In addition to traditional biological risk factors, several social determinants play a significant role in cardiovascular risk. The Social Determinants of Health (SDH) refer to the social, economic, cultural, ethnic, educational, and environmental conditions in which people live and how these conditions impact health. These determinants can encompass factors such as income, working conditions, access to health services, education, housing, transportation, support networks, and others.^,

The relationship between socioeconomic factors and health began to be observed during the Industrial Revolution in Europe. One of the pioneers in this field was Rudolf Virchow, a German physician, and politician who, in the mid-nineteenth century, highlighted the impact of social conditions on health. He emphasized that addressing issues such as education, housing, and work was necessary to improve the population’s health. It is from Virchow the phrase “medicine is a social science, and politics is nothing but medicine on a large scale”.

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Cardiovascular diseases (CVD) are the main causes of death in women and men in Brazil. Since 1980, there has been a significant reduction in mortality from these diseases. From 1980 to 2012, the smallest reduction was 31% for ischemic heart diseases (IHD) in men, and the largest reduction was 54% for cerebrovascular diseases (CBVD) in women. Despite an important reduction in mortality due to IHD, the reduction in mortality due to CBVD was the one that most contributed to the total reduction in mortality due to CVD. However, comparative analyses of the periods from 1980 to 2006 with those from 2007 to 2012 showed a greater percentage reduction in mortality from CVD, IHD, and CBVD in the period from 1980 to 2006. In the period from 2007 to 2012, there was a significant, but less intense, reduction in mortality from CVD and CBVD when compared to the previous period, while mortality from IHD remained unchanged in women and men. The same phenomenon was observed in the USA and in some European countries for this period, and this unfavorable trend has been associated with the increase in the incidence of obesity and diabetes mellitus and with the inadequate control of risk factors.^– The control of the main risk factors for CVD reduces CVD mortality by at least 50%, and the highlight in this process is primary prevention by controlling the main risk factors, namely hypertension, smoking, diabetes, and dyslipidemia.^,

Hypertension is the main risk factor in the genesis of CBVD, while the other risk factors also participate in the genesis of IHD, which leads to greater difficulty in preventing IHD, justifying the unfavorable tendency of IHD compared to CBVD. Currently, socioeconomic status (family income, employment, education, and environmental factors) is also considered an independent risk factor for CVD that is equivalent to traditional risk factors. The influence of socioeconomic status is one of the main factors responsible for the highest mortality from CVD in the least favored populations.

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Reply

We are thankful to the comments and for the interest in our study, which is about a relevant topic, i.e., readmission of patients with acute coronary syndrome (ACS) and its determinants to both public hospitals (Brazil’s public health system — SUS) and private hospitals. A better understanding of the findings we reached, which certainly reflect what happens in the country, will result in benefits for the therapeutic approach of those who have this major disease.

The expressive rate of readmissions observed, which certainly has a significant impact on health costs, results not only from clinical factors, but also from the type of assistance received by the patient, both during hospitalization and after discharge. It is worth noting that about 72% of the Brazilian population depends exclusively on the public health system. Therefore, as we said, Primary Health Care (PHC) can play a pivotal role in the adoption and reinforcement of secondary prevention measures that will surely be successful for those particularly affected by ACS. According to Ordinance No. 2436 of the Ministry of Health, published on 21/9/2017, Brazil’s Policy on Primary Health Care provides for the longitudinality of care, with monitoring of the effects of health interventions and coordination of care. Therefore, person-centered care, also advocated in this ordinance, places PHC in a fundamental role of helping patients to develop knowledge, skills and competence to better take care of their own health. Health education actions are essential to stress self-care and the prevention of subsequent readmissions. Finally, co-responsibility between health professionals and patients in the implementation of actions to prevent complications of the disease, health promotion and proper therapeutic adherence can positively influence the reduction of readmission rates.

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