Inequalities in secondary prevention pathways after ischaemic heart disease: a cohort study

Background

Socioeconomic inequalities in outcomes after ischaemic heart disease are well documented, yet less is known about how these inequalities manifest across the full pathway of secondary prevention, particularly during the transition from hospital to primary care.

Methods

We conducted a nationwide population-based cohort study including 93,159 individuals hospitalised with ischaemic heart disease in Denmark (2016–2022). Secondary prevention was assessed across three key components: cardiac rehabilitation, preventive medication (antiplatelet or statin therapy), and annual general practice follow-up. A composite indicator captured receipt of all three components. Relative risks (RR) were estimated using modified Poisson regression, adjusted for demographic and clinical factors. Socioeconomic position was measured using education, income, cohabitation, and workforce status.

Results

Cardiac rehabilitation uptake was 41.2%, with 73.7% adherence among participants. Preventive medication was widely used (antiplatelet: 86.1%; statins: 77.0%), while 56.0% attended general practice follow-up. Only 25.9% received all three components, and 7.6% received none. Lower socioeconomic position was consistently associated with reduced likelihood of comprehensive secondary prevention, particularly among individuals with low income (RR 0.70, 95% CI 0.67–0.73), those living alone (RR 0.77, 0.75–0.79), and those unemployed (RR 0.82, 0.75–0.89). Inequalities were most pronounced for cardiac rehabilitation uptake and persisted over time.

Conclusions

Substantial socioeconomic inequalities persist across the full pathway of secondary prevention after ischaemic heart disease, even within a universal healthcare system. These inequalities accumulate across care components and highlight critical gaps at the transition from hospital to community care.

Key messages

• Inequalities in secondary prevention after ischaemic heart disease extend beyond single interventions and accumulate across care pathways.

• Equity-oriented, cross-sectoral strategies targeting care transitions are needed to improve uptake and continuity of preventive care after ischaemic heart disease.