Educational Disparities in the Impact of Suicidal Ideation on Long-Term Cardio-Cerebrovascular Outcomes: A Prospective Cohort Study

Objective This study investigated whether educational attainment independently predicts long-term prognosis following acute coronary syndrome (ACS) and stroke, and whether this association is modified by acute-phase suicidal ideation (SI).Methods Data from two prospective cohorts (1,152 ACS; 396 stroke) were analyzed. Educational attainment (low ≤10 high vs. high >10 years) and SI were assessed approximately 2 weeks post-event. Primary endpoints—major adverse cardiac events (MACE) for ACS and cerebro-cardiovascular events (CCVE) for stroke—were ascertained over a 5–14 year follow-up. Hierarchical Cox models sequentially adjusted for vascular factors (Model 1), psychosocial/disease severity (Model 2), and combined covariates (Model 3). Sensitivity analyses used a ≥12-year education cutoff.Results Educational attainment was not an independent predictor of outcomes in either cohort across all models. However, a significant education×SI interaction emerged for MACE in the ACS cohort across all models (p=0.031–0.046). Among ACS patients with SI, higher education was associated with significantly reduced MACE risk (hazard ratio [HR]=0.54, 95% confidence interval 0.34–0.86, p=0.009), while no association existed without SI (HR=1.05, p=0.690). Similar interaction patterns in the stroke cohort achieved significance in Models 1 and 3, though stratified effects were attenuated, likely reflecting limited statistical power. Sensitivity analyses demonstrated directional consistency in both cohorts with some attenuation in fully adjusted models.Conclusion Educational background modifies the prognostic impact of psychological distress in post-ACS patients. Lower-educated patients experiencing SI represent a high-risk subgroup requiring targeted psychosocial intervention. These findings support integrating educational status into psychosocial risk stratification protocols for acute cardiovascular care.