Level of education and mortality in the vulnerable period following an acute heart failure hospitalization

Abstract

Abstract Introduction Patients hospitalized for acute heart failure (HF) are at increased risk of death in the early post-discharge period, so-called the "vulnerable period" (1). Post-discharge treatment strategies can help improve outcomes, but the role of the patient's level of education on this regard is unclear. Purpose To analyse the association between level of education and 180-day mortality after discharge from acute HF hospitalization. Methods We performed a prospective cohort study of patients who were discharged alive following hospitalization for acute HF in 26 hospitals in Brazil from February 2016 and September 2021. Patients were classified according to the International Standard Classification of Education 2011 into four groups: Less than Basic, Basic, Intermediate and Advanced. We analysed all-cause mortality in the 180 days following hospital discharge using Cox regression. Results We evaluated 2724 patients (mean age 61±15 years; 42% women) hospitalized for acute HF, who were divided according to education level: less than basic (n = 280, 10%), basic (n = 1503, 55%), intermediate (n = 716, 26%) and advanced (n = 225, 8%). Patients with lower education levels were older (68±12 vs 62±14 vs 56±16 vs 58±15 years, p-for-trend<0.001), more frequently women (47% vs 43% vs 40% vs 37%, p-for-trend = 0.005) and non-whites (77% vs 66% vs 65% vs 53%, p-for-trend<0.001), compared with those with higher education levels. At discharge, a prescription of both angiotensin-converting enzyme inhibitors /angiotensin receptor blockers, beta-blocker and mineralocorticoid receptor antagonists (41% vs 45% vs 49% vs 53%, p-for-trend = 0.001), vaccine counselling (52% vs 50% vs 55% vs 62%, p-for-trend = 0.002) and weigh management counselling (72% vs 69% vs 72% vs 81%, p-for-trend = 0.007) were less frequently provided for patients with lower education. Education level was inversely associated with the risk of death in the follow-up period (Hazard ratio (HR) 0.71, 95%CI 0.61 – 0.84, p = <0.001; Figure). This association remained significant after adjusting for baseline characteristics (age, sex, race, left-ventricle ejection fraction, previous HF, HF aetiology, cardiac resynchronization therapy/implantable cardiac defibrillator use, chronic kidney disease and income) and prescription of disease-modifying drugs, vaccine and weight management counselling at discharge (adjusted HR 0.78, 95% CI 0.64 – 0.95, p = 0.011). Conclusion In this large cohort of patients discharged after hospitalization for acute HF, lower education levels were independently associated with higher mortality rates in the vulnerable period.