148 Chapter 6 Table 1). Ohm et al described higher statin use among higher educated patients (19), while the PURE study described higher medication use among lower educated patients in HICs (9), and the most recent EUROASPIRE survey reported no differences in secondary prevention medication use by educational level (7). Half of the participants in SURF CHD II reported to have participated in a cardiac rehabilitation program, which is a higher estimate than the one reported in Euroaspire IV (32). Cardiac rehabilitation has proven to be effective in reducing morbidity and mortality risk in coronary patients, and a comprehensive cardiac rehabilitation program has class 1A recommendation by clinical guidelines (4,33). Attendance to cardiac rehabilitation was remarkably lower in UMICs (25.7%) and LMICs (21.8%) compared to HICs (74.5%). Patients with primary education only were less likely to participate in cardiac rehabilitation in HICs and UMICs. Accordingly, previous studies in Europe and the US have shown lower referral rates for cardiac rehabilitation (34), and lower participation attendance in patients with a lower educational level compared to those with higher education. (32,35). Barriers to cardiac rehabilitation, like lack of availability or access to programs, low awareness on the program benefits, large distances to health centers, out-of-pocket payments, and disadvantages and costs caused by absence from work (19,36), may impact patients with a lower educational level disproportionately. Cardiac rehabilitation programs are available only in 54.7% of countries (37), and especially in UMICs and LMICs, there are financial barriers associated with coverage for cardiac rehabilitation (38,39). Our results show that even with high levels of medication use, risk factor target attainment remained poor. Further research on the use of drug combinations, dose adequacy, and adherence, might help to clarify the difficulties controlling risk factors. The fact that higher educated participants were generally more likely to use medication and to attend cardiac rehabilitation could partly contribute to the higher levels of risk factor target attainment among patients with secondary or tertiary education. Implications and future research Our results emphasize the importance of addressing barriers to risk factor target attainment and cardiac rehabilitation that are specific to people with lower educational levels. This could be adapted communication strategies, intensive and personalized follow-up to improve target attainment, and promotion of access to affordable and (partly) remote cardiac rehabilitation programs. One of the main findings of our study is that the associations between educational level and risk factor target attainment and treatment are heterogeneous. Therefore, future studies should investigate local circumstances that hinder risk factor target attainment and treatment in daily practice, with attention to patients’ educational attainment. The resulting insights may support the design of efficient preventive strategies at regional, country, and center level. Strengths and limitations
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