# Educational level, clinical outcomes and quality of care in a Swiss cohort of patients with acute coronary syndromes

## TL;DR

In Switzerland, patients with lower education levels face worse outcomes and less quality care after heart attacks, despite universal healthcare.

## Contribution

This study identifies educational disparities in acute coronary syndrome care and outcomes in a universal healthcare system.

## Key findings

- Patients with lower education had more cardiovascular risk factors and less access to cardiac rehabilitation and specialist follow-up.
- Preventive targets like smoking cessation and LDL-C control were less achieved in lower education groups.
- Lower education was associated with higher risk of major cardiac events and mortality.

## Abstract

Despite universal coverage, inequities persist in acute coronary syndrome (ACS) care. This study examines how educational levels impact the quality and outcomes of health care.

A cohort of ACS patients hospitalized in five Swiss university hospitals was categorized into four educational levels (EL) with EL1 defined as lower than vocational school and EL4 as a university degree. The use of medical therapies, achievement of preventive targets and risk of clinical events were evaluated across ELs at baseline (N = 6040), 1‐year (N = 5756) and 5‐years (N = 2253) and presented with adjusted marginal odds ratios (mOR), average marginal effect (AME) and hazard ratios (HRs).

Among 6040 patients, the mean age was 63 years, and 81% were male. Participants with lower EL had a greater burden of cardiovascular risk factors at baseline. Compared with EL4 participants EL1 participants had lower adherence to cardiac rehabilitation (mOR = .6 [95% CI .5–.8], AME = −10%) and were less likely to be followed by a cardiologist (mOR .6 [95% CI .5–.8], AME = −6%). Use of medical therapies did neither differ across EL at discharge nor during follow‐up. At 1 year, smoking cessation (mOR = .7 [95% CI .5–.9], AME = −10%) and weight reduction ≥5% among overweight or obese participants (mOR = .7 [95% CI .5–.9], AME = −6%) were less frequent in individuals with EL1 compared with EL4. At long term, achievement of LDL‐C <1.8 mmol/L (<70 mg/dL) (mOR = .6 [95% CI .4–.9], AME = −9%) was less frequent in individuals with EL1 compared with EL4. Lower EL was associated with an increased risk of major acute coronary event (MACE) at short‐ (aHR = 1.4 [95% CI 1.0–2.0] for EL1 vs. EL4) and long term (aHR = 1.3 [95% CI 1.0–1.6] for EL1 vs. EL4) and all‐cause death at long term (aHR = 1.6 [95% CI 1.1–2.2] for EL1 vs. EL4).

In Switzerland, disparities in ACS care and outcomes remain across EL, emphasising the need for tailored interventions to reduce inequities.

Despite universal healthcare in Switzerland, disparities in post‐acute coronary syndrome (ACS) care persist across educational levels. In a cohort of 6040 patients, those with the lowest education had more cardiovascular risk factors and were less likely to attend cardiac rehabilitation or receive cardiology follow‐up. Preventive targets like smoking cessation, weight loss and LDL‐C control were less often achieved. Although medication use was similar, lower education was linked to higher mortality. These findings highlight the need for targeted strategies to address educational inequities in ACS care.