Background: Despite universal coverage, inequities persist in acute coronary syndrome (ACS) care. This study examines how educational levels impact the quality and outcomes of health care.

Methods: A cohort of ACS patients hospitalized in five Swiss university hospitals was categorized into four educational levels (EL) with EL1 defined as lower than vocational school and EL4 as a university degree. The use of medical therapies, achievement of preventive targets and risk of clinical events were evaluated across ELs at baseline (N = 6040), 1-year (N = 5756) and 5-years (N = 2253) and presented with adjusted marginal odds ratios (mOR), average marginal effect (AME) and hazard ratios (HRs).

Results: Among 6040 patients, the mean age was 63 years, and 81% were male. Participants with lower EL had a greater burden of cardiovascular risk factors at baseline. Compared with EL4 participants EL1 participants had lower adherence to cardiac rehabilitation (mOR = .6 [95% CI .5-.8], AME = -10%) and were less likely to be followed by a cardiologist (mOR .6 [95% CI .5-.8], AME = -6%). Use of medical therapies did neither differ across EL at discharge nor during follow-up. At 1 year, smoking cessation (mOR = .7 [95% CI .5-.9], AME = -10%) and weight reduction ≥5% among overweight or obese participants (mOR = .7 [95% CI .5-.9], AME = -6%) were less frequent in individuals with EL1 compared with EL4. At long term, achievement of LDL-C <1.8 mmol/L (<70 mg/dL) (mOR = .6 [95% CI .4-.9], AME = -9%) was less frequent in individuals with EL1 compared with EL4. Lower EL was associated with an increased risk of major acute coronary event (MACE) at short- (aHR = 1.4 [95% CI 1.0-2.0] for EL1 vs. EL4) and long term (aHR = 1.3 [95% CI 1.0-1.6] for EL1 vs. EL4) and all-cause death at long term (aHR = 1.6 [95% CI 1.1-2.2] for EL1 vs. EL4).

Conclusion: In Switzerland, disparities in ACS care and outcomes remain across EL, emphasising the need for tailored interventions to reduce inequities.