Inverse relationship between level of education and risk of cardiovascular disease

1. In this prospective cohort study, educational attainment was inversely associated with cardiovascular disease (CVD) risk, in a dose-response relationship.

2. The largest gap in lifetime CVD risk was seen between those who graduated high school and those who did not.

Evidence Rating Level: 2 (Good)

Study Rundown: Health literacy and educational attainment are factors within the broader scope of socioeconomic wellbeing that may contribute to health outcomes in cardiovascular disease (CVD). However, the exact association is not fully characterized. This study aimed to determine what the lifetime risks of CVD are according to educational attainment.

This study found an inverse, dose-response association between one’s level of education and cumulative CVD risk. The most striking gap was evident in those who completed high school versus those who did not. In men, the lifetime CVD risk was 59.0% for those who completed up to grade school and 42.4% if they completed graduate/professional education. In women, the results were 50.8% and 28.0%, respectively. This relationship between educational attainment and CVD risk remained robust despite other important socioeconomic characteristics like family income, occupation, and parental educational level. Strengths of this study included the size of the cohort and the long-term follow up. Weaknesses of the study included differences in the social and political climate of the cohorts based on the time studied. In addition, education obtained later in life was not well captured by this study.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Social Determinants of Risk and Outcomes for Cardiovascular Disease

In-Depth [prospective cohort]: This large-scale, prospective was conducted from 1987 to December 2013 in 4 US communities (Washington County, Maryland; Forsynth County, North Carolina; Jackson, Mississippi; suburbs of Minneapolis, Minnesota) and included participants aged 45-64 years in the Atherosclerosis Risk in Communities (ARIC) study who were all free of cardiovascular disease at baseline. These patients were followed for all CVD events (coronary heart disease, heart failure and stroke) and lifetime risk was determined using the life table approach. The exposure of interest was educational attainment and was determined by self-report at baseline and was grouped into grade school, high school without graduation, high school with graduation, vocational school, college with or without graduation, and graduate or professional school. Outcomes were adjusted for competing risks of death from underlying causes other than CVD.

The cohort of 13,948 participants (6108 men and 7840 women) provided 269,210 person-years of observation. There were 4512 CVD events during the follow-up period. The overall lifetime risks at age 85 were 55% (95% CI 51.4-58.6), 50.5% (95% CI 47.3-53.3), 41.7% (95% CI 39.5-43.8), 39.7% (95% CI 35.5-43.4), 39.2% (95% CI 36.6-41.4), 36.1 (95% CI 31.9-39.7) for grade school., high school without graduation, high school with graduation, vocational school, college with or without graduation and graduate/professional school respectively. Lifetime risks for men and women were 59%, 52.5%, 50.9%, 47.2%, 46.4%, 42.2% and 50.8%, 49.3%, 36.3%, 32.2%, 32.8%, 28.0% respectively. The impact of educational attainment remained even when assessing for other potential CVD risk factors like socioeconomic status, family income, occupation and parental educational attainment.

Image: PD

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