Objective  To investigate the association between different educational levels and the risk of major adverse cardiovascular events (MACE) among Chinese adults with hypertension.

Methods The data from the China cohort of the Prospective Urban Rural Epidemiology (PURE) study was utilized. Adults aged 35–70 years were enrolled between January 1, 2005 and December 31, 2009 from 115 urban and rural communities across 12 provinces in China. Participants were followed up every three years, with the last follow-up on August 30, 2021. The primary outcome was MACE, comprising cardiovascular death, non-fatal myocardial infarction, stroke, and heart failure. Cox proportional hazards frailty models were used to assess the association between educational level and MACE, reporting hazard ratios (HRs) with 95% confidence intervals (CIs).

Results  A total of 18 920 patients with hypertension were enrolled, with a median follow-up time of 11.9 years (P₂₅, P₇₅: 9.5, 12.6 years). The mean age was (57.3 ± 8.3) years. The age- and sex-standardized incidence densities (/1 000 person-years) of major cardiovascular events in the primary school or below, middle school, and college/university or above groups were 14.9 (95%CI 13.8–15.9), 10.8 (95%CI 10.1–11.5), and 8.4 (95%CI 7.3–9.4), respectively. After multivariable adjustment, compared with the college/university or above group, the risk of major cardiovascular events was increased by 37% (HR=1.37, 95%CI 1.13–1.65) in the primary school or below group and by 26% (HR=1.26, 95%CI 1.05–1.49) in the middle school group.

Conclusion  In Chinese adults with hypertension, lower educational levels are significantly associated with an elevated risk of MACE. These findings suggest that educational attainment is an important social determinant of cardiovascular health, warranting consideration in public health policies.