Impact of educational attainment on left atrial remodelling by sex: data from the Akershus Cardiac Examination (ACE) 1950 study

Background Atrial fibrillation (AF) represents a growing public health burden. Several established risk factors for AF are more prevalent among individuals with lower socioeconomic status (SES), yet evidence regarding the relationship between SES and AF incidence remains inconsistent. Left atrial remodelling, assessed by echocardiographic left atrial volumes and strain, is associated with AF and may reflect the cumulative burden of cardiovascular risk factors. However, evidence on the association between SES and left atrial remodelling by sex remains limited. Purpose To investigate whether educational attainment, as an indicator of SES, is associated with left atrial remodelling by sex. Methods We used data from a population-based cohort study including 62–64-year-old individuals residing in a county in Norway. All participants underwent standardized echocardiography with assessment of maximum and minimum left atrial volume index (LAVImax and LAVImin) as well as reservoir and contractile strain (LASr and LASct). Educational attainment was self-reported and categorized as primary (≤10 years), secondary (11–13 years), or tertiary (>13 years) education. Demographic and clinical characteristics were presented across educational groups and stratified by sex. Left atrial remodelling parameters were displayed in unadjusted bar graphs stratified by sex. Trends across ordered educational groups were assessed using Cuzick’s non-parametric test for trend. Results After excluding individuals with AF at baseline (n=156), missing education (n=11), and without left atrial echocardiographic measurements (n=517), the total study population consisted of 3,022 individuals, 1,490 (49.9%) were women and mean age was 64.0 ±0.64 years. Most AF risk factors were more prevalent among individuals with lower educational attainment in both men and women (Table 1), but those with higher education were taller, and women with higher education reported greater alcohol consumption. Differences in left atrial remodelling according to educational attainment, stratified by sex, are shown in Figure 1. Among women, higher educational attainment was associated with larger maximum and minimum left atrial volumes. Among men, no significant trends were observed, although a similar non-significant pattern was seen for maximum left atrial volume. Left atrial strain did not show significant trends across educational groups in either women or men. Conclusion Markers of adverse left atrial remodelling were not observed among individuals with lower education, despite a higher prevalence of atrial fibrillation risk factors. Instead, larger left atrial volumes were observed among women with higher education despite fewer risk factors, except for greater height and alcohol consumption. These findings suggest that socioeconomic patterns in atrial structure and function may reflect a more complex pathway toward atrial fibrillation than traditionally assumed.