72 Chapter 3 cardiometabolic RF but not in lifestyle RF may indicate that the same unhealthy behaviors may result in a higher risk of chronic conditions in women. Several studies have found that behavioral RF impact women more strongly, and women have higher CHD morbidity and mortality from the same RF (36,39,40). Other factors that could possibly contribute to the higher RF burden in women may relate to cardiovascular disease awareness, healthcare utilization, and medication use. Previous literature suggests that women show lower awareness of cardiovascular disease (27,41) and higher rates of healthcare services utilization in several world regions (42,43). Use of cardioprotective medication is an important measure to control cardiovascular RF in secondary prevention of CHD. It is widely reported that women with CHD have lower medication rates (27,44) and less attendance to cardiac rehabilitation compared to men (45). In the CESCAS Study, and more generally in Latin America, women presented with higher awareness and treatment levels for hypertension and diabetes (46–48). However, these results refer to the general population, and are not specific for subjects with established CHD. Literature also points at a later age of diagnosis of CHD in women (11,27,36) as a potential explanation for the higher RF profile. The investigation of sex differences in RF awareness and treatment in CESCAS participants with CHD is beyond the scope of this analysis, but might provide further understanding of our results, and should be addressed in further studies. Our results show that sex differences were marked among participants with primary educational attainment and that women with lower educational attainment had the highest burden of RF. Literature shows that lower educational level is associated with presenting with a higher number of RF (5,8,33,34). Previous studies have described that the association of educational level or other socioeconomic factors with a higher number of RF is stronger in women than in men (11,28,36,38,49). In Argentina, Rodriguez et al (12) describes an increase in the prevalence of most cardiovascular RF from 2005 to 2013, and that this increase was more pronounced among women with low educational levels. Our results add to previous studies showing that the double inequality of sex and educational level is also observed in subjects with CHD with high cardiovascular risk. Our results have implications for research, health policies and clinical practice. In terms of research, it is important to study sex not as isolated determinant of cardiovascular health, but encompassed in the subject’s socioeconomic circumstances. The findings of our study also highlight the need to tailor prevention and RF management strategies to specific population groups. Understanding potential drivers of RF burden and clusters (such as awareness, medication use and adherence), and how these determinants may vary according to different demographics of individuals with CHD, is important to design interventions that are effective in improving RF management, including patient education in lifestyle and medication use, screening, treatment and cardiac rehabilitation programs, specific advice in clinical guidelines, and policies that promote healthy lifestyles and access to medication. Strategies targeting populations with lower educational attainment are challenging to implement (50), and can benefit from a deeper insight on RF profiles and their drivers in this population groups to improve their reach and effectiveness, and eventually improve the cardiovascular health of individuals at high cardiovascular risk, particularly of those in vulnerable groups.
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