Key result
Primary school education is linked to ~29% higher odds of silent plaque versus advanced degrees.
Why the study?
Social determinants of health are established risk factors for cardiovascular events, yet their association with silent atherosclerosis in universal healthcare settings remained poorly characterised.
Does lower educational attainment increase the prevalence of silent atherosclerosis compared to higher educational attainment in a Danish population-based cohort?
Cross-Sectional (n=7,131)
Yes
Does lower educational attainment increase the prevalence of silent atherosclerosis compared to higher educational attainment in a Danish population-based cohort?
Even within a universal healthcare system, lower educational attainment and geographic clustering are independently associated with a higher burden of subclinical multi-territory atherosclerosis, highlighting targets for focused cardiovascular prevention.
Lower education was associated with more plaque; hypothesis-generating and should not yet change practice.
Background Social determinants of health are established risk factors for cardiovascular events, yet their association with silent atherosclerosis in a universal healthcare settings remains poorly characterised. Purpose The aim was to determine the prevalence of silent atherosclerosis across educational strata and geographic areas in a large Danish population-based cohort. Methods In a cross-sectional population based study, we included 7,131 Danish participants from the REACT study (52% female, mean age 45±13 years). Atherosclerotic plaque was defined by the Mannheim criteria using vascular ultrasound of bilateral carotid and femoral arteries. Educational attainment was categorised as primary school, vocational, upper secondary, bachelor's, or master's/PhD. Logistic regression estimated odds ratios adjusted for age, sex, and examination site. Geographic variation was mapped at postal-code level using inverse distance weighting interpolation. Preliminary Results Crude plaque prevalence ranged from 42.7% (primary school) to 29.4% (master's/PhD). After adjustment for age, sex, and site, lower educational attainment remained independently associated with any plaque (primary school vs master's/PhD: OR 1.29, 95% CI 1.01–1.65; vocational: OR 1.21, 1.03–1.43; P-for-trend=0.004). The education gradient was more pronounced for multi-territory disease (primary school: OR 1.62, 1.19–2.20; P-for-trend <0.001) (Figure 1). Spatial mapping revealed geographic clustering of high-prevalence areas, with significant inter-site variation ('site H' vs 'site R': OR 1.35, 1.14–1.59, P<0.001) (Figure 2). Conclusion In this large Danish population-based cohort, lower educational attainment was independently associated with higher prevalence of silent atherosclerosis, particularly multi-territory plaque burden. Geographic clustering suggests that area-level socioeconomic factors may influence subclinical cardiovascular disease despite universal healthcare access, and may inform targeted prevention strategies.Figure 1Figure 2
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Kunkel et al. (2026) conducted a cross-sectional in Silent atherosclerosis (n=7,131). Lower educational attainment (primary school) vs. Master's/PhD education was evaluated on Prevalence of any atherosclerotic plaque defined by Mannheim criteria on carotid and femoral ultrasound (OR 1.29, 95% CI 1.01-1.65, p=0.004). Primary school education was independently associated with higher odds of silent atherosclerotic plaque compared to master's/PhD education (42.7% vs 29.4%; OR 1.29, 95% CI 1.01-1.65).
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