Background: China has a growing burden of acute myocardial infarction (AMI) and wide variation in educational attainment. Less education is associated with worse cardiovascular outcomes in Western populations; whether this relationship exists in China is unclear. We assessed the association between educational attainment and AMI outcomes in China to inform future healthcare interventions.
Methods: We used data from the prospective China PEACE-Prospective AMI study of 3369 consecutive patients hospitalized with AMI from 53 hospitals across all 21 provinces between 2012 and 2015. We collected detailed information from abstraction of hospital records, supplemented with patient interviews. Educational attainment was categorized into: high (high school, college or postgraduate degree), intermediate (junior high school), or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year all-cause mortality and major adverse cardiovascular events (MACE: all-cause death, nonfatal myocardial infarction, nonfatal stroke, heart failure), both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors.
Results: The mean participant age was 60.7±11.9 years, 23.2% (781 of 3369) were women, and 33.3% (1123 of 3369) had high, 32.4% (1092 of 3369) intermediate, and 34.3% (1154 of 3369) low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of death (HR for low vs high education 3.09, 95% CI 1.69-5.65) and MACE (HR 2.41, 95% CI 1.72-3.37)(Figure). In risk-adjusted analyses, the association between education and mortality was attenuated and no longer statistically significant (adjusted HR 1.68, 95%CI 0.89-3.19, P = .11). However, the risk of MACE at one year remained significantly greater (adjusted HR 1.81, 95%CI 1.27-2.58, P = .001).
Conclusions: In a national Chinese cohort of patients hospitalized with AMI, lower educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to explore mechanisms underlying this relationship, and to consider interventions for adults with lower levels of education.