Low Educational Attainment is a Predictor of Adverse Outcomes in Patients With Coronary Artery Disease

• Type of Material: Article
• Authors: Heval M. Kelli, Emory University; Anurag Mehta, Emory University; Ayman S. Tahhan, Emory University; Chang Liu, Emory University; Jeong Hwan Kim, Emory University; Tiffany A. Dong, Emory University; Devinder S. Dhindsa, Emory University; Bahjat Ghazzal, Emory University; Muaaz K. Choudhary, Emory University; Pratik B. Sandesara, Emory University; Salim S. Hayek, University of Michigan; Matthew L. Topel, Emory University; Ayman A. Alkhoder, Emory University; Mohammed A. Martini, Emory University; Arianna Sidoti, Emory University; Yi-An Ko, Emory University; Arshed Ali Quyyumi, Emory University; Tene Lewis, Emory University; Laura Vaccarino, Emory University; Laurence S Sperling, Emory University
• Language: English
• Date: 2019-09-03
• Publisher: Wiley Open Access: Creative Commons Attribution Non-Commercial
• Publication Version: Final Published Version
• Copyright Statement: Copyright © 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1161/JAHA.119.013165
• Title of Journal or Parent Work: Journal of the American Heart Association
• ISSN: 2047-9980
• Volume: 8
• Issue: 17
• Start Page: e013165
• End Page: e013165
• Grant/Funding Information: Mehta is supported by American Heart Association grant 19POST34400057.; Kelli, Mehta, Tahhan, Kim, Dhindsa, and Sandesara have been supported by the Abraham J. and Phyllis Katz Foundation.; Kelli has been supported by NHLBI T32 THL130025A grant.; Quyyumi is supported by NIH grants 1R61HL138657‐02; 1P30DK111024‐03S1; 5R01HL095479‐08; 3RF1AG051633‐01S2; 5R01AG042127‐06; 2P01HL086773‐08; U54AG062334‐01; 1R01HL141205‐01; 5P01HL101398‐02; 1P20HL113451‐01; 5P01HL086773‐09; 1RF1AG051633‐01; R01 NS064162‐01; R01 HL89650‐01; HL095479‐01; 1DP3DK094346‐01; 2P01HL086773; and American Heart Association grant 15SFCRN23910003.
• Keywords: cardiovascular outcomes; education; socioeconomic position; RISK-FACTORS; secondary prevention; HEART-DISEASE; SOCIOECONOMIC-STATUS; INCOME; CARDIOVASCULAR OUTCOMES; Cardiovascular System & Cardiology; Science & Technology; risk assessment; Cardiac & Cardiovascular Systems; Life Sciences & Biomedicine
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Epidemiology; Biology, Biostatistics

Abstract

Background: Educational attainment is an indicator of socioeconomic status and is inversely associated with coronary artery disease risk. Whether educational attainment level (EAL) among patients with coronary artery disease influences outcomes remains understudied. Methods and Results: Patients undergoing cardiac catheterization had their highest EAL assessed using options of elementary/middle school, high school, college, or graduate education. Primary outcome was all-cause mortality and secondary outcomes were a composite of cardiovascular death/non-fatal myocardial infarction and non-fatal myocardial infarction during follow-up. Cox models adjusted for clinically relevant confounders were used to analyze the association of EAL with outcomes. Among 6318 patients (63.5 years, 63% men, 23% black) enrolled, 16%, 42%, 38%, and 4% had received graduate or higher, college, high school, and elementary/middle school education, respectively. During 4.2 median years of follow-up, there were 1066 all-cause deaths, 812 cardiovascular deaths/non-fatal myocardial infarction, and 276 non-fatal myocardial infarction. Compared with patients with graduate education, those in lower EAL categories (elementary/middle school, high school, or college education) had a higher risk of all-cause mortality (hazard ratios 1.52 [95% CI 1.11-2.09]; 1.43 [95% CI 1.17-1.73]; and 95% CI 1.26 [1.03-1.53], respectively). Similar findings were observed for secondary outcomes. Conclusions: Low educational attainment is an independent predictor of adverse outcomes in patients undergoing angiographic coronary artery disease evaluation. The utility of incorporating EAL into risk assessment algorithms and the causal link between low EAL and adverse outcomes in this high-risk patient population need further investigation.