the relationship between interarm systolic blood pressure and cardiovascular disease risk factors. J Clin Hypertens (Greenwich). 2017;19(5):466-71. doi: 10.1111/jch.12987.
30. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Executive summary: heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013;127(1):143-52. doi: 10.1161/ CIR.0b013e318282ab8f.
31. Scherr C, Magalhaes CK, Malheiros W. Lipid profile analysis in school children. Arq Bras Cardiol. 2007;89(2):65-70, 3-8. doi: 10.1590/ s0066-782x2007001400001.
32. Hopkins PN, Wu LL, Hunt SC, Brinton EA. Plasma triglycerides and type III hyperlipidemia are independently associated with premature familial coronary artery disease. J Am Coll Cardiol. 2005;45(7):1003-12. doi: 10.1016/j. jacc.2004.11.062.
33. Masaki KH, Curb JD, Chiu D, Petrovitch H, Rodriguez BL. Association of body mass index with blood pressure in elderly Japanese American men. The Honolulu Heart Program. Hypertension. 1997;29(2):673-7. doi: 10.1161/01. hyp.29.2.673.
34. Mansfield E, McPHERSON R, Koski KG. Diet and waist-to-hip ratio: important predictors of lipoprotein levels in sedentary and active young men with no evidence of cardiovascular disease. Journal of the American Dietetic Association. 1999;99(11):1373-9. doi: 10.1016/S0002- 8223(99)00335-1.
35. Mandviwala T, Khalid U, Deswal A. Obesity and Cardiovascular Disease: a Risk Factor or a Risk Marker? Curr Atheroscler Rep. 2016;18(5):21. doi: 10.1007/s11883-016-0575-4.
36. Lizicarova D, Hirnerova E, Krahulec B. [Obesity the risk factor of cardiovascular disease in patients with chronic kidney disease?]. Vnitr Lek. 2010;56(10):1088-92.
37. Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009;53(21):1925-32. doi: 10.1016/j. jacc.2008.12.068.
38. Monraats PS. Obesity as a global risk factor for cardiovascular disease: Stockholm, 5 September 2005. Neth Heart J. 2005;13(Suppl 2):18-9.
39. Rao SV, Donahue M, Pi-Sunyer FX, Fuster V. Results of Expert Meetings: Obesity and Cardiovascular Disease. Obesity as a risk factor in coronary artery disease. Am Heart J. 2001;142(6):1102-7. doi: 10.1067/mhj.2001.119419.
40. Moebus S, Balijepalli C, Losch C, Gores L, von Stritzky B, Bramlage P, et al. Age- and sex-specific prevalence and ten-year risk for cardiovascular disease of all 16 risk factor combinations of the metabolic syndrome - A cross-sectional study. Cardiovasc Diabetol. 2010;9:34. doi: 10.1186/1475- 2840-9-34.
41. Subramanian U, Schmittdiel JA, Gavin N, Traylor A, Uratsu CS, Selby JV, et al. The association of patient age with cardiovascular disease risk factor treatment and control in diabetes. J Gen Intern Med. 2009;24(9):1049-52. doi: 10.1007/ s11606-009-1059-9.
42. Sniderman AD, Furberg CD. Age as a modifiable risk factor for cardiovascular disease. Lancet. 2008;371(9623):1547-9. doi: 10.1016/S0140- 6736(08)60313-X.
43. Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, Beiser A, Wilson PW, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006;113(6):791-8. doi: 10.1161/ CIRCULATIONAHA.105.548206.
44. Tabenkin H, Eaton CB, Roberts MB, Parker DR, McMurray JH, Borkan J. Differences in cardiovascular disease risk factor management in primary care by sex of physician and patient. Ann Fam Med. 2010;8(1):25-32. doi: 10.1370/afm.1071.
45. Winston GJ, Barr RG, Carrasquillo O, Bertoni AG, Shea S. Sex and racial/ethnic differences in cardiovascular disease risk factor treatment and control among individuals with diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care. 2009;32(8):1467-9. doi: 10.2337/ dc09-0260.
46. Kreatsoulas C, Natarajan MK, Khatun R, Velianou JL, Anand SS. Identifying women with severe angiographic coronary disease. J Intern Med. 2010;268(1):66-74. doi: 10.1111/j.1365- 2796.2009.02210.x.
47. Chiha J, Mitchell P, Gopinath B, Plant AJH, Kovoor P, Thiagalingam A. Gender differences in the severity and extent of coronary artery disease. Int J Cardiol Heart Vasc. 2015;8:161-6. doi: 10.1016/j.ijcha.2015.07.009.
48. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectivenessbased guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the american heart association. Circulation. 2011;123(11):1243-62. doi: 10.1161/ CIR.0b013e31820faaf8.
49. Hosseini SA, Salehi A. The relationship between coronary risk factors and coronary artery involvement based on angiogrpahy findings. Koomesh. 2012;14(1):7-12.
50. Mousavinasab N, Yazdani Cherat J, Bagheri B, Bakhti F-s, Bakhti Z. Identifying the risk factors for cardiovascular disease in individuals aged above 35 years using logistic regression model. Journal of Mazandaran University of Medical Sciences. 2017;26(144):50-6.
51. Veeranna V, Pradhan J, Niraj A, Fakhry H, Afonso L. Traditional cardiovascular risk factors and severity of angiographic coronary artery disease in the elderly. Prev Cardiol. 2010;13(3):135-40. doi: 10.1111/j.1751-7141.2009.00062.x.
52. Banerjee A. A review of family history of cardiovascular disease: risk factor and research tool. Int J Clin Pract. 2012;66(6):536-43. doi: 10.1111/j.1742-1241.2012.02908.x.
53. de Giorgis T, Giannini C, Scarinci A, D’Adamo E, Agostinelli S, Chiarelli F, et al. Family history of premature cardiovascular disease as a sole and independent risk factor for increased carotid intima-media thickness. J Hypertens. 2009;27(4):822-8. doi: 10.1097/ HJH.0b013e328325d81b.
54. Hoseini K, Sadeghian S, Mahmoudian M, Hamidian R, Abbasi A. Family history of cardiovascular disease as a risk factor for coronary artery disease in adult offspring. Monaldi Arch Chest Dis. 2008;70(2):84-7. doi: 10.4081/monaldi.2008.427. 55. Polsky S, Akturk HK. Alcohol Consumption, Diabetes Risk, and Cardiovascular Disease Within Diabetes. Curr Diab Rep. 2017;17(12):136. doi: 10.1007/s11892-017-0950-8.
56. Johnston-Cox H, Mather PJ. Cardiovascular Disease and Alcohol Consumption. Am J Med Sci. 2018;355(5):409-10. doi: 10.1016/j. amjms.2018.01.016.
57. Braillon A. Alcohol: Cardiovascular Disease and Cancer. J Am Coll Cardiol. 2018;71(5):582-3. doi: 10.1016/j.jacc.2017.10.096.
58. Lidal IB, Denison E, Mathisen M. Relationships Between Intake of Alcohol and Cardiovascular Disease. Oslo: NIPH Systematic Reviews: Executive Summaries; 2013.
59. VanWagner LB, Ning H, Allen NB, Ajmera V, Lewis CE, Carr JJ, et al. Alcohol Use and Cardiovascular Disease Risk in Patients
With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2017;153(5):1260-72 e3. doi: 10.1053/j.gastro.2017.08.012.
60. Mukamal K, Lazo M. Alcohol and cardiovascular disease. BMJ. 2017;356:j1340. doi: 10.1136/bmj. j1340.
61. Kalla A, Figueredo VM. Alcohol and cardiovascular disease in the geriatric population. Clin Cardiol. 2017;40(7):444-9. doi: 10.1002/ clc.22681.
62. Toma A, Pare G, Leong DP. Alcohol and Cardiovascular Disease: How Much is Too Much? Curr Atheroscler Rep. 2017;19(3):13. doi: 10.1007/ s11883-017-0647-0.
63. Krzyzanowski M, Cohen A, Anderson R, Group WHOW. Quantification of health effects of exposure to air pollution. Occup Environ Med. 2002;59(12):791-3. doi: 10.1136/oem.59.12.791.
64. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health. 1992;82(6):816-20. doi: 10.2105/ajph.82.6.816.
65. Gregory CO, Dai J, Ramirez-Zea M, Stein AD. Occupation is more important than rural or urban residence in explaining the prevalence of metabolic and cardiovascular disease risk in Guatemalan adults. J Nutr. 2007;137(5):1314-9. doi: 10.1093/jn/137.5.1314.
66. Carson AP, Rose KM, Catellier DJ, Diez-Roux AV, Muntaner C, Wyatt SB. Employment status, coronary heart disease, and stroke among women. Ann Epidemiol. 2009;19(9):630-6. doi: 10.1016/j.annepidem.2009.04.008.
67. Potvin L, Richard L, Edwards AC. Knowledge of cardiovascular disease risk factors among the Canadian population: relationships with indicators of socioeconomic status. Cmaj. 2000;162(9 suppl):S5-S11.
68. Stelmach W, Kaczmarczyk-Chalas K, Bielecki W, Drygas W. How education, income, control over life and life style contribute to risk factors for cardiovascular disease among adults in a post-communist country. Public Health. 2005;119(6):498-508. doi: 10.1016/j. puhe.2004.09.006.
69. Moise N, Bertoni AG. Invited Commentary: Sex and Race Differences in Diabetes and Cardiovascular Disease-Achieving the Promise of Sex and Race Subgroup Analyses in Epidemiologic Research. Am J Epidemiol. 2018;187(3):411-4. doi: 10.1093/aje/kwx327.
70. Emerson KG, Gay J. Physical Activity and Cardiovascular Disease Among Older Adults: The Case of Race and Ethnicity. J Aging Phys Act. 2017;25(4):505-9. doi: 10.1123/japa.2016-0012.
71. Bell CN, Thorpe RJ, Jr., Bowie JV, LaVeist TA. Race disparities in cardiovascular disease risk factors within socioeconomic status strata. Ann Epidemiol. 2018;28(3):147-52. doi: 10.1016/j. annepidem.2017.12.007.
72. Khoja SO, Miedany YE, Iyer AP, Bahlas SM, Balamash KS, Elshal MF. Association of Paraoxonase 1 Polymorphism and Serum 25-Hydroxyvitamin D with the Risk of Cardiovascular Disease in Patients with Rheumatoid Arthritis. Clin Lab. 2017;63(11):1841- 9. doi: 10.7754/Clin.Lab.2017.170609.
73. Simeoni E, Winkelmann BR, Hoffmann MM, Fleury S, Ruiz J, Kappenberger L, et al. Association of RANTES G-403A gene polymorphism with increased risk of coronary arteriosclerosis. Eur Heart J. 2004;25(16):1438-46. doi: 10.1016/j. ehj.2004.05.005.
74. Mahdavi Shahri S M, Soltani A, Abbasi P, Moradi Z. Unhealthy diet: A preventable risk factor of cardiovascular disease. Cardiovascular Nursing Journal. 2014;3(3):58-66.
75. Panagiotakos D, Bountziouka V, Zeimbekis A, Vlachou I, Polychronopoulos E. Food pattern analysis and prevalence of cardiovascular disease risk factors among elderly people from Mediterranean islands. J Med Food. 2007;10(4):615-21. doi: 10.1089/jmf.2007.414.
76. Haghighatdoost F, Zaribaf F, Azadbakht L, Esmaillzadeh A. Association between major dietary patterns and risk factors for cardiovascular disease among women. Iranian Journal of Nutrition Sciences & Food Technology. 2012;7(3):19-30.
77. Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC. Prospective study of major dietary patterns and risk of coronary heart disease in men. Am J Clin Nutr. 2000;72(4):912- 21. doi: 10.1093/ajcn/72.4.912.
78. Salimzadeh H, Eftekhar H, Asasi N, Salarifar M, DOROSTI A. Dietetic risk factors and ischemic heart disease. Journal of School of Public Health and Institute of Public Health Research. 2004;2(4):1-14
79. Maleki A, Ashjaearvan M, Karimi A. Multifactorial analysis of dietary patterns in healthy and coronary artery disease patients: brief report. Tehran University Medical Journal. 2015;73(1):65-9.
80. Akesson A, Larsson SC, Discacciati A, Wolk A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men: a population-based prospective cohort study. J Am Coll Cardiol. 2014;64(13):1299-306. doi: 10.1016/j. jacc.2014.06.1190.
81. Farzaneh R, Hoseini K, Vahedi S, Hamzeh N. Obesity and cardiovascular disease. Iranian Journal of Diabetes and Lipid. 2013;12(5):451-60. 
82. Seo YG, Choi MK, Kang JH, Lee HJ, Jang HB, Park SI, et al. Cardiovascular disease risk factor clustering in children and adolescents: a prospective cohort study. Arch Dis Child. 2018;103(10):968-73. doi: 10.1136/ archdischild-2017-313226.
83. Azizi F. Tehran lipid and glucose study. The final report of first phase. 1th ed. Tehran: Endocrine Research Center; 2001.
84. Azizi F, Esmaeilzadeh A, Mirmiran P. Obesity and cardiovascular risk factors: An epidemiological study in Tehran. Iranian Journal of Endocrinology and Metabolism. 2004;5(4):389-97.
85. Agheli N, Assefzadeh S, Rajabi M. The prevalence of cardiovascular risk factors among population aged over 30 years in Rasht and Qazvin. Journal of Inflammatory Disease. 2005;9(2):59-65.
86. Daniels SR, Loggie JM, Khoury P, Kimball TR. Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension. Circulation. 1998;97(19):1907-11. doi: 10.1161/01. cir.97.19.1907.
87. McGill HC, Jr., McMahan CA, Herderick EE, Zieske AW, Malcom GT, Tracy RE, et al. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation. 2002;105(23):2712-8. doi: 10.1161/01. cir.0000018121.67607.ce.
88. Heidari MM, Ghasemi S, Hadadzadeh M. Comparison of AGTR1 rs5186 (A1166C) Polymorphism between Coronary Artery Disease Patients and Normal Subjects: a Case Control Study. Journal of Birjand University of Medical Sciences. 2017;24(1):10-8.
89. Vettore MV, Faerstein E, Baker SR. Social position, social ties and adult’s oral health: 13 year cohort study. J Dent. 2016;44:50-6. doi: 10.1016/j.jdent.2015.12.004.
90. Marmot MG. Understanding social inequalities in health. Perspect Biol Med. 2003;46(3 Suppl):S9-23. doi: 10.1353/pbm.2003.0056.
91. Eberle A, Luttmann S, Foraita R, Pohlabeln H. Socioeconomic inequalities in cancer incidence and mortality—a spatial analysis in Bremen, Germany. Journal of Public Health. 2010;18(3):227- 35. doi: 10.1007/s10389-009-0306-1.
92. Malekafzali H, Oliaiimanesh A, Zakeri M, Beheshtian M. Health equity indicators: Health ministry; 2012.
93. Rohani Rasaf M, Rohani Rasaf M, Rahimi F, Mehrazma M, Golmohammadi A, Motiedoost R, et al. Distribution of cancer incidence in districts and neighbourhoods of a number of Tehran districts in 1386. Razi Journal of Medical Sciences. 2011;18(89):34-45.
94. Pourreza A, Barat A, Hosseini M, Akbari Sari A, Oghbaie H. Relationship between socioeconomic factors and coronary artery disease among under-45 year-old individuals in Shahid Rajaee Hospital, Tehran, Iran: A case-control study. Journal of School of Public Health & Institute of Public Health Research. 2010;7(4):25-32.
95. Albus C. Health literacy: Is it important for cardiovascular disease prevention? Eur J Prev Cardiol. 2018;25(9):934-5. doi: 10.1177/2047487318770519.
96. Hardarson T, Gardarsdottir M, Gudmundsson KT, Thorgeirsson G, Sigvaldason H, Sigfusson N. The relationship between educational level and mortality. The Reykjavik Study. J Intern Med. 2001;249(6):495-502. doi: 10.1046/j.1365- 2796.2001.00834.x.
97. Malyutina S, Bobak M, Simonova G, Gafarov V, Nikitin Y, Marmot M. Education, marital status, and total and cardiovascular mortality in Novosibirsk, Russia: a prospective cohort study. Ann Epidemiol. 2004;14(4):244-9. doi: 10.1016/ S1047 2797(03)00133-9.
98. Asefzadeh S, Alikhani S, Javadi H. Socioeconomic status and mortality from cardiovascular diseases in Qazvin (2009). Journal of Inflammatory Disease. 2013;16(4):40-6.
99. Marmot MG, Shipley MJ, Rose G. Inequalities in death—specific explanations of a general pattern? The Lancet. 1984;323(8384):1003-6. doi: 10.1016/ S0140-6736(84)92337-7.
100. Reinier K, Stecker EC, Vickers C, Gunson K, Jui J, Chugh SS. Incidence of sudden cardiac arrest is higher in areas of low socioeconomic status: a prospective two year study in a large United States community. Resuscitation. 2006;70(2):186- 92. doi: 10.1016/j.resuscitation.2005.11.018.
101. Siddique I, Mitchell DA. The impact of a community-based health education programme on oral cancer risk factor awareness among a Gujarati community. Br Dent J. 2013;215(4):E7. doi: 10.1038/sj.bdj.2013.829.