149 Cardiovascular risk factors by educational level in CHD patients: SURF CHD II 6 Our study is among the first to investigate risk factor recording, target attainment, and treatment in secondary prevention by educational level and country income group in a clinical setting. Research on risk factor recording is scarce, especially for secondary prevention, and we present results for registration of risk factor information in daily practice. The simplicity of the SURF CHD II audit allows registration of the most relevant information of risk factors, while requiring little time and few financial resources. This also facilitates participation of smaller units and low-resource areas, which often have been underrepresented in research, despite high cardiovascular risk (40). Therefore, SURF CHD provides real-world evidence on secondary prevention globally. The large sample size of the study allows for context specific analysis. SURF CHD II provides a useful tool for health centers of any level to assess secondary prevention outcomes in their specific context and apply and evaluate tailor-made prevention strategies. This study has some limitations. First, centers were not randomly selected, although the diversity in the included centers was promoted. Second, health professionals were instructed to only register information collected during routine visits, but it is possible that some additional measurements were performed. These factors may have resulted in some overestimation of the risk factor recording, target attainment and treatment levels in our results. Additionally, the high level of missing values for BMI, waist circumference and lipid measurements, may influence the recording and target attainment estimates. As educational level was not registered in some centers, we were, unfortunately, not able to include these participants in the main analysis. Although the simplicity of SURF CHD II is one of its main strengths, it inevitably limits the information that can be collected for study participants, such as information on variables that might have provided more insights into the results, like in-depth information on risk factors, sex-specific risk factors, statin intensity, adherence to medication, or time since index event. Conclusion The SURF CHD II study conducted in 13,884 CHD patients from 29 HICs, UMICs and LMICs provides global, real-world evidence on secondary prevention of CHD. SURF CHD II shows poor attainment of risk factor targets and participation in cardiac rehabilitation, highlighting the urge for improvement in secondary prevention of CHD in daily practice. The association between educational level and risk factor target attainment is heterogeneous and complex. Further research into health inequalities on secondary prevention outcomes in different contexts might support the identification of barriers to secondary prevention, and the application of more effective preventive strategies, which are most needed. ACKNOWLEDGEMENTS SURF CHD II study group is very grateful to participants and staff for their efforts and enthusiastic participation. The list of national coordinators, center coordinators and centers participating in SURF CHD II is detailed in Supplementary Table 3. FUNDING INFORMATION
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