title: Higher education is associated with reduced risk of heart failure among patients with acute myocardial infarction: A nationwide analysis using data from the CVDNOR project.
abstract: Coronary heart disease (CHD) outcomes are characterised by socioeconomic gradients. Although heart failure (HF) is a severe complication of CHD, sparse evidence exists on the association between socioeconomic status and HF among coronary patients. This study aimed to explore potential educational differences in the risk of HF among acute myocardial infarction (AMI) patients in Norway during 2001-2009.
  
  
  
  A total of 70,506 patients hospitalised for an incident (first) AMI and without history of HF were included in the analyses. Information on education was obtained from the Norwegian Education Database and categorised into primary, secondary or tertiary. In 12,487 (17.7%) patients, HF was present at admission or developed during the AMI hospitalisation (early-onset HF). Compared to patients with primary education, patients with secondary or tertiary education had 9% [incidence rate ratio (IRR) = 0.91; 95% confidence interval (CI): 0.87-0.94] and 20% (IRR = 0.80; 95% CI: 0.75-0.86) lower risks of early-onset HF, respectively. Of the 54,095 AMI patients discharged alive without concurrent HF, 6375 (11.8%) were subsequently hospitalised with or died from late-onset HF during a median follow-up period of 3.4 years. Compared to patients with primary education, those with secondary or tertiary education had 14% [hazard ratio (HR = 0.86; 95% CI: 0.82-0.91] and 27% (HR = 0.73; 95% CI: 0.66-0.80) lower risks of HF, respectively. Educational differences in the risk of HF were not influenced by gender.
  
  
  
  We observed an inverse association between educational level and risk of HF. More efforts in preventing this severe complication of AMI among less educated patients may help to reduce the socioeconomic gap in survival following coronary events.
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway Domain for Health Data and Digitalization, Norwegian Institute of Public Health, Norway gerhard.sulo@uib.no.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Sulo
authors.affiliation: Department of Clinical Science, University of Bergen, Norway Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
authors.forename: Ottar
authors.initials: O
authors.lastname: Nygård
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway Centre for Burden of Disease, Norwegian Institute of Public Health, Norway.
authors.forename: Stein Emil
authors.initials: SE
authors.lastname: Vollset
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway.
authors.forename: Jannicke
authors.initials: J
authors.lastname: Igland
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway Domain for Health Data and Digitalization, Norwegian Institute of Public Health, Norway.
authors.forename: Marta
authors.initials: M
authors.lastname: Ebbing
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway.
authors.forename: Enxhela
authors.initials: E
authors.lastname: Sulo
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway Domain for Health Data and Digitalization, Norwegian Institute of Public Health, Norway.
authors.forename: Grace M
authors.initials: GM
authors.lastname: Egeland
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Norway Domain for Health Data and Digitalization, Norwegian Institute of Public Health, Norway.
authors.forename: Grethe S
authors.initials: GS
authors.lastname: Tell
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006333:Heart Failure / Q000453:epidemiology / Q000209:etiology* / Q000523:psychology; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000453:epidemiology / Q000523:psychology; D009664:Norway / Q000453:epidemiology; D011159:Population Surveillance; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012959:Socioeconomic Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
keywords: CVDNOR; Heart failure; Norway; educational differences; myocardial infarction