Cardiovascular health in young and middle adulthood and medical care utilization and costs at older age - The Chicago Heart Association Detection Project Industry (CHA)

Cumulative Life's Essential 8 Scores and Cardiovascular Disease Risk

Importance

Most literature on the association between cardiovascular health (CVH) and incident cardiovascular disease (CVD) and mortality has relied on single midlife measurements. Understanding how cumulative CVH over time influences later-life CVD and mortality may aid early prevention.

Objective

To determine whether cumulative CVH, as measured by the American Heart Association Life's Essential 8 (LE8) from age 18 to 45 years, is associated with incident CVD and mortality in midlife.

Design, Setting, and Participants

This cohort study, the Coronary Artery Risk Development in Young Adults (CARDIA) study, collected CVH data for participants from 4 US centers from 1985 to 2020. Multivariate Cox proportional hazard models assessed the associations of (1) cumulative LE8 score by quartile, (2) cumulative LE8 score and score at age 45 years, and (3) cumulative LE8 score and LE8 score slope from age 18 to 45 years with incident CVD and mortality after age 45 years.

Main Outcomes and Measures

Incident CVD and all-cause mortality. Cumulative LE8 score was calculated as the area under the curve of the LE8 score (0-100, higher is better CVH) over time from age 18 to 45 years.

Results

There were 4832 CARDIA participants (2690 [55.7%] female and 2142 [44.3%] male) with a mean (SD) cumulative LE8 score from age 18 to 45 years of 2018.8 (95.0) point × years. Compared with quartile 1 (Q1, ie, lowest CVH), Q2, Q3, and Q4 had significantly lower hazards for CVD (Q2 HR, 0.44; 95% CI, 0.32-0.61; Q3 HR, 0.26; 95% CI, 0.18-0.38; Q4 HR, 0.12; 95% CI, 0.07-0.21) and mortality (Q2 HR, 0.51; 95% CI, 0.36-0.71; Q3 HR, 0.38; 95% CI, 0.26-0.55; Q4 HR, 0.29; 95% CI, 0.18-0.45) after age 45 years. When cumulative LE8 score from age 18 to 45 years and LE8 score at age 45 years were in the model together, both were significantly associated with lower risk for CVD. Likewise, both cumulative LE8 score and positive slope of (improving) LE8 score from age 18 to 45 years were significantly associated with lower hazards for incident CVD after age 45 years.

Conclusions and Relevance

Greater cumulative CVH and improvement in CVH during young adulthood, as well as better CVH in middle age, were all independently associated with lower risk for incident CVD in midlife. These results emphasize the importance of maintaining and improving CVH throughout young adulthood.

Associations of early-onset coronary heart disease and genetic susceptibility with incident dementia and white matter hyperintensity: A prospective cohort study

BACKGROUND

The associations of early-onset coronary heart disease (CHD) and genetic susceptibility with incident dementia and brain white matter hyperintensity (WMH) remain unclear. Elucidation of this problem could promote understanding of the neurocognitive impact of early-onset CHD and provide suggestions for the prevention of dementia.

OBJECTIVES

This study aimed to investigate whether observed and genetically predicted early-onset CHD were related to subsequent dementia and WMH volume.

DESIGN

Prospective cohort study.

SETTING

UK Biobank.

PARTICIPANTS

500 671 individuals without dementia at baseline.

MEASUREMENTS

Early-onset CHD (male ≤55 years; female ≤65 years) was ascertained using hospital inpatient records. Incident dementia including all-cause dementia, Alzheimer's disease, and vascular dementia was ascertained using hospital inpatient records, mortality register data, and self-reported data. WMH volume was measured through brain magnetic resonance imaging (MRI). Cox proportional hazards models and linear regression models were used to analyze the associations of early-onset CHD with incident dementia and WMH. Subsequently, a polygenetic risk score (PRS) analysis was conducted to investigate the associations of genetically predicted early-onset CHD with outcomes.

RESULTS

Among 500 671 individuals (female: 272 669, 54.5%; mean age: 57.0 ± 8.1 years), 9 294 dementia occurred during a median follow-up of 13.8 years. Compared with the non-CHD group, both early-onset (n = 16 133) and late-onset CHD (n = 43 944) groups had higher risks of developing dementia (hazard ratio [HR]: 1.99, 95% confidence interval [CI]: 1.81 to 2.19 for early-onset group; HR: 1.20, 95% CI: 1.14 to 1.27 for late-onset group). Among CHD participants, early-onset CHD was associated with a significantly higher risk of incident dementia, compared with late-onset CHD (HR: 1.56, 95% CI: 1.39 to 1.75). In a subset of 40 290 individuals who completed brain MRI scans during a median follow-up of 9.3 years, participants with early-onset CHD exhibited the largest WMH volume among the three groups (early-onset CHD, late-onset CHD, and non-CHD, Ptrend<0.001). The PRS analysis supported the associations of early-onset CHD with dementia (odds ratio [OR] for the highest quartile: 1.37, 95% CI: 1.28 to 1.46, Ptrend<0.001) and WMH volume (β for the highest quartile: 0.042, 95% CI: 0.017 to 0.068, Ptrend=0.002).

CONCLUSIONS

Early-onset CHD and genetic susceptibility are associated with a higher risk of incident dementia and a larger WMH volume. Additional attention should be paid to the neurocognitive status of individuals with early-onset CHD.

The impact of cardiovascular health on mortality in US adults with cardiometabolic disease: A prospective nationwide cohort study

BACKGROUND AND AIMS

Individuals with cardiometabolic disease (CMD) face high risks of adverse outcomes. However, there is little evidence of the effectiveness of comprehensive risk assessment using the Life's Essential 8 (LE8) score in CMD. This study aimed to examine the associations between LE8 and all-cause and cardiovascular mortality rates in individuals with CMD.

METHODS AND RESULTS

This study included 11,198 NHANES participants, categorized into low, moderate, and high CVH groups according to LE8 scores. The LE8 score consists of eight components: diet, physical activity, nicotine exposure, sleep health, BMI, blood lipids, blood glucose, and blood pressure. A higher LE8 score indicates better cardiovascular health. Multivariable Cox proportional hazard regression and restricted cubic splines were employed to estimate the associations. Subgroup analyses considered age, sex, race and ethnicity, income, marital status, and education. During a median follow-up of 91 months, 1079 deaths were recorded, 325 of which were cardiovascular. The multivariable adjusted hazard ratio (HR) per 10-point increase in LE8 was 0.79 (95% confidence interval (CI), 0.75-0.84) for all-cause mortality and 0.71 (95% CI, 0.64-0.79) for cardiovascular mortality. Participants with moderate and high LE8 levels showed similar inverse associations. Those under 60 exhibited more pronounced associations (P for interaction <0.05). After adjusting for multiple variables, a linear relationship was observed between LE8 and all-cause and cardiovascular mortality in the CMD population.

CONCLUSIONS

The newly introduced LE8 showed a significant negative association with all-cause and cardiovascular mortality risk among CMD individuals, highlighting its potential for CMD tertiary prevention.

Association between serum testosterone level and cardiovascular health in US male adults: results from the 2013-2016 NHANES

BACKGROUND

There have been many studies of the association between testosterone and cardiovascular disease (CVD). However, limited research has examined the association between testosterone and Life's Essential 8 (LE8), a recently updated algorithm for assessing cardiovascular health (CVH).

OBJECTIVES

This study aims to investigate the association between serum total testosterone (TT) levels and LE8 scores-where higher LE8 scores indicate better CVH-among adult males in the United States.

METHOD

Data from 3308 adult males were extracted from the National Health and Nutrition Examination Survey conducted between 2013 and 2016. Weighted univariate and multivariate linear regression models [β and 95% confidence intervals (CIs)] and logistic regression models [odds ratios (ORs) and 95% CIs] were used to explore the association between testosterone and LE8 and high CVH risk. Additionally, a smoothed curve fit (penalized spline method) and generalized additive model regression were applied to further explore these relationships.

OUTCOMES

LE8 includes 4 health behaviors (nicotine exposure, diet, physical activity, and sleep duration) and 4 health factors (body mass index, non-high-density lipoprotein cholesterol, blood pressure, and blood glucose).

RESULTS

Serum TT levels were strongly associated with LE8 scores after adjusting for all confounders (continuous: β = 2.75, 95% CI: 1.92, 3.57, P < .0001; quartiles: Q4 vs Q1: β = 3.89, 95% CI: 2.78, 5.01, P < .0001). Similarly, high levels of TT were associated with a significantly lower CVH risk (OR = 0.59, 95% CI: 0.49, 0.73, P < .001). Compared to low TT levels, normal TT levels significantly reduced the risk of CVH (OR = 0.51, 95% CI: 0.38, 0.69, P < .001). Smoothed curve fitting showed a positive linear correlation between TT levels and LE8 scores, as well as a consistent linear negative correlation with CVH risk.

CLINICAL IMPLICATIONS

These findings highlight the importance of endogenous TT levels in promoting CVH and provide new insights into factors influencing CVH.

STRENGTHS AND LIMITATIONS

This study is the first to investigate the association between serum TT level and LE8 scores as well as LE8-assessed CVH among adult males. However, the observational nature of this study precludes any assessment of causality.

CONCLUSIONS

This study demonstrates a robust positive association between serum TT levels and LE8 scores in a nationally representative sample of adult men in the United States.

Associations of Neighborhood Food and Physical Activity Environments in Young Adulthood With Cardiovascular Health in Midlife: The CARDIA Study

BACKGROUND

Adults who maintain ideal cardiovascular health (CVH) profiles up to midlife have lower risk of several chronic diseases and better quality of life. Some evidence suggests that individual-level exposures earlier in life shape midlife CVH, but the impact of neighborhood-level exposures over the life course remains understudied.

METHODS AND RESULTS

Participants were 3017 Black and White men and women aged 18 to 30 years at baseline (1985-1986), recruited from Birmingham, Alabama; Minneapolis, Minnesota; Chicago, Illinois; and Oakland, California, as part of the CARDIA (Coronary Artery Risk Development in Young Adults) study. Measures of the neighborhood food and physical activity environment were linked to participant addresses collected at baseline. CVH was measured on the basis of the American Heart Association's Life's Simple 7 criteria in young adulthood and 30 years later (2015-2016) when participants were midlife (aged 48-60 years). Associations of young adult neighborhood food environment and physical activity resources with midlife CVH (moderate versus high and low versus high) were examined using multinomial logistic regression. Models were adjusted for young adult sociodemographic factors. Participants who lived farther away from a major park in young adulthood were more likely to have low versus high CVH scores (odds ratio, 1.54 [95% CI, 1.22-1.96]) and more likely to have moderate versus high CVH scores (odds ratio, 1.39 [95% CI, 1.12-1.73]) in midlife. No other neighborhood measures were significantly associated with CVH.

CONCLUSIONS

Young adulthood may be a sensitive period in which having convenient access to physical activity-promoting resources may help them establish healthy habits that can carry into midlife.

Association Between Cardiovascular Health Status and Healthcare Utilization in a Large Integrated Healthcare System

Introduction

The American Heart Association Life's Simple 7 schema can be used to categorize patients' cardiovascular health status as poor, intermediate, or ideal on the basis of smoking, BMI, physical activity, dietary patterns, blood pressure, cholesterol, and fasting blood sugar. This study examined the association between cardiovascular health status and subsequent healthcare utilization.

Methods

This was an observational cohort study of adults from an integrated healthcare delivery system-Kaiser Permanente Northern California-that had outpatient care between 2013 and 2014. Patients were categorized by American Heart Association cardiovascular health status: poor, intermediate, or ideal. Individual-level healthcare utilization and costs in 2015 were accumulated for each patient and compared across the 3 cardiovascular health categories and stratified by age groups.

Results

A total of 991,698 patients were included in the study. A total of 194,003 (19.6%) were aged 18-39 years; 554,129 (55.9%) were aged 40-64 years; and 243,566 (24.6%) were aged ≥65 years. A total of 259,931 (26.2%) had ideal cardiovascular health; 521,580 (52.6%) had intermediate cardiovascular health; and 210,187 (21.2%) had poor cardiovascular health. Healthcare utilization measured by average relative cost per patient increased monotonically across age categories (p<0.001). In addition, cardiovascular health category was inversely associated with lower cost in each age group (p<0.001).

Conclusions

Adults who were younger and had more ideal cardiovascular health had relatively lower healthcare costs across age groups. Interventions to promote better cardiovascular health may improve patient outcomes and reduce overall healthcare expenditures.

The association between cardiovascular health and depression: Results from the 2007-2020 NHANES

BACKGROUND

Limited research has been conducted on the correlation between Life's Essential 8 (LE8), the recently updated algorithm for evaluating cardiovascular health (CVH), and depression.

METHODS

A total of 21,942 individuals were chosen from the National Health and Nutrition Examination Survey (NHANES) conducted between 2007 and 2020. The depression was determined using the Patient Health Questionnaire (PHQ-9), with a score of 10 or higher indicating diagnosis. The LE8 score consists of 8 metrics: sleep health, diet, physical activity, nicotine exposure, body mass index, blood lipids, blood glucose, and blood pressure. Each LE8 metric was scored from 0 to 100 points. The summation of all metrics divided by 8 generated the total LE8 score and was categorized into low (0-49), moderate (50-79), and high (80-100) CVH. Weighted logistic regression and restricted cubic splines (RCS) were used to assess the association between LE8 score and depression.

RESULTS

A significant inversely nonlinear relationship was observed between LE8 score and depression. When compared to participants with high CVH, those with moderate CVH had multivariable adjusted odds ratios (ORs) for depression of 2.36 (95 % CI, 1.79-3.10), while those with low CVH had ORs of 4.71 (95 % CI, 3.44-6.47). Moreover, the effect size of the LE8 score on depression remained stable in all pre-specified subgroups, with all P-values for interaction being more than 0.05.

CONCLUSIONS

The results indicate a significant inversely nonlinear relationship between LE8 score and depression, particularly among males. These findings emphasize the importance of maintaining higher CVH as a preventive measure against depression.

Personalized versus generic digital weight loss interventions delivered on university campuses: a 6-month cost-benefit analysis

Cost-effectiveness analyses of weight loss programs for university students can inform administrator decision-making. This study quantifies and compares the costs and cost-effectiveness of implementing two digitally-delivered weight loss interventions designed for university populations. Healthy Body Healthy U (HBHU) was a randomized controlled trial comparing TAILORED (personalized) versus TARGETED (generic) weight loss interventions adapted specifically for young adults to a CONTROL intervention. Participants (N = 459; 23.3 ± 4.4 years; mean BMI 31.2 ± 4.4 kg/m2) were recruited from two universities. Implementation costs were examined from a payer (i.e., university) perspective, comparing both the average cost effectiveness ratio (ACER) and the incremental cost effectiveness ratio (ICER) of the two interventions. Cost-effectiveness measures were calculated for changes in body weight, abdominal circumference, HDL cholesterol, systolic and diastolic blood pressure, and HbA1c. The overall 6-month implementation costs were $105.66 per person for the TAILORED intervention and $91.44 per person for the TARGETED intervention. The ACER for weight change was $107.82 for the TAILORED and $179.29 for the TARGETED interventions. The ICER comparing TAILORED with TARGETED for change in body weight was $5.05, and was even lower ($2.28) when including only those with overweight and not obesity. The ICERs for change in abdominal circumference, HDL cholesterol, systolic and diastolic blood pressure, and HbA1c were $3.49, $59.37, $1.57, $2.64, and $47.49, respectively. The TAILORED intervention was generally more cost-effective compared with the TARGETED intervention, particularly among those with overweight. Young adults with obesity may require more resource-intensive precision-based approaches.

Status of Cardiovascular Health in US Adults and Children Using the American Heart Association's New "Life's Essential 8" Metrics: Prevalence Estimates From the National Health and Nutrition Examination Survey (NHANES), 2013 Through 2018

BACKGROUND

The American Heart Association recently published an updated algorithm for quantifying cardiovascular health (CVH)-the Life's Essential 8 score. We quantified US levels of CVH using the new score.

METHODS

We included individuals ages 2 through 79 years (not pregnant or institutionalized) who were free of cardiovascular disease from the National Health and Nutrition Examination Surveys in 2013 through 2018. For all participants, we calculated the overall CVH score (range, 0 [lowest] to 100 [highest]), as well as the score for each component of diet, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose, and blood pressure, using published American Heart Association definitions. Sample weights and design were incorporated in calculating prevalence estimates and standard errors using standard survey procedures. CVH scores were assessed across strata of age, sex, race and ethnicity, family income, and depression.

RESULTS

There were 23 409 participants, representing 201 728 000 adults and 74 435 000 children. The overall mean CVH score was 64.7 (95% CI, 63.9-65.6) among adults using all 8 metrics and 65.5 (95% CI, 64.4-66.6) for the 3 metrics available (diet, physical activity, and body mass index) among children and adolescents ages 2 through 19 years. For adults, there were significant differences in mean overall CVH scores by sex (women, 67.0; men, 62.5), age (range of mean values, 62.2-68.7), and racial and ethnic group (range, 59.7-68.5). Mean scores were lowest for diet, physical activity, and body mass index metrics. There were large differences in mean scores across demographic groups for diet (range, 23.8-47.7), nicotine exposure (range, 63.1-85.0), blood glucose (range, 65.7-88.1), and blood pressure (range, 49.5-84.0). In children, diet scores were low (mean 40.6) and were progressively lower in higher age groups (from 61.1 at ages 2 through 5 to 28.5 at ages 12 through 19); large differences were also noted in mean physical activity (range, 63.1-88.3) and body mass index (range, 74.4-89.4) scores by sociodemographic group.

CONCLUSIONS

The new Life's Essential 8 score helps identify large group and individual differences in CVH. Overall CVH in the US population remains well below optimal levels and there are both broad and targeted opportunities to monitor, preserve, and improve CVH across the life course in individuals and the population.

Cardiovascular health in pediatric heart transplant patients

BACKGROUND

Ideal "cardiovascular health" (CVH)-optimal diet, exercise, nonsmoking, BMI, BP, lipids, and glucose-is associated with healthy longevity in adults. Pediatric heart transplant (HT) patients may be at risk for suboptimal CVH.

METHODS

Single-center retrospective study of HT patients 2003-2014 who survived 1 year post-transplant. Five CVH metrics were collected at listing, 1, 3 and 5 years post-transplant (diet and exercise were unavailable). CVH was scored by summing individual metrics: ideal = 2, intermediate = 1, and poor = 0 points; total scores of 8-10 points were considered high (favorable). CVH was compared between HT patients and the US pediatric population (GP) utilizing NHANES 2007-2016. Logistic regression was performed to examine the association of CVH 1 year post-transplant with a composite adverse outcome (death, re-listing, coronary vasculopathy, or chronic kidney disease) 3 years post-transplant.

RESULTS

We included 110 HT patients (median age at HT: 6 years [range 0.1-21]) and 19,081 NHANES participants. CVH scores among HT patients were generally high at listing (75%), 1 (74%), 3 (87%) and 5 (76%) years post-transplant and similar to GP, but some metrics (e.g., glucose) were worse among HT patients. Among HT patients, CVH was poorer with older age and non-Caucasian race/ethnicity. Per 1-point higher CVH score, the demographic-adjusted OR for adverse outcomes was 0.95 (95% CI, 0.7-1.4).

CONCLUSIONS

HT patients had generally favorable CVH, but some metrics were unfavorable and CVH varied by age and race/ethnicity. No significant association was detected between CVH and adverse outcomes in this small sample, but study in a larger sample is warranted.

Associations of gestational cardiovascular health with pregnancy outcomes: the Hyperglycemia and Adverse Pregnancy Outcome study

BACKGROUND

The American Heart Association's formal characterization of cardiovascular health combines several metrics in a health-oriented, rather than disease-oriented, framework. Although cardiovascular health assessment during pregnancy has been recommended, its significance for pregnancy outcomes is unknown.

OBJECTIVE

The purpose of this study was to examine the association of gestational cardiovascular health-formally characterized by a combination of 5 metrics-with adverse maternal and newborn outcomes.

STUDY DESIGN

We analyzed data from the Hyperglycemia and Adverse Pregnancy Outcome study, including 2304 mother-newborn dyads from 6 countries. Maternal cardiovascular health was defined by the combination of the following 5 metrics measured at a mean of 28 (24-32) weeks' gestation: body mass index, blood pressure, lipids, glucose, and smoking. Levels of each metric were categorized using pregnancy guidelines, and the total cardiovascular health was scored (0-10 points, where 10 was the most favorable). Cord blood was collected at delivery, newborn anthropometrics were measured within 72 hours, and medical records were abstracted for obstetrical outcomes. Modified Poisson and multinomial logistic regression were used to test the associations of gestational cardiovascular health with pregnancy outcomes, adjusted for center and maternal and newborn characteristics.

RESULTS

The average age of women at study exam was 29.6 years old, and they delivered at a mean gestational age of 39.8 weeks. The mean total gestational cardiovascular health score was 8.6 (of 10); 36.3% had all ideal metrics and 7.5% had 2+ poor metrics. In fully adjusted models, each 1 point higher (more favorable) cardiovascular health score was associated with lower risks for preeclampsia (relative risk, 0.67 [95% confidence interval, 0.61-0.73]), unplanned primary cesarean delivery (0.88 [0.82-0.95]), newborn birthweight >90th percentile (0.81 [0.75-0.87]), sum of skinfolds >90th percentile (0.84 [0.77-0.92]), and insulin sensitivity <10th percentile (0.83 [0.77-0.90]). Cardiovascular health categories demonstrated graded associations with outcomes; for example, relative risks (95% confidence intervals) for preeclampsia were 3.13 (1.39-7.06), 5.34 (2.44-11.70), and 9.30 (3.95-21.86) for women with ≥1 intermediate, 1 poor, or ≥2 poor (vs all ideal) metrics, respectively.

CONCLUSION

More favorable cardiovascular health at 24 to 32 weeks' gestation was associated with lower risks for several adverse pregnancy outcomes in a multinational cohort.

The 'Heart Kuznets Curve'? Understanding the relations between economic development and cardiac conditions

As countries turn wealthier, some health indicators, such as child mortality, seem to have well-defined trends. However, others, including cardiovascular conditions, do not follow clear linear patterns of change with economic development. Abnormal blood pressure is a serious health risk factor with consequences for population growth and longevity as well as public and private expenditure in health care and labor productivity. This also increases the risk of the population in certain pandemics, such as COVID-19. To determine the correlation of income and blood pressure, we analyzed time-series for the mean systolic blood pressure (SBP) of men's population (mmHg) and nominal Gross Domestic Product per capita (GDPPC) for 136 countries from 1980 to 2008 using regression and statistical analysis by Pearson's correlation (r). Our study finds a trend similar to an inverted-U shaped curve, or a 'Heart Kuznets Curve'. There is a positive correlation (increase GDPPC, increase SBP) in low-income countries, and a negative correlation in high-income countries (increase GDPPC, decrease SBP). As country income rises people tend to change their diets and habits and have better access to health services and education, which affects blood pressure. However, the latter two may not offset the rise in blood pressure until countries reach a certain income. Investing early in health education and preventive health care could avoid the sharp increase in blood pressure as countries develop, and therefore, avoiding the 'Heart Kuznets Curve' and its economic and human impacts.