Educational Attainment May Be Independent Mortality Risk Factor in CVD

The effect of education on survival outcomes was evaluated both overall and as it related to cardiovascular disease (CVD).

Ultimate education level may be an independent risk factor for all-cause and cardiovascular disease (CVD)–related mortalities in patient populations overall and specifically among those who have atherosclerotic CVD (ASCVD), according to new study findings published in BMC Public Health.

“Educational attainment is an important social determinant of health for CVD,” the study authors wrote. “However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the United States, especially in individuals with ASCVD.”

For this analysis, there were 4 categories of self-reported educational level: less than high school, high school/general education development, some college, and at least a college degree. The 2006-2014 National Death Index-linked National Health Interview Survey provided the study data on 210,853 initial participants, of whom 8% had ASCVD. Most participants were male, non-Hispanic White, and fit into the lowest-income (41.2%) bracket for those with less than a high school education vs a high-income bracket (60.2%) for those with at least a college degree, per the federal poverty level from the US Census Bureau. The most common cardiovascular risk factors was insufficiently active status across all levels of educational attainment.

Overall, an adult patient population of close to 189 million was represented, and their median (IQR) follow-up was 4.5 (2.5-6.4) years. The age-adjusted mortality rates were per 100,000 person-years.

The most common education level was attainment of a college degree (38.0%), while the fewest study participants (14.7%) had less than a high diploma. Twenty-seven percent had high school/general education development and 20.3%, some college.

There were significant differences between the lowest and highest education categories when comparing all-cause age-adjusted mortality rates overall and among those with ASCVD. For those with less than a high school education vs having at least a college degree, respectively, the mortality rate was 47.9% higher overall (400.6 vs 208.6) and 32.0% higher just among the adults who had ASCVD (1446.7 vs 984.0).

Similar age-adjusted mortality rates were seen when considering CVD. Mortality rates were lower overall among the study population who had at least a college degree: by 52.7% overall (82.1 vs 38.7) and by 38.8% among the adults who had ASCVD (456.4 vs 279.5).

An additional analysis shows a positive association between 10-year survival and education level overall and among those with CVD. Among individuals with less than a high school diploma, the 10-year survival rate was 94.0% for all-cause mortality but 83.0% among those with CVD compared with 99.0% and 96.0%, respectively, for those with at least a college degree.

Further, after adjusting for age, sex, race/ethnicity, income, and insurance status, having less than a high school education was linked to a 39.0% greater risk of all-cause mortality (HR, 1.39; 95% CI, 1.29-1.50) and a 50.0% greater risk of CVD-related mortality (HR, 1.5; 95% CI, 1.26-1.81) in the total study population. Among the subpopulation with ASCVD, the corresponding rates were 21.0% greater (HR, 1.21; 95% CI, 1.06-1.38) and 38.0% greater (HR, 1.38; 95% CI, 1.04-1.82).

“To our knowledge, this is the largest nationally representative study evaluating the longitudinal impact (approximately 10 years) of educational attainment on all-cause and CVD mortality in the general adult population and adults with ASCVD in the United States,” the study authors wrote. “We observed an inverse relationship between educational attainment and risk of all-cause and CVD in both the total and ASCVD populations.”

They added that their findings echo previous research showing lower life expectancy and higher mortality from lower total education—but that this could be for several reasons: lower health literacy, income level, lack of access to care, and age and racial disparities leading to socioeconomic challenges.

“The factors mentioned above merit further investigation as their effect on the education-mortality association may be unique,” the authors concluded. “These cumulative results necessitate upstream interventions (eg, social reform, public health policies), which can help improve midstream determinants over time to improve educational attainment and reduce mortality rates.”


Khan N, Javed Z, Acquah I, et al. Low educational attainment is associated with higher all-cause and cardiovascular mortality in the United States adult population. BMC Public Health. Published online May 16, 2023. doi:10.1186/s12889-023-15621-y

Related Videos
Sheila Garland, PhD, MSc, Memorial University
Dayna Johnson, PhD, MPH, MSW, MS, Rollins School of Public Health at Emory University
Ariel Williamson, PhD, DBSM, Children's Hospital of Philadelphia/Perelman School of Medicine
Judite Blanc, PhD, Miller School of Medicine/University of Miami
Mark Fendrick, MD
Mitzi Joi Williams, MD, FAAN, Joi Life Wellness Neurology Clinic
Screenshot of Byron Lam, MD
Mitzi Joi Williams, MD, FAAN, Joi Life Wellness Neurology Clinic
Screenshot of Sancy Leachman, MD, PhD, smiling
Related Content
© 2023 MJH Life Sciences
All rights reserved.