Association between education attainment and carotid plaque score in middle-aged women and men: data from the ACE 1950 study

Abstract Background The mechanisms linking lower educational attainment to cardiovascular disease (CVD) are not fully understood. Carotid plaque score strongly predicts cardiovascular disease, outperforming carotid intima-media thickness. The relationship between education level and carotid plaque score has not been thoroughly investigated and it is unclear if any association differs between women and men. Purpose To investigate the association between attained educational level and carotid plaque score in middle-aged women and men from the general population. Methods This cross-sectional analysis utilizes data from baseline of the prospective Akershus Cardiac Examination 1950 study, conducted from 2012-2015, which invited all individuals born in 1950 and residing in Akershus county, Norway. Attained educational level was self-reported and categorized as basic (elementary or middle school, 7-10 years), secondary (high school or vocational education, 11-13 years), or tertiary (college or university, >13 years). Carotid plaque score was measured using high-resolution B-mode ultrasound imaging of the carotid arteries. The largest plaque in each extra-cranial segment of the carotid artery on both sides was scored from 0-3 points based on the diameter. Carotid plaque score was calculated as the sum of all segments, ranging from 0 (no plaque) to 24 (significant plaque in all segments). A Poisson regression model was used to assess the relative association between educational level and carotid plaque score and tested for interaction with sex. The analyses were then stratified by sex and adjusted for body mass index, hypertension, smoking status and LDL-cholesterol level. Results Out of 5,287 eligible individuals 3,706 (64%) completed the baseline examination, of whom 1,807 (48.8%) were women. Carotid plaque score was available for 3,683 participants and mean score was 2.6 (±2.1). There were 639 individuals (17.3%) with low education, 1,343 (36.4%) with medium education, and 1,713 (46.4%) with high education. There was a graded association between lower attained educational level and higher carotid plaque score in both sexes (Figure 1, Table 1). Low compared to high education was associated with 32% higher carotid plaque score in women and 24% higher carotid plaque score in men. The association between education and carotid plaque score was similar between sexes (p for interaction >0.05). The associations remained statistically significant in adjusted analyses. Conclusion In this cross-sectional population-based study, lower educational level was associated with increased carotid plaque score, independent of common cardiovascular risk factors. Men had higher plaque scores than women, but the effect of education was similar between sexes. Our findings highlight the preventive role of education in subclinical atherosclerosis in both sexes.