Attained Educational Level and Incident Atherothrombotic Events in Low- and Middle-Income Compared With High-Income Countries

Abstract

for the Reduction of Atherothrombosis for Continued Health (REACH) Registry InvestigatorsBackground-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 lowand middle-income countries (LMICs), which bear Ͼ80% of the global burden of cardiovascular disease. Methods and 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 (PϽ0.0001), more modest in women from HICs (Pϭ0.0026) and in men from LMICs (Pϭ0.082), and essentially absent in women from LMICs (Pϭ0.32). Conclusion-In contrast to HICs, higher AEL may not be protective against cardiovascular events in LMICs, particularly in women. (Circulation. 2010;122:1167-1175.)

Impact of Socioeconomic Status, Ethnicity, and Urbanization on Risk Factor Profiles of Cardiovascular Disease in Africa

“…Pampel et al 24 and Goyal et al 25 described that although socioeconomic status and weight have a positive association in low-income countries, they have a negative association in higher-income countries. However, the authors introduce a caveat emphasizing that the relationship and its causes need to be tested in large and diverse national databases.…”

Should There Be a Different Cardiovascular Prevention Polypill Strategy for Women and Men?

“…Data from the World Health Organization's Prevention of Recurrences of Myocardial Infarction and Stroke (WHO-PREMISE) demonstrated that women who had a prior myocardial infarction or stroke were 53% less likely to take aspirin, 16% less likely to take ACE inhibitors, and 29% less likely to take statins at 6 months compared to men [36]. Sex differences in antiplatelet use, but not lipid-lowering therapy, were also seen in LMIC in the Reduction of Atherothrombosis for Continued Health (REACH) Registry participants [37]. Reasons for these differences between men and women are speculative and merit further exploration.…”

Letter by Nabi Regarding Article, “Attained Educational Level and Incident Atherothrombotic Events in Low- and Middle-Income Compared With High-Income Countries”

“…I read with great interest the recent study by Goyal et al, 1 who examined the association between attained educational level and incident atherothrombotic events in men and women in low-and middleincome countries (LMICs) compared with high-income countries. The results revealed a clear inverse association between higher education and incidence of cardiovascular events in men from high-income countries, a modest inverse association in women from high-income countries, a modest positive association in men from LMICs, and no association in women from LMICs.…”

“…I was very surprised by this recommendation, since it has been shown that educated individuals make better use of health-related information than those who are less educated, even in LMICs. 2 There are at least 2 reasons that call for better interpretation of the findings by Goyal et al 1 First, the LMIC entity includes countries that are at different stages of urbanization and industrialization. Furthermore, recent evidence suggests that the health gradient between the well educated and less educated changes as a function of economic development and the increase in the overall level of income of a country.…”