November 06, 2023

3 min read

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Key takeaways:

  • Higher educational attainment was associated with reduced lifetime CVD risk.
  • The analysis did not account for residual confounders such as household and individual income.

College graduates may have lower CV risk in middle and older age compared with individuals who did not complete college or high school earlier in life, researchers reported.

Findings from the Cardiovascular Disease Lifetime Risk Pooling Project were published in JAMA Cardiology.

Graphical depiction of source quote presented in the article

“That education is a prominent social determinant of health is well established. But we sought to investigate the association of education with lifetime risk of cardiovascular events,” Jared W. Magnani, MD, MSc, cardiologist and associate professor of medicine at the University of Pittsburgh Medical Center, told Healio. “We wanted to understand how education, completed usually in adolescence, has long-term effects on CV health across middle age and older adulthood.”

For the Cardiovascular Disease Lifetime Risk Pooling Project, researchers aggregated 10-year community- and population-level follow-up data to improve phenotyping across the Atherosclerosis Risk in Communities (ARIC) study, the Cardiovascular Health Study, the Coronary Artery Risk Development in Young Adults (CARDIA) study, the Framingham Heart Study, the Framingham Offspring cohort and the Multi-Ethnic Study of Atherosclerosis (MESA).

“Education is an avenue for social capital and hence a gateway for health care access,” Magnani told Healio. “Limitations of our analysis include the lack of inclusion of household income. Having such data would likely attenuate the effect of education which we observed in our analysis.”

Educational attainment and lifetime CV risk

Participants had no CVD at baseline and had complete data on education, CV risk factors and prospective CVD outcomes data. The analysis included 40,998 participants (mean age, 58 years; 56.2% women; 25% Black).

Educational attainment was defined as less than high school, high school completion, some college or college graduate.

CV events of interest included fatal and nonfatal CHD, HF, stroke, CVD-related death and total CVD encompassing any of these events.

Overall, 25.9% of participants who self-identified as Black had less than high school education and 31.4% had college completion. In comparison, 12.9% of white participants had less than high school education and 36.2% had college completion.

After adjusting for age, race, BP, BMI, cholesterol, diabetes, smoking status and treatment for hypertension, researchers reported that educational attainment below college completion was associated with elevated risk for all CV events, among both men and women and among both middle age (40 to 59 years) and older age (60 to 79 years) groups.

In middle-aged men, compared with participants with college completion, HRs for risk for any CV event were 1.58 (95% CI, 1.38-1.8) for those with less than high school education, 1.3 (95% CI, 1.1-1.46) for those with high school completion and 1.16 (95% CI, 1-1.34) among those with some college education.

For middle-aged women, compared with participants with college completion, risk for any CV event was higher in those with less than high school education (HR = 1.7; 95% CI, 1.49-1.95) and high school completion (HR = 1.19; 95% CI, 1.05-1.35) but not in those with some college education (HR = 0.98; 95% CI, 0.83-1.15).

The researchers observed similar patterns in participants of older age.

‘An enduring, longitudinal contribution’

“We know that education is usually in adolescence, but it has an enduring, longitudinal contribution to CV risk. However, our study found that education has an enduring effect for multiple decades, well into older adulthood,” Magnani told Healio. “First, our findings suggest that addressing inequitable access to education has long-term potential to reduce social and medical costs of CVD. If we can bridge educational gaps in early life, then maybe we can reduce the toll of CV adversity over middle and later adulthood. Second, it is paramount that clinical trials, registries and cohort studies collect data on participants’ educational attainment. That is just a single question, but it provides opportunity to assess generalizability by educational attainment and to understand how education may relate to CV risk and behaviors.

“Clinicians ignore assessing educational attainment at their patients’ peril,” Magnani said. “Education is a marker of social resources, health literacy, and, as shown in our analysis, cardiovascular risk. Assessing education provides guidance toward providing increased attention and care for patients who are likely to experience increased risk for CVD.”

For more information:

Jared W. Magnani, MD, MSc, can be reached at



Magnani reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.