Level of education and risk of heart failure: a prospective cohort study with echocardiography evaluation.

AIMS: With increasing socioeconomic disparity in cardiovascular risk factors, there is a need to assess the role of socioeconomic factors in chronic heart failure (CHF) and to what extent this is caused by modifiable risk factors. METHODS AND
RESULTS: In a prospective cohort of 18 616 men and women without known myocardial infarction or CHF examined in 1976-78, 1981-83, 1991-94, and 2001-03 in the Copenhagen City Heart Study, we studied the effect of education on CHF incidence. During a median follow-up of 21 years (range 0-31), 2190 participants were admitted to hospital for CHF. Age-adjusted hazard ratio (HR) for intermediary (8-10 years) and high level of education (>10 years) with low (< 8 years) as reference was 0.69 (0.62-0.78) and 0.52 (0.43-0.63), respectively, with similar associations in men and women. After adjusting for updated cardiovascular risk factors, corresponding HRs were 0.75 (0.67-0.85) and 0.61 (0.50-0.73). In a random subset of the population examined with echocardiography in 2001-03 (n = 3589), education was associated with left ventricular (LV) hypertrophy, LV dilatation, reduced LV ejection fraction, and severe diastolic dysfunction (P for trend, all <0.05), whereas no association was found for mild diastolic dysfunction (P for trend, 0.61). With the exception of LV hypertrophy, significant associations persisted after adjustment for potential mediating factors.
CONCLUSION: In this cohort study, the level of education was associated with cardiac dysfunction and predicted future hospital admission for CHF. Only a minor part of the excess risk was mediated through traditional cardiovascular risk factors. Strategies to reduce this inequality should be strengthened.