147 Cardiovascular risk factors by educational level in CHD patients: SURF CHD II 6 (9). The differences in risk factor target attainment by educational level shown in our results could be partly attributed to risk factor awareness and health literacy. Patients with higher educational level are more likely to be aware of their risk factors, measured levels, and targets (7), and to have more extensive health literacy (20,21). Patient’s awareness of their risk factor profile is a key to motivate lifestyle changes, and it is associated with preventionseeking behaviors and risk factor control (22,23). Adequate health literacy allows patients to understand health-related information and make informed decisions (24,25). Knowledge on risk factors has been associated with improved health behaviors (22) and results from a systematic review (24) show that patients with low health literacy have less knowledge on preventive methods and use of preventive health services. Differences in care provision by public and private centers can contribute to the differential target attainment by educational level. Therefore, we included the private or public organization of participating centers in our analysis. Most SURF CHD II patients in HICs, with generally strong public healthcare systems and universal health coverage (26), attended public centers regardless of their educational level, whereas in LMICs most patients with higher education attended private centers (Supplementary Table 2). Previous studies conducted in Brazil showed that CHD patients treated in the private system were more likely to meet the physical activity target, and to use and adhere to guideline-recommended medications (27,28) suggesting that patients using private care in such settings may have better access to medications (29), as well as more frequent healthcare utilization (30) and thus a more effective management of risk factors. As provision of services in public and private health systems varies greatly by country, future specific analysis should allow for in-depth research on this topic. Variations in target attainment by country income group (such as in BMI and waist circumference), could further be influenced by the differential ethnic distribution, for example, the majority of participants in LMICs were Asian, while most patients in HICs were white. Differences in risk factors at baseline by educational level could also play a role in the association between educational level and target attainment. In our data, for example, the proportion of patients who never smoked is similar across educational level groups, while the proportion of patients who quit or were current smokers varies by educational level (Supplementary Table 2). However, changes in risk factors could not be assessed due to the cross-sectional design of the study. Medication and cardiac rehabilitation We observe overall high levels of usage of all medication classes in SURF CHD II, in line with the previous surveys in secondary prevention (17,31). Patients with secondary or tertiary education were more likely to use antiplatelet, antihypertensive, and lipid-lowering medications in HICs, and lipid-lowering medication and oral hypoglycemics in LMICs, while a more inconsistent pattern was observed in UMICs. Although these differences were significant, in many cases these differences were small: for example 96.7% vs. 95.2% for antihypertensives, and 94.6% vs 91.9% for lipid-lowering drugs in HICs (Supplementary
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