Background Social inequalities in CHD risk are well-documented in England, but the relative contribution of educational attainment to later risk of CHD is not fully understood. Very few studies have investigated the underlying mechanisms of this relationship and none have assessed how this may vary across cohorts. In England, educational attainment has risen dramatically, alongside simultaneous declines in CHD mortality and incidence. These secular trends have not been considered and it is not known whether those with low educational attainment face increasing marginalisation and thus a greater risk of CHD.

Methods Cross-sectional data from eighteen annual surveys (1994-2011) from the Health Survey for England (HSE) were linked to mortality records from the Office for National Statistics (ONS), yielding a sample of 92,711 adults born from 1908 to 1958. Information on highest obtained qualifications and potential social pathways between education and CHD were collected by interviews among HSE participants. Two synthetic cohorts were defined based on changes in minimum school leaving age policies. Cox proportional hazards regression models were fitted within each synthetic cohort in order to assess the extent of heterogeneity between cohorts. Subsequent models tested the potential mediating role of social pathways between education and CHD death within cohorts.

Results The association between educational attainment and CHD mortality was modest among adults born from 1908 to 1932. Adults with no qualifications were at a greater risk of CHD death in comparison to counterparts with degrees or equivalent. The hazard ratios (HRs) were 1.33 (1.11–1.59) and 1.40 (1.02–1.91) among men and women, adjusted for age and ethnicity. This heightened risk was explained by occupational class, work status and smoking behaviour. Unlike the 1908-1932 synthetic cohort, a robust educational gradient emerged for adults born from 1933 to 1958. The age and ethnicity adjusted HRs were 1.80 (1.33–2.44), 1.64 (1.17–2.28), 2.13 (1.58–2.88), 2.62 (2.01–3.40) among men with professional, A-level, CSE/O-level, and no qualifications. Only women with professional qualifications and those with no qualifications were at a greater risk of CHD death than women with degrees: 2.20 (1.07–4.51) and 3.90 (2.00–7.59), adjusted for age and ethnicity. Potential pathways did not significantly attenuate the association between educational attainment and CHD death among men and women born from 1933 to 1958.

Conclusion This study finds worsening educational inequalities in CHD mortality among English adults born from 1908 to 1958, which are only partly explained by potential study mediators.