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Coronary artery disease
Original research article
Education level and outcomes after acute myocardial infarction in China
  1. Xiqian Huo1,
  2. Rohan Khera2,
  3. Lihua Zhang1,
  4. Jeph Herrin3,
  5. Xueke Bai1,
  6. Qianying Wang1,
  7. Yuan Lu4,
  8. Khurram Nasir4,
  9. Shuang Hu1,
  10. Jing Li1,
  11. Xi Li1,
  12. Xin Zheng1,
  13. Frederick A Masoudi5,
  14. John A Spertus6,
  15. Harlan M Krumholz3,4,7,
  16. Lixin Jiang1
  1. 1 National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
  2. 2 Division of Cardiology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
  3. 3 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  4. 4 Center for Outcomes Research and Evaluation, Yale-New Heaven Hospital, New Heaven, Connecticut, USA
  5. 5 Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Connecticut, USA
  6. 6 Health Outcomes Research, Saint Luke’s Mid America Heart Institude/University of Missouri-Kansas City, Kansas City, Missouri, USA
  7. 7 Department of Health Policy and Management, Yale Univeristy School of Public Health, New Heaven, Connecticut, USA
  1. Correspondence to Dr Lixin Jiang, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Beijing 100037, China; jiangl{at}fwoxford.org

Abstract

Objective To assess the association between educational attainment and acute myocardial infarction (AMI) outcomes in China to inform future healthcare interventions.

Methods We used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective AMI study of 3369 consecutive patients hospitalised with AMI from 53 hospitals. Educational attainment was categorised as: high (senior 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 major adverse cardiovascular events (MACE), all-cause mortality, both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors.

Results The median participant age was 61 (52, 69) years, 23.2% were women, and 33.3% had high, 32.4% intermediate and 34.3% low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of MACE (HR 2.41, 95% CI 1.72 to 3.37) and death (HR for low vs high education 3.09, 95% CI 1.69 to 5.65). In risk-adjusted analyses, the association between education and death was attenuated and no longer statistically significant (adjusted HR 1.41, 95% CI 0.74 to 2.69, p=0.30). However, the risk of 1-year MACE (adjusted HR 1.68, 95% CI 1.18 to 2.41, p=0.004) remained significantly greaterin low educational attainment group.

Conclusions In a national Chinese cohort of patients hospitalised with AMI, low educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to consider interventions to improve AMI outcomes in adults with low levels of education.

Clinical trial registration NCT01624909; Results.

  • acute myocardial infarction
  • quality and outcomes of care

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/heartjnl-2018-313752

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    Footnotes

    • Xiqian Huo and Rohan Khera are joint first authors.

    • 33 Harlan M. Krumholz and Lixin Jiang are joint senior authors.

    • 34 Harlan M. Krumholz and Lixin Jiang are joint senior authors.

    • Contributors HMK and LJ: conceived the China PEACE prospective study and take responsibility for all aspects of it. JL, XL, XZ, FAM, JAS, HMK and LJ: participated in designing the study. XB, QW and SH: analysed the data. XH and RK: generated the first draft of manuscript, with further support from LZ, JH, YL, KN, JL, XL, XZ, FAM, JAS, HMK and LJ. All authors provided critical revision of the paper, read and approved the final manuscript.

    • Funding This project was supported by the National Key Research and Development Program (2017YFC1310801, 2017YFC1310803) from the Ministry of Science and Technology of China, the Central Public-Interest Scientific Institution Basal Research Fund (2017NL32002) from CAMS, the Research Special Fund for Public Welfare Industry of Health (201202025) from the National Health and Family Planning Commission of China, the CAMS Innovation Fund for Medical Science (2017-I2M-B&R-02), the 111project (B16005) from the Ministry of Education of China.

    • Competing interests HMK is the recipient of a research grant from Medtronic and Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing; chairs a cardiac scientific advisory board for United Health; works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. FAM receives salary support from the American College of Cardiology for his role as the Chief Science Officer of the National Cardiovascular Data Registries. The authors declare no conflict of interest.

    • Patient consent Obtained.

    • Ethics approval The central ethics committee at the National Center for Cardiovascular Diseases, local ethics committees at participating hospitals, and the Yale University Institutional Review Board approved the China PEACE-Prospective AMI study.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Correction notice Since this paper was first published online first, figure 2 has been updated. The replacement version includes the survival times data under part A and B of the figure.