I read the article by Consuegra-Sánchez et al1 with great interest. In their study, the authors report an inverse and independent relationship between educational level and long-term mortality in post-myocardial infarction patients. I would like to make a few points about the methodology and results of the article.1 In their study, the authors report the mean left ventricular ejection fraction (LVEF) of all patients and indicate LVEF as a predictor of long-term mortality. However, there are no data about the mean LVEF for each group. It is known that LVEF < 40% is an independent predictor of mortality after myocardial infarction.2 Therefore, the authors should state the mean LVEF and incidence of patients with LVEF < 40% for each group and compare the mean LVEF among the groups. A higher incidence of patients with LVEF < 40% in illiterate and primary education patient groups may be another significant reason for higher mortality rates. Additionally, the study by Consuegra-Sánchez et al1 includes patients with impaired left ventricle systolic function (mean LVEF=49% for all patients). Aldosterone antagonists significantly reduce all-cause mortality in post-myocardial infarction patients with LVEF < 40%, in addition to standard medical therapy.3 In the study by Consuegra-Sánchez et al,1 there are no data on the incidence of patients treated with aldosterone antogonists. A higher incidence of treatment with aldosterone antagonists in secondary education and higher education patient groups may be the reason for lower mortality rates.

In conclusion, low educational levels may be associated with adverse outcomes in post-myocardial infarction patients. However, LVEF and aldosterone antagonists may still have an effect on the results of the study by Consuegra-Sánchez et al.1 To indicate low levels of education as a predictor of mortality, it should be proven that there were no differences in the mean LVEF of all patient groups and that all patient groups were treated similarly with all medications that are known to reduce mortality in post-myocardial infarction patients.