We certainly agree with Dr. Eyuboglu that left ventricular ejection fraction (LVEF) is a major determinant of outcome in patients with acute myocardial infarction. The author of the letter questions whether the independent association observed in our study1 between low educational level and outcome might be confounded by a different LVEF across the educational levels. Indeed, we observed an ascending gradient between educational levels and LVEF: illiterate 47%±10%, primary education 48%±11%, secondary education 50%±10% and university 50%±10% (P for trend=.004). However, as indicated in Table 5 of the original manuscript,1 LVEF was entered in the multivariable model thus virtually rejecting the hypothesis suggested by Dr. Eyuboglu. Furthermore, when interaction analyses were performed in patients with and without depressed LVEF, the association between educational level and outcome remained virtually unchanged.10.1016/j.recesp.2015.07.014
The in-hospital prescription of aldosterone antagonists was globally low in our study cohort (n=141, 2.4%). They were mainly prescribed to illiterate patients (16, 3.9%). To satisfy this reader's concern we have performed a new multivariable analysis considering aldosterone antagonists as a new covariate in addition to those variables already entered in the model shown in the original manuscript. Importantly, in that model, the low educational level (illiterate or primary) remained independently associated with higher mortality (hazard ratio=1.16, 95% confidence interval, 1.02-1.34; P=.03). Furthermore, the use of aldosterone antagonists was inversely associated with mortality (hazard ratio=0.74, 95% confidence interval, 0.57-0.96; P=.02).
In conclusion, our study shows that a higher educational level, as a marker of higher socioeconomic status, is associated with a more favorable prognosis for long-term mortality after acute myocardial infarction, even after a carefully adjusted multivariable model. The above-mentioned analyses further support our previously reported findings.