Cardiovascular Health in a Southern Mediterranean European Country

Prevalence, impact and management of hypertension-mediated organ damage in type 2 diabetes patients

OBJECTIVE

To determine the prevalence, impact and management of hypertension-mediated organ damage (HMOD) according to the presence of type 2 diabetes (T2DM).

METHODS

IBERICAN is an ongoing multicenter, observational and prospective study, including outpatients aged 18-85 years who attended the Primary Care setting in Spain. In this study, the prevalence, impact and management of HMOD according to the presence of T2DM at baseline were analyzed.

RESULTS

At baseline, 8066 patients (20.2% T2DM, 28.6% HMOD) were analyzed. Among patients with T2DM, 31.7% had hypertension, 29.8% dyslipidemia and 29.4% obesity and 49.3% had ≥1 HMOD, mainly high pulse pressure (29.6%), albuminuria (16.2%) and moderate renal impairment (13.6%). The presence of T2DM significantly increased the risk of having CV risk factors and HMOD. Among T2DM population, patients with HMOD had more dyslipidemia (78.2% vs 70.5%; P=0.001), hypertension (75.4% vs 66.4%; P=0.001), any CV disease (39.6% vs 16.1%; P=0.001) and received more drugs. Despite the majority of types of glucose-lowering agents were more frequently taken by those patients with HMOD, compared to the total T2DM population, the use of SGLT2 inhibitors and GLP-1 receptor agonists was marginal.

CONCLUSIONS

In patients daily attended in primary care setting in Spain, one in five patients had T2DM and nearly half of these patients had HMOD. In patients with T2DM, the presence of HMOD was associated with a higher risk of CV risk factors and CV disease. Despite the very high CV risk, the use of glucose-lowering agents with proven CV benefit was markedly low.

Cardiovascular health in Spain based on the Life's Essential 8 and its association with all-cause and cardiovascular mortality: the ENRICA cohort

INTRODUCTION AND OBJECTIVES

The American Heart Association has recently developed the Life's Essential 8 (LE8) score to encourage prevention of cardiovascular disease (CVD). This study assessed the distribution of LE8 in the Spanish adult population and its association with all-cause and CVD death.

METHODS

We used data from 11 616 individuals aged 18 years and older (50.5% women) from the ENRICA study, recruited between 2008 and 2010 and followed up until 2020 to 2022. The LE8 score includes 8 metrics (diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids and glucose, and blood pressure) and ranges from 0 to 100. The association of LE8 score with mortality was summarized with hazard ratios (HR), obtained from Cox regression.

RESULTS

In total, 13.2% of participants (range, 6.1%-16.9% across regions) had low cardiovascular health (LE8 ≤ 49). During a median follow-up of 12.9 years, 908 total deaths occurred, and, during a median follow-up of 11.8 years, 207 CVD deaths were ascertained. After adjustment for the main potential confounders and compared with being in the least healthy (lowest) quartile of LE8, the HR (95%CI) of all-cause mortality for the second, third and fourth quartiles were 0.68 (0.56-0.83), 0.63 (0.51-0.78), and 0.53 (0.39-0.72), respectively. The corresponding figures for CVD mortality, after accounting for competing mortality risks, were 0.62 (0.39-0.97), 0.55 (0.32-0.93), and 0.38 (0.16-0.89).

CONCLUSIONS

A substantial proportion of the Spanish population showed low cardiovascular health. A higher LE8 score, starting from the second quartile, was associated with lower all-cause and CVD mortality.

Ideal cardiovascular health and risk of death in a large Swedish cohort

BACKGROUND

Ideal cardiovascular health (CVH) can be assessed by 7 metrics: smoking, body mass index, physical activity, diet, hypertension, dyslipidemia and diabetes, proposed by the American Heart Association. We examined the association of ideal CVH metrics with risk of all-cause, CVD and non-CVD death in a large cohort.

METHODS

A total of 29,557 participants in the Swedish National March Cohort were included in this study. We ascertained 3,799 deaths during a median follow-up of 19 years. Cox regression models were used to estimate hazard ratios with 95% confidence intervals (95% CIs) of the association between CVH metrics with risk of death. Laplace regression was used to estimate 25th, 50th and 75th percentiles of age at death.

RESULTS

Compared with those having 6-7 ideal CVH metrics, participants with 0-2 ideal metrics had 107% (95% CI = 46-192%) excess risk of all-cause, 224% (95% CI = 72-509%) excess risk of CVD and 108% (31-231%) excess risk of non-CVD death. The median age at death among those with 6-7 vs. 0-2 ideal metrics was extended by 4.2 years for all-causes, 5.8 years for CVD and 2.9 years for non-CVD, respectively. The observed associations were stronger among females than males.

CONCLUSIONS

The strong inverse association between number of ideal CVH metrics and risk of death supports the application of the proposed seven metrics for individual risk assessment and general health promotion.

Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care

BACKGROUND

Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events (K/CVEs) and on mortality among community dwellers.

METHODS

Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) (n = 71,770), were enrolled. The control group (n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases.

RESULTS

The median follow-up was 138.61 months (IQR: 124.68-143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80-5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64-210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90-3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02-1.28 for ages 45 to 54).

CONCLUSION

The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.

The social determinants of ideal cardiovascular health: A global systematic review

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = 24) and income/wealth (n = 17) were the most frequently examined social determinants in both HICs and LMICs. Although most studies assessed ideal CVH using reliable and valid methods (n = 24), only 7 used criteria pre-defined by the American Heart Association to characterize ideal levels of each CVH metric. Despite heterogeneity in how outcome measures were derived and analyzed, consistent associations were evident between multiple markers of higher social status (i.e. greater education, income/wealth, socioeconomic status, racial/ethnic majority status) and greater levels of ideal CVH across both country contexts. Gaps in the literature include evidence from LMICs and HICs other than the United States, longitudinal research, and investigations of a wider array of social determinants beyond education and income/wealth.

Association of ideal cardiovascular health with cardiovascular events and risk advancement periods in a Mediterranean population-based cohort

BACKGROUND

The American Heart Association recommends Life's Simple 7 as ideal cardiovascular health (ICVH) to reduce cardiovascular risk. Rate advancement period (RAP), a useful tool to quantify and communicate exposure impact on risks, may enhance communication about the benefits of achieving ICVH. We aimed to examine whether greater adherence to ICVH metrics was associated with reduced incidence of cardiovascular risk in a population-based cohort and estimate its impact on the timing of occurrence using RAP.

METHODS

Prospective analyses of 3826 participants, initially free from cardiovascular disease at baseline, enrolled in the Vascular Risk in Navarra Study (RIVANA), a Mediterranean population-based cohort of Spanish adults. ICVH metrics were defined using participants' baseline information as follows: never-smoker or quitting > 12 months ago, body mass index < 25 kg/m², ≥ 150 min/week of moderate physical activity or equivalent, healthy dietary pattern (≥ 9 points on a validated 14-item Mediterranean diet adherence screener), untreated cholesterol < 200 mg/dL, untreated blood pressure < 120/80 mmHg, and untreated fasting blood glucose < 100 mg/dL. Participants were assigned 1 point for each achieved metric and were grouped according to their number of accumulated metrics in ≤ 2, 3, 4, and ≥ 5. The primary endpoint was major cardiovascular events (composite of myocardial infarction, stroke, or death from cardiovascular causes). Cox proportional hazard ratios (HRs) and RAPs with their corresponding 95% confidence intervals (95% CI) adjusted for potential confounders were calculated.

RESULTS

During a median follow-up of 12.8 years (interquartile range 12.3-13.1), a total of 194 primary endpoints were identified. Compared to participants with ≤ 2 ideal metrics, HR (95% CI) for major cardiovascular events among participants meeting ≥ 5 metrics was 0.32 (0.17-0.60) with RAP (95% CI) of - 14.4 years (- 22.9, - 5.9).

CONCLUSIONS

Greater adherence to ICVH metrics was associated with lower cardiovascular risk among Spanish adults of the RIVANA cohort. Adherence to ideal metrics may substantially delay cardiovascular risk.

Educational Attainment, Race, and Ethnicity as Predictors for Ideal Cardiovascular Health: From the National Health and Nutrition Examination Survey

Background Educational attainment is protective for cardiovascular health (CVH), but the benefits of education may not persist across racial and ethnic groups. Our objective was to determine whether the association between educational attainment and ideal CVH differs by race and ethnicity in a nationally representative sample. Methods and Results Using the National Health and Nutrition Examination Survey, we determined the distribution of ideal CVH, measured by Life's Simple 7, across levels of educational attainment. We used multivariable ordinal logistic regression to assess the association between educational attainment (less than high school, high school graduate, some college, college graduate) and Life's Simple 7 category (ideal, intermediate, poor), by race and ethnicity (Asian, Black, Hispanic, White). Covariates were age, sex, history of cardiovascular disease, health insurance, access to health care, and income-poverty ratio. Of 7771 National Health and Nutrition Examination Survey participants with complete data, as level of educational attainment increased, the criteria for ideal health were more often met for most metrics. After adjustment for covariates, effect of education was attenuated but remained significant (P<0.01). Those with at least a college degree had 4.12 times the odds of having an ideal Life's Simple 7 compared with less than high school (95% CI, 2.70-5.08). Among all racial and ethnic groups, as level of educational attainment increased, so did Life's Simple 7. The magnitude of the association between education and CVH varied by race and ethnicity (interaction P<0.01). Conclusions Our findings demonstrate that educational attainment has distinct associations with ideal CVH that differs by race and ethnicity. This work demonstrates the need to elucidate barriers preventing individuals from racial and ethnic minority groups from achieving equitable CVH.

Demographic and socioeconomic inequalities in ideal cardiovascular health: A systematic review and meta-analysis

BACKGROUND

In 2010, the American Heart Association introduced a new concept of ideal cardiovascular health (CVH) defined as the simultaneous presence of 7 favorable CVH metrics (smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting blood glucose). The objective of this study was to conduct a systematic literature review and meta-analysis of studies examining the prevalence of ideal CVH, and each of the ideal CVH metrics as well as the relationship between socio-demographic determinants and ideal CVH.

METHODS

A comprehensive literature search was conducted in Medline and Scopus databases for studies published between 1 January 2010 and 30 June 2020. A total of 50 studies including 2,148,470 participants were analyzed. Associations were estimated using DerSimonian-Laird random-effect models. Heterogeneity was investigated through subgroup analyses, Q-test, and I2 statistics.

RESULTS

This study showed a low prevalence of ideal CVH defining as 6 and 7 ideal metrics (3.3%). Among seven ideal CVH metrics, smoking was the best metric (71%), while the poorest CVH metric was a healthy diet (5.8%). Gender was a statistically significant moderator of ideal smoking (81% in females and 60% in males) and ideal blood pressure (42% in females and 30% in males). Females and young adults had better CVH status compared to males and older adults. Also, more educated and better-off individuals had a greater number of ideal CVH metrics.

CONCLUSIONS

To the best of our knowledge, this is the first systematic review on the relationship between participants' socioeconomic status and ideal CVH. The results suggest that the prevalence of ideal CVH and most metrics was unsatisfactory. In order to achieve the improvement of the CVH metrics and the overall ideal CVH, nationwide prevention efforts at the population and individual levels are urgently needed.

Cardiovascular disease risk factors in Spain: A comparison of native and immigrant populations

Cardiovascular disease (CDV) risk factors are highly prevalent among adults with low social class in Spain. However, little is known on how these factors are distributed in the immigrant population, a socio-economic disadvantaged population. Thus, this study aims to examine inequalities in CVD risk factors among immigrant and native populations. We conducted a cross-sectional study using data from the Spanish National Health Survey 2017 and used log-binomial regression to quantify the association of immigrant status on CVD risk factors among adults aged 25-64 years. The probabilities of having at least three CVD risk factors were higher for immigrants from Eastern Europe (PR: 1.25; 95% CI: 1.15-1.35) and lower for immigrants from Africa (PR: 0.79; 95% CI: 0.69-0.89) when compared with natives. The association of immigrant status and CVD risk factors varies with educational attainment (p-interaction = 0.001). Immigrants from Eastern Europe with low educational attainment have a higher probability of having at least three CVD risk factors compared with their native counterparts. In contrast, immigrants from Africa and Latin America with low educational attainment had a protective effect against having at least three CVD risk relative to natives. Health prevention and promotion strategies to reduce the burden of CVD taking should account for educational attainment given its differential effect among the immigrant population in Spain.

Geographical variations in cardiovascular health in China: A nationwide population-based survey of 74,726 adults

Background

Cardiovascular disease is the leading cause of death in China. The aim of this study was to evaluate the levels of cardiovascular health among Chinese adults and to understand the geographic pattern of cardiovascular health.

Methods

In 2015, a total of 74,726 respondents aged ≥ 20 years with no history of cardiovascular disease were randomly sampled from 298 counties/districts of 31 provinces in mainland China and were interviewed. Seven metrics, including smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting glucose, were determined. Ideal cardiovascular health was defined as the simultaneous presence of all metrics at the ideal level. A score ranging from 0 to 14 was calculated as the sum of all seven metrics for each province. Scores for cardiovascular health behaviors (smoking, body mass index, physical activity and diet) and those for cardiovascular health factors (smoking, total cholesterol, blood pressure, and fasting glucose) were also calculated.

Findings

The mean age was 44.4 ± 15.9 years, and 49.3% were women. The age-sex-standardized prevalence of ideal cardiovascular health was universally poor, ranging from 0.02% [95% confidence interval (CI): 0%, 0.05%] in Tibet to 2.76% (95% CI: 0.45%, 5.07%) in Heilongjiang. Ideal diet (7.1%) was the least common factor of the seven metrics in each province and varied considerably across provinces. Other component metrics of ideal cardiovascular health were also spatially patterned. In all provinces, women had higher scores than men for cardiovascular health, health behaviors and health factors. Differences in cardiovascular health and health behavior scores between urban and rural areas were associated with levels of socio-economic development.

Interpretation

Strategies for addressing poor cardiovascular health require geographic targeting and localized consideration.

Funding

This research was supported by National Key R&D Program, the Shenzhen Strategic Emerging Industry Development Special Fund, and the Fund of "Sanming" Project of Medicine in Shenzhen.

Who does what the cardiologist recommends? Psychosocial markers of unhealthy behavior in coronary disease patients

Patients diagnosed with coronary heart disease should follow lifestyle recommendations that can reduce their cardiovascular risk (e.g., avoid smoking). However, some patients fail to follow these recommendations and engage in unhealthy behavior. With the aim to identify psychosocial factors that characterize patients at high risk of repeated cardiovascular events, we investigated the relationship between social support, mental health (coping, self-esteem, and perceived stress), and unhealthy behavior. We conducted a cross-sectional study of 419 patients recently diagnosed with coronary heart disease (myocardial infarction or angina) who participated in the National Health Survey in Spain (2018). Unhealthy behaviors were defined according to the European Guidelines on cardiovascular disease prevention. Only 1% of patients reported no unhealthy behaviors, with 11% reporting one, 40% two, 35% three, and 13% four or more unhealthy behaviors. In multiple regression controlling for demographic and traditional risk factors, mental health was the only significant psychosocial factor, doubling the odds of accumulated unhealthy behaviors, OR(high vs. low) = 2.03, 95% CI [1.14, 3.64]. Mental health was especially strongly related to unhealthy behavior among patients with obesity, OR(high vs. low) = 3.50, 95% CI [1.49, 8.45]. The relationship between mental health and unhealthy behaviors suggests that a large proportion of patients may not adhere to lifestyle recommendations not because they purposefully choose to do so, but because they lack coping skills to maintain the recommended healthy behaviors. Low mental well-being may be especially detrimental for behavior change of patients with obesity.

Impact of Life's Simple 7 on the incidence of major cardiovascular events in high-risk Spanish adults in the PREDIMED study cohort

INTRODUCTION AND OBJECTIVES

The Life's Simple 7 strategy of the American Heart Association proposes 7 metrics of ideal cardiovascular health: body mass index (BMI) <25mg/m², not smoking, healthy diet, moderate physical activity ≥ 150min/wk, total blood cholesterol <200mg/dL, systolic and diastolic blood pressures <120 and <80mmHg, respectively, and fasting blood glucose <100mg/dL. It is important to assess the combined effect of these 7 metrics in the Spanish population. We prospectively analyzed the impact of baseline Life's Simple 7 metrics on the incidence of major cardiovascular events in the PREDIMED cohort (57.5% women, average baseline age, 67 years).

METHODS

The healthy diet metric was defined as attaining ≥ 9 points on a validated 14-item Mediterranean diet adherence screener. An incident major cardiovascular event was defined as a composite of myocardial infarction, stroke, or cardiovascular death. Cox regression was used to calculate multivariable adjusted hazard ratios (HR) and their 95% confidence intervals (95%CI) for successive categories of health metrics.

RESULTS

After a median follow-up of 4.8 years in 7447 participants, there were 288 major cardiovascular events. After adjustment for age, sex, center, and intervention group, HRs (95%CI) were 0.73 (0.54-0.99), 0.57 (0.41-0.78), and 0.34 (0.21-0.53) for participants with 2, 3, and ≥ 4 metrics, respectively, compared with participants with only 0 to 1 metrics.

CONCLUSIONS

In an elderly Spanish population at high cardiovascular risk, better adherence to Life's Simple 7 metrics was progressively associated with a substantially lower rate of major cardiovascular events.

Life's simple 7 and cardiovascular disease risk knowledge in Hong Kong

BACKGROUND

This study aimed at investigating the CV health and CV disease knowledge in terms of LS7 score among 3 age groups in Hong Kong.

METHODS

A cross-sectional multicenter observational study was conducted to observe the CV health and disease risk knowledge in Hong Kong. Elderly subjects were recruited from 15 elderly centers, whereas young adults and the middle-aged were recruited from 6 on-campus health check sessions. Subjects' demographics, lifestyle behavior and risk knowledge were obtained through questionnaire while their body mass index, random capillary blood glucose, blood cholesterol and blood pressure were measured. LS7 score and risk knowledge score was calculated.

RESULTS

The LS7 of younger adult, middle-aged and elderly were 10.6 ± 1.3, 9.3 ± 1.9 and 9.7 ± 1.7 respectively. Only 0.6% participants have attained ideal CV health and 35.9% have 5 to 7 ideal CV health metrics. Elderly performed worst in risk knowledge with a score of 8.1 ± 3.3 while young adult and middle-aged were similar (9.6 ± 1.8 and 9.7 ± 1.5). 71% of the participants correctly identified ≥9 components. Logistic regression revealed that subjects aged ≤65 years (OR 2.341, 95% CI 1.779 to 3.080) and with tertiary education (OR 2.031, 95% CI 1.527 to 2.701) were more likely to obtain optimum LS7. No association was found between having optimum LS7 and full knowledge.

CONCLUSION

Only few adults in this study population had ideal CV health as defined by AHA. Knowledge has no association but young age and tertiary education has positive association with CV health.

Assessment of the American Heart Association's "Life's simple 7" score in French-speaking adults from Québec

BACKGROUND AND AIMS

The "Life's Simple 7" (LS7) metrics were developed by the American Heart Association (AHA) to assess and promote cardiovascular health in the American population. The purpose of this study was to assess the overall cardiovascular health of French-speaking adults from the Province of Quebec using the LS7 score.

METHODS AND RESULTS

A total of 777 age and sex-representative participants of five different administrative regions in the Province of Quebec (387 men and 390 women; mean age ± SEM: 41.9 ± 0.1 years) were included in these analyses. Metrics of the LS7 score (smoking, physical activity, diet, body mass index, blood pressure, fasting total cholesterol and blood glucose) were analysed to generate a final score ranging from 0 to 7. Only 0.5% of participants met all criteria for ideal cardiovascular health. The diet metric showed the lowest prevalence of "ideal" scores (4.8%) whereas not smoking was the metric with the highest prevalence (88.1%). Women had a higher LS7 score than men, while age and education level (negative and positive association, respectively; p < 0.0001) were also associated with the LS7 score.

CONCLUSION

Consistent with studies conducted among other populations, very few French-speaking adults from the Province of Quebec achieve an ideal cardiovascular health. These data indicate that further public health efforts aimed at promoting the LS7 metrics, focusing primarily on diet, are urgently needed. Specific groups, including older adults and those with lower levels of education, should be targeted when developing cardiovascular health promotion interventions.

Status of cardiovascular health in the Republic of Serbia: Results from the National Health Survey

BACKGROUND

Cardiovascular diseases (CVD) remain the most significant cause of death in low- and middle-income countries where the burden of CVD continues to rise due to the increasing incidence of CVD. The aim of this study was to assess the prevalence of ideal cardiovascular health (CVH) across sex and age groups and to analyze associations between demographic and socio-economic variables and ideal CVH metrics in the adult population of the Republic of Serbia.

METHODS

Information on demographic (age, sex, marital status, and type of settlement) and socio-economic characteristics (education, and wealth index), and the 7 ideal CVH metrics (smoking, physical activity, healthy diet, BMI, blood pressure, cholesterol, and glucose) was obtained for 13100 respondents aged 20 years and above, from the 2013 National Health Survey in the Republic of Serbia. According to the American Heart Association, the ideal CVH was defined as the simultaneous presence of 7 ideal CVH metrics.

RESULTS

Out of all ideal CVH metrics, the most prevalent components were ideal glucose (92.2%), ideal cholesterol (86.4%) and ideal smoking (63%), while the least prevalent ideal CVH component was ideal healthy diet (2.4%). Only 0.1% had all 7 CVH components at the ideal level. According to the multivariable logistic regression analysis the higher number of ideal CVH metrics was observed in women (OR = 4.46), younger people (OR = 7.12), people living without partner (OR = 1.70), more educated (OR = 2.51 for middle educated and OR = 3.57 for high educated), as well as among the rich (OR = 1.43).

CONCLUSION

Our findings of existing age-specific, sex and socio-economic differences in the prevalence and number of ideal CVH metrics should serve for the development of appropriate CVD prevention policies tailored to fit specific needs of both sexes, all age groups and people with different socioeconomic status.

Low levels of ideal cardiovascular health in a semi-urban population of Western Nepal: a population-based, cross-sectional study

Background

The aim of this study was to assess the status of cardiovascular health among a semi-urban population of Nepal, and determine factors associated with ideal cardiovascular health.

Methods

A population-based, cross-sectional study using a systematic random sample was conducted among 2310 adults aged ≥ 25 years in a semi-urban area of the Pokhara Metropolitan City previously named Lekthnath in Nepal. The ideal, intermediate and poor cardiovascular health were defined as the presence of 6-7, 4-5 or 1-3 health metrics, among a list of 7 health behaviours and healthfactors, namely smoking, body mass index, physical activity, fruits and vegetables intakes, harmful alcohol consumption, blood pressure, and fasting blood glucose. We used univariate and multivariate Poisson regression models adjusting for sex, age groups, ethnicity, educational level and socioeconomic status, and calculated the prevalence ratios with 95% CIs.

Results

Only 14.3 % of the participants had ideal cardiovascular health, whereas 67.0% and 18.7% of the participants had intermediate and poor cardiovascular health, respectively. Age groups 45-54 years (prevalence ratio 0.88, 95% CI: 0.83 to 0.94, p<0.001) and 55-64 years (prevalence ratio 0.84, 95% CI: 0.79 to 0.90, p<0.001) were significantly associated with low prevalence of ideal cardiovascular health compared with the age group 35-44 years. Ethnic groups, including Janajati (prevalence ratio 0.89, 95% CI: 0.85 to 0.93, p<0.001) and Dalit (prevalence ratio 0.9, 95% CI: 0.84 to 0.95, p=0.001), were significantly associated with low prevalence of ideal cardiovascular health.

Conclusions

Prevalence of ideal cardiovascular health is low in the semi-urban population in Nepal. Concerted efforts are needed to develop a population-based intervention to improve cardiovascular health in Nepal.

Ideal Cardiovascular Health Is Inversely Associated with Nonalcoholic Fatty Liver Disease: A Prospective Analysis

BACKGROUND

Cardiovascular health has been proven to be associated with major cardiometabolic diseases. However, little is known of associations between cardiovascular health and nonalcoholic fatty liver disease.

METHODS

This study included 3424 adults aged ≥40 years who were free of nonalcoholic fatty liver disease at baseline from a community cohort followed for up to 5 years. Liver ultrasonography was conducted at baseline and at follow-up to diagnose incident nonalcoholic fatty liver disease. Six metrics including smoking, physical activity, body mass index, total cholesterol, blood pressure, and fasting glucose were used to define cardiovascular health status. Associations of individual cardiovascular health metrics, number of cardiovascular health metrics, and overall cardiovascular health status at baseline, as well as changes in cardiovascular health during follow-up with risks of developing nonalcoholic fatty liver disease, were examined.

RESULTS

A total of 649 participants developed nonalcoholic fatty liver disease during follow-up. Risks of nonalcoholic fatty liver disease reduced in a dose-response manner in participants with 3-4 ideal cardiovascular health metrics (odds ratio 0.50; 95% confidence interval, 0.41-0.61) and in participants with 5-6 ideal metrics (odds ratio 0.34; 95% confidence interval 0.22-0.51) compared with participants with 0-2 ideal metrics. An overall ideal or intermediate cardiovascular health was associated with 37% reduction in developing nonalcoholic fatty liver disease compared with poor cardiovascular health. In addition, improving cardiovascular health during follow-up reduced the risk by 71% compared with deteriorating cardiovascular health. Furthermore, an overall ideal or intermediate cardiovascular health was significantly associated with a lower fibrosis score in nonalcoholic fatty liver disease patients compared with an overall poor cardiovascular health.

CONCLUSIONS

Ideal cardiovascular health was inversely associated with risks of nonalcoholic fatty liver disease. Although treatment of nonalcoholic fatty liver disease and subsequent inflammation and fibrosis remains a challenge, cardiovascular health goals should be advocated for nonalcoholic fatty liver disease prevention.

Prevalence of the cardiovascular health status in adults: A systematic review and meta-analysis

BACKGROUND AND AIMS

The American Heart Association has outlined seven cardiovascular health (CVH) metrics, including smoking, body mass index, physical activity, dietary pattern, total cholesterol, and fasting plasma glucose, to define and monitor CVH status. Our study was to evaluate the global CVH in adults.

METHODS AND RESULTS

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and reference lists of relevant articles for studies published between 1 January 2010 and 30 June 2018. Included studies should report the proportions of ideal status for the seven CVH metrics and/or provide the prevalence of overall poor (having 0-2 ideal metrics) or ideal (having 5-7 ideal metrics) CVH status in adults. 88 articles were identified: 75 for the prevalence of ideal CVH metrics, 58 for the proportion of overall poor CVH status, and 55 for the proportion of overall ideal CVH status. Smoking had the highest prevalence of ideal status (69.1%) while dietary pattern has the lowest (12.1%). 32.2% and 19.6% of participants had overall poor and ideal CVH, respectively. Females and young adults had better CVH status when compared to males and older adults. There existed regional variations in ideal CVH metrics and overall CVH status. The overall CVH status had improved over study time.

CONCLUSION

The prevalence of ideal status was low for some metrics, such as dietary pattern, and the overall CVH status was still unsatisfactory. We should continue to measure the CVH status and carry out lifestyle interventions to improve the CVH status in the whole population.

The Status of Cardiovascular Health in Rural and Urban Areas of Janów Lubelski District in Eastern Poland: A Population-Based Study

Ideal cardiovascular health (CVH) has been defined by the American Heart Association as the lack of cardiovascular disease and the presence of seven key factors and health behaviors. In this study, we aimed to estimate the prevalence of ideal and poor CVH among the Polish adult population based on the example of the inhabitants of Janów district in Lubelskie Voivodship, taking the chosen socio-demographic factors into consideration. This is a cross-sectional study conducted among 3901 adults without cardiovascular diseases, aged between 35 and 64 years. Participants completed a questionnaire, and they had anthropometric and physiological measurements taken. Blood samples were analyzed for fasting glucose and cholesterol levels. Ideal CVH was found in 5.4% of the participants, with the advantage of being toward city dwellers over those living in the rural areas (6.3% vs. 5.0%) p = 0.02. In the case of the residents of rural areas, their likelihood of having an ideal body mass index (BMI) was found to be 22% lower (odds ratio (OR) = 0.78; 95% CI: 0.66–0.92), their likelihood of having an ideal diet was found to be 27% lower (OR = 0.71; 95% CI: 0.54–0.94), their likelihood of having perfect blood pressure was found to be 29% lower (OR = 0.71; 95% CI: 0.56–0.89), and their likelihood of having the perfect glucose levels was found to be 28% lower (OR = 0.72; 95% CI: 0.63–0.84), than the residents of urban areas. The prevalence of ideal cardiovascular behaviors and factors is lower in the rural community compared with people living in the city. Results indicate that more effort should be dedicated toward the country’s health policy, specifically concerning primary prevention. Preventive actions in the field of cardiovascular disease should be addressed to the residents of rural areas to a larger extent.

Ideal cardiovascular health and its association with sedentary behaviour and fitness in psychiatric patients. The PsychiActive project

BACKGROUND AND AIMS

Ideal cardiovascular health (CVH) was defined as meeting ideal levels of 4 health behaviours (smoking, body mass index, physical activity, and diet) and 3 biological factors (blood pressure, total cholesterol, and glucose) and is inversely related to cardiovascular disease and mortality. However, the prevalence of ideal CVH in patients with severe mental illness and the possible independent associations of sedentary behaviour and fitness with CVH score are unexplored.

METHODS AND RESULTS

This study included 142 (34 women) outpatients with severe mental illness (primarily schizophrenia, n = 92). CVH was evaluated according to the American Heart Association guidelines. Sedentary behaviour, cardiorespiratory fitness, and muscular strength were measured by an activity-monitor, the 6-min walk test, and handgrip dynamometry. Cardiorespiratory fitness and strength values were combined in a composite fitness score. The prevalence of ideal CVH was: non-smoking (47.9%), body mass index (16.9), physical activity (83.1%), diet (10.4%), blood pressure (40.4%), total cholesterol (62.9%), and plasma glucose (66.7%). Low levels of sedentary behaviour and high cardiorespiratory, strength, and composite fitness score were associated with meeting the ideal threshold in most CVH metrics and having higher global CVH score; however, only cardiorespiratory and composite fitness score remained significantly related to global CVH score independent of sedentary behaviour and multiple confounders.

CONCLUSIONS

Patients with severe mental illness generally have low prevalence of ideal CVH metrics, especially diet and body mass index. Additionally, our findings suggest the need or considering cardiorespiratory fitness, regardless of sedentary behaviour, to promote ideal CVH in this population.

Ideal cardiovascular health among Ghanaian populations in three European countries and rural and urban Ghana: the RODAM study

Cardiovascular health (CVH) is a construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal definition. CVH has, until now, not been evaluated in Sub-Saharan African populations. The aim of this study was to investigate differences in the prevalence of ideal CVH and its constituent metrics among Ghanaians living in rural and urban Ghana and Ghanaian migrants living in three European countries. The AHA definition of CVH is based on 7 metrics: smoking, body mass index, diet, physical activity, blood pressure, total cholesterol, and fasting plasma glucose. These were evaluated among 3510 Ghanaian adults (aged 25-70 years) residing in rural and urban Ghana and three European cities (Amsterdam, London and Berlin) in the multi-centre RODAM study. Differences between groups were assessed using logistic regression with adjustments for gender, age, and education. Only 0.3% of all participants met all 7 metrics of the AHA's definition of ideal CVH. Compared to rural Ghana (25.7%), the proportions and adjusted odds ratio (OR) of individuals who had 6-7 CVH metrics in the ideal category were substantially lower in urban Ghana, (7.5%; OR 0.204, 95% CI 0.15-0.29), Amsterdam (4.4%; 0.13, 0.08-0.19), Berlin (2.7%; 0.06, 0.03-0.11), and London (1.7%; 0.04, 0.02-0.09), respectively. The proportion of ideal CVH for the various metrics ranged from 96% for all sites in the smoking metric to below 6% in the diet metric. The proportion of ideal CVH is extremely low in Ghanaians, especially among those living in urban Ghana and Ghanaian migrants in Europe.

DASH Score and Subsequent Risk of Coronary Artery Disease: The Findings From Million Veteran Program

BACKGROUND

While adherence to healthful dietary patterns has been associated with a lower risk of coronary artery disease (CAD) in the general population, limited data are available among US veterans. We tested the hypothesis that adherence to Dietary Approach to Stop Hypertension (DASH) food pattern is associated with a lower risk of developing CAD among veterans.

METHODS AND RESULTS

We analyzed data on 153 802 participants of the Million Veteran Program enrolled between 2011 and 2016. Information on dietary habits was obtained using a food frequency questionnaire at enrollment. We used electronic health records to assess the development of CAD during follow-up. Of the 153 802 veterans who provided information on diet and were free of CAD at baseline, the mean age was 64.0 (SD=11.8) years and 90.4% were men. During a mean follow-up of 2.8 years, 5451 CAD cases occurred. The crude incidence rate of CAD was 14.0, 13.1, 12.6, 12.3, and 11.1 cases per 1000 person-years across consecutive quintiles of Dietary Approach to Stop Hypertension score. Hazard ratios (95% confidence interval) for CAD were 1.0 (ref), 0.91 (0.84-0.99), 0.87 (0.80-0.95), 0.86 (0.79-0.94), and 0.80 (0.73-0.87) from the lowest to highest quintile of Dietary Approach to Stop Hypertension score controlling for age, sex, body mass index, race, smoking, exercise, alcohol intake, and statin use (P linear trend, <0.0001).

CONCLUSIONS

Our data are consistent with an inverse association between Dietary Approach to Stop Hypertension diet score and incidence of CAD among US veterans.

Sex Differences in Epidemiology of Cardiac and Vascular Disease

In spite of a remarkable decline in death rates from cardiovascular disease (CVD) observed over the last decades, CVD still remains the leading cause of mortality in both men and women worldwide. Overall the age-adjusted CVD mortality and morbidity rates are highest in men than in women. However, the risk of CVD in women should not be underestimated given that approximately one of two women in developed countries will die of mostly preventable heart diseases or stroke. Although men and women share the same cardiovascular risk factors, there are substantial sex differences in the first manifestation and clinical presentation of CVD. In this part of the chapter, we will discuss the recent epidemiological data on sex discrepancies in the prevalence and burden of different CVDs.

Combined Healthy Behaviors and Healthcare Services Use in Older Adults

INTRODUCTION

Data on the combined impact of healthy behaviors on healthcare use in older adults are limited.

METHODS

Study with community-dwelling individuals aged ≥60 years from the Spanish Seniors-ENRICA cohort, recruited in 2008-2010, followed through 2012-2013, and analyzed in 2016 (N=2,021). At baseline, the following healthy behaviors were self-reported: three traditional (never smoking, being physically active, having a healthy diet) and three emerging (sleeping 7-8 hours/day, sitting <8 hours/day, not living alone). Outcomes were self-reported polypharmacy (five or more drugs per day), primary care physician visits (one or more per month), medical specialist visits (more than one per year), and hospitalization (one or more in the last year). The associations between baseline healthy behaviors and healthcare services used in 2012-2013 were summarized with ORs and 95% CIs from multiple logistic regression, adjusting for demographics, lifestyles, comorbidities, and baseline health services used.

RESULTS

Most single healthy behaviors were associated with lower use of most health services. Compared with participants with zero or one healthy behavior, those with five or six healthy behaviors showed lower risk of polypharmacy (OR=0.46, 95% CI=0.24, 0.85, p-trend=0.001), visits to the primary care physician (OR=0.50, 95% CI=0.26, 0.96, p-trend=0.013), and hospitalization (OR=0.50, 95% CI=0.24, 1.01, p-trend=0.016). No association was found with visits to the medical specialist.

CONCLUSIONS

The combination of five to six healthy behaviors in older adults is associated with half the risk of polypharmacy and using several healthcare services. In an era of constrained resources in most countries, this information may help inform health policy to control healthcare spending in the future.

Ideal Cardiovascular Health and Incident Cardiovascular Disease: Heterogeneity Across Event Subtypes and Mediating Effect of Blood Biomarkers: The PRIME Study

BACKGROUND

The aim of this study was to investigate whether the association between baseline cardiovascular health (CVH) and incident cardiovascular disease differs according to coronary heart disease (CHD) and stroke subtypes, and to assess the mediating effect of inflammatory and hemostatic blood biomarkers.

METHODS AND RESULTS

The association of ideal CVH with outcomes was derived in 9312 middle-aged men from Northern Ireland and France (whole cohort) in multivariable Cox proportional hazards regression analysis. The mediating effect of baseline inflammatory and hemostatic blood biomarkers was evaluated in a case-control study nested within the cohort after 10 years of follow-up. After a median follow-up of 10 years, 614 first CHD events and 117 first stroke events were adjudicated. Compared with those with poor CVH, those with an ideal CVH profile at baseline had a 72% lower risk of CHD (hazard ratio=0.28; 95% confidence interval, 0.17; 0.46) and a 76% lower risk of stroke (hazard ratio =0.24; 95% confidence interval, 0.06; 0.98). The magnitude of the risk reductions was similar for incident angina and myocardial infarction, but was lower for ischemic stroke. In the controls, the mean concentrations of high-sensitivity C-reactive protein, IL-6, and fibrinogen decreased with higher CVH status. Furthermore, the association of behavioral CVH with incident CHD was partly mediated by high-sensitivity C-reactive protein (16.69%), IL-6 (8.52%), and fibrinogen (7.30%) CONCLUSIONS: Our study shows no clear heterogeneity in the association of baseline CVH with the main subtypes of cardiovascular disease. This supports a universal promotion of ideal CVH for all cardiovascular disease subtypes. Furthermore, our mediation analysis suggests that the lower risk of CHD associated with ideal CVH is partly mediated by lower inflammatory and hemostatic blood biomarkers.

NLRP3-inflammasome inhibition prevents high fat and high sugar diets-induced heart damage through autophagy induction

The NLRP3-inflammasome complex has emerged as an important component of inflammatory processes in metabolic dysfunction induced by high-caloric diets. In this study, we investigate the molecular mechanisms by which NLRP3 inhibition may attenuate diet-induced cardiac injury. Here we show the cardiac damage induced by high sugar diet (HSD), high fat diet (HFD) or high sugar/fat diet (HSFD) over 15 weeks. Genetic ablation of NLRP3 protected against this damage by autophagy induction and apoptotic control. Furthermore, NLRP3 inhibition by the selective small molecule MCC950 resulted in similar autophagy induction and apoptotic control in hearts after diets. These data were reproduced in THP-1 cells treated with MCC950 and cultured in media supplemented with serum from mice dosed with MCC950 and fed with diets. NLRP3 inhibition exerted beneficial metabolic, and autophagic adaptations in hearts from obesogenic diets. The inhibition of NLRP3 activation may hold promise in the treatment of metabolic and cardiovascular diseases.

Sex disparities in ideal cardiovascular health

OBJECTIVE

To quantify the gap in the distribution of ideal cardiovascular health (CVH) between men and women accounting for comorbidities, socioeconomic and psychological confounding factors.

METHODS

A cross-sectional analysis was conducted among 9012 French men and women aged 50-75 years who were participants of the Paris Prospective Study 3. Each of the seven metrics was defined according to the American Heart Association criteria, and the CVH was considered as poor (0 or 1 ideal health metric), intermediate (2, 3 or 4 ideal health metrics) and ideal (5-7 ideal health metrics). The odds of intermediate and ideal CVH in women compared with men were estimated by multivariate polytomous logistic regression analysis using poor CVH as the reference category.

RESULTS

The mean age was 59.49 year (SD 6.25) and there were 38.54% of women. Though women were slightly older, less educated, more deprived, more often depressed, they were twice more often in ideal CVH than men (14.77% vs 6.84%, p<0.0001). After adjustment for age, deprivation score, education and depression, women were four times more often in ideal CVH (OR 4.01, 95% CI 3.42 to 4.69) and two times more often in intermediate CVH (OR 2.07, 95% CI 1.88 to 2.28) than men.

CONCLUSION

The sex disparities in the prevalence of ideal CVH have the potential to guide sex-specific strategies for improving CVH status in the general population.

CLINICAL TRIAL REGISTRATION

NCT00741728;Pre-results.

Influence of the degree of adherence to the Mediterranean diet on the cardiometabolic risk in peri and menopausal women. The Flamenco project

BACKGROUND AND AIMS

The Mediterranean diet (MD) has been associated with reduced morbidity from cardiovascular diseases in the general population. The aim of this study was to assess whether different degrees of adherence to the MD were associated with the cardiometabolic risk in peri and menopausal women.

METHODS AND RESULTS

This cross-sectional study included 198 peri and menopausal women participating in the Flamenco project. Validated questionnaires were used to assess menopause health-related quality of life and degree of adherence to the MD (low, medium and high). The following cardiometabolic risk factors were assessed: fat mass percentage, waist circumference, blood pressure and resting heart rate, plasma markers (total cholesterol, high and low-density lipoprotein cholesterol [HDL-C and LDL-C, respectively], total cholesterol/HDL ratio, triglycerides, C-reactive protein and fasting glucose), Physical activity levels and smoking status. The degree of adherence to the MD among the study sample was 27%, 40% and 30% for low, medium and high adherence, respectively. After controlling for potential confounders, women with a high adherence to the MD showed lower plasma total cholesterol (p = 0.025), resting heart rate (p = 0.005), LDL-C (p = 0.019), triglycerides (p = 0.046) and C-reactive protein (p = 0.009) compared to those with a low adherence. Likewise women with high adherence to the MD showed lower total cholesterol/HDL-C ratio (p = 0.020) compared to those with a medium adherence. The high MD adherence group also showed lower clustered cardiometabolic risk (p = 0.004). Moreover, when analysing specific MD components, whole grain cereals, pulses (both p < 0.05) and red wine (p < 0.01) consumption were inversely associated with the clustered cardiometabolic risk.

CONCLUSION

The present findings suggest that a high but not medium adherence to the MD is associated with a cardioprotective effect in peri and menopausal women. As a low percentage of the sample showed a high adherence to the MD, future research aimed at increasing the adherence to this dietary pattern for a better cardiometabolic status during peri and menopause is warranted.

Ideal cardiovascular health and psychosocial risk factors among Finnish female municipal workers

Aims: Ideal cardiovascular health has been defined by the American Heart Association as the absence of disease and the presence of seven key health factors and behaviours. However, little is known about the mental aspects associated with ideal cardiovascular health metrics. The objective of this study was to assess the relationships between psychosocial risk factors and ideal cardiovascular health metrics among Finnish women at municipal work units. Method: A cross-sectional study was conducted in Finland among 732 female employees (mean±SD age 48±10 years) from ten work units in 2014. Ideal cardiovascular health metrics were evaluated with a physical examination, laboratory tests, medical history and self-administrated questionnaires. Psychosocial risk factors (social isolation, stress, depressive symptoms, anxiety, hostility and type D personality) were assessed with core questions as suggested by the European Society of Cardiology. Results: The prevalence of having 5–7 ideal cardiovascular health metrics was 183 (25.0%), of whom 54.1% had at least one psychosocial risk factor. Anxiety (31.3%), work stress (30.7%) and type D personality (26.1%) were the most prevalent of the psychosocial risk factors. The prevalence of depressive symptoms ( p<0.001) and type D personality ( p=0.049) decreased linearly according to the sum of ideal cardiovascular health metrics after adjustment for age and years of education. Conclusions: Even women with good cardiovascular health are affected by psychosocial risk factors at municipal work units. Although the association is possibly bidirectional, screening and treating depression and dealing with type D personality might be crucial in improving cardiovascular health among women.

Cardiovascular health among two ethnic groups living in the same region: A population-based study

BACKGROUND

Poor cardiovascular health (CVH) among ethnic/racial minorities, studied primarily in the USA, may reflect lower access to healthcare. We examined factors associated with minority CVH in a setting of universal access to healthcare.

METHODS AND RESULTS

CVH behaviors and factors were evaluated in a random population sample (551 Arabs, 553 Jews) stratified by sex, ethnicity and age. More Jews (10%) than Arabs (3%) had 3 ideal health behaviors. Only one participant had all four. Although ideal diet was rare (≤1.5%) across groups, Arabs were more likely to meet intake recommendations for whole grains, but less likely to meet intake recommendations for fruits/vegetables and fish. Arabs had lower odds of attaining ideal levels for body mass index and physical activity. Smoking prevalence was 57% among Arab men and 6% among Arab women. Having four ideal health factors (cholesterol, blood pressure, glucose, smoking) was observed in 2% and 8% of Arab and Jewish men, respectively, and 13% of Arab and Jewish women. Higher prevalence of ideal total-cholesterol corresponded to lower high-density lipoprotein cholesterol among Arabs. No participant met ideal levels for all 7 metrics and only 1.8% presented with 6. Accounting for age and lower socioeconomic status, Arabs were less likely to meet a greater number of metric goals (odds ratio (95% confidence interval): 0.62 (0.42-0.92) for men, and 0.73 (0.48-1.12) for women).

CONCLUSIONS

Ideal CVH, rare altogether, was less prevalent among the Arab minority albeit universal access to healthcare. Health behaviors were the main contributors to the CVH disparity.

Ideal Cardiovascular Health and Subclinical Markers of Carotid Structure and Function: The Paris Prospective Study III

OBJECTIVE

We hypothesized that subclinical markers of vascular structure and function, which are independent predictors of cardiovascular disease, would be less frequent in subjects with ideal than poor cardiovascular health (CVH) as defined by the American Heart Association (AHA).

APPROACH AND RESULTS

Carotid parameters were measured using high-precision echotracking device in 9155 nonreferred participants attending a health checkup in a large health center in Paris (France) between 2008 and 2012. According to the AHA, participants with 0 to 2, 3 to 4, and 5 to 7 metrics (smoking, physical activity, body mass index, diet, blood glucose and total cholesterol, blood pressure) at the ideal level were categorized as having poor, intermediate, and ideal CVH. Carotid parameters were dichotomized according to their median value, and multivariable logistic regression analysis was performed. Mean age was 59.5 (SD 6.3) years; 39% were females, and ideal CVH was present in 10.11% of the study participants. After adjustment for age, sex, education, and living alone and compared with a poor CVH, an ideal CVH was associated with lower common carotid artery intima-media thickness (odds ratio=1.64; 95% confidence interval 1.40, 1.93), absence of carotid plaques (odds ratio=2.14; 95% confidence interval 1.60, 2.87), lower Young's elastic modulus (odds ratio=2.43; 95% confidence interval 2.07, 2.84), and higher carotid distensibility coefficient (odds ratio=2.90; 95% confidence interval 2.47, 3.41).

CONCLUSIONS

In community subjects aged 50 to 75 years, ideal CVH was associated with substantially less arterial stiffness and thickness. These associations might contribute to the lower risk of cardiovascular diseases in subjects with ideal CVH.

Status of cardiovascular health among adults in a rural area of Northwest China: Results from a cross-sectional study

The aim of this study was to assess the status of cardiovascular health among a rural population in Northwest China and to determine the associated factors for cardiovascular health.A population-based cross-sectional study was conducted in the rural areas of Hanzhong in Northwest China. Interview, physical examination, and fasting blood glucose and lipid measurements were completed for 2693 adults. The construct of cardiovascular health and the definitions of cardiovascular health metrics proposed by the American Heart Association were used to assess cardiovascular health. The proportions of subjects with cardiovascular health metrics were calculated, adjusting for age and sex. The multiple logistic regression model was used to evaluate the association between ideal cardiovascular health and its associated factors.Only 0.5% (0.0% in men vs 0.9% in women, P = 0.002) of the participants had ideal cardiovascular health, whereas 33.8% (18.0% in men vs 50.0% in women, P < 0.001) and 65.7% (82.0% in men vs 49.1% in women, P < 0.001) of the participants had intermediate and poor cardiovascular health, respectively. The prevalence of poor cardiovascular health increased with increasing age (P < 0.001 for trend). Participants fulfilled, on average, 4.4 (95% confidence interval: 4.2-4.7) of the ideal cardiovascular health metrics. Also, 22.2% of the participants presented with 3 or fewer ideal metrics. Only 19.4% of the participants presented with 6 or more ideal metrics. 24.1% of the participants had all 4 ideal health factors, but only 1.1% of the participants had all 4 ideal health behaviors. Women were more likely to have ideal cardiovascular health, whereas adults aged 35 years or over and those who had a family history of hypertension were less likely to have ideal cardiovascular health.The prevalence of ideal cardiovascular health was extremely low among the rural population in Northwest China. Most adults, especially men and the elderly, had a poor cardiovascular health status. To improve cardiovascular health among the rural population, efforts, especially lifestyle improvements, education and interventions to make healthier food choices, reduce salt intake, increase physical activities, and cease smoking, will be required at the individual, population, and social levels.

Cross-sectional analysis of deprivation and ideal cardiovascular health in the Paris Prospective Study 3

AIMS

We hypothesised that deprivation might represent a barrier to attain an ideal cardiovascular health (CVH) as defined by the American Heart Association (AHA).

METHODS AND RESULTS

The baseline data of 8916 participants of the Paris Prospective Study 3, an observational cohort on novel markers for future cardiovascular disease, were used. The AHA 7-item tool includes four health behaviours (smoking, body weight, physical activity and optimal diet) and three biological measures (blood cholesterol, blood glucose and blood pressure). A validated 11-item score of individual material and psychosocial deprivation, the Evaluation de la Précarité et des Inégalités dans les Centres d'Examens de Santé-Evaluation of Deprivation and Inequalities in Health Examination centres (EPICES) score was used. The mean age was 59.5 years (standard deviation 6.2), 61.2% were men and 9.98% had an ideal CVH. In sex-specific multivariable polytomous logistic regression, the odds ratio (OR) for ideal behavioural CVH progressively decreased with quartile of increasing deprivation, from 0.54 (95% CI 0.41 to 0.72) to 0.49 (0.37 to 0.65) in women and from 0.61 (0.50 to 0.76) to 0.57 (0.46 to 0.71) in men. Associations with ideal biological CVH were confined to the most deprived women (OR=0.60; 95% CI 0.37 to 0.99), whereas in men, greater deprivation was related to higher OR of intermediate biological CVH (OR=1.28; 95% CI 1.05 to 1.57 for the third quartile vs the first quartile).

CONCLUSIONS

Higher material and psychosocial deprivation may represent a barrier to reach an ideal CVH.

TRIAL REGISTRATION NUMBER

NCT00741728.

A Systematic Review of the Prevalence and Outcomes of Ideal Cardiovascular Health in US and Non-US Populations

Several population-based studies have examined the prevalence and trends of the American Heart Association's ideal cardiovascular health (CVH) metrics as well as its association with cardiovascular disease (CVD)-related morbidity and mortality and with non-CVD outcomes. However, no efforts have been made to aggregate these studies. Accordingly, we conducted a systematic review to synthesize available data on the distribution and outcomes associated with ideal CVH metrics in both US and non-US populations. We conducted a systematic search of relevant studies in the MEDLINE and CINAHL databases, as well as the Cochrane Register of Controlled Trials (CENTRAL). Search terms used included "life's simple 7", "AHA 2020" and "ideal cardiovascular health". We included articles published in English Language from January 1, 2010, to July 31, 2015. Of the 14 US cohorts, the prevalence of 6 to 7 ideal CVH metrics ranged from as low as 0.5% in a population of African Americans to 12% in workers in a South Florida health care organization. Outside the United States, the lowest prevalence was found in an Iranian study (0.3%) and the highest was found in a large Chinese corporation (15%). All 6 mortality studies reported a graded inverse association between the increasing number of ideal CVH metrics and the all-cause and CVD-related mortality risk. A similar relationship between ideal CVH metrics and incident cardiovascular events was found in 12 of 13 studies. Finally, an increasing number of ideal CVH metrics was associated with a lower prevalence and incidence of non-CVD outcomes such as cancer, depression, and cognitive impairment. The distribution of ideal CVH metrics in US and non-US populations is similar, with low proportions of persons achieving 6 or more ideal CVH metrics. Considering the strong association of CVH metrics with both CVD and non-CVD outcomes, a coordinated global effort for improving CVH should be considered a priority.

Status of cardiovascular health in Chinese adults

BACKGROUND

Cardiovascular disease has become the leading cause of death in China.

OBJECTIVES

The goal of this study was to evaluate the current status of cardiovascular health in Chinese adults.

METHODS

Cardiovascular health data were collected from a nationally representative sample of 96,121 Chinese adults age ≥ 20 years in 2010. Ideal cardiovascular health was defined according to the American Heart Association's 2020 Strategic Impact Goals as follows: the simultaneous presence of 4 favorable health behaviors (ideal smoking status, ideal body mass index, physical activity at goal, and healthy dietary habits) and 4 favorable health factors (ideal smoking status, untreated total cholesterol <200 mg/dl, untreated blood pressure <120/<80 mm Hg, and untreated fasting plasma glucose <100 mg/dl) in the absence of a history of cardiovascular disease.

RESULTS

The estimated percentage of ideal cardiovascular health was 0.2% in the general adult population in China (0.1% in men and 0.4% in women). An estimated 0.7% (0.4% in men and 1.0% in women) of Chinese adults had all 4 ideal health behaviors, and 13.5% (5.0% in men and 22.3% in women) had all 4 ideal health factors. Men most frequently had 3 to 4 ideal components, and women most commonly had 4 to 5 ideal components of the 7 cardiovascular health metrics. Ideal diet (1.6%) was the least common among all cardiovascular health metrics. Female sex and younger age were the 2 most common protective factors for cardiovascular health in Chinese adults.

CONCLUSIONS

The percentage of ideal cardiovascular health in Chinese adults is extremely low. Both population-wide and high-risk strategies should be implemented with great effort to promote cardiovascular health in China.

Modified Ideal Cardiovascular Health Status is Associated with Lower Prevalence of Stroke in Rural Northeast China

Background: In 2010, the American Heart Association developed a new definition of ideal cardiovascular health (CVH) based on seven cardiovascular health metrics. This study aimed to investigate the relationship between modified ideal CVH metrics and the risk of stroke in the rural population of Northeast China. Methods: We included 11,417 adults from the rural population in Northeast China and collected all the information, including the baseline characteristics, history of stroke, and the seven ideal CVH metrics. Results: Our results showed that the presence of stroke was associated with high body mass index (BMI), poor diet score (salt intake), high total cholesterol (TC), high blood pressure (BP), and high fasting plasma glucose (FPG). The prevalence of stroke increased as the number of ideal CVH metrics decreased, and peaked to 13.1% among those with only one ideal CVH metric. Participants with only one ideal CVH had a 4.40-fold increased susceptibility of stroke than those with all seven ideal health metrics. Conclusion: This study revealed that people with a better CVH status had a lower prevalence of stroke and the susceptibility of stroke increased with the decreasing of the number of ideal CVH metrics.

High level of depressive symptoms as a barrier to reach an ideal cardiovascular health. The Paris Prospective Study III

We hypothesized that depression might represent a barrier to reach an ideal cardiovascular health (CVH) as estimated by the 7-item tool proposed by the American Heart Association. Between 2008 and 2012, 9,417 subjects 50-75 years of age were examined in a large health center and enrolled in the Paris Prospective Study III (PPS3). Participants with 0-2, 3-4 and 5-7 health metrics at the ideal level were categorized as having poor, intermediate and ideal CVH, respectively. Participants with a score ≥ 7 on the 13-item Questionnaire of Depression 2nd version, Abridged or who were on antidepressants were referred as having high level of depressive symptoms (HLDS). The mean age of the 9417 study participants was 59.57 (SD 6.28) years and 61.16% were males. A total of 9.55% had HLDS. Poor, intermediate and ideal CVH was present in 40.38%, 49.52% and 10.10% of the participants. In multivariate polytomous logistic regression analysis, HLDS was inversely associated with ideal CVH (odds ratio = 0.70; 95% CI: 0.55;0.90). This was driven by an association with the behavioural component of the CVH. Participants with HLDS had a substantial reduced chance of reaching an ideal CVH.

A Comprehensive Lifestyle Peer Group-Based Intervention on Cardiovascular Risk Factors: The Randomized Controlled Fifty-Fifty Program

BACKGROUND

Cardiovascular diseases stem from modifiable risk factors. Peer support is a proven strategy for many chronic illnesses. Randomized trials assessing the efficacy of this strategy for global cardiovascular risk factor modification are lacking.

OBJECTIVES

This study assessed the hypothesis that a peer group strategy would help improve healthy behaviors in individuals with cardiovascular risk factors.

METHODS

A total of 543 adults 25 to 50 years of age with at least 1 risk factor were recruited; risk factors included hypertension (20%), overweight (82%), smoking (31%), and physical inactivity (81%). Subjects were randomized 1:1 to a peer group-based intervention group (IG) or a self-management control group (CG) for 12 months. Peer-elected leaders moderated monthly meetings involving role-play, brainstorming, and activities to address emotions, diet, and exercise. The primary outcome was mean change in a composite score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT score, 0 to 15). Multilevel models with municipality as a cluster variable were applied to assess differences between groups.

RESULTS

Participants' mean age was 42 ± 6 years, 71% were female, and they had a mean baseline Fuster-BEWAT score of 8.42 ± 2.35. After 1 year, the mean scores were significantly higher in the IG (n = 277) than in the CG (n = 266) (IG mean score: 8.84; 95% confidence interval (CI): 8.37 to 9.32; CG mean score: 8.17; 95% CI: 7.55 to 8.79; p = 0.02). The increase in the overall score was significantly larger in the IG compared with the CG (difference: 0.75; 95% CI: 0.32 to 1.18; p = 0.02). The mean improvement in the individual components was uniformly greater in the IG, with a significant difference for the tobacco component.

CONCLUSIONS

The peer group intervention had beneficial effects on cardiovascular risk factors, with significant improvements in the overall score and specifically on tobacco cessation. A follow-up assessment will be performed 1 year after the final assessment reported here to determine long-term sustainability of the improvements associated with peer group intervention. (Peer-Group-Based Intervention Program [Fifty-Fifty]; NCT02367963).