title: Attained educational level and incident atherothrombotic events in low- and middle-income compared with high-income countries.
abstract: BACKGROUND
  Studies report a protective effect of higher attained educational level (AEL) on cardiovascular outcomes. However, most of these studies have been conducted in high-income countries (HICs) and lack representation from low- and middle-income countries (LMICs), which bear >80% of the global burden of cardiovascular disease.
  
  
  RESULTS
  The Reduction of Atherothrombosis for Continued Health (REACH) Registry is a prospective study of 67 888 subjects with either established atherothrombotic (coronary, cerebrovascular, and/or peripheral arterial) disease or multiple atherothrombotic risk factors enrolled from 5587 physician practices in 44 countries. At baseline, AEL (0 to 8 years, 9 to 12 years, trade or technical school, and university) was self-reported for 61 332 subjects. Outcomes included the baseline prevalence of atherothrombotic risk factors and the rate of incident cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) through 23 months across AEL groups, stratified by sex and world region (LMICs or HICs). Educational attainment was inversely associated with age and diabetes mellitus and directly associated with hypercholesterolemia in all subjects. However, for other risk factors such as obesity, smoking, hypertension, and baseline burden of vascular disease, AEL was protective (inversely associated) in HICs but not protective in LMICs. The protective effect of greater AEL on incident cardiovascular events was strongest in men from HICs (P<0.0001), more modest in women from HICs (P=0.0026) and in men from LMICs (P=0.082), and essentially absent in women from LMICs (P=0.32).
  
  
  CONCLUSIONS
  In contrast to HICs, higher AEL may not be protective against cardiovascular events in LMICs, particularly in women.
authors.affiliation: Emory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322, USA. agoyal4@emory.edu
authors.forename: Abhinav
authors.initials: A
authors.lastname: Goyal
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.forename: P Gabriel
authors.initials: PG
authors.lastname: Steg
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Alberts
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Ramón
authors.initials: R
authors.lastname: Corbalán
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Efrain
authors.initials: E
authors.lastname: Gaxiola
authors.forename: Runlin
authors.initials: R
authors.lastname: Gao
authors.forename: Shinya
authors.initials: S
authors.lastname: Goto
authors.forename: Ralph B
authors.initials: RB
authors.lastname: D'Agostino
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Smith
authors.forename: Peter W F
authors.initials: PW
authors.lastname: Wilson
mesh_terms: D000368:Aged; D002561:Cerebrovascular Disorders / Q000453:epidemiology*; D003324:Coronary Artery Disease / Q000453:epidemiology*; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007182:Income; D007391:International Cooperation; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000453:epidemiology*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D012727:Sex Characteristics; D012923:Social Class