Educational level and cardiovascular outcomes in patients hospitalized with first-detected atrial fibrillation: a Swedish nationwide cohort study
Socioeconomic factors are associated with cardiovascular morbidity. We investigated the association between education level and incident heart failure (HF), acute coronary events (AMI), and cerebrovascular events (stroke) following hospitalization with first-detected atrial fibrillation (AF). In this nationwide retrospective observational cohort study using linked Swedish national registers, we included patients who received a first diagnosis of AF during hospitalization from 1995 to 2008. Education levels were categorized as primary, secondary, or academic, and patients were followed for up to five years. Outcomes were first hospitalization for HF, AMI, or stroke. Associations were assessed using cause-specific Cox proportional hazard models, for men and women separately. Models were adjusted for age, calendar year of AF diagnosis, whether AF was the primary or secondary admission diagnosis, comorbidity diagnoses and thromboembolic risk. The cohort comprised 263,172 patients (mean age 72.5 ± 10.4 years; 56.2% male). Compared with primary education, secondary and academic education levels were associated with lower adjusted risks of HF and AMI in both females and males. For HF, adjusted hazard ratios (HR) were 0.96 (95% CI 0.93–1.00) for secondary and 0.82 (95% CI 0.77–0.87) for academic education in females, and 0.93 (95% CI 0.90–0.96) and 0.76 (95% CI 0.72–0.80), respectively, in males. For AMI, adjusted HRs were 0.89 (95% CI 0.85–0.93) and 0.71 (95% CI 0.65–0.77) in females, and 0.91 (95% CI 0.87–0.94) and 0.75 (95% CI 0.71–0.80) in males. For stroke, lower adjusted risks were observed only in the academic education group. Baseline comorbidity burden and thromboembolic risk were higher in lower education groups. In this large nationwide cohort of patients hospitalized with AF, higher education level was associated with lower adjusted hazards of incident HF and AMI over five years, while the association with stroke was weaker. Education level may be considered a risk marker when planning follow-up and preventive care after hospitalization with AF.