{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T15:32:22Z","timestamp":1787671942137,"version":"build-2736575974"},"reference-count":24,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003710","name":"Korea Health Industry Development Institute","doi-asserted-by":"publisher","award":["RS-2025-19252970"],"award-info":[{"award-number":["RS-2025-19252970"]}],"id":[{"id":"10.13039\/501100003710","id-type":"DOI","asserted-by":"publisher"}]},{"award":["RS-2025-19252970"],"award-info":[{"award-number":["RS-2025-19252970"]}],"id":[{"id":"https:\/\/ror.org\/00fdzyk40","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: Metabolic syndrome (MetS) and low socioeconomic status (SES) are each established drivers of coronary artery disease (CAD), a leading cause of acute cardiovascular presentations to emergency and acute care services. Whether SES modifies the long-term association between MetS and CAD in a universal health coverage setting is unclear. We examined the independent and joint associations of MetS and income-based SES with 20-year incident CAD. Methods: In this nationwide retrospective cohort study using the Korean National Health Insurance Service database, 489,521 adults aged 40\u201379 years who underwent a national health examination in 2005 and were free of CAD at baseline were followed through 31 December 2024 (up to 20 years). At baseline, the mean age was 54.1 \u00b1 9.2 years, and 252,818 participants (51.6%) were men. MetS was defined by modified harmonized criteria, with body mass index (BMI) \u2265 25 kg\/m2 substituted for waist circumference. SES was measured by health insurance premium deciles and classified as high (deciles 8\u201310), middle (4\u20137), low income (1\u20133), and Medical Aid (decile 0). The outcome was incident CAD (myocardial infarction or angina pectoris). Multivariable Cox proportional hazards models were adjusted for age, sex, smoking, alcohol consumption, regular exercise, BMI, chronic kidney disease, alternate exposure, and estimated adjusted hazard ratios (aHRs); joint exposure and additive interaction (relative excess risk due to interaction, RERI) were assessed. Results: MetS prevalence was 30.6%. During follow-up, 48,428 participants (9.9%) developed CAD. MetS was independently associated with CAD (aHR 1.84; 95% CI 1.78\u20131.91), as was a graded socioeconomic gradient (Medical Aid vs. high SES aHR 1.62; 1.54\u20131.70). Incidence rates ranged from 3.13 (high-SES without MetS) to 11.40 (Medical Aid with MetS) per 1000 person-years. In the joint analysis, Medical Aid beneficiaries with MetS had the highest risk (aHR 2.92; 2.78\u20133.08 vs. high-SES without MetS; p for interaction &lt; 0.001), with positive additive interaction (RERI 0.68). Conclusions: Over two decades, low SES amplified the CAD burden associated with MetS. Adults living in the most severe material deprivation who also had MetS constituted the highest risk group, of direct relevance to risk stratification and disparities in emergency and acute cardiovascular care.<\/jats:p>","DOI":"10.3390\/jcm15176562","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T15:01:07Z","timestamp":1787670067000},"page":"6562","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Socioeconomic Status Modifies the 20-Year Association Between Metabolic Syndrome and Incident Coronary Artery Disease: A Nationwide Cohort Study of Korean Adults"],"prefix":"10.3390","volume":"15","author":[{"given":"U Chul","family":"Ju","sequence":"first","affiliation":[{"name":"Department of Gynecology and Oncology, Chonnam National University Medical School, Gwangju 61748, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ja Young","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Nursing, Nambu University, Gwangju 62271, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyun Yi","family":"Kook","sequence":"additional","affiliation":[{"name":"Department of Nursing, Nambu University, Gwangju 62271, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yeon Ji","family":"Seong","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61748, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ho Goon","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Surgery, Chonnam National University Medical School, Gwangju 61748, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eujene","family":"Jung","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61748, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global burden of cardiovascular diseases and risk factors, 1990\u20132019: Update from the GBD 2019 study","volume":"76","author":"Roth","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1001\/jama.287.3.356","article-title":"Prevalence of the metabolic syndrome among US adults: Findings from the Third National Health and Nutrition Examination Survey","volume":"287","author":"Ford","year":"2002","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.2337\/dc10-2109","article-title":"Increasing prevalence of metabolic syndrome in Korea: The Korean National Health and Nutrition Examination Survey for 1998\u20132007","volume":"34","author":"Lim","year":"2011","journal-title":"Diabetes Care"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1113","DOI":"10.1016\/j.jacc.2010.05.034","article-title":"The metabolic syndrome and cardiovascular risk: A systematic review and meta-analysis","volume":"56","author":"Mottillo","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.jacc.2006.09.032","article-title":"Metabolic syndrome and risk of incident cardiovascular events and death: A systematic review and meta-analysis of longitudinal studies","volume":"49","author":"Gami","year":"2007","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"683","DOI":"10.2337\/diacare.24.4.683","article-title":"Cardiovascular morbidity and mortality associated with the metabolic syndrome","volume":"24","author":"Isomaa","year":"2001","journal-title":"Diabetes Care"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1640","DOI":"10.1161\/CIRCULATIONAHA.109.192644","article-title":"Harmonizing the metabolic syndrome: A joint interim statement of the IDF Task Force on Epidemiology and Prevention; NHLBI; AHA; WHF; IAS; and IASO","volume":"120","author":"Alberti","year":"2009","journal-title":"Circulation"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2735","DOI":"10.1161\/CIRCULATIONAHA.105.169404","article-title":"Diagnosis and management of the metabolic syndrome: An American Heart Association\/National Heart, Lung, and Blood Institute Scientific Statement","volume":"112","author":"Grundy","year":"2005","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1973","DOI":"10.1161\/01.CIR.88.4.1973","article-title":"Socioeconomic factors and cardiovascular disease: A review of the literature","volume":"88","author":"Kaplan","year":"1993","journal-title":"Circulation"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"712","DOI":"10.1038\/nrcardio.2009.163","article-title":"Socioeconomic status and cardiovascular disease: Risks and implications for care","volume":"6","author":"Clark","year":"2009","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1387","DOI":"10.1016\/0140-6736(91)93068-K","article-title":"Health inequalities among British civil servants: The Whitehall II study","volume":"337","author":"Marmot","year":"1991","journal-title":"Lancet"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2166","DOI":"10.1161\/CIRCULATIONAHA.117.029652","article-title":"Socioeconomic status and cardiovascular outcomes: Challenges and interventions","volume":"137","author":"Schultz","year":"2018","journal-title":"Circulation"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1229","DOI":"10.1016\/S0140-6736(16)32380-7","article-title":"Socioeconomic status and the 25 \u00d7 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1.7 million men and women","volume":"389","author":"Stringhini","year":"2017","journal-title":"Lancet"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1056\/NEJM200107123450205","article-title":"Neighborhood of residence and incidence of coronary heart disease","volume":"345","author":"Merkin","year":"2001","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1093\/ije\/dyg244","article-title":"Health inequalities in Korea: Age- and sex-specific educational differences in the 10 leading causes of death","volume":"33","author":"Khang","year":"2004","journal-title":"Int. J. Epidemiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"320","DOI":"10.4070\/kcj.2020.0424","article-title":"Thirty-six year trends in mortality from diseases of circulatory system in Korea","volume":"51","author":"Baek","year":"2021","journal-title":"Korean Circ. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1097\/JCN.0000000000000624","article-title":"Socioeconomic disparities in cardiovascular health in South Korea: A systematic review","volume":"36","author":"Lee","year":"2021","journal-title":"J. Cardiovasc. Nurs."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/j.annepidem.2006.07.002","article-title":"Socioeconomic disparities in metabolic syndrome differ by gender: Evidence from NHANES III","volume":"17","author":"Loucks","year":"2007","journal-title":"Ann. Epidemiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1001\/archinte.163.4.427","article-title":"The metabolic syndrome: Prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988\u20131994","volume":"163","author":"Park","year":"2003","journal-title":"Arch. Intern. Med."},{"key":"ref_20","first-page":"799","article-title":"Data Resource Profile: The National Health Information Database of the National Health Insurance Service in South Korea","volume":"46","author":"Seong","year":"2017","journal-title":"Int. J. Epidemiol."},{"key":"ref_21","first-page":"e15","article-title":"Cohort Profile: The National Health Insurance Service\u2013National Sample Cohort (NHIS-NSC), South Korea","volume":"46","author":"Lee","year":"2017","journal-title":"Int. J. Epidemiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"121","DOI":"10.7570\/jomes23031","article-title":"Diagnosis of obesity: 2022 update of clinical practice guidelines for obesity by the Korean Society for the Study of Obesity","volume":"32","author":"Haam","year":"2023","journal-title":"J. Obes. Metab. Syndr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"937","DOI":"10.1016\/S0140-6736(04)17018-9","article-title":"Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study","volume":"364","author":"Yusuf","year":"2004","journal-title":"Lancet"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"265","DOI":"10.23736\/S0031-0808.21.04284-1","article-title":"How to fill the GAPS-I in secondary prevention: Application of a strategy based on GLP1 analogues, antithrombotic agents, PCSK9 inhibitors, SGLT2 inhibitors and immunomodulators","volume":"64","author":"Sabouret","year":"2022","journal-title":"Panminerva Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6562\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T15:10:30Z","timestamp":1787670630000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6562"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,25]]},"references-count":24,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15176562"],"URL":"https:\/\/doi.org\/10.3390\/jcm15176562","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,25]]}}}