Life's Simple 7 and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis

Cardiovascular Health Trajectories and Prevalent Metabolic Dysfunction-Associated Steatotic Liver Disease in Midlife: The CARDIA Study

BACKGROUND

Metabolic-dysfunction associated steatotic liver disease (MASLD) is associated with prevalent cardiovascular disease. More favorable cardiovascular health (CVH) profiles are associated with a lower prevalence of MASLD in cross-sectional studies. The relationship between long-term CVH patterns and MASLD prevalence in midlife remains unknown.

METHODS AND RESULTS

Participants (aged 18-30 years at baseline) of the CARDIA (Coronary Artery Risk Development in Young Adults) study who had individual CVH components measured at 7 examinations over 20 years and liver fat assessed by noncontrast computed tomography at year 25 follow-up were included. CVH score was defined using published American Heart Association definitions. Group-based trajectory modeling was used to identify CVH trajectories. MASLD was defined as liver attenuation of ≤51 Hounsfield units with at least 1 metabolic risk factor after excluding other causes of liver fat. Logistic regression was used to examine associations of CVH trajectory groups and MASLD prevalence. At baseline, 39% of 2529 participants had high and 5% had low CVH, respectively. MASLD prevalence at year 25 was 23% (n=587). Five distinct CVH trajectories were identified. Between the 2 groups that started at similar CVH scores, those whose CVH declined over time had a higher prevalence of MASLD at year 25 (7.0% in high-stable versus 23.0% high-decreasing; 24.4% in moderate-stable versus 35.7% in moderate-decreasing). Lower and decreasing trajectories were associated with higher year-25 MASLD prevalence compared with the high-stable trajectory.

CONCLUSIONS

Achieving and maintaining high CVH scores starting in young adulthood lowers the risk of prevalent MASLD in midlife.

Association of Life's Essential 8 with incidence of heart failure modified by depressive symptoms: a prospective cohort study from UK Biobank

BACKGROUND

The Life's Essential 8 (LE8) proposed by the American Heart Association for assessing cardiovascular health (CVH) has been demonstrated to be associated with cardiovascular disease, but rarely includes heart failure (HF), and the role of psychological factors has not been considered. We aimed to prospectively investigate the independent, joint, and interactive associations of LE8 and depressive symptoms with HF incidence.

METHODS

A total of 336,939 participants recruited from UK Biobank without HF, coronary heart disease, and stroke were included in the cohort study. The LE8 score consisted of four behavioral (diet, physical activity, nicotine exposure, and sleep) and four biological factors (glucose, blood lipids, blood pressure, and body mass index) and was classified into three levels: low, moderate, and high CVH. Depressive symptoms at baseline were identified by self-report and linkage to medical records. Incident HF cases during follow-up were extracted through primary care, hospital admissions, self-reports, and death registrations. Cox proportional hazard models were conducted to examine the associations of LE8 and depressive symptoms with HF incidence, with findings presented as hazard ratios (HRs) (95% confidence interval, CI).

RESULTS

A total of 9379 (2.8%) participants developed HF during a median follow-up of 13.6 years. Compared with low-CVH individuals, the multivariate-adjusted HRs with 95% CI for incident HF were 0.596 (0.565-0.629) and 0.458 (0.408-0.514) in those with moderate and high CVH, respectively. Per standard deviation increment in LE8 was associated with a 25.5% (HR = 0.745; 95% CI: 0.729-0.762) lower risk of HF. The stratification analysis indicated that the detrimental effect of low CVH on HF was more pronounced in participants with depressive symptoms compared to those without, with a significant multiplicative interaction (P for multiplicative interaction = 0.016). The joint test showed that the lowest risk of HF was observed in participants with high CVH and no depressive symptoms (HR = 0.344; 95% CI: 0.295-0.401), which may be attributed to a significant additive interaction observed.

CONCLUSIONS

The cohort study revealed that LE8-defined CVH not only could predict the incidence of HF, but also mitigate the increased risk of HF attributable to depressive symptoms. Achieving the high LE8 scores recommended by the AHA to improve CVH will be beneficial in reducing the population burden of HF, especially among patients with depressive symptoms.

A data harmonization project of 3 large prospective cardiovascular health-focused cohorts

Few prospective studies examine multilevel resilience resources and psychosocial factors in relation to cardiovascular health and disease. Recent research indicates that resilience resources are associated with a reduction in the incidence of cardiovascular disease-related events, but few studies have examined this relationship across different racial/ethnic populations or in large cohorts. Harmonization may address these limitations because it allows data from several cohorts to be analyzed together, potentially increasing sample size and in turn power overall and in minority populations. This article describes the process involved in combining 3 cardiovascular health-focused cohorts: Jackson Heart Study, Multi-Ethnic Study of Atherosclerosis, and Mediators of Atherosclerosis in South Asians Living in America Study. Using a systematic process, we identified appropriate data harmonization techniques to use in harmonizing variables across cohorts. Variables included exposures (eg, resilience resources), outcomes (eg, American Heart Association's Life's Simple 7), and covariates (eg, race and ethnicity). Post-harmonization examinations included psychometric analyses of the harmonized variables. A total of 13 284 participants were included in the final harmonized data set. This project provides opportunities for future research in resilience resources and informs future studies that need to harmonize data. Results based on the harmonized data set could inform interventions and policies.

Cardiovascular Health Status in US Adults With Chronic Diseases: National Health and Nutrition Examination Survey (NHANES), 2013-2018

BACKGROUND

Cardiovascular health (CVH) assessment may have important benefits for adults with chronic diseases to prevent incident cardiovascular disease and additional chronic conditions. Few studies have compared CVH in adults with chronic diseases and healthy adults without chronic disease using the American Heart Association's (AHA's) Life's Essential 8 (LE8) metrics.

METHODS AND RESULTS

We used National Health and Nutrition Examination Survey data from 2013 to 2018 to identify the presence of 16 chronic diseases by participant self-report of diagnosis. We included adults aged 20 to 79 years. CVH was defined by AHA's LE8 metrics. Overall mean LE8 (range 0-100, higher = better CVH) and individual LE8 metric scores were calculated according to disease status for all participants and stratified by self-identified sex, race, and ethnicity. There were 12 296 adults (51% women; mean age, 46 years) representing >186 million noninstitutionalized US adults. Significantly, and often substantially, lower CVH scores were noted for adults with chronic disease (14 of 16 diseases studied) versus unaffected adults, including all subtypes of cardiovascular disease, lung diseases, chronic kidney disease, liver conditions, cancer, arthritis, cognitive decline, and depression. For example, mean overall LE8 score was 14.0 points lower in those with versus without chronic obstructive pulmonary disease (51.0 versus 65.0, P<0.0001). Men and Black adults consistently had lower LE8 scores.

CONCLUSIONS

CVH is significantly poorer in adults with many chronic diseases compared with unaffected adults. These data suggest the utility of the LE8 score to identify groups for targeted optimization of CVH to enhance primary and secondary prevention efforts for cardiovascular disease and potentially for concomitant chronic diseases of aging.

Ideal cardiovascular health and cardiovascular-related events: a systematic review and meta-analysis

AIMS

The aim of this study was to systematically review and quantitatively summarize the evidence on the association between Life Simple's 7 (LS7) and multiple cardiovascular diseases (CVDs) and cardiometabolic diseases (CMDs).

METHODS AND RESULTS

EMBASE and PubMed were searched from January 2010 to March 2022 for observational studies that investigated the association between ideal cardiovascular health (CVH) with CVD or CMD outcomes in an adult population. Two reviewers independently selected studies according to the eligibility criteria, extracted data, and evaluated risk of bias. Data were analysed with a random-effects meta-analysis. This meta-analysis included 59 studies (1 881 382 participants). Participants with ideal CVH had a considerably lower risk of a variety of CVDs and CMDs as compared with those with poor CVH, varying from 40% lower risk for atrial fibrillation (AF) {hazard ratio [HR] = 0.60 [95% confidence interval (CI) 0.44-0.83]} to 82% lower risk for myocardial infarction [HR = 0.18 (95% CI 0.12-0.28)]. Intermediate CVH was associated with 27-57% lower risk in CVDs and CMDs compared with poor CVH, with the highest hazard for AF [HR = 0.73 (95% CI 0.59-0.91)] and the lowest hazard for peripheral arterial disease [HR = 0.43 (95% CI 0.30-0.60)].

CONCLUSION

Ideal and moderate CVH were associated with a lower incidence of CVDs and CMDs than poor CVH. Life Simple's 7 holds significant potential for promoting overall CVH and thereby contributing to the prevention of CVDs.

Blood pressure, hypertension, and the risk of heart failure: a systematic review and meta-analysis of cohort studies

AIMS

Several observational studies have investigated the association between hypertension or elevated systolic blood pressure and diastolic blood pressure and risk of heart failure, but not all the studies have been consistent. This systematic review and meta-analysis aimed to summarize the available data from cohort studies on the association between hypertension, systolic and diastolic blood pressure, and the risk of heart failure.

METHODS AND RESULTS

PubMed and Embase databases were searched for relevant articles from inception to 10 June 2022. Cohort studies on hypertension or blood pressure and heart failure were included. Random effect models were used to calculate summary relative risks (RRs) and 95% confidence intervals (CIs) for the association between hypertension or blood pressure and heart failure. Forty-seven cohort studies were included. The summary RR was 1.71 (95% CI: 1.53-1.90, I2 = 98.4%) for hypertension vs. no hypertension (n = 43 studies, 166 798 cases, 20 359 997 participants), 1.28 (95% CI: 1.22-1.35, I2 = 90.3%) per 20 mmHg of systolic blood pressure (24 studies, 31 639 cases and 2 557 975 participants), and 1.12 (95% CI: 1.04-1.21, I2 = 92.6%) per 10 mmHg of diastolic blood pressure (16 studies, 23 127 cases and 2 419 972 participants). There was a steeper increase in heart failure risk at higher blood pressure levels and a three- to five-fold increase in RR at around 180/120 mmHg of systolic and diastolic blood pressure compared with 100/60 mmHg, respectively. There was little indication of publication bias across analyses.

CONCLUSION

This meta-analysis suggests a strong positive association between hypertension and systolic and diastolic blood pressure and the risk of heart failure. These results support efforts to reduce blood pressure in the general population to reduce the risk of heart failure.

Association of Achievement of the American Heart Association's Life's Essential 8 Goals With Incident Cardiovascular Diseases in the SHFS

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in American Indian people. In 2022, the American Heart Association developed the Life's Essential 8 goals to promote cardiovascular health (CVH) for Americans, composed of diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood pressure, and blood glucose. We examined whether achievement of Life's Essential 8 goals was associated with incident CVD among SHFS (Strong Heart Family Study) participants.

METHODS AND RESULTS

A total of 2139 SHFS participants without CVD at baseline were included in analyses. We created a composite CVH score based on achievement of Life's Essential 8 goals, excluding sleep. Scores of 0 to 49 represented low CVH, 50 to 69 represented moderate CVH, and 70 to 100 represented high CVH. Incident CVD was defined as incident myocardial infarction, coronary heart disease, congestive heart failure, or stroke. Cox proportional hazard models were used to examine the relationship of CVH and incident CVD. The incidence rate of CVD at the 20-year follow-up was 7.43 per 1000 person-years. Compared with participants with low CVH, participants with moderate and high CVH had a lower risk of incident CVD; the hazard ratios and 95% CIs for incident CVD for moderate and high CVH were 0.52 (95% CI, 0.40-0.68) and 0.25 (95% CI, 0.14-0.44), respectively, after adjustment for age, sex, education, and study site.

CONCLUSIONS

Better CVH was associated with lower CVD risk which highlights the need for comprehensive public health interventions targeting CVH promotion to reduce CVD risk in American Indian communities.

Comparative Discrimination of Life's Simple 7 and Life's Essential 8 to Stratify Cardiovascular Risk: Is the Added Complexity Worth It?

BACKGROUND

Life's Simple 7 (LS7) is an easily calculated and interpreted metric of cardiovascular health based on 7 domains: smoking, diet, physical activity, body mass index, blood pressure, cholesterol, and fasting glucose. The Life's Essential 8 (LE8) metric was subsequently introduced, adding sleep metrics and revisions of the previous 7 domains. Although calculating LE8 requires additional information, we hypothesized that it would be a more reliable index of cardiovascular health.

METHODS

Both the LS7 and LE8 metrics yield scores with higher values indicating lower risk. These were calculated among 11 609 Black and White participants free of baseline cardiovascular disease (CVD) in the Reasons for Geographic and Racial Differences in Stroke study, enrolled in 2003 to 2007, and followed for a median of 13 years. Differences in 10-year risk of incident CVD (coronary heart disease or stroke) were calculated as a function LS7, and LE8 scores were calculated using Kaplan-Meier and proportional hazards analyses. Differences in incident CVD discrimination were quantified by difference in the c-statistic.

RESULTS

For both LS7 and LE8, the 10-year risk was approximately 5% for participants around the 99th percentile of scores, and a 4× higher 20% risk for participants around the first percentile. Comparing LS7 to LE8, 10-year risk was nearly identical for individuals at the same relative position in score distribution. For example, the "cluster" of 2013 participants with an LS7 score of 7 was at the 35.8th percentile in distribution of LS7 scores, and had an estimated 10-year CVD risk of 8.4% (95% CI, 7.2%-9.8%). In a similar location in the LE8 distribution, the 1457 participants with an LE8 score of 60±2.5 at the 39.4th percentile of LE8 scores had a 10-year risk of CVD of 8.5% (95% CI, 7.1%-10.1%), similar to the cluster defined by LS7. The age-race-sex adjusted c-statistic of the LS7 model was 0.691 (95% CI, 0.667-0.705), and 0.695 for LE8 (95% CI, 0.681-0.709) (P for difference, 0.12).

CONCLUSIONS

Both LS7 and LE8 were associated with incident CVD, with discrimination of the 2 indices practically indistinguishable. As a simpler metric, LS7 may be favored for use by the general population and clinicians.

Association between the trajectory of ideal cardiovascular health metrics and incident chronic kidney disease among 27,635 older adults in northern China-a prospective cohort study

BACKGROUND

There is a lack of relevant studies evaluating the long-term impact of cardiovascular health factor (CVH) metrics on chronic kidney disease (CKD).

OBJECTIVE

This study investigates the long-term change in CVH metrics in older people and explores the relationship between CVH metrics trajectory and CKD.

METHODS

In total, 27,635 older people aged over 60 from the community-based Tianjin Chronic Kidney Disease Cohort study were enrolled. The participants completed five annual physical examinations between January 01, 2014, and December 31, 2018, and a subsequent follow-up between January 01, 2019, and December 31, 2021. CVH metrics trajectories were established by the group-based trajectory model to predict CKD risk. The relationships between baseline CVH, CVH change (ΔCVH), and CKD risk were also explored by logistic regression and restricted cubic spline regression model. In addition, likelihood ratio tests were used to compare the goodness of fit of the different models.

RESULTS

Six distinct CVH metrics trajectories were identified among the participants: low-stable (11.19%), low-medium-stable (30.58%), medium-stable (30.54%), medium-high-decreased (5.46%), medium-high-stable (18.93%), and high-stable (3.25%). After adjustment for potential confounders, higher CVH metrics trajectory was associated with decreased risk of CKD (P for trend < 0.001). Comparing the high-stable with the low-stable group, the risk of CKD decreased by 46%. All sensitivity analyses, including adjusting for baseline CVH and removing each CVH component from the total CVH, produced consistent results. Furthermore, the likelihood ratio test revealed that the model established by the CVH trajectory fit better than the baseline CVH and Δ CVH.

CONCLUSION

The higher CVH metrics trajectory and improvement of CVH metrics were associated with decreased risk of CKD. This study emphasized the importance of improving CVH to achieve primary prevention of CKD in older people.

Life's Essential 8 and risk of incident heart failure in community population without cardiovascular disease: Results of the sub-cohort of China PEACE Million Persons Project

OBJECTIVE

The American Heart Association has introduced the Life's Essential 8 metrics to evaluate and promote cardiovascular health (CVH) and we aimed to evaluate the association of CVH and incident heart failure (HF).

METHODS

The China PEACE Million Persons Project is a population-based cardiovascular disease (CVD) screening study. This was a sub-cohort of the project that included individuals free of CVD at baseline. Components and classifications of CVH, including diet, physical activity, smoking status, sleep status, body mass index (BMI), non-high density lipoprotein (non-HDL), blood glucose and blood pressure, were determined based on the Life's Essential 8. CVH status was categorized as poor, intermediate and ideal status. HF cases were identified by linking hospital records.

RESULTS

Among the cohort (n = 38,571, median age 54 years and women 60.5%), proportion of individuals with poor, intermediate and ideal CVH was 30.7%, 56.9% and 12.4%. After a median follow-up of 3.56 years, the incidence of HF in individuals with poor, intermediate and ideal CVH was 2.5%, 1.1% and 0.5% respectively. Compared to poor CVH, intermediate (adjusted HR: 0.52 [95% CI: 0.43-0.61]) and ideal CVH (adjusted HR: 0.38 [95% CI: 0.26-0.57]) were associated with a lower HF risk. A gradient of association between CVH and HF risk was observed (P-trend<0.001). Ideal physical activity, ideal smoking status, and intermediate and ideal status of BMI, blood glucose and blood pressure were associated with a lower HF risk.

CONCLUSION

Poor CVH was associated with an increased risk of HF, and promotion of CVH may help prevent HF development.

Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population

The relative distribution of proportions of cardiovascular health (CVH) categories within racial groups has been examined. However, little scientific evidence exists on the gap trend in racial/ethnic disparities in mean CVH score among non-Hispanic (NH) Whites and Blacks. This study examined the trend(s) in the gap(s) in predicted CVH scores between NH Whites and Blacks over 10 years. In a cross-sectional analytical study, 10 years of Medical Expenditure Panel Survey data from 2008 to 2018 were pooled, utilizing multivariate Poisson's regression of CVH metrics on race, while controlling for relevant covariates. The interactions of acute coronary syndrome (ACS) with CVH metrics, and other key variables such as trends and grouped Charlson Comorbidity Index allowed for variations in the effect of these variables on the subgroups. The mean gap in CVH scores was on average 0.15 [95% confidence interval (CI) 0.137 to 0.170], with Blacks consistently having reduced odds of having ideal CVH until 2014. The overall impact of having an ACS decreased acquired CVH scores by 24.1% [95% CI -0.275 to 0.207], and was equal for both racial subgroups (P < 0.05). The Affordable Care Act (ACA)-trend was positive, increasing the likelihood of improved CVH in the sample (P < 0.05), deflecting a downward trend in acquired CVH scores for both races, as the gap narrowed into more recent years. The CVH gap was stabilized by the ACA, but never really converged, suggesting that efforts to reduce existing disparities between Blacks and NH Whites in the United States would require government policies to look beyond mere "access" and/or "affordability" to health care.

Preventing new-onset heart failure: Intervening at stage A

Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.

Personal Health Literacy and Life Simple 7: The Multi-Ethnic Study of Atherosclerosis

Background

Personal Health literacy (PHL) is essential in cardiovascular risk management. Hindrances in PHL can lead to poor cardiovascular outcomes.

Purpose

To investigate whether limited PHL is associated with lower likelihoods of i) overall cardiovascular health and ii) individual cardiovascular health components as defined by the American Heart Association's Life Simple (LS7).

Methods

Multi-Ethnic Study of Atherosclerosis participants (N=3719; median age[range]: 59[45-84]) completed a PHL questionnaire in 2016-2018. PHL was classified as limited (score ≥10) or adequate (score <10). LS7 components were measured in 2000-2002. Robust Poisson regression was employed to compute prevalence ratios and 95% confidence intervals (PR[95%CI]) of LS7 measures.

Results

14.7% of participants had limited PHL. Limited PHL was associated with lower likelihoods of optimal LS7 (0.69[0.50, 0.95], p=0.02) and average LS7 (0.95[0.88, 1.02], p=0.15) after adjustment. Limited PHL was significantly associated with a 7% lower likelihood of ideal fasting blood glucose level after adjustment (0.93[0.89, 0.98], p<0.01).

Discussion

Limited PHL was modestly associated with suboptimal cardiovascular health and elevated blood glucose, independent of income and education.

Translation to Health Education Practice

Health educators and providers should equitably address PHL barriers to improve cardiovascular management and quality of care for patients and communities.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications

BACKGROUND

The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied.

OBJECTIVE

To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV.

METHODS

We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm.

RESULTS

In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (β=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well.

CONCLUSIONS

Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11185.

Metabolomic Profiles, Ideal Cardiovascular Health, and Risk of Heart Failure and Atrial Fibrillation: Insights From the Framingham Heart Study

Background The American Heart Association's framework "ideal cardiovascular health" (CVH) focuses on modifiable risk factors to reduce cardiovascular disease (CVD). Metabolomics provides important pathobiological insights into risk factors and CVD development. We hypothesized that metabolomic signatures associate with CVH status, and that metabolites, at least partially, mediate the association of CVH score with atrial fibrillation (AF) and heart failure (HF). Methods and Results We studied 3056 adults in the FHS (Framingham Heart Study) cohort to evaluate CVH score and incident outcomes of AF and HF. Metabolomics data were available in 2059 participants; mediation analysis was performed to evaluate the mediation of metabolites in the association of CVH score and incident AF and HF. In the smaller cohort (mean age, 54 years; 53% women), CVH score was associated with 144 metabolites, with 64 metabolites shared across key cardiometabolic components (body mass index, blood pressure, and fasting blood glucose) of the CVH score. In mediation analyses, 3 metabolites (glycerol, cholesterol ester 16:1, and phosphatidylcholine 32:1) mediated the association of CVH score with incident AF. Seven metabolites (glycerol, isocitrate, asparagine, glutamine, indole-3-proprionate, phosphatidylcholine C36:4, and lysophosphatidylcholine 18:2), partly mediated the association between CVH score and incident HF in multivariable-adjusted models. Conclusions Most metabolites that associated with CVH score were shared the most among 3 cardiometabolic components. Three main pathways: (1) alanine, glutamine, and glutamate metabolism; (2) citric acid cycle metabolism; and (3) glycerolipid metabolism mediated CVH score with HF. Metabolomics provides insights into how ideal CVH status contributes to the development of AF and HF.

Ideal Cardiovascular Health and Adipokine Levels: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

To evaluate the association between ideal cardiovascular health (CVH) and adipokine levels. Adipokines are hormones implicated in obesity and its cardiometabolic consequences. The concept of ideal CVH was introduced to promote 7 key health factors and behaviors in the general population. Previous studies have found strong associations between obesity and ideal CVH. However, existing literature on the link between CVH and adipokines is scarce.

METHODS

We studied 1842 Multi-Ethnic Study of Atherosclerosis participants free of cardiovascular disease who had 7 CVH metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting blood glucose) measured at baseline and serum adipokine levels measured at a median of 2.4 years later. Each CVH metric was assigned a score of 0 (poor), 1 (intermediate), or 2 (ideal), and all scores were summed for a total CVH score (0-14). The total CVH scores of 0 to 8, 9 to 10, and 11 to 14 were considered inadequate, average, and optimal, respectively. We used multivariable linear regression models to assess the nonconcurrent associations between the CVH score and log-transformed adipokine levels.

RESULTS

The mean age was 62.1 ± 9.8 years; 50.2% of participants were men. After adjusting for sociodemographic factors, a 1-unit higher CVH score was significantly associated with 4% higher adiponectin and 15% and 1% lower leptin and resistin levels. Individuals with optimal CVH scores had 27% higher adiponectin and 56% lower leptin levels than those with inadequate CVH scores. Similar trends were observed for those with average versus inadequate CVH scores.

CONCLUSION

In a multi-ethnic cohort free of cardiovascular disease at baseline, individuals with average and optimal CVH scores had a more favorable adipokine profile than those with inadequate CVH scores.

Weight gain prevention interventions in the Study of Novel Approaches to Weight Gain Prevention (SNAP) trial promote ideal cardiovascular health in young adults

OBJECTIVE

Cardiovascular health (CVH) declines in young adulthood. This study assessed whether weight gain prevention interventions promoted ideal CVH.

METHODS

Young adults (n = 599; age 18-35 years; BMI: 21.0-30.9 kg/m2 ) from a randomized controlled trial comparing two weight gain prevention interventions (self-regulation with large or small changes) and a self-guided control group completed anthropometric and clinical assessments at baseline and 2 years. CVH was quantified via the American Heart Association's Life's Simple 7 (LS7) number of ideal components met.

RESULTS

Both interventions showed significant improvements in the average number of ideal LS7 components met at 2 years compared with control (pre- to post-treatment means; large change: 0.24, small change: 0.34, control: -0.2, p < 0.05). Moreover, a greater percentage of participants in both interventions improved by ≥1 ideal component (large change: 35%, small change: 37%, control: 29%) and a smaller percentage declined by ≥1 ideal component (large change: 16%, small change: 20%, control: 30%) compared with control. For individual LS7 components, the odds of having an ideal BMI and glucose varied by treatment condition at 2 years.

CONCLUSIONS

Two weight gain prevention interventions led to improvements in ideal CVH at 2 years. Interventions explicitly focused on a broader constellation of LS7 domains might lead to even greater changes in CVH.

Differences in Adherence to American Heart Association's Life's Essential 8, Diet Quality, and Weight Loss Strategies Between Those With and Without Recent Clinically Significant Weight Loss in a Nationally Representative Sample of US Adults

Background The American Heart Association defines ideal cardiovascular health based on 8 risk factors (Life's Essential 8 [LE8]); a high LE8 score (range 0-100) reflects greater adherence to their recommendations. Weight status influences cardiovascular health, yet individuals may use detrimental diet and weight loss strategies to improve weight status. We assessed differences in LE8 adherence, diet quality, and weight loss strategies between those with and without a recent history of clinically significant weight loss (CSWL). Methods and Results Data from 2007 to 2016 National Health and Nutrition Examination Survey questionnaires, clinical measures, and 24-hour dietary recalls were assessed to determine LE8 adherence, diet quality (Healthy Eating Index), and weight loss strategies between adults with: (1) intentional CSWL ≥5%; and (2) non-CSWL <5%, weight maintenance, or weight gain over the past 12 months using ANCOVA and chi-square tests. Those with CSWL demonstrated higher scores for diet quality (P=0.014), physical activity (P<0.001), and blood lipids (P<0.001). Those without CSWL reported lower BMI (P<0.001). There were no differences in total LE8 cardiovascular health scores between those with and without CSWL. More individuals with CSWL reported weight loss strategies of exercising (P=0.016); those without CSWL reported skipping meals (P=0.002) and using prescription diet pills (P<0.001). Conclusions Greater adherence to the LE8 recommendations was observed among individuals with CSWL, although overall LE8 scores were low. Future research should address the implementation of evidence-based strategies that improve diet quality while promoting optimal cardiovascular health among those with intent to lose weight.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Cardiovascular health trajectories and subsequent cardiovascular disease and mortality: The multi-ethnic study of atherosclerosis (MESA)

Objective

Longitudinal trajectories of cardiovascular health (CVH) may reflect vascular risk burden due to prolonged cumulative exposure to non-ideal CVH levels. Identifying individuals who have a higher risk CVH trajectory may facilitate treatment, screening, and prevention. We aimed to characterize 10-year trajectories of CVH and examine the associations between CVH trajectories and subsequent cardiovascular disease (CVD) and mortality.

Methods

We analyzed 3674 MESA participants who completed four exams and remained CVD-free from 2000 to 2011. A 12-point CVH score was calculated based on physical activity, smoking status, body mass index, cholesterol, blood pressure, and glucose. Ideal CVH was defined as a score ≥ 9. Group-based trajectory modeling was used to identify trajectories of ideal CVH. Cox models were used to examine the association of CVH trajectories with incident CVD and death from 2011 to 2018, adjusting for age, sex, race/ethnicity, income, education, and marital status.

Results

Three trajectories were identified based on the probability of achieving ideal CVH: high (n = 1251), medium (n = 760), and persistently low (n = 1663). Almost half (45.3%) of the participants had a persistently low trajectory. During a median of 7.7 years follow-up, 392 incident CVD events and 459 deaths occurred. Compared with the high CVH group, participants in the persistently low CVH trajectory group had elevated risks for CVD (adjusted hazard ratios 1.49, 95% confidence interval 1.15-1.93) and mortality (1.34, 1.06-1.70), and participants in the medium group had moderate risks for CVD (1.17, 0.86-1.59) and mortality (1.15, 0.87-1.53) (p-value for trend 0.002 for CVD, 0.014 for mortality).

Conclusion

Persistently nonideal CVH is a common trajectory. Targeted prevention programs might benefit individuals with persistently nonideal CVH given their elevated risk of subsequent CVD and mortality.

Social support, psychosocial risks, and cardiovascular health: Using harmonized data from the Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America Study, and Multi-Ethnic Study of Atherosclerosis

Purpose

Social support may have benefits on cardiovascular health (CVH). CVH is evaluated using seven important metrics (Life's Simple 7; LS7) established by the American Heart Association (e.g., smoking, diet). However, evidence from longitudinal studies is limited and inconsistent. The objective of this study is to examine the longitudinal relationship between social support and CVH, and assess whether psychosocial risks (e.g., anger and stress) modify the relationship in a racially/ethnically diverse population.

Methods

Participants from three harmonized cohort studies - Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America, and Multi-Ethnic Study of Atherosclerosis - were included. Repeated-measures modified Poisson regression models were used to examine the overall relationship between social support (in tertiles) and CVH (LS7 metric), and to assess for effect modification by psychosocial risk.

Results

Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96-1.03). For medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98-1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95% CI) of 1.04 (0.99-1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94-1.03) and 0.97 (0.91-1.03), respectively.

Conclusion

Overall, we observed no strong evidence for an association between social support and CVH. However, some psychosocial risks may be modifiers. Prospective studies are needed to assess the social support-CVH relationship by psychosocial risks in racially/ethnically diverse populations.

Association of a Multiancestry Genome-Wide Blood Pressure Polygenic Risk Score With Adverse Cardiovascular Events

BACKGROUND

Traditional cardiovascular risk factors and the underlying genetic risk of elevated blood pressure (BP) determine an individual's composite risk of developing adverse cardiovascular events. We sought to evaluate the relative contributions of the traditional cardiovascular risk factors to the development of adverse cardiovascular events in the context of varying BP genetic risk profiles.

METHODS

Genome-wide polygenic risk score (PRS) was computed using multiancestry genome-wide association estimates among US adults who underwent whole-genome sequencing in the Trans-Omics for Precision program. Individuals were stratified into high, intermediate, and low genetic risk groups (>80th, 20-80th, and <20th centiles of systolic BP [SBP] PRS). Based on the ACC/AHA Pooled Cohort Equations, participants were stratified into low and high (10 year-atherosclerotic cardiovascular disease [CVD] risk: <10% or ≥10%) cardiovascular risk factor profile groups. The primary study outcome was incident cardiovascular event (composite of incident heart failure, incident stroke, and incident coronary heart disease).

RESULTS

Among 21 897 US adults (median age: 56 years; 56.0% women; 35.8% non-White race/ethnicity), 1 SD increase in the SBP PRS, computed using 1.08 million variants, was associated with SBP (β: 4.39 [95% CI, 4.13-4.65]) and hypertension (odds ratio, 1.50 [95% CI, 1.46-1.55]), respectively. This association was robustly seen across racial/ethnic groups. Each SD increase in SBP PRS was associated with a higher risk of the incident CVD (multivariable-adjusted hazards ratio, 1.07 [95% CI, 1.04-1.10]) after controlling for ACC/AHA Pooled Cohort Equations risk scores. Among individuals with a high SBP PRS, low atherosclerotic CVD risk was associated with a 58% lower hazard for incident CVD (multivariable-adjusted hazards ratio, 0.42 [95% CI, 0.36-0.50]) compared to those with high atherosclerotic CVD risk. A similar pattern was noted in intermediate and low genetic risk groups.

CONCLUSIONS

In a multiancestry cohort of >21 000 US adults, genome-wide SBP PRS was associated with BP traits and adverse cardiovascular events. Adequate control of modifiable cardiovascular risk factors may reduce the predisposition to adverse cardiovascular events among those with a high SBP PRS.

Redefining Cardiovascular Health to Include Sleep: Prospective Associations With Cardiovascular Disease in the MESA Sleep Study

Background Although sufficient and healthy sleep is inversely associated with cardiovascular disease (CVD) and its risk factors, the American Heart Association's Life's Simple 7 (LS7), as a measure of cardiovascular health (CVH), did not include sleep. We evaluated an expanded measure of CVH that includes sleep as an eighth metric in relation to CVD risk. Methods and Results The analytic sample consisted of MESA (Multi-Ethnic Study of Atherosclerosis) Sleep Study participants who had complete data on sleep characteristics from overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and the outcome. We computed the LS7 score and 4 iterations of a new CVH score: score 1 included sleep duration, score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea), scores 3 and 4 included sleep characteristics associated with CVD in MESA (score 3: sleep duration and efficiency, daytime sleepiness, and obstructive sleep apnea; score 4: score 3+sleep regularity). Multivariable-adjusted logistic and Cox proportional hazards models evaluated associations of the LS7 and CVH scores 1 to 4 with CVD prevalence and incidence. Among 1920 participants (mean age: 69±9 years; 54% female), there were 95 prevalent CVD events and 93 incident cases (mean follow-up, 4.4 years). Those in the highest versus lowest tertile of the LS7 score and CVH scores 1 to 4 had up to 80% lower odds of prevalent CVD. The LS7 score was not significantly associated with CVD incidence (hazard ratio, 0.62 [95% CI, 0.37-1.04]). Those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratio, 0.57 [95% CI, 0.33-0.97]; and hazard ratio, 0.53 [95% CI, 0.32-0.89]), respectively. Conclusions CVH scores that include sleep health predicted CVD risk in older US adults. The incorporation of sleep as a CVH metric, akin to other health behaviors, may enhance CVD primordial and primary prevention efforts. Findings warrant confirmation in larger cohorts over longer follow-up.

Abnormal ankle-brachial index, cardiovascular risk factors and healthy lifestyle factors in hypertensive patients: prospective cohort study from a primary care urban population

Background

Peripheral arterial disease (PAD) and arterial stiffness (AS) may be hypertension-mediated vascular lesions. Both are determined by an abnormal ankle-brachial index (ABI) and are predictors of cardiovascular disease (CVD) and mortality. We assessed the relationship in urban hypertensive patients between an abnormal ABI and an ideal cardiovascular health (CVH) score, plus other healthy factors, with unfavourable outcomes.

Methods

We studied 243 hypertensive patients from a primary care urban population, followed for two years. Clinical data, comorbid conditions, including hypertension-mediated organ damage (HMOD) and hypertension-related comorbidities (HRC), hospitalizations and mortality were also recorded.

Results

A low prevalence of ideal CVH was observed in urban hypertensive patients. The ABI ≤ 0.9 group (n = 16) showed a higher proportion of prior CVD other than PAD, mortality and hospitalizations than the ABI > 1.4 group (n = 41), and a poorer lipid, metabolic and renal profile. An inverse relationship between CVH score and ABI ≤ 0.9 and unfavourable outcomes (HMOD, HRC, death or hospitalization) was observed. Chronic kidney disease (CKD) and diabetes were independently associated with an ABI ≤ 0.9. Age, sex, diabetes, CKD, ABI ≤ 0.9 and ideal cholesterol were also associated with outcomes, but not other CVH metrics.

Conclusions

Besides a low prevalence of ideal CVH, an inverse relationship between CVH score and ABI ≤ 0.9 and unfavourable outcomes was observed in hypertensive patients from an urban population. Stronger efforts to promote ideal CVH may improve outcomes in this particular population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01837-1.

Life's Simple 7 at Midlife and Risk of Recurrent Cardiovascular Disease and Mortality after Stroke: The ARIC study

BACKGROUND

Stroke is a leading cause of morbidity and mortality among adults in the U.S. Ideal levels of the Life's Simple 7 (LS7) are associated with lower cardiovascular disease (CVD) and all-cause mortality. However, the association of LS7 with CVD, recurrent stroke, and all-cause mortality after incident stroke is unknown.

METHODS

We used data from the ARIC study, a cohort of 13,508 adults from four US communities, 45-64 years old at baseline (1987-1989). Cardiovascular hospitalizations and mortality were ascertained in follow-up through December 31st, 2017. We defined cardiovascular health (CVH) based on AHA definitions for LS7 (range 0-14) and categorized CVH into four levels: LS7 0-3, 4-6, 7-9, and ≥10 (ideal LS7), according to prior studies. Outcomes included incident stroke, CVD, recurrent stroke, all-cause mortality, and a composite outcome including all the above. Adjusted hazard ratios (95% CI) were estimated with Cox proportional hazards regression models.

RESULTS

Median (25%-75%) follow-up for incident stroke was 28 (18.6-29.2) years. Participants with incident stroke were 55.7 (SD 5.6) years-old at baseline, 53% were women and 35% Black. Individuals with LS7 score ≥10 had 65% lower risk (HR: 0.35; 95% CI: 0.29-0.41) of incident stroke than those with LS7 4-6 (reference group). Of 1,218 participants with incident stroke, 41.2% (n=502) had composite CVD and 68.3% (n=832) died during a median (25%-75%) follow-up of 4.0 (0.76-9.95) years. Adjusted HR (95% CI) for stroke survivors with LS7≥10 at baseline were 0.74 (0.58-0.94) for the composite outcome, 0.38(0.17-0.85) for myocardial infarction, 0.60 (0.40-0.90) for heart failure, 0.63 (0.48-0.84) for all-cause mortality, and 0.65 (0.39-1.08) for recurrent stroke.

CONCLUSIONS

Good and excellent midlife cardiovascular health are associated with lower risks of incident stroke and CVD after stroke. Clinicians should stress the importance of a healthy lifestyle for primary and secondary CVD prevention.

New strategies and therapies for the prevention of heart failure in high-risk patients

Despite declines in total cardiovascular mortality rates in the United States, heart failure (HF) mortality rates as well as hospitalizations and readmissions have increased in the past decade. Increases have been relatively higher among young and middle-aged adults (<65 years). Therefore, identification of individuals HF at-risk (Stage A) or with pre-HF (Stage B) before the onset of overt clinical signs and symptoms (Stage C) is urgently needed. Multivariate risk models (e.g., Pooled Cohort Equations to Prevent Heart Failure [PCP-HF]) have been externally validated in diverse populations and endorsed by the 2022 HF Guidelines to apply a risk-based framework for the prevention of HF. However, traditional risk factors included in the PCP-HF model only account for half of an individual's lifetime risk of HF; novel risk factors (e.g., adverse pregnancy outcomes, impaired lung health, COVID-19) are emerging as important risk-enhancing factors that need to be accounted for in personalized approaches to prevention. In addition to determining the role of novel risk-enhancing factors, integration of social determinants of health (SDoH) in identifying and addressing HF risk is needed to transform the current clinical paradigm for the prevention of HF. Comprehensive strategies to prevent the progression of HF must incorporate pharmacotherapies (e.g., sodium glucose co-transporter-2 inhibitors that have also been termed the "statins" of HF prevention), intensive blood pressure lowering, and heart-healthy behaviors. Future directions include investigation of novel prediction models leveraging machine learning, integration of risk-enhancing factors and SDoH, and equitable approaches to interventions for risk-based prevention of HF.

Interconnected Clinical and Social Risk Factors in Breast Cancer and Heart Failure

Breast cancer and heart failure share several known clinical cardiovascular risk factors, including age, obesity, glucose dysregulation, cholesterol dysregulation, hypertension, atrial fibrillation and inflammation. However, to fully comprehend the complex interplay between risk of breast cancer and heart failure, factors attributed to both biological and social determinants of health must be explored in risk-assessment. There are several social factors that impede implementation of prevention strategies and treatment for breast cancer and heart failure prevention, including socioeconomic status, neighborhood disadvantage, food insecurity, access to healthcare, and social isolation. A comprehensive approach to prevention of both breast cancer and heart failure must include assessment for both traditional clinical risk factors and social determinants of health in patients to address root causes of lifestyle and modifiable risk factors. In this review, we examine clinical and social determinants of health in breast cancer and heart failure that are necessary to consider in the design and implementation of effective prevention strategies that altogether reduce the risk of both chronic diseases.

Current state of unhealthy living characteristics in White, African American and Latinx populations

The United States (US) is similar to most industrialized countries in that it falls short on many of the basic metrics related to cardiovascular and overall health. These metrics include nutritional patterns, levels of physical activity (PA), cardiorespiratory fitness (CRF), and prevalence of overweight and obesity. These issues are even more apparent in underserved communities, among whom unhealthy living characteristics cluster and contribute to a disproportionate chronic disease burden. The reasons for these inequities are complex and include social and economic factors as well as reduced access to health care. CRF has been demonstrated to be a critically important risk factor that tends to be lower in disadvantaged groups. In this article we discuss the current state of health & lifestyle characteristics in the US, the impact of social inequality on health, and the particular role that CRF and PA patterns play in the current state of unhealthy living characteristics as they relate to underserved populations.

Favorable Cardiovascular Health Is Associated With Lower Prevalence, Incidence, Extent, and Progression of Extracoronary Calcification: MESA

BACKGROUND

Ideal cardiovascular health (CVH) is associated with a lower incidence of cardiovascular disease. Extracoronary calcification (ECC)-measured at the aortic valve, mitral annulus, ascending thoracic aorta, and descending thoracic aorta-is an indicator of systemic atherosclerosis. This study examined whether favorable CVH was associated with a lower risk of ECC.

METHODS

We analyzed data from MESA (Multi-Ethnic Study of Atherosclerosis) participants aged 45 to 84 years without cardiovascular disease at baseline. ECC was measured by noncontrast cardiac computed tomography scan at baseline and after an average of 2.4 years. Prevalent ECC was defined as an Agatston score >0 at the baseline scan. Incident ECC was defined as Agatston score >0 at the follow-up scan among participants with Agatston score of 0 at the baseline scan. Each CVH metric (smoking, physical activity, body mass index, diet, blood pressure, total cholesterol, and blood glucose) was scored 0 to 2 points, with 2 indicating ideal; 1, intermediate; and 0, poor. The aggregated CVH score was 0 to 14 points (0-8, inadequate; 9-10, average; 11-14, optimal). We used Poisson and linear mixed-effects regression models to examine the association between CVH and ECC adjusted for sociodemographic factors.

RESULTS

Of 6504 participants, 53% were women with a mean age (SD) of 62 (10) years. Optimal and average CVH scores were associated with lower ECC prevalence, incidence, and extent. For example, optimal CVH scores were associated with 57%, 56%, 70%, and 54% lower risk of incident aortic valve calcification, mitral annulus calcification, ascending thoracic aorta calcification, and descending thoracic aorta calcification, respectively. In addition, optimal and average CVH scores were associated with lower ECC progression at 2 years, although these associations were only significant for mitral annulus calcification and descending thoracic aorta calcification.

CONCLUSIONS

In this multiethnic cohort, favorable CVH was associated with a lower risk of extracoronary atherosclerosis. These findings emphasize the importance of primordial prevention as an intervention to reduce the burden of cardiovascular disease.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Ideal Cardiovascular Health in Young Adults With Established Cardiovascular Diseases

There has been an increase in the prevalence of cardiovascular diseases among young adults in the United States that has been attributed, in part, to a rise in overweight and obesity, use of combustible tobacco and unhealthy diet and exercise patterns. These factors are influenced further by socioeconomic status and other social determinants of health. In the My Research Legacy study, we examined ideal cardiovascular health in young adults aged 18– <50 years with cardiovascular disease using the Life's Simple 7 survey and data from digital health devices. Young adults with cardiovascular disease (n = 349) were older, had a lower socioeconomic status, a higher prevalence of risk factors, and lower Life's Simple 7 Health Scores (6.4 ± 1.5 vs. 7.1 ± 1.5, p < 0.01) compared to young adults without cardiovascular disease (n = 696). Analysis of digital health device data revealed that young adults with cardiovascular disease performed a similar number of weekly minutes of moderate and vigorous exercise as those without disease leading to similar ideal activity scores. Young adults with cardiovascular disease also shared similarities in modifiable risk factors with adults aged ≥50 years with cardiovascular disease (n = 217), including weight, dietary habits, and weekly minutes of exercise. Latent class analysis identified two phenogroups of young adults with cardiovascular disease: phenogroup 1 was characterized by more advantageous cardiovascular health factors and behaviors resulting in higher Life's Simple 7 Health Scores than phenogroup 2 (7.4 ± 1.2 vs. 5.5 ± 1.1, p < 0.01). These findings in young adults with cardiovascular disease may inform the design of behavioral and therapeutic interventions in the future to decrease cardiovascular morbidity and mortality.

Optimal lifestyle behaviors and 10-year progression of arterial stiffness: The multi-ethnic study of atherosclerosis

Majority of previous studies showed no association between a single health behavior and arterial stiffness, but the benefit of simultaneously having multiple healthy behaviors (optimal lifestyle) on the progression of arterial stiffness is unknown. Among 2810 individuals (age 60.0 ± 9.4, 46.5% male), optimal lifestyle marker (yes/no) on four health behaviors (ie, BMI < 25 kg/m², never or former smoker, never or moderate drinker, exercised > 500 METS min/week) across four visits (≈ 5 years) were summed to create an optimal lifestyle score. Carotid arterial stiffness was measured using distensibility coefficient (DC) and Young's elastic modulus (YEM) at visit 1 and after a mean of 9.5 years (visit 5). The association of optimal lifestyle with 10‐year percent change in DC and YEM was assessed using multiple linear regression. DC decreased by 5.3% and YEM increased by 24.4% over 10 years. Mean optimal lifestyle score was 9.4 ± 3.1 (range: 0–16). Individuals in quintiles 2–5 of optimal lifestyle score compared to quintile 1 (with the least optimal lifestyle score) did not show slower deceleration of DC [Q2, −0.3% (95% CI: −6.0, 5.4); Q3, −0.01% (−4.5, 4.5); Q4, −0.6% (−5.2, 3.9); Q5, −0.4% (−5.3, 4.4)], trend p‐value = .82] or slower progression of YEM [Q2, 0.1% (−7.1, 7.3); Q3, −0.8% (−8.0, 6.5); Q4, 4.5% (−2.3, 11.3); Q5, −0.2% (−8.3, 7.9)], trend p‐value = .49] after adjusting for risk factors. The association remained non‐significant when stratified by categories of age, sex, race, BP control, and diabetes. Our findings indicate that optimal score on multiple health behaviors may not independently slow arterial stiffness progression.

A systematic review of the bidirectional relationship between depressive symptoms and cardiovascular health

Depression is a mental health disorder associated with a 2-fold increase in cardiovascular disease risk. However, the association between depression and cardiovascular health (CVH), as reflected by the American Heart Association's (AHA) CVH metrics, is incompletely understood. We aimed to systematically review the current evidence to understand and clarify whether a bidirectional relationship exists between depressive symptoms and CVH. We conducted a systematic review by searching EMBASE, Google Scholar, PubMed and Web of Science from inception to May 2021. MeSH terms and keywords were used to identify studies with information on depressive symptoms and CVH. Among 132 articles screened, 11 studies were included with 101,825 participants. Eight studies were cross-sectional while 3 studies used a prospective cohort design. Five studies found an association between participants with unfavorable CVH and depressive symptoms. Six studies found an association between participants with depressive symptoms and unfavorable CVH. In summary, we found a bidirectional relationship may exist between depressive symptoms and CVH. Further research is required to quantify the risk and identify the biological mechanisms underlying the association between depressive symptoms and unfavorable CVH so adequate screening and interventions can be directed towards people with depressive symptoms or unfavorable CVH.

Examining Optimism, Psychosocial Risks, and Cardiovascular Health Using Life's Simple 7 Metrics in the Multi-Ethnic Study of Atherosclerosis and the Jackson Heart Study

Background: Optimism has been shown to be positively associated with better cardiovascular health (CVH). However, there is a dearth of prospective studies showing the benefits of optimism on CVH, especially in the presence of adversities, i.e., psychosocial risks. This study examines the prospective relationship between optimism and CVH outcomes based on the Life's Simple 7 (LS7) metrics and whether multilevel psychosocial risks modify the aforementioned relationship. Methods: We examined self-reported optimism and CVH using harmonized data from two U.S. cohorts: Multi-Ethnic Study of Atherosclerosis (MESA) and Jackson Heart Study (JHS). Modified Poisson regression models were used to estimate the relationship between optimism and CVH using LS7 among MESA participants (N = 3,520) and to examine the relationship of interest based on four biological LS7 metrics (body mass index, blood pressure, cholesterol, and blood glucose) among JHS and MESA participants (N = 5,541). For all CVH outcomes, we assessed for effect measure modification by psychosocial risk. Results: Among MESA participants, the adjusted risk ratio (aRR) for ideal or intermediate CVH using LS7 comparing participants who reported high or medium optimism to those with the lowest level of optimism was 1.10 [95% Confidence Interval (CI): 1.04-1.16] and 1.05 (95% CI: 0.99-1.11), respectively. Among MESA and JHS participants, the corresponding aRRs for having all ideal or intermediate (vs. no poor) metrics based on the four biological LS7 metrics were 1.05 (0.98-1.12) and 1.04 (0.97-1.11), respectively. The corresponding aRRs for having lower cardiovascular risk (0-1 poor metrics) based on the four biological LS7 metrics were 1.01 (0.98-1.03) and 1.01 (0.98-1.03), respectively. There was some evidence of effect modification by neighborhood deprivation for the LS7 outcome and by chronic stress for the ideal or intermediate (no poor) metrics outcome based on the four biological LS7 metrics. Conclusion: Our findings suggest that greater optimism is positively associated with better CVH based on certain LS7 outcomes among a racially/ethnically diverse study population. This relationship may be effect measure modified by specific psychosocial risks. Optimism shows further promise as a potential area for intervention on CVH. However, additional prospective and intervention studies are needed.

Cardiovascular health is associated with the epigenetic clock in the Berlin Aging Study II (BASE-II)

The epigenetic clock parameter DNAm age acceleration is a promising biomarker of aging. We have recently described an epigenetic clock based on only seven cytosine-phosphate-guanine sites, which is highly associated with chronological age. The aim of this study was to examine this epigenetic clock with respect to its relationship with cardiovascular health (CVH) in older adults. We used data from the Berlin Aging Study II (BASE-II; 1,671 participants; 68.8 ± 3.7 years old). CVH was operationalized using two different CVH scores, the Framingham Risk Score (FRS), and the Life's simple 7 (LS7). To adjust for potential confounding, e.g. by sex, we performed regression analyses. The LS7 score was higher, i.e. more favorable, in woman than in men (8.8 ± 2 vs. 8.2 ± 2, p < 0.001). DNAm age acceleration was associated with the FRS (β = 0.122, p = 0.028) and with the LS7 (β = -0.804, p = 0.032). In more detail, physical activity (β = -0.461, p = 0.05), HDL-cholesterol (β = 0.343, p = 0.03) and total cholesterol (β = -0.364, p = 0.002) were associated with epigenetic age acceleration. We present evidence suggesting that better CVH is associated with decelerated biological aging measured by the epigenetic clock.

Healthy Lifestyle and Mortality Among Adults Receiving Hemodialysis: The DIET-HD Study

RATIONALE & OBJECTIVE

A healthy lifestyle promotes cardiovascular health and reduces cardiac-related mortality in the general population but its benefits for people receiving maintenance hemodialysis are uncertain.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

5,483 of 9,757 consecutive adults receiving maintenance hemodialysis (January 2014 to June 2017, median dialysis vintage: 3.6 yrs) in a multinational private dialysis network and with complete lifestyle data.

EXPOSURES

Based on the American Heart Association's recommendations for cardiovascular prevention, a modified healthy lifestyle score was the sum of four components addressing use of smoking tobacco, physical activity, diet, and control of systolic blood pressure.

OUTCOMES

Cardiovascular and all-cause mortality.

ANALYTICAL APPROACH

Adjusted proportional hazards (aHRs) regression analyses with country as a random effect to estimate the associations between lifestyle score (low [0-2 points] as the referent, medium [3-5], and high [6-8]) and mortality. Associations were expressed as aHRs with 95% confidence intervals (CIs).

RESULTS

During a median of 3.8 years (17,451 person-years in total), there were 2,163 deaths, of which 826 were related to cardiovascular disease. Compared to patients with a low lifestyle score, the aHRs (95% CIs) for all-cause mortality among those with medium and high lifestyle scores were 0.75 (0.65-0.85) and 0.64 (0.54-0.76), respectively. Compared to patients with a low lifestyle score, the aHRs (95% CIs) for cardiovascular mortality among those with medium and high lifestyle scores were 0.73 (0.59-0.91) and 0.65 (0.49-0.85), respectively.

LIMITATIONS

Self-reported lifestyle, data-driven approach.

CONCLUSIONS

A healthier lifestyle is associated with lower all-cause and cardiovascular mortality among patients receiving maintenance hemodialysis.

Further understanding of ideal cardiovascular health score metrics and cardiovascular disease

INTRODUCTION

The American Heart Association (AHA) introduced the construct of 'cardiovascular health (CVH)', to focus on primordial prevention to reduce the burden of cardiovascular disease (CVD). The CVH score includes seven health and behavioral metrics (smoking, physical activity, body mass index, diet, total cholesterol, blood pressure, blood glucose), which are characterized as being ideal, intermediate, or poor.

AREAS COVERED

In this review, we describe the utility of the CVH score for monitoring and promoting wellness, overall and by key sociodemographic groups, and for tracking of temporal trends.

EXPERT OPINION

Notably, the seven factors are all modifiable, which differs from 10-year CVD risk scores that include non-modifiable components such as age, sex, and race. Numerous epidemiological studies have shown that achievement of a greater number of ideal CVH metrics is associated with lower incidences of CVD, cardiovascular mortality, and all-cause mortality. Longer duration of favorable CVH is associated with greater longevity and compressed morbidity. Nevertheless, the prevalence of favorable CVH is low, with <20% of U.S. adults meeting ≥5 metrics at ideal levels and significant racial/ethnic disparities persist. Many challenges must be overcome to improve CVH at individual and societal levels if the AHA Impact Goals are to be fully realized.

Cardiovascular Complications of Sleep Disorders: A Better Night's Sleep for a Healthier Heart / From Bench to Bedside

Sleep is essential to and an integral part of life and when lacking or disrupted, a multitude of mental and physical pathologies ensue, including cardiovascular (CV) disease, which increases health care costs. Several prospective studies and meta-analyses show that insomnia, short (<7h) or long (>9h) sleep and other sleep disorders are associated with an increased risk of hypertension, metabolic syndrome, myocardial infarction, heart failure, arrhythmias, CV disease risk and/or mortality. The mechanisms by which insomnia and other sleep disorders lead to increased CV risk may encompass inflammatory, immunological, neuro-autonomic, endocrinological, genetic and microbiome perturbations. Guidelines are emerging that recommend a target of >7 h of sleep for all adults >18 years for optimal CV health. Treatment of sleep disorders includes cognitive-behavioral therapy considered the mainstay of non-pharmacologic management of chronic insomnia, and drug treatment with benzodiazepine receptor agonists binding to gamma aminobutyric acid type A (benzodiazepine and non-benzodiazepine agents) and some antidepressants. However, observational studies and meta-analyses indicate an increased mortality risk of anxiolytics and hypnotics, although bias may be involved due to confounding and high heterogeneity in these studies. Nevertheless, it seems that the risk incurred by the non-benzodiazepine hypnotic agents (Z drugs) may be relatively less than the risk of anxiolytics, with evidence indicating that at least one of these agents, zolpidem, may even confer a lower risk of mortality in adjusted models. All these issues are herein reviewed.

Occupations Associated With Poor Cardiovascular Health in Women: The Women's Health Initiative Observational Study

INTRODUCTION

Research on the effect of occupation on cardiovascular health (CVH) among older women is limited.

METHODS

Each of the seven American Heart Association's CVH metrics was scored as ideal (1) or non-ideal (0) and summed. Multivariable logistic regression was used to estimate the odds of poor overall CVH (CVH score of 0 to 2) comparing women employed in each of the top 20 occupational categories to those not employed in that category, adjusting for age, marital status, and race/ethnicity.

RESULTS

(1) Bookkeeping, accounting, and auditing clerks; (2) first-line supervisors of sales workers; (3) first-line supervisors of office and administrative support workers; and (4) nursing, psychiatric, and home health aides were more likely to have poor overall CVH compared to women who did not work in these occupations.

CONCLUSIONS

Several commonly held occupations among women were associated with poor CVH.

Race- and Sex-Specific Population Attributable Fractions of Incident Heart Failure: A Population-Based Cohort Study From the Lifetime Risk Pooling Project

BACKGROUND

Race- and sex-specific differences in heart failure (HF) risk may be related to differential burden and effect of risk factors. We estimated the population attributable fraction (PAF), which incorporates both prevalence and excess risk of HF associated with each risk factor (obesity, hypertension, diabetes, current smoking, and hyperlipidemia), in specific race-sex groups.

METHODS

A pooled cohort was created using harmonized data from 6 US longitudinal population-based cohorts. Baseline measurements of risk factors were used to determine prevalence. Relative risk of incident HF was assessed using a piecewise constant hazards model adjusted for age, education, other modifiable risk factors, and the competing risk of death from non-HF causes. Within each race-sex group, PAF of HF was estimated for each risk factor individually and for all risk factors simultaneously.

RESULTS

Of 38 028 participants, 55% were female and 22% Black. Hypertension had the highest PAF among Black men (28.3% [95% CI, 18.7%-36.7%]) and women (25.8% [95% CI, 16.3%-34.2%]). In contrast, PAF associated with obesity was the highest in White men (21.0% [95% CI, 14.6%-27.0%]) and women (17.9% [95% CI, 12.8%-22.6%]). Diabetes disproportionately contributed to HF in Black women (PAF, 16.4% [95% CI, 12.7%-19.9%]). The cumulative PAF of all 5 risk factors was the highest in Black women (51.9% [95% CI, 39.3%-61.8%]).

CONCLUSIONS

The observed differences in contribution of risk factors across race-sex groups can inform tailored prevention strategies to mitigate disparities in HF burden. This novel competing risk analysis suggests that a sizeable proportion of HF risk may not be associated with modifiable risk factors.

Sleep, Sedentary Behavior, Physical Activity, and Cardiovascular Health: MESA

INTRODUCTION

Sleep, sedentary behavior, and physical activity are each independently associated with cardiovascular health (CVH). It is unknown how substituting time in sedentary behavior with sleep or physical activity affects overall CVH.

METHODS

Data for this analysis were taken from the Multi-Ethnic Study on Atherosclerosis Sleep Ancillary Study. Eligible participants (N = 1718) wore Actiwatch accelerometers for 24 h and had at least 3 d of valid accelerometry. The American Heart Association's Life's Simple 7 was used to represent the CVH score after excluding the physical activity component, with higher scores indicating more favorable CVH. Isotemporal substitution modeling was conducted to examine the effect of substituting 30 min of sedentary time for an equivalent amount of sleep, light-intensity physical activity (LIPA), or moderate to vigorous physical activity (MVPA).

RESULTS

Substituting 30 min of sedentary time to sleep, LIPA, and MVPA was associated with a significantly higher CVH score [β (95% confidence interval) = 0.077 (0.056), 0.039 (0.033), and 0.485 (0.127), respectively]. Substituting 30 min of sedentary time to sleep was associated with lower body mass index (BMI). Substituting 30 min of sedentary time to LIPA was associated with higher diastolic blood pressure and total cholesterol, and lower BMI. Substituting 30 min of sedentary time to MVPA was associated with lower systolic and diastolic blood pressure, and lower BMI.

CONCLUSIONS

Sleep, LIPA, and MVPA are all associated with more favorable overall CVH and several key risk factors for cardiovascular disease. These findings underscore the importance of lifestyle modifications in improving CVH.

Coronary Artery Calcium Score for Personalization of Antihypertensive Therapy: A Pooled Cohort Analysis

Supplemental Digital Content is available in the text.

The 2017 American College of Cardiology/American Heart Association high blood pressure (BP) guidelines recommend risk assessment of atherosclerotic cardiovascular disease to inform hypertension treatment in adults with elevated BP or low-risk stage I hypertension. The use of coronary artery calcium (CAC) score to guide hypertension therapy has not been adequately evaluated. Participants free of cardiovascular disease were pooled from Multi-Ethnic Study of Atherosclerosis, Coronary Artery Risk Development in Young Adults, and Jackson Heart Study. The risk for incident cardiovascular events (heart failure, stroke, coronary heart disease), by CAC status (CAC-0 or CAC>0) and BP treatment group was assessed using multivariable-adjusted Cox regression. The 10-year number needed to treat to prevent a single cardiovascular event was also estimated. This study included 6461 participants (median age 53 years; 53.3% women; 32.3% Black participants). Over a median follow-up of 8.5 years, 347 incident cardiovascular events occurred. Compared with those with normal BP, the risk of incident cardiovascular event was higher among those with elevated BP/low-risk stage I hypertension and CAC>0 (hazard ratio, 2.4 [95% CI, 1.7–3.4]) and high-risk stage I/stage II hypertension (BP, 140–160/80–100 mm Hg) with CAC>0 (hazard ratio, 2.9 [95% CI, 2.1–4.0]). A similar pattern was evident across racial subgroups and for individual study outcomes. Among those with CAC-0, the 10-year number needed to treat was 160 for elevated BP/low-risk stage I hypertension and 44 for high-risk stage I or stage II hypertension (BP, 140–160/80–100 mm Hg). Among those with CAC>0, the 10-year number needed to treat was 36 and 22, respectively. Utilization of the CAC score may guide the initiation of hypertension therapy and preventive approaches to personalize cardiovascular risk reduction among individuals where the current guidelines do not recommend treatment.

Heart Failure Risk Distribution and Trends in the United States Population, NHANES 1999-2016

BACKGROUND

Implementation of effective preventive interventions requires identification of high-risk individuals. We sought to define the distribution and trends of heart failure risk in the US population.

METHODS

We calculated 10-year predicted heart failure risk among a representative sample of US adults aged 30-79 years, without baseline cardiovascular disease, from the National Health and Nutrition Examination Surveys (NHANES) 1999-2016. We used the published Pooled Cohort Equations to Prevent Heart Failure (PCP-HF) model, which integrates demographic and risk factor data, to estimate 10-year heart failure risk. Participants were stratified by NHANES cycle, sex, age, and race/ethnicity and by 10-year heart failure risk, defined as low (<1%), intermediate (1% to <5%), and high (≥5%).

RESULTS

From 1999-2000 to 2015-2016, mean predicted 10-year heart failure risk increased significantly from 2.0% to 3.0% (P < .05) in the population, most notably among non-Hispanic black (2.1% to 3.7%) and non-Hispanic white (2.4% to 3.6%) men. In 2013-2016, 17.6% of the studied population was at high predicted 10-year heart failure risk. The prevalence of high predicted heart failure risk was highest among non-Hispanic black men (23.1%), followed by non-Hispanic white men (19.2%) and non-Hispanic white women (17.9%).

DISCUSSION

Mean population risk of heart failure increased significantly from 1999-2016. A substantial proportion of US adults are at high 10-year heart failure risk (≥5%), particularly non-Hispanic black men. These data underscore the importance of identifiying individuals at increased heart failure risk for targeted prevention measures to reduce the future burden of heart failure.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Risk-Based Approach for the Prediction and Prevention of Heart Failure

Targeted prevention of heart failure (HF) remains a critical need given the high prevalence of HF morbidity and mortality. Similar to risk-based prevention of atherosclerotic cardiovascular disease, optimal HF prevention strategies should include quantification of risk in the individual patient. In this review, we discuss incorporation of a quantitative risk-based approach into the existing HF staging landscape and the clinical opportunity that exists to translate available data on risk estimation to help guide personalized decision making. We first summarize the recent development of key HF risk prediction tools that can be applied broadly at a population level to estimate risk of incident HF. Next, we provide an in-depth description of the clinical utility of biomarkers to personalize risk estimation in select patients at the highest risk of developing HF. We also discuss integration of genomics-enhanced approaches (eg, Titin [TTN]) and other risk-enhancing features to reclassify risk with a precision medicine approach to HF prevention. Although sequential testing is very likely to identify low and high-risk individuals with excellent accuracy, whether or not interventions based on these risk models prevent HF in clinical practice requires prompt attention including randomized placebo-controlled trials of candidate therapies in risk-enriched populations. We conclude with a summary of unanswered questions and gaps in evidence that must be addressed to move the field of HF risk assessment forward.

Adherence to Ideal Cardiovascular Health Metrics Is Associated With Reduced Odds of Hepatic Steatosis

The American Heart Association (AHA) introduced Life's Simple 7 as a metric to define ideal cardiovascular health. We examined the association between cardiovascular health score (CHS) and prevalent nonalcoholic fatty liver disease (NAFLD) among Framingham Heart Study participants with varying genetic risk of NAFLD. Framingham Heart Study participants who underwent abdominal computed tomography scans were included (n = 2,773). We defined hepatic steatosis as the mean Hounsfield unit attenuation of the liver compared to a phantom control. We calculated CHS based on adherence to metrics from the AHA's Life's Simple 7 guidelines, including blood sugar, total cholesterol, blood pressure, body mass index (BMI), time spent on physical activity per week, and smoking status. We used multivariable-adjusted regression models to evaluate the association between CHS and hepatic steatosis, accounting for covariates and stratifying by NAFLD genetic risk. Overall, 12% of the sample achieved 0-1 goals and 25%, 27%, 21%, 13%, and 2.6% achieved 2, 3, 4, 5, or 6 goals, respectively. For each 1-unit increase in CHS, there was a decrease in the odds ratio (OR) of prevalent hepatic steatosis (OR, 0.54; 95% confidence interval, 0.49-0.59). Individually, BMI had the strongest association with NAFLD. Participants with high or intermediate genetic risk of NAFLD demonstrated higher relative decreases in hepatic steatosis with increased CHS compared to those at low genetic risk. Conclusion: Adhering to the AHA Life's Simple 7 metrics was associated with reduced odds of prevalent NAFLD, particularly for those at high genetic risk. Additional longitudinal studies are needed.

Physical activity and the risk of heart failure: a systematic review and dose-response meta-analysis of prospective studies

Although physical activity is an established protective factor for cardiovascular diseases such as ischemic heart disease and stroke, less is known with regard to the association between specific domains of physical activity and heart failure, as well as the association between cardiorespiratory fitness and heart failure. We conducted a systematic review and meta-analysis of prospective observational studies to clarify the relations of total physical activity, domains of physical activity and cardiorespiratory fitness to risk of heart failure. PubMed and Embase databases were searched up to January 14th, 2020. Summary relative risks (RRs) were calculated using random effects models. Twenty-nine prospective studies (36 publications) were included in the review. The summary RRs for high versus low levels were 0.77 (95% CI 0.70–0.85, I² = 49%, n = 7) for total physical activity, 0.74 (95% CI 0.68–0.81, I² = 88.1%, n = 16) for leisure-time activity, 0.66 (95% CI 0.59–0.74, I² = 0%, n = 2) for vigorous activity, 0.81 (95% CI 0.69–0.94, I² = 86%, n = 3) for walking and bicycling combined, 0.90 (95% CI 0.86–0.95, I² = 0%, n = 3) for occupational activity, and 0.31 (95% CI 0.19–0.49, I² = 96%, n = 6) for cardiorespiratory fitness. In dose–response analyses, the summary RRs were 0.89 (95% CI 0.83–0.95, I² = 67%, n = 4) per 20 MET-hours per day of total activity and 0.71 (95% CI 0.65–0.78, I² = 85%, n = 11) per 20 MET-hours per week of leisure-time activity. Nonlinear associations were observed in both analyses with a flattening of the dose–response curve at 15–20 MET-hours/week for leisure-time activity. These findings suggest that high levels of total physical activity, leisure-time activity, vigorous activity, occupational activity, walking and bicycling combined and cardiorespiratory fitness are associated with reduced risk of developing heart failure.

Cardiovascular health decline in adolescent girls in the NGHS cohort, 1987-1997

Adolescence is a critical time for the preservation or loss of cardiovascular health. We aimed to describe trajectories of cardiovascular health in adolescent girls and identify early adolescent factors associated with cardiovascular health in young adulthood. We used data from the National Growth and Health Study, a longitudinal cohort of 2,379 girls followed annually from ages 9-19 years. We classified participants as having ideal, intermediate, or poor levels of the seven cardiovascular health metrics at four developmental stages: early (ages 9-11), middle (ages 12-14), and late (ages 15-17) adolescence, and early young adulthood (ages ≥ 18). We calculated total cardiovascular health scores (range 0-14) at each stage and empirically identified patterns of cardiovascular health trajectories. We examined associations between trajectory group membership and various demographic, behavioral, and physiological factors. Mean cardiovascular health scores declined with age from 10.8 to 9.4 in white girls and 10.3 to 8.9 in black girls; 17% of white girls and 23% of black girls had low cardiovascular health (score < 8) by early young adulthood. We identified five cardiovascular health trajectories: high-stable (14% of participants), high-to-moderate (48%), high-to-low (20%), moderate-stable (10%), and moderate-to-low (8%). Exceeding 14 h per week of television in early adolescence and teen pregnancy were associated with higher odds of being in several less healthy trajectory groups. In conclusion, cardiovascular health declines during adolescence and black-white disparities begin before early adolescence. Key targets for improving cardiovascular health in adolescent girls may include reductions in sedentary behavior and prevention of teen pregnancy.

Nondietary Cardiovascular Health Metrics With Patient Experience and Loss of Productivity Among US Adults Without Cardiovascular Disease: The Medical Expenditure Panel Survey 2006 to 2015

Background

The American Heart Association 2020 Impact Goals aimed to promote population health through emphasis on cardiovascular health (CVH). We examined the association between nondietary CVH metrics and patient‐reported outcomes among a nationally representative sample of US adults without cardiovascular disease.

Methods and Results

We included adults aged ≥18 years who participated in the Medical Expenditure Panel Survey between 2006 and 2015. CVH metrics were scored 1 point for each of the following: not smoking, being physically active, normal body mass index, no hypertension, no diabetes mellitus, and no dyslipidemia, or 0 points if otherwise. Diet was not assessed in Medical Expenditure Panel Survey. Patient‐reported outcomes were obtained by telephone survey and included questions pertaining to patient experience and health‐related quality of life. Regression models were used to compare patient‐reported outcomes based on CVH, adjusting for sociodemographic factors and comorbidities. There were 177 421 Medical Expenditure Panel Survey participants (mean age, 45 [17] years) representing ~187 million US adults without cardiovascular disease. About 12% (~21 million US adults) had poor CVH. Compared with individuals with optimal CVH, those with poor CVH had higher odds of reporting poor patient‐provider communication (odds ratio, 1.14; 95% CI, 1.05–1.24), poor healthcare satisfaction (odds ratio, 1.15; 95% CI, 1.08–1.22), poor perception of health (odds ratio, 5.89; 95% CI, 5.35–6.49), at least 2 disability days off work (odds ratio, 1.39; 95% CI, 1.30–1.48), and lower health‐related quality of life scores.

Conclusions

Among US adults without cardiovascular disease, meeting a lower number of ideal CVH metrics is associated with poor patient‐reported healthcare experience, poor perception of health, and lower health‐related quality of life. Preventive measures aimed at optimizing ideal CVH metrics may improve patient‐reported outcomes among this population.

Sociodemographic Determinants of Life's Simple 7: Implications for Achieving Cardiovascular Health and Health Equity Goals

Background

Life's Simple 7 (LS7; nutrition, physical activity, cigarette use, body mass index, blood pressure, cholesterol, glucose) predicts cardiovascular health. The principal objective of our study was to define demographic and socioeconomic factors associated with LS7 to better inform programs addressing cardiovascular health and health equity.

Methods

National Health and Nutrition Examination Surveys 1999-2016 data were analyzed on non-Hispanic White [NHW], NH Black [NHB], and Hispanic adults aged ≥20 years without cardiovascular disease. Each LS7 variable was assigned 0, 1, or 2 points for poor, intermediate, and ideal levels, respectively. Composite LS7 scores were grouped as poor (0-4 points), intermediate (5-9), and ideal (10-14).

Results

32,803 adults were included. Mean composite LS7 scores were below ideal across race/ethnicity groups. After adjusting for confounders, NHBs were less likely to have optimal LS7 scores than NHW (multivariable odds ratios (OR .44; 95% CI .37-.53), whereas Hispanics tended to have better scores (1.18; .96-1.44). Hispanics had more ideal LS7 scores than NHBs, although Hispanics had lower incomes and less education, which were independently associated with fewer ideal LS7 scores. Adults aged ≥45 years were less likely to have ideal LS7 scores (.11; .09-.12) than adults aged <45 years.

Conclusions

NHBs were the least likely to have optimal scores, despite higher incomes and more education than Hispanics, consistent with structural racism and Hispanic paradox. Programs to optimize lifestyle should begin in childhood to mitigate precipitous age-related declines in LS7 scores, especially in at-risk groups. Promoting higher education and reducing poverty are also important.