This study attempts to calculate lifetime risk estimates of incident cardiovascular disease (CVD) and CVD subtypes and estimate years lived with and without CVD by education.
Key Points
Question
What is the association of educational attainment with the lifetime risk of cardiovascular disease (CVD) in middle and older adulthood?
Findings
In this study pooling 6 community-based cohorts, educational attainment was significantly associated with CVD. Lower educational attainment was associated with shorter longevity and a greater proportion of life lived with CVD, and those without a high school education had the greatest likelihood of competing risk of CVD.
Meaning
The results from this study provide critical perspective on CVD and its association with educational attainment; educational opportunity in early life may have lasting effects in middle age and older age.
Abstract
Importance
Education is a social determinant of health. Quantifying its association with lifetime cardiovascular disease (CVD) risk has public health importance.
Objective
To calculate lifetime risk estimates of incident CVD and CVD subtypes and estimate years lived with and without CVD by education.
Design, Setting, and Participants
Included community-based cohort studies with adjudicated cardiovascular events used pooled individual-level data from 1985 to 2015 of 6 prospective cohort studies. The study team assessed the association between education and lifetime CVD risk with modified Kaplan-Meier and Cox models accounting for competing risk of noncardiovascular death. The study team estimated years lived with and without CVD by education with the Irwin restricted mean and the utility of adding educational attainment to CVD risk assessment. Participants (baseline 40 to 59 years old and 60 to 79 years old) were without CVD at baseline and had complete education, cardiovascular risk factors, and prospective CVD outcomes data. Data were analyzed from January 2022 to September 2022.
Exposures
Educational attainment (less than high school, high school completion, some college, or college graduate).
Main outcome and measures
Cardiovascular events (fatal and nonfatal coronary heart disease, heart failure, and stroke; CVD-related deaths; and total CVD encompassing any of these events).
Results
There were 40 998 participants (23 305 female [56.2%]) with a mean (SD) age of 58.1 (9.7) years for males and 58.3 (9.9) years for females. Compared with college graduates, those with less than high school or high school completion had higher lifetime CVD risks. Among middle-aged men, the competing hazard ratios (HRs) for a CVD event were 1.58 (95% CI, 1.38-1.80), 1.30 (95% CI, 1.10-1.46), and 1.16 (95% CI, 1.00-1.34) in those with less than high school, high school, and some college, respectively, compared with those with college completion. Among women, these competing HRs were 1.70 (95% CI, 1.49-1.95), 1.19 (95% CI, 1.05-1.35), and 0.98 (95% CI, 0.83-1.15). Individuals with higher education had longer duration of life prior to incident CVD. Education provided limited contribution toward enhancing CVD risk prediction.
Conclusions and relevance
Lower education was associated with lifetime CVD risk across adulthood; higher education translated to healthy longevity. Educational policy initiatives may associate with long-term health benefits.
Introduction
Educational attainment is related to health outcomes and longevity. Population-based surveys consistently demonstrate the association of educational attainment with mortality,1 determining that individuals with lower education experience from 3 to 15 fewer years of life compared with those with higher education.2,3,4 Education comes with opportunity for vocational selectivity, financial earnings, health insurance, and social capital. Alongside such benefits are access to health care and health-related resources, social networks, community-based services to facilitate health, and neighborhood residence. Racial gaps in educational achievement reflect generational inequities fostered by structural racism.5 Furthermore, analyses have demonstrated that consideration of educational attainment results in reduced racial disparities in cardiovascular risk factors.6,7,8 Enhanced education provides multiple opportunities to improve health care access, health literacy, and behaviors, thereby, conveying longitudinal benefits across the life course.
Prior studies have examined educational attainment as a constituent of socioeconomic position and social determinant in relation to cardiovascular risk and outcomes.9,10 Limitations of studies examining the relationship between educational attainment and cardiovascular risk include cross-sectional design, absence of lifetime risk, or absence of accounting for competing risk of death from noncardiovascular disease (CVD) causes.11,12,13,14,15 Here, we examined how educational attainment informs lifetime cardiovascular risk assessment by pooling multiple community-based cohorts and examining events into older adulthood. We hypothesized that educational attainment completed in young adulthood would be associated with substantive contributions to cardiovascular lifetime risk and CVD-free longevity in the following decades of life.
Methods
The Cardiovascular Disease Lifetime Risk Pooling Project (LRPP) is an aggregation of community- and population-based US studies.16 Its primary objective is to harmonize phenotyping across multiple longitudinal studies to determine estimates of lifetime cardiovascular risk. Prior LRPP analyses have ascertained the longitudinal contributions of CVD risk factors and outcomes over decades to describe CVD across the life course.17,18,19,20,21,22 LRPP participants have a minimum 10-year follow-up with surveillance for cardiovascular events. For this analysis, we included individuals from the Atherosclerosis Risk in Communities Study,23 Cardiovascular Health Study,24 Coronary Artery Risk Development in Young Adults Study,25 Framingham Heart Study,26 Framingham Offspring cohort,27 and Multi-Ethnic Study of Atherosclerosis.28
The approach toward data harmonization in the LRPP includes demographics, anthropometrics, laboratory studies, cardiovascular events, and vital status.16 Individuals with prevalent cardiovascular disease, missing educational attainment, older than 40 years, and with baseline examinations prior to 1985 were excluded. As in prior LRPP analyses, we included only those individuals identified as non-Hispanic Black or White race, given the limited numbers of those of other race or ethnicity in the cohorts. The independent variable in this analysis was the highest level of educational attainment for each participant, obtained by self-report and harmonized across cohorts for categorization as (1) less than high school, (2) high school graduate, (3) some college, or (4) college graduate. Demographic variables included date of birth, sex, and self-reported race. Participants were assigned to an age group (middle-aged, age 40 to 59 years; or older, age 60 to 79 years) according to age at baseline. As such, no individual was included in both age categories. Participants in all cohorts had measurement of weight and height (used to determine body mass index), blood pressure (systolic and diastolic), cholesterol (total and high- and low-density lipoproteins), triglycerides, and fasting glucose. Smoking status was determined by self-report and described as current or prior vs never having smoked. Diabetes status was ascertained at the cohort level using standardized criteria. Individuals were categorized as receiving treatment for cholesterol or hypertension based on review of prescribed medications and self-report. Events in this analysis were defined as fatal or nonfatal coronary heart disease, heart failure, or stroke; other CVD-related deaths; total CVD, defined as the combination of any of these events; and non-CVD deaths. Consistent with the Pooled Cohort Equations (PCE), we defined atherosclerotic CVD (ASCVD) as a combined outcome of fatal or nonfatal coronary heart disease and stroke.29 Mortality status was ascertained by each cohort.
We summarized baseline characteristics by their frequencies and distributions. We calculated incident rates for the first event for each age group through age 95 years or the oldest age with robust person-time of at least 100 person-years of follow-up. Consistent with prior LRPP analyses,17,22 we determined the lifetime cumulative risk for incident events in age- and sex-stratified analyses by accounting for non-CVD death as a competing risk rather than as a censoring event. We then determined the associations of educational attainment with the events by age and sex strata. In stratified analyses, we used the Fine and Gray method to account for the joint, multivariable-adjusted competing risks for CVD events and non-CVD death within each category of educational attainment.30 Analyses adjusted for race, blood pressure, cholesterol, triglycerides, glucose, smoking status, diabetes, and treatment for hypertension or cholesterol. We estimated the mean survival time, ie, years lived without and with CVD, using the Irwin restricted mean to assess differences in compression of morbidity by education.31 The Irwin restricted mean is mathematically equivalent to the area under the survival curve. For each age group, the mean was restricted to 95 years of age. We conducted prespecified race-stratified analyses, given the differences in CVD, education, and longevity between Black individuals and White individuals.32
We assessed the discrimination and calibration of educational attainment using the PCE for ASCVD risk prediction.29 We used the Harrell C statistic to estimate the discrimination of the PCE with and without education and computed the bootstrap optimism-corrected C statistic. We assessed calibration by using the Greenwood-Nam-D’Agostino statistic and plotting the cumulative predicted vs observed events across deciles of risk. We calculated the predictive utility of adding education using the net reclassification improvement. We then used bootstrapping to calculate 95% CIs.
Data were deidentified. Each LRPP cohort received approval by their respective institutional review board at their coordinating institution and participants underwent informed consent by the cohort for each examination. Analyses were conducted using SAS version 9.4 (SAS Institute) and R version 3.1.2 (The R Foundation).
Results
The study cohort included 40 998 individuals from 6 community-based cohorts, of whom 19 030 were middle age (40 to 59 years old) and 21 968 were older (60 to 79 years old) at baseline examinations. Participants were 56.2% female and the mean (SD) age was 58.1 (9.7) years for males and 58.3 (9.9) years for females. In total, 10 103 self-identified as Black (24.6%), of whom 25.9% had less than high school education and 31.4% college completion. Of the 30 895 individuals who self-identified as White (75.4%), 12.9% had less than high school education, and 36.2% college completion. In both middle- and older-age strata, lower educational attainment was associated with higher rates of systolic and diastolic blood pressure, body mass index, total and high-density cholesterol, triglycerides, glucose, and smoking (Table 1).
Table 1. Baseline Characteristics and Their Distributions by Category of Educational Attainmenta.
| Characteristic | Less than high school | High school | Some college | College graduate or higher |
|---|---|---|---|---|
| Middle aged (40 to 59 y) | ||||
| No. | 2473 | 5445 | 3909 | 7203 |
| Age, y, mean (SD) | 52.0 (5.0) | 50.1 (5.4) | 47.9 (5.7) | 49.0 (5.5) |
| Sex, No. (%) | ||||
| Female | 1385 (56.0) | 3305 (60.7) | 2194 (56.1) | 3708 (51.5) |
| Male | 1088 (44.0) | 2140 (39.3) | 1715 (43.9) | 3495 (48.5) |
| Race,b No. (%) | ||||
| Black | 1211 (49.0) | 1324 (24.3) | 1258 (32.2) | 1779 (24.7) |
| White | 1242 (51.0) | 4103 (75.7) | 2651 (67.8) | 5424 (75.3) |
| Systolic blood pressure, mm Hg, mean (SD) | 124.3 (19.7) | 120.0 (17.8) | 119.4 (16.5) | 115.8 (16.0) |
| Diastolic blood pressure, mm Hg, mean (SD) | 76.1 (12.2) | 74.5 (11.1) | 75.3 (10.9) | 73.0 (10.6) |
| Body mass index,c mean (SD) | 29.0 (6.2) | 28.0 (5.9) | 28.7 (6.3) | 27.3 (5.3) |
| Total cholesterol, mg/dL, mean (SD) | 212.3 (44.2) | 208.2 (41.4) | 198.8 (38.9) | 200.1 (39.8) |
| HDL cholesterol, mg/dL, mean (SD) | 50.8 (16.7) | 51.6 (16.5) | 51.2 (15.4) | 52.7 (16.5) |
| LDL cholesterol, mg/dL, mean (SD) | 135.9 (42.1) | 131.9 (38.1) | 124.4 (36.0) | 124.5 (36.9) |
| Triglycerides, mg/dL, mean (SD) | 131.6 (89.3) | 126.5 (87.8) | 119.7 (95.3) | 117.0 (89.4) |
| Glucose, mg/dL, mean (SD) | 111.7 (47.8) | 102.8 (35.6) | 96.4 (27.2) | 97.1 (25.2) |
| Current smoker, No. (%) | 982 (39.8) | 1641 (30.2) | 992 (25.4) | 1183 (16.4) |
| Diabetes, No. (%) | 329 (13.4) | 425 (7.8) | 222 (5.7) | 375 (5.2) |
| Hypertension treatment, No. (%) | 199 (9.7) | 221 (4.5) | 128 (3.4) | 189 (2.9) |
| Cholesterol treatment, No. (%) | 768 (31.1) | 1113 (20.5) | 678 (17.4) | 1182 (16.4) |
| Older aged (60-79 y) | ||||
| No. | 4134 | 6606 | 4083 | 7145 |
| Age, y, mean (SD) | 66.4 (5.8) | 65.7 (5.4) | 65.9 (5.4) | 65.5 (5.4) |
| Sex, No. (%) | ||||
| Female | 2342 (56.7) | 4245 (64.3) | 2354 (57.7) | 3501 (49.0) |
| Male | 1792 (43.3) | 2361 (35.7) | 1729 (42.3) | 3644 (51.0) |
| Race,b No. (%) | ||||
| Black | 1410 (34.1) | 927 (14.0) | 803 (19.7) | 1391 (19.5) |
| White | 2724 (65.9) | 5679 (86.0) | 3280 (80.3) | 5754 (80.5) |
| Systolic blood pressure, mm Hg, mean (SD) | 133.6 (20.8) | 130.4 (20.0) | 130.1 (19.9) | 126.6 (19.2) |
| Diastolic blood pressure, mm Hg, mean (SD) | 72.8 (11.3) | 71.7 (10.5) | 72.5 (10.5) | 71.5 (10.4) |
| Body mass index,c mean (SD) | 28.5 (5.5) | 27.9 (5.2) | 27.9 (5.1) | 27.7 (5.3) |
| Total cholesterol, mg/dL, mean (SD) | 211.1 (41.2) | 208.3 (41.3) | 204.7 (39.7) | 200.4 (39.3) |
| HDL cholesterol, mg/dL, mean (SD) | 51.2 (15.7) | 52.4 (16.4) | 54.0 (16.6) | 53.5 (16.8) |
| LDL cholesterol, mg/dL, mean (SD) | 132.7 (38.2) | 128.6 (36.9) | 125.5 (35.5) | 121.7 (35.4) |
| Triglycerides, mg/dL, mean (SD) | 137.6 (82.6) | 140.8 (88.8) | 133.2 (79.8) | 126.9 (79.2) |
| Glucose, mg/dL, mean (SD) | 115.1 (45.8) | 108.1 (34.5) | 104.7 (30.8) | 105.2 (31.9) |
| Current smoker, No. (%) | 850 (20.7) | 1012 (15.4) | 584 (14.3) | 733 (10.3) |
| Diabetes, No. (%) | 776 (18.9) | 873 (13.3) | 506 (12.5) | 835 (11.7) |
| Hypertension treatment, No. (%) | 1896 (46.0) | 2817 (42.7) | 1651 (40.6) | 2741 (38.6) |
| Cholesterol treatment, No. (%) | 417 (10.1) | 1154 (17.5) | 691 (17.0) | 1332 (18.7) |
Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein.
Continuous measures provided by distribution and categorical by their frequency.
Race was self-reported.
Calculated as weight in kilograms divided by height in meters squared.
The incidence rates for each outcome per 1000 person-years are summarized in Table 2, stratified by age group, sex, and educational attainment; sex- and race-stratified event rates are presented in eTable 1 in Supplement 1 (middle age) and eTable 2 in Supplement 1 (older age). Event rates were higher across levels of educational attainment, such that those with less than high school education consistently had the highest number of all cardiovascular events. Black, middle-aged individuals had higher event rates than their counterparts of White race across all levels of educational attainment. In all sex and race strata, event rates decreased with increasing educational attainment. Similar patterns were observed in sex- and race-stratified events in individuals of older age.
Table 2. Event Rates per 1000 Person-Years According to Educational Attainment Stratified by Age and Sexa.
| Event rate (95% CI) | ||||
|---|---|---|---|---|
| Less than high school | High school | Some college | College completion | |
| Coronary heart disease | ||||
| Middle-aged (40-59 y) | ||||
| Men | 4.78 (3.93-5.80) | 3.60 (3.08-4.20) | 3.73 (3.11-4.47) | 2.14 (1.84-2.50) |
| Women | 2.58 (2.07-3.21) | 1.25 (1.02-1.53) | 1.20 (0.91-1.59) | 0.64 (0.49-0.84) |
| Older aged (60-79 y) | ||||
| Men | 11.11 (9.90-12.47) | 9.83 (8.81-10.97) | 9.24 (8.11-10.53) | 6.40 (5.74-7.14) |
| Women | 7.99 (7.15-8.93) | 5.63 (5.08-6.23) | 5.83 (5.10-6.66) | 3.53 (3.06-4.08) |
| Heart failure | ||||
| Middle-aged (40-59 y) | ||||
| Men | 8.85 (7.74-10.12) | 6.18 (5.50-6.94) | 3.26 (2.70-3.95) | 3.84 (3.42-4.30) |
| Women | 9.05 (8.05-10.16) | 4.54 (4.09-5.05) | 2.35 (1.93-2.86) | 3.34 (2.97-3.76) |
| Older aged (60-79 y) | ||||
| Men | 21.23 (19.46-23.17) | 16.83 (15.43-18.35) | 14.11 (12.63-15.77) | 12.20 (11.25-13.23) |
| Women | 19.67 (18.23-21.23) | 12.90 (12.03-13.84) | 9.93 (8.90-11.09) | 10.21 (9.34-11.16) |
| Stroke | ||||
| Middle-aged (40-59 y) | ||||
| Men | 4.82 (4.01-5.80) | 3.01 (2.55-3.55) | 2.72 (2.20-3.36) | 1.95 (1.66-2.29) |
| Women | 3.94 (3.31-4.68) | 2.40 (1.08-2.77) | 2.26 (1.85-2.78) | 1.75 (1.48-2.06) |
| Older aged (60-79 y) | ||||
| Men | 9.00 (7.89-10.27) | 8.20 (7.25-9.26) | 7.61 (6.56-8.83) | 5.83 (5.19-6.55) |
| Women | 9.31 (8.37-10.36) | 7.05 (6.42-7.73) | 6.71 (5.89-7.65) | 5.18 (4.58-5.89) |
| Total cardiovascular death | ||||
| Middle-aged (40-59 y) | ||||
| Men | 6.11 (5.22-7.16) | 4.18 (3.64-4.81) | 2.12 (1.68-2.69) | 2.77 (2.42-3.17) |
| Women | 5.34 (4.61-6.18) | 2.23 (1.93-2.58) | 1.53 (1.21-1.95) | 1.38 (1.15-1.65) |
| Older aged (60-79 y) | ||||
| Men | 15.65 (14.20-17.25) | 12.03 (10.90-13.28) | 9.67 (8.50-11.00) | 8.81 (8.03-9.67) |
| Women | 14.01 (12.86-15.27) | 8.58 (7.90-9.32) | 7.53 (6.66-8.51) | 6.07 (5.42-6.79) |
| Any cardiovascular event | ||||
| Middle-aged (40-59 y) | ||||
| Men | 16.75 (15.12-18.55) | 12.18 (11.19-13.27) | 9.36 (8.33-10.52) | 8.03 (7.41-8.71) |
| Women | 14.38 (13.10-15.79) | 7.76 (7.15-8.41) | 5.41 (4.73-6.17) | 5.46 (4.97-5.99) |
| Older aged (60-79 y) | ||||
| Men | 37.64 (35.17-40.29) | 30.49 (28.54-32.59) | 26.93 (24,80-29.24) | 22.82 (21.28-24.25) |
| Women | 33.47 (31.53-35.54) | 22.60 (21.42-23.85) | 19.13 (7.65-20.74) | 17.49 (16.32-18.74) |
| Noncardiovascular death | ||||
| Middle-aged (40-59 y) | ||||
| Men | 13.68 (12.32-15.19) | 9.99 (9.14-10.93) | 7.68 (6.78-8.69) | 7.33 (6.75-7.96) |
| Women | 10.29 (9.26-11.42) | 7.28 (6.70-7.90) | 5.08 (4.44-5.81) | 6.01 (5.51-6.60) |
| Older aged (60-79 y) | ||||
| Men | 34.61 (32.41-36.96) | 27.34 (25.60-29.19) | 24.94 (23.00-27.05) | 21.35 (20.11-22.67) |
| Women | 24.24 (22.71-25.87) | 20.33 (19.26-21.46) | 17.09 (15.75-18.53) | 17.38 (16.26-18.58) |
Events indicate fatal and nonfatal coronary heart disease, heart failure, or stroke, deaths related to cardiovascular disease, total cardiovascular disease encompassing any of these events, and non-cardiovascular disease death.
Figure 1 presents the cumulative lifetime risk of incident CVD events by age group and sex for each level of education over follow-up (shown with 95% CIs in eFigure 1 in Supplement 1). Event data are provided in eTable 3 in Supplement 1. The curves demonstrate early, pronounced differences in CVD event probability by level of educational attainment, such that those with less than high school education had higher likelihood of incident CVD events throughout multiple decades of follow-up. Conversely, those who completed college had the lowest probability of CVD events across the life course. Race-specific cumulative lifetime risk estimates for Black individuals are presented in eFigure 2 in Supplement 1 and for White individuals in eFigure 3 in Supplement 1.
Figure 1. Cumulative Lifetime Risk Estimates for Total Cardiovascular Disease (CVD) Events Accounting for Competing Risk of Non-CVD Death by Educational Attainment.
The competing risk for all CVD events was elevated across age and sex strata in those with less than high school and high school completion compared with those with a college education. The multivariable-adjusted cumulative risk of CVD events is summarized in Table 3, stratified by age category and sex, accounting for competing risk of non-CVD death, as per the Fine and Gray method.30 Compared with those who completed college, middle- and older-aged men with less than high school or high school education had significantly increased lifetime risk for all outcomes. Competing hazard ratios (HRs) generally decreased in both age groups as educational attainment increased. These trends were similar for women in both age groups.
Table 3. Estimates of Multivariable-Adjusted Hazard Ratios (HRs) for Events by Educational Attainment Category, Stratified by Age and Sex and Accounting for Competing Risk of Noncardiovascular Deatha,b.
| HR (95% CI) | ||||
|---|---|---|---|---|
| Less than high school | High school | Some college | College completion | |
| Coronary heart disease | ||||
| Middle-aged (40-59 y) | ||||
| Men | 1.56 (1.20-2.03) | 1.28 (1.02-1.60) | 1.49 (1.16-1.90) | [Reference] |
| Women | 1.92 (1.34-2.75) | 1.33 (0.94-1.88) | 1.45 (0.98-2.16) | |
| Older aged (60-79 y) | ||||
| Men | 1.46 (1.24-1.72) | 1.36 (1.15-1.59) | 1.35 (1.14-1.60) | [Reference] |
| Women | 1.69 (1.40-2.03) | 1.33 (1.11-1.59) | 1.44 (1.18-1.75) | |
| Heart failure | ||||
| Middle-aged (40-59 y) | ||||
| Men | 1.62 (1.36-1.93) | 1.39 (1.18-1.63) | 0.88 (0.71-1.10) | [Reference] |
| Women | 1.71 (1.45-2.01) | 1.12 (0.96-1.31) | 0.69 (0.55-0.88) | |
| Older aged (60-79 y) | ||||
| Men | 1.51 (1.34-1.71) | 1.28 (1.13-1.44) | 1.12 (0.97-1.29) | [Reference] |
| Women | 1.45 (1.28-1.64) | 1.11 (0.98-1.25) | 0.91 (0.79-1.05) | |
| Stroke | ||||
| Middle-aged (40-59 y) | ||||
| Men | 1.83 (1.43-2.35) | 1.38 (1.10-1.74) | 1.42 (1.09-1.86) | [Reference] |
| Women | 1.46 (1.14-1.86) | 1.18 (0.95-1.47) | 1.27 (0.97-1.67) | |
| Older aged (60-79 y) | ||||
| Men | 1.33 (1.11-1.60) | 1.29 (1.09-1.54) | 1.26 (1.04-1.53) | [Reference] |
| Women | 1.47 (1.23-1.75) | 1.23 (1.05-1.45) | 1.22 (1.02-1.47) | |
| Total cardiovascular death | ||||
| Middle-aged (40-59 y) | ||||
| Men | 1.39 (1.24-1.56) | 1.22 (1.11-1.35) | 1.01 (0.88-1.15) | [Reference] |
| Women | 1.48 (1.32 1.66) | 1.13 (1.02-1.26) | 0.97 (0.83-1.12) | |
| Older aged (60-79 y) | ||||
| Men | 1.41 (1.31-1.53) | 1.23 (1.14-1.33) | 1.15 (1.05-1.25) | [Reference] |
| Women | 1.34 (1.20-1.46) | 1.14 (1.05-1.23) | 1.04 (0.95-1.14) | |
| Any cardiovascular event | ||||
| Middle-aged (40-59 y) | ||||
| Men | 1.58 (1.38-1.80) | 1.30 (1.10-1.46) | 1.16 (1.00-1.34) | [Reference] |
| Women | 1.70 (1.49-1.95) | 1.19 (1.05-1.35) | 0.98 (0.83-1.15) | |
| Older aged (60-79 y) | ||||
| Men | 1.41 (1.20-1.55) | 1.22 (1.11-1.34) | 1.14 (1.03-1.27) | [Reference] |
| Women | 1.50 (1.36-1.65) | 1.15 (1.05-1.26) | 1.04 (0.93-1.16) | |
Events, fatal and nonfatal coronary heart disease, heart failure, and stroke, any cardiovascular event, a combination of these, and other cardiovascular death, death from cardiovascular disease not captured by the events listed here.
Adjusted for age, race, systolic blood pressure, body mass index, total and high-density cholesterol, diabetes, smoking, and treatment for hypertension.
eTable 4 in Supplement 1 presents race-stratified results for middle-aged men and women, also accounting for competing lifetime risk of noncardiovascular death. For middle-aged men and women of both races, less than high school education continued to be associated with increased lifetime risk for cardiovascular events compared with those with a college completion. However, the magnitude of the effect of education on lifetime CVD risk varied by race. For example, middle-aged Black men without high school completion had a lifetime risk for cardiovascular death of 1.44 (95% CI, 1.18-1.75) while those with high school completion had a risk of 1.58 (95% CI, 1.28-1.95). In contrast, for White men these risks were 1.39 (95% CI, 1.21-1.60) for those without high school completion and 1.13 (95% CI, 1.01-1.27) for those with high school completion. Likewise, Black men with and without high school completion had a 2-fold increased risk of stroke in comparison with those with college completion. In contrast, in White men, only those without high school completion had an increased lifetime competing risk of stroke (HR, 1.72; 95% CI, 1.24-2.37) compared with those with college completion. For middle-aged White women, none of the competing HRs were statistically significant when comparing those with high school completion with the referent with college completion. For Black middle-aged women, those with high school completion had a 1.3-fold (95% CI, 1.04-1.63) increased lifetime risk of any cardiovascular event compared with those with college completion.
When examining the race-stratified results for older-aged adults (eTable 5 in Supplement 1), racial differences in the associations between educational attainment and CVD outcomes were further apparent. For Black men, there was no significant association between educational attainment and lifetime risk of coronary heart disease or stroke, for example, compared with those with college completion. For older-aged Black women and White women, those with less than high school education had significantly increased risks of events compared with those with college completion. However, for White women, education was consistently associated with risk for cardiovascular outcomes while the comparison differed for Black women.
For both middle- and older-aged adults, overall longevity following baseline examinations was higher with educational attainment. Middle-aged men and women with high school education had an overall survival time after the index examination of 22.6 and 24.3 years, respectively. In contrast, men who completed college had survival times of 27.0 years and women a survival time of 28.2 years. Similar patterns were observed in older-aged adults, albeit with shorter overall survival time, given the older index age. Overall survival without CVD increased progressively across level of educational attainment, such that higher levels of education brought more years of event-free, healthy life: middle-aged men and women with college education or higher had an additional 5 years of healthy life compared with those with less than high school education. Differences in survival time by educational attainment were observed in older-aged men and women, as well as those with college education who had had 4 additional longevity years than those with less than high school education. Furthermore, average years lived with CVD decreased inversely to progressive educational attainment, indicating the compression of morbidity experienced by those with higher educational attainment. Figure 2 graphically presents survival without and with CVD by age and sex strata, demonstrating the extension of health span with increasing educational attainment. eTable 6 in Supplement 1 presents these data numerically.
Figure 2. Years Lived With and Without Cardiovascular Disease (CVD) Among Middle- and Older-Aged Adults in Age- and Sex-Stratified Analyses.
Middle-aged individuals were followed up with for 30 years and older aged for 25 years following the baseline examination. Across strata, individuals with higher education experienced more years free of CVD and decreased time living with CVD, demonstrating compression of morbidity.
eTable 7 in Supplement 1 presents the model performance with the addition of education to the PCE for the prediction of 10-year ASCVD. Results are stratified by age, sex, and race in accordance with the derivation of the PCE. Overall, improvement in risk prediction was limited. The most robust improvement was observed in older-aged Black women, in whom the optimism-corrected C statistic improved from 0.724 (95% CI, 0.659-0.789) to 0.735 (95% CI, 0.661-0.799).
Discussion
We pooled 6 community-based cohorts to examine the comparison between educational attainment and lifetime risk for CVD and CVD-free longevity. Our results identified a gradient of risk, such that higher educational attainment was significantly associated with lower incidence and risk of CVD events alongside greater health span, ie, years lived without CVD. These results were consistent through middle age (40-59 years) and older adulthood (60-79 years) for both men and women. In multivariable-adjusted analyses incorporating CVD risk factors and treatment, we observed that men and women with less than high school education were 1.4- to 1.7-fold more likely to experience any cardiovascular event than those who had completed college. The observed differences in lifetime risk estimates translate to increasing longevity without CVD (health span) across categories of educational attainment. Those with higher education appreciate a compression of morbidity, with longer lives without CVD. Including education did not substantively improve risk estimation using the PCE. Lastly, our race-stratified analyses identified that the association between education and risk of cardiovascular events differed by race. The modulation of risk with progressive education was more evident in middle- and older-age individuals of White race compared with those of Black race.
Studies have consistently determined that educational attainment is associated with health outcomes.9,10,12,33,34,35 Our work complements such prior research with extended duration of follow-up and consideration of competing risk for noncardiovascular death. The multiple decades of follow-up used in our analysis suggests that education in early life—given college completion typically occurs in young adulthood—may have lifelong relevance for cardiovascular risk. Our work describes the compression of morbidity by educational status; those with higher education lived both longer lives and also more years without CVD. On average, CVD is a disease of aging that occurs later among individuals with progressively higher educational attainment.
Education may be related to health outcomes through multiple avenues.36 Most evident is the vocational opportunity provided by education, tied to access to health care in the US. Contemporary data from the National Health Interview Survey11 demonstrate the cross-sectional association between educational attainment and access to general and specialty care in individuals reporting CVD. Education further shapes vocational circumstances, opportunities, and environmental and psychological exposures relevant to lifelong health beyond the workplace.37 Hence, with education comes the capacity to afford and obtain health treatment alongside immediate and long-term material advantages that shape longevity and determine the direct correlation between income and life expectancy; in the US, men and women in the top 1% of household income live approximately 14 and 11 years longer, respectively, than those in the bottom 1%.38 While education provides a step forward toward access to social resources, it has been demonstrated as insufficient to overcome the profound, generational obstacles presented by structural racism. The results here provide further demonstration of the differences in the associations between education and cardiovascular outcomes by race. Pointedly, even when individuals of Black race achieve higher education, their CVD risk remains elevated compared with referents of White race.8,39,40
Educational attainment is related to health literacy and health-related behaviors that may contribute to CVD risk. Education promotes general literacy and the health literacy associated with improved success with health care access and related behaviors, such as patient activation, advocacy, and navigation of a complex health system, alongside contributing toward an array of health behaviors with longitudinal effects.41 Studies have consistently identified significant relations between educational attainment and an array of cardiovascular risk factors, including smoking, cholesterol levels, physical activity, and achievement of ideal cardiovascular health.8,10,42,43 Education may yield additional psychological benefits which contribute to cardiovascular risk,44,45 not accounted for by our analysis.
Our analyses may have direct implications for social policy, public health, and CVD prevention. The absence of equitable higher education opportunities in the US is a significant barrier to economic advancement and has long-term repercussions on cardiovascular health. Education intersects with race, poverty, neighborhood segregation, health literacy, vocational opportunity, income, and other social factors to potentiate structural barriers that exacerbate health inequities. Improving access to higher education would address entrenched obstacles to social mobility and impact the generational wealth gap experienced by individuals, families, and communities experiencing social disadvantage.
The absence of statistically meaningful enhancement to the PCE does not mitigate the importance of assessment of education as part of routine cardiovascular risk and delivery of clinical care. The determination of educational attainment is more rapidly ascertained than genetic or biomarker testing as part of personalized or precision medicine, in addition to likely being more informative. Assessing patients’ education identifies those individuals who face structural obstacles to equitable care and may guide interventions to address the accompanying social, financial, and health literacy obstacles. We further advocate for including measurement of social factors in clinical trials and registries. Such data would inform the heterogeneity and social diversity of participants and in turn facilitate the more important next steps of informing interventions to address obstacles to deliver equitable cardiovascular care from the least to most educated.
Strengths and Limitations
Our analysis has several fundamental strengths. We incorporated 6 community-based cohorts to include approximately 41 000 individuals, leveraging cohorts’ longitudinal surveillance and adjudication of cardiovascular events. We further recognize the limitations of our analysis. First, our assessment of education did not incorporate metrics of educational quality. Second, we are not able to exclude residual confounding from individual-, family-, and neighborhood-level social determinants, typically more difficult to measure or quantify, that may be associated with successful completion of educational milestones or cardiovascular outcomes. Among such factors are household and individual income, not included in this analysis because of their absence of harmonization in LRPP. Third, we recognize challenges to the generalizability of our analysis as we included only individuals who self-identified as Black or White. Furthermore, while we incorporate strengths of community-based cohorts, we recognize that cohort participants are not representative of a heterogenous population that faces diverse health obstacles and challenges. Fourth, our analysis did not incorporate mechanisms that may link education and health outcomes, such as access to health care, structural barriers to health behaviors, and health literacy. Subsequent analyses are essential to ascertain how such metrics contribute to the association between education and CVD risk.
Conclusion
In conclusion, we observed a significant gradient of lifetime CVD incidence across levels of educational attainment in adults. Our analysis confirms that education, accomplished in early life, may have longitudinal implications across the life course.
eTable 1. Event rates for middle aged (40-59 years) individuals, per 1000 person-years according to educational attainment stratified by sex and race
eTable 2. Event rates for older aged (60-79 years) individuals, per 1000 person-years according to educational attainment stratified by sex and race
eTable 3. Risk estimates with 95% confidence intervals to inform presentation of competing risk by educational attainment
eTable 4. Estimates of multivariable-adjusted Hazard Ratios (95% Confidence Intervals) for events† by educational attainment category for middle aged (40-59 years) individuals, stratified by sex and race and accounting for competing risk of non-cardiovascular death
eTable 5. Estimates of multivariable-adjusted* Hazard Ratios (95% Confidence Intervals) for events† by educational attainment category for older aged (60-79 years) individuals, stratified by sex and race and accounting for competing risk of non-cardiovascular death
eTable 6. Years lived with and without cardiovascular disease by age category, sex, and educational attainment following the baseline examination
eTable 7. Model performance for the prediction of ASCVD with the addition of education to Pooled Cohort Equations
eFigure 1. Cumulative lifetime risk estimates for total CVD events in individuals of white race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men, shown with 95% Confidence Intervals
eFigure 2. Cumulative lifetime risk estimates for total CVD events in individuals of Black race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men
eFigure 3. Cumulative lifetime risk estimates for total CVD events in individuals of white race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men
Data sharing statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Event rates for middle aged (40-59 years) individuals, per 1000 person-years according to educational attainment stratified by sex and race
eTable 2. Event rates for older aged (60-79 years) individuals, per 1000 person-years according to educational attainment stratified by sex and race
eTable 3. Risk estimates with 95% confidence intervals to inform presentation of competing risk by educational attainment
eTable 4. Estimates of multivariable-adjusted Hazard Ratios (95% Confidence Intervals) for events† by educational attainment category for middle aged (40-59 years) individuals, stratified by sex and race and accounting for competing risk of non-cardiovascular death
eTable 5. Estimates of multivariable-adjusted* Hazard Ratios (95% Confidence Intervals) for events† by educational attainment category for older aged (60-79 years) individuals, stratified by sex and race and accounting for competing risk of non-cardiovascular death
eTable 6. Years lived with and without cardiovascular disease by age category, sex, and educational attainment following the baseline examination
eTable 7. Model performance for the prediction of ASCVD with the addition of education to Pooled Cohort Equations
eFigure 1. Cumulative lifetime risk estimates for total CVD events in individuals of white race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men, shown with 95% Confidence Intervals
eFigure 2. Cumulative lifetime risk estimates for total CVD events in individuals of Black race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men
eFigure 3. Cumulative lifetime risk estimates for total CVD events in individuals of white race by educational attainment, defined as less than high school, high school, some college, or college or greater, in (A) Middle-aged women; (B) Older-aged women; (C) Middle-aged men; and (D) Older-aged men
Data sharing statement