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Education and risk for acute myocardial infarction in 52 high, middle and low income countries. INTERHEART case-control study
  1. Annika Rosengren1,*,
  2. S. V Subramanian2,
  3. Shofiqul Islam3,
  4. Clara K Chow3,
  6. Khawar Kazmi5,
  7. Karen Sliwa6,
  8. Mohammad Zubaid7,
  9. Sumathy Rangarajan3,
  10. Salim Yusuf3
  1. 1 Sahlgrenska University Hospital/Ostra, Sweden;
  2. 2 Department of Society, Human Development, and Health, Harvard School of Public Health, United States;
  3. 3 Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada;
  4. 4 Dante Pazzanese Institute Of Cardiology, Canada;
  5. 5 Department of Cardiology, Aga Khan University, Karachi, Brazil;
  6. 6 Chris-Hani-Baragwanath Hospital, University of the Witwatersrand, Pakistan;
  7. 7 Kuwait University, South Africa
  1. Correspondence to: Annika Rosengren, Sahlgrenska University Hospital/Ostra, Sahlgrenska University Hospital/Ostra, Goteborg, SE-41685, Sweden; annika.rosengren{at}


Objective: To determine the effect of education and other measures of socioeconomic status (SES) on risk of acute myocardial infarction (AMI) in patients and controls from countries of diverse economic circumstances (high, middle, and low income countries).

Design: Case-control study.

Setting: 52 countries from all inhabited regions of the world.

Participants: 12,242 cases and 14,622 controls.

Main outcome measures: First non-fatal AMI

Results: Socioeconomic status was measured using education, family income, possessions in the household and occupation. Low levels of education (≤ 8 yrs) were more common in cases compared to controls (45.0% and 38.1%; p<0.0001). The odds ratio for low education adjusted for age, sex, and region was 1.56 (95% confidence interval 1.47 to 1.66). After further adjustment for psychosocial, lifestyle, other factors, and mutually for other socioeconomic factors, the OR associated with education ≤ 8 years was 1.31 (1.20 to 1.44) (p<0.0001). Modifiable lifestyle factors (smoking, exercise, consumption of vegetables and fruits, alcohol and abdominal obesity) explained about half of the socioeconomic gradient. Family income, numbers of possessions, and non-professional occupation were only weakly or not at all independently related to AMI. In high-income countries (World Bank Classification), the risk factor adjusted OR associated with low education was 1.61 (1.33 to 1.94), whereas it was substantially lower in low- and middle-income countries: 1.25 (1.14 to 1.37) (p for interaction 0.045).

Conclusion: Of the socioeconomic status measures which we studied, low education was the marker most consistently associated with increased risk for AMI globally, most markedly in high-income countries.

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