Atherosclerosis Risk Rises With Less Education; Smoking Is the Link

Liam Davenport

August 01, 2019

An association between achieved level of education and the presence of subclinical atherosclerosis in a cohort of middle-aged adults seemed to be driven by whether they were smokers and how much they smoked.

Those with less than a university education showed a significant 46% increased adjusted risk for generalized atherosclerosis on imaging studies compared with people who had attended university.

More than 70% of the association between education level and vascular disease could be attributed to lifestyle factors, with smoking status and daily cigarette use making an overwhelming contribution and diet playing only a small role.

Interestingly, the analysis of more than 4000 people in Spain, who were initially without symptoms or known vascular disease, did not show a significant independent effect of annual income on the presence of subclinical vascular disease, despite its well-known relation to education level.

"Lower education level may increase cardiovascular risk by accelerating the development of atherosclerosis in its earlier stage," conclude the authors of the analysis, led by Lidia Redondo-Bravo, MD, MPH, Hospital Universitario La Paz, Madrid, Spain.

"As tobacco consumption seems to be the main mediator in this association, smoking prevention campaigns should be considered a key preventative strategy, particularly in populations with a lower education level," notes their report, published in the July 30 issue of the Journal of the American College of Cardiology.

The analysis comes from the prospective Progression of Early Subclinical Atherosclerosis (PESA) study of employees 40 to 54 years of age at a corporate headquarters in Madrid, who were recruited from 2010 to 2014.

"An advantage of the study design is that the population was drawn from employees at a single bank in one city in Spain, providing a more homogeneous cohort than a general population study," according to an accompanying editorial.

"This theoretically may provide somewhat of an internal control to better assess education and income's impact without considerable influence from measured (occupation) and unmeasured confounders," writes Jacob A. Udell, MD, MPH, Toronto General Hospital and University of Toronto.

"The disadvantage of this approach is that the results may not be widely generalizable across a broader range of education, income, and occupational categories."

However, even with the study's limitations, the results should be applicable to populations in other developed countries, Udell told theheart.org | Medscape Cardiology. The study is "probably going to be very translatable to at least a Western environment."

Still, "we always caution that what is required really is to see replication," he said. "It may not be sexy but it's important to verify this in independent groups of people."

The study's 4025 participants completed a demographic, socioeconomic, lifestyle, and cardiovascular risk-factor assessment, and underwent ultrasound and CT coronary calcium imaging to look for coronary, carotid, aortic, and iliofemoral arterial disease.

Subclinical atherosclerosis, defined as detection of any atherosclerotic plaque or a coronary calcium score of at least 1, was present in 62.7%. It was generalized — that is, observed at four to six vascular sites — in 13.5% of participants; generalized atherosclerosis was seen in 6.2% of women and 18.0% of men (P < .001).

Education level was inversely associated with generalized atherosclerosis after age, sex, and income were accounted for (adjusted odds ratio [OR], 1.46; 95% CI, 1.15 - 1.85; P = .002) for people with no university studies compared with those who attended university.

Women were more likely to have undertaken university studies than men (77.1% vs 72.9%; P = .003).

After adjusting their analysis for age and sex, the team found that smoking status and number of cigarettes smoked per day remained significantly associated with generalized atherosclerosis (P < .001 for both), whereas dietary pattern became nonsignificant.

Overall, the three lifestyle factors mediated 70.5% of the effect of education level on the presence of generalized atherosclerosis, with smoking status contributing 34.9%, cigarettes smoked per day 32.1%, and dietary pattern only 3.5%.

That means that 29.5% of the education–atherosclerosis association is not explained by diet or smoking, "so further research on potential mechanisms between education level and diffuse atherosclerosis, including other behavioral factors, is warranted," the group writes.

Efforts to direct antismoking educational programs at current smokers may not be very successful, as "perhaps the horse was already out of the barn," Udell said.

"We need to target the kids, middle grades to tweens, to start talking about the potential health effects of smoking and potentially discourage the taking up of smoking."

When it comes to changing smoking habits, "you've really got to be ahead of the curve," and include social media campaigns, as well as consulting with potential patients and "even younger kids to figure out what works for getting their attention."

PESA is funded by the Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), and Banco Santander, Madrid, Spain . The report states that it is also "part of a project" that has received funding from the European Union's Horizon 2020 research and innovation program under a Marie Skłodowska-Curie grant agreement, and from the American Heart Association. Redondo-Bravo reports no relevant relationships; disclosures for the other authors are in the report. Udell discloses serving on advisory boards of Amgen, AstraZeneca, Boehringer Ingelheim, Janssen, Merck, Novartis, and Sanofi; receiving speaker honoraria from Boehringer Ingelheim and Sanofi; and receiving research funding from AstraZeneca, Novartis, and Sanofi.

J Am Coll Cardiol. 2019;74:526-535 and 536-537. Full text, Editorial

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