The Impact of Education on All-cause Mortality Following St-Segment Elevation Myocardial Infarction (STEMI): Results from the Brazilian Heart Study

Barreto, Joaquim; Silva, Jose Carlos Quinaglia e; Sposito, Andrei C.; Carvalho, Luiz Sergio

doi:10.36660/abc.20190854

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Arquivos Brasileiros de Cardiologia

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Original Article • Arq. Bras. Cardiol. 117 (1) • July 2021 • https://doi.org/10.36660/abc.20190854 copy

The Impact of Education on All-cause Mortality Following St-Segment Elevation Myocardial Infarction (STEMI): Results from the Brazilian Heart Study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Low schooling has been considered an important modifiable risk factor for the development of cardiovascular disease for a long time. Despite that, whether this factor impacts the outcomes following ST-segment elevation myocardial infarction (STEMI) is poorly understood.

Objective

To investigate whether schooling stands as an independent risk factor for mortality in STEMI patients.

Methods

STEMI-diagnosed patients were consecutively enrolled from a prospective cohort (Brasilia Heart Study) and categorized according to years of study quartiles (0-3, 4-5, 6-10 and >10 years). Groups were compared by student’s t test for continuous variables and qui-square for categorical. Incidence of all-cause mortality was compared with Kaplan-Meyer with Cox regression adjusted by age, gender, and GRACE score. Values of p < 0.05 were considered significant. SPSS21.0 was used for all analysis.

Results

The mean schooling duration was 6.63±4.94 years. During the follow-up period (mean: 21 months; up to 6.8 years), 83 patients died (cumulative mortality of 15%). Mortality rate was higher among the lowest quartile compared to those in the highest quartile [18.5 vs 6.8%; HR 2.725 (95% CI: 1.27-5.83; p=0.01)]. In multivariate analysis, low schooling has lost statistical significance for all-cause mortality after adjustment for age and gender, with HR of 1.305 (95% CI: 0.538-3.16; p=0.556), and after adjustment by GRACE score with an HR of 1.767 (95% CI: .797-3.91; p=0.161).

Conclusion

Low schooling was not an independent risk factor for mortality in STEMI patients.

Cardiovascular Diseases; Risk Factors; Mortality; Cohort Studies; Acute Coronary Syndrome; Atherosclerosis; Scholarity

	Schooling, years
	0 - 3	4 - 5	6 - 10	>10	p-value^t
N	144	133	112	153
Demographics
Age, years	67.31 ± 12	62.4 ± 12^¶	59.4 ± 11	58.12 ± 10	.001
Schooling, years	2.4 ± 0.8	4.3 ± 0.5^¶	7.5 ± 0.9	12.8 ± 3.1	.001
Male, %	69.4	74.4^¶	84.8	77.1	.037
BMI, kg/m²	26 ± 4.9	26.4 ± 4.3	27.2 ± 4	27.9 ± 4.3	.003
Medical History
Prior MI, %	11.1	9^¶	16.1	8.5	.213
Smoking, %	37.1	31.6	39.3	37.3	.613
Diabetes mellitus, %	34	29.3	29.5	32.7	.794
Hypertension, %	66.7	64.7	61.6	51.6	.039
Dyslipidemia, %	45	47	48	46	.886
Family history for CAD, %	33.3	43.6^¶	57.1	52.3	.001
Hemodynamics
SBP, mmHg	132.3 ± 30	133.5 ± 29	138.3 ± 27	139.9 ± 32	0.091
DBP, mmHg	81.9 ± 17	83.8 ± 19	88.5 ± 18	87 ± 21	.02
Heart Rate, bpm	77.3 ± 18	76.2 ± 17	77.3 ± 16	78.6 ± 16	0.70
GRACE, units	150 ± 28	138.5 ± 27	131.9 ± 21	128.7 ± 26	.001
LV Ejection fraction, %	51.5 ± 11	56.8 ± 11	50 ± 10	56 ± 11	.007
Killip class I, %	83	90	92	92	.267
Biochemical Analyses
Fasting glucose, mg/dL	143.6 ± 65	152 ± 67	150 ± 57	155 ± 77	.51
Glycosylated hemoglobin, %	6.5 ± 1.7	6.6 ± 1.9	6.3 ± 1.5	6.5 ± 2.1	.644
CrCl, ml/min/1.73m²	65.6 ± 24	72.1 ± 23	71.6 ± 20	71.9 ± 24	.052
HDL-C, mg/dL	40.2 ± 11.1	37 ± 9.9^¶	37.3 ± 10.5	37.2 ± 11	.045
LDL-C, mg/dL	125 ± 151	124.6 ± 66	119.1 ± 40	128.3 ± 44	.894
TG, mg/dL	137.3 ± 88	154.4 ± 113	183.7 ± 148	208.8 ± 258	.002
CRP, mg/L	1.6 ± 2.9	1.1 ± 1.5	1.4 ± 2.6	1.4 ± 2.5	.390
CK-MB peak, mg/dL	264 ± 213	290.9 ± 206	281 ± 193	240 ± 169	.147
Infarction mass (CMR), g	17.5 ± 9	15.9 ± 9	19.5 ± 13	14 ± 10	.192
Treatment
Tenecteplase, %	60.4	63.2	65.2	62.7	.89
Primary PCI, %	50	42.9	50	55.6	.204
Time to reperfusion, min	160.9 ± 149.3	199.8 ± 194	167.5 ± 167	156.7 ± 164	.139
Time to hospital, min	128 ± 111	134 ± 144	130 ± 129	119 ± 127	.344
Simvastatin, %	60.1	65.4	76.9	70.7	.032
Outcomes
All-cause death, n (%)	20 (18.5)	22 (17.3)^¶	16 (9.5)	10 (6.8)	.016
MACE, n (%)	18 (16.7)	20 (15.7)	22 (13.1)	15 (10.2)	.515

Variable	Model 1 (Crude)			Model 2^a			Model 3^b
Variable	HR	95%CI	p-value	HR	95%CI	p-value	HR	95%CI	p-value
Age	1.081	1.06-1.11	.001	1.071	1.05-1.10	.001	1.079	1.05-1.11	.001
Male	1.063	0.65-1.75	.810	1.054	0.61-1.85	.854	1.012	.575-1.78	.967
Dyslipidemia	1.218	0.75-1.99	.428	1.314	.756-2.28	.333	1.356	.779-2.36	.282
Diabetes mellitus	1.146	0.67-1.96	.620	.957	.531-1.72	.957	1.055	.581-1.91	.860
Hypertension	0.683	0.42-1.10	.117	.723	.412-1.27	.258	.825	.485-1.40	.479
Smoking	1.685	1.01-2.81	.046	1.102	.611-1.99	.747	1.068	.607-1.87	.686
Killip class > I	1.912	1.15-3.18	.013	1.932	1.13-3.31	.017	1.985	1.12-3.50	.018
Schooling Quartiles			.021			.844			.223
1^st vs. 4^th	2.725	1.27-5.83	.010	1.305	.538-3.16	.556	1.767	.797-3.91	.161
2^nd vs. 4^th	2.469	1.17-5.22	.018	1.470	.634-3.41	.369	2.206	1.01-4.83	.048
3^rd vs. 4^th	1.386	0.63-3.05	.419	1.324	.579-3.024	.506	1.018	1.01-1.03	.497

Study	Data	Groups	Outcomes	Results
Present study	n=542, prospective cohort of STEMI patients, Brazil	<3, 4-6, 7-10, >10 years of study	All-cause mortality	Not independently related
Mehta et al., 2011	11,326 STEMI, retrospective, 9 developed countries	< 8 vs. > 16 years of study	One-year mortality rate	five-fold higher in those least educated patients; significant after adjustment for baseline characteristics and country of enrollment
Strand, Tverdal, 2004⁴	n=44,684, prospective, Norway	High education (secondary level/ university/ college) vs. low (primary or no schooling)	IHD mortality	Adjustment for risk factors reduced excess IHD mortality in the low educational groups by 91% for men and 67% for women.
J. Igland et al., 2014⁵	N=111,993; AMI; Norway	Basic vs. tertiary education	28-day and one-year mortality	1.18-fold increase in one year, and 1.04-fold increase in 30-day mortality rate, for fully adjusted model for patients aged 70-94 years old. Included income in adjustment model.
L. Consuegra-Sanchez et al., 2011²⁰	N=5797; AMI; eight years prospective follow-up; Spain;	No schooling or basic education vs. Secondary school or higher education	All-cause mortality	15% higher risk in the least educated group
Coady et al., 2014⁶	N=15972; United States	Lower than high school education vs. college degree	Long-term mortality (1-5 years)	1.6- and 1.37-fold increased long-term mortality for the least educated men and women, respectively.
Kirchberger et al., 2014⁷	N=3419; AMI; Germany	Low education (without completed formal vocational training) vs. High education	Long-term mortality	No effect of education on mortality was found for the total sample. In 65+ years old patients, those least educated had 1.4-fold increased mortality rate.

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