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

Association between adherence to life's simple 7 metrics and risk of obstructive sleep apnea among adults in the United States

BACKGROUND

We aimed to explore the impact of adherence to Life's Simple 7 (LS7) metrics on risk of obstructive sleep apnea (OSA), and the impact of inflammation on the association, in adults in the United States.

METHODS

Data from 13,825 community-dwelling adults aged ≥ 20 years recruited in the National Health and Nutrition Examination Surveys (NHANES) 2005-2008, 2015-2018 was analyzed. The LS7 score was calculated based on the AHA definition of LS7 metrics. The diagnosis of OSA was based on self-reported symptoms of sleep disturbance using a standard questionnaire. The Multivariable Apnea Prediction (MAP) Index score was also calculated to assess the risk of OSA. Log-binominal regression and negative binomial regression were performed to estimate the associations between LS7 and OSA and MAP index, with odds ratios (ORs) and prevalence ratios (PRs) and their 95% confidence intervals (CIs) calculated. Mediation analysis was performed to estimate the mediating effects of inflammatory indicators on the associations.

RESULTS

A total of 4473 participants (32.4%) had OSA, and the mean MAP index was 0.39. In fully adjusted log-binominal regression models, with total score < 6 as the reference, the ORs (95% CIs) for risk of OSA were 0.90 (0.73, 1.10), 0.76 (0.65, 0.89), 0.78 (0.64, 0.95), and 0.45 (0.38, 0.54) for total score = 6, total score = 7, total score = 8, and total score > 8, respectively (P for trend < 0.001). When LS7 score was analyzed as a continuous variable, each 1-point increase in LS7 score was associated with a 15% decrease in OSA risk (P < 0.001). In negative binominal regression models, the adjusted PRs (95% CIs) for the MAP index were 0.93 (0.90, 0.97), 0.87 (0.84, 0.91), 0.80 (0.77, 0.84), and 0.55 (0.53, 0.57) for total score = 6, total score = 7, total score = 8, and total score > 8, respectively (P for trend < 0.001). For each 1-point increase in LS7 score, the risk of OSA decreased by 13% (P < 0.001). Consistent results were observed in subgroup analysis. Mediation analysis indicated that inflammatory factors, including blood cell count, neutrophil count, and C-reactive protein, positively mediated the association of LS7 with OSA, with a mediation proportion of 0.022 (P = 0.04), 0.02 (P = 0.04), and 0.02 (P = 0.02), respectively.

CONCLUSIONS

In a nationally representative sample of US adults, adherence to LS7 metrics was independently associated with reduced OSA risk. Inflammation plays a mediating role in the association between LS7 and OSA.

Life's Essential 8 is inversely associated with high-sensitivity C-reactive protein

Life's Essential 8 (LE8) is a score that includes modifiable risk factors for cardiovascular disease. Four health behaviors (diet, physical activity, nicotine exposure and sleep health) and four health factors (non-HDL cholesterol, blood glucose, blood pressure and body mass index) are included. These modifiable risk factors promote inflammation, and inflammation is one of the biological mechanisms of cardiovascular disease development. Thus, we examined the relationship between cardiovascular health measured by LE8 and low-grade inflammation measured by high-sensitivity C-reactive protein (hs-CRP) in the cross-sectional population-based Swedish CArdioPulmonary bioImage Study (SCAPIS). The study consisted of 28,010 participants between 50 and 64 years (51.5% women, mean age 57.5 years). All individual LE8 components were assigned a score between 0 (unhealthy) and 100 (healthy) points, and a global score was calculated. The association between LE8 scores and high-risk hs-CRP (defined as > 3.0 mg/L) was analyzed using adjusted logistic regression with spline analyses. There was a strong, dose response and inverse association between LE8 scores and levels of hs-CRP. Thus, those with a low LE8 score (= 50.0 points) had 5.8 higher (95% confidence interval [CI] 5.2-6.4) odds ratio (OR) of having high hs-CRP as compared to those with a high LE8 score (= 80.0 points). In conclusion, our findings show strong inverse associations between LE8 scores and levels of hs-CRP.

Adherence to Life's Essential 8 is associated with delayed biological aging: a population-based cross-sectional study

INTRODUCTION AND OBJECTIVES

The aim of this study was to explore the potential of adhering to the American Heart Association's updated Life's Essential 8 (LE8) scores in delaying biological aging amid growing concerns about aging populations and related diseases.

METHODS

A total of 18 261 adults (≥ 20 years old) were examined using National Health and Nutrition Examination Survey data from 2005-2010 and 2015-2018. The LE8 includes 8 components, covering health behaviors and factors. Acceleration of biological aging was defined as an excess of biological/phenotypic age over chronological age, assessed by using clinical biomarkers. The association between LE8 score and biological aging was explored through regression analyses.

RESULTS

Each 10-point increase in LE8 scores was associated with a 1.19-year decrease in biological age and a 1.63-year decrease in phenotypic age. Individuals with high cardiovascular health (CVH) had a 90% reduction in their risk of accelerated aging based on biological age and an 81% reduction based on phenotypic age compared with individuals with low CVH. Bootstrap-based model estimates and weighted quantile sum regression suggested that health factors, particularly blood glucose, had strong impact on delaying aging. The association between smoking and biological aging seemed to differ depending on the definition of aging used. Among all subgroups, LE8 consistently correlated negatively with biological aging, despite observed interactions. Three sensitivity analyses confirmed the robustness of our conclusions.

CONCLUSIONS

A higher CVH is associated with a lower risk of biological aging. Maintaining elevated LE8 levels across demographics, regardless of cardiovascular history, is recommended to delay aging and promote healthy aging, with significant implications for primary health care.

Association of life's essential 8 and risk of fragility fractures: A large cohort study

Cardiovascular health (CVH) score is not only associated with cardiovascular diseases, but also some disorders in other systems. This study aims to investigate the association between CVH score and the risk of fragility fractures. The analysis enrolled 89,464 participants at baseline in Kailuan study initiated in 2006-2007. All participants were then followed up every 2 years and the incidence of fragility fractures was recorded annually. A total CVH score was classified as low (0-49 points), moderate (50-79 points), and ideal (80-100 points). The primary outcome was incident fragility fractures before December 31, 2021. Kaplan-Meier was used to estimate cumulative incidence. Multivariable adjusted Cox proportional hazards regression models and time-dependent Cox hazards regression models were used to estimate fragility fracture hazard ratios (aHR) and 95% confidence intervals (95% CI). After 13.98 ± 2.84 years of follow-up, a total of 1534 cases of fragility fractures were identified, with an incidence density of 1.23 per 1000 person-years. Compared with the low CVH group, the risk of fragility fractures was significantly lower in moderate (aHR = 0.78, 95% CI: 0.66-0.92) and ideal CVH groups (aHR = 0.65, 95% CI: 0.51-0.83), particularly in the age <60 group (aHR = 0.72, 95% CI: 0.59-0.88; aHR= 0.55, 95% CI: 0.41-0.73, respectively). Time-dependent Cox hazards regression models, sensitivity analysis, and death competition model confirmed the reliability of these findings. The ideal CVH score is associated with a decreased risk of fragility fractures. With the increase of CVH score, the risk of fragility fracture decreases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Metabolite Signature of Life's Essential 8 and Risk of Coronary Heart Disease Among Low-Income Black and White Americans

BACKGROUND

Life's essential 8 (LE8) is a comprehensive construct of cardiovascular health. Yet, little is known about the LE8 score, its metabolic correlates, and their predictive implications among Black Americans and low-income individuals.

METHODS

In a nested case-control study of coronary heart disease (CHD) among 299 pairs of Black and 298 pairs of White low-income Americans from the Southern Community Cohort Study, we estimated LE8 score and applied untargeted plasma metabolomics and elastic net with leave-one-out cross-validation to identify metabolite signature (MetaSig) of LE8. Associations of LE8 score and MetaSig with incident CHD were examined using conditional logistic regression. The mediation effect of MetaSig on the LE8-CHD association was also examined. The external validity of MetaSig was evaluated in another nested CHD case-control study among 299 pairs of Chinese adults.

RESULTS

Higher LE8 score was associated with lower CHD risk (standardized odds ratio, 0.61 [95% CI, 0.53-0.69]). The MetaSig, consisting of 133 metabolites, showed significant correlation with LE8 score (r=0.61) and inverse association with CHD (odds ratio, 0.57 [0.49-0.65]), robust to adjustment for LE8 score and across participants with different sociodemographic and health status ([odds ratios, 0.42-0.69]; all P<0.05). MetaSig mediated a large portion of the LE8-CHD association: 53% (32%-80%). Significant associations of MetaSig with LE8 score and CHD risk were found in validation cohort (r=0.49; odds ratio, 0.57 [0.46-0.69]).

CONCLUSIONS

Higher LE8 score and its MetaSig were associated with lower CHD risk among low-income Black and White Americans. Metabolomics may offer an objective measure of LE8 and its metabolic phenotype relevant to CHD prevention among diverse populations.

Association of a Healthy Lifestyle, Life's Essential 8 Scores With Incident Macrovascular and Microvascular Disease Among Individuals With Type 2 Diabetes

Background The association of a healthy lifestyle with the prognosis of type 2 diabetes remains uncertain. We aimed to evaluate the associations of a healthy lifestyle and a higher American Heart Association's Life's Essential 8 score with incident macrovascular and microvascular diseases in type 2 diabetes. Methods and Results A total of 13 543 participants with baseline type 2 diabetes and free of macrovascular and microvascular diseases from the UK Biobank were included. A healthy lifestyle was determined based on body mass index, smoking, alcohol consumption, physical activity, sleep duration, and diet. Life's Essential 8 scores were generated from 8 metrics according to the American Heart Association's cardiovascular health advisory, ranging from 0 to 100. During a median follow-up of 12.1 years, 3279 (24.2%) incident macrovascular diseases and 2557 (18.9%) microvascular diseases were documented. Compared with those with a poor lifestyle, participants with an ideal lifestyle had significantly lower risks of incident macrovascular disease (hazard ratio [HR], 0.46 [95% CI, 0.36-0.59]) and microvascular disease (HR, 0.60 [95% CI, 0.47-0.77]). Significantly lower risks of macrovascular disease (HR, 0.20 [95% CI, 0.05-0.79]) and microvascular disease (HR, 0.24 [95% CI, 0.06-0.98]) were also found in the high cardiovascular health group (Life's Essential 8 scores: 80-100), compared to the low cardiovascular health group (scores: 0-49). Adhering to an ideal lifestyle may prevent 37.0% of macrovascular disease and 24.7% of microvascular disease, and attaining a high cardiovascular health may prevent 71.9% of macrovascular disease and 67.5% of microvascular disease. Conclusions A healthy lifestyle and a higher Life's Essential 8 score were associated with lower risks of macrovascular and microvascular diseases among participants with type 2 diabetes.

Life's Essential 8 and Risk of Stroke: A Prospective Community-Based Study

BACKGROUND

Data are lacking regarding cardiovascular health (CVH) with Life's Essential 8 approach and future stroke risk. We sought to elucidate whether the CVH score constructed by the Life's Essential 8 metrics predicted stroke risk in 2 Chinese ongoing cohorts.

METHODS

This included 41 043 participants of the Kailuan I study and 27 842 participants of the Kailuan II study who were free of cardiovascular disease or cancer in 2014. CVH score (ranged from 0 to 100) was assessed using the Life's Essential 8 metrics (body mass index, cigarette smoking, diet quality, physical activity, sleep health, lipid, blood glucose, and blood pressure). A composite of incident stroke events (ischemic stroke and hemorrhagic stroke) was identified via review of medical records. The follow-up period was calculated from the finishing date of the 2014 survey to either the date of stroke occurrence, death, loss to follow-up, or the end of follow-up (December 31, 2020). We also examined the longitudinal association between the CVH score and arterial stiffness status, as assessed by brachial-ankle pulse wave velocity, in 25 922 participants free of cardiovascular disease during the follow-up. We performed a meta-analysis to assess the association between CVH, based on the 2010 American Heart Association recommendation, and stroke integrating the results of current study and previous studies.

RESULTS

During a median follow-up of 5.65 years (interquartile range, 5.20-6.09), a total of 1750 incident stroke events were identified in the pooled Kailuan study. The pooled hazard ratios were 0.33 (95% CI, 0.20-0.54) for ideal versus poor health category of CVH (Ptrend<0.0001). Higher CVH scores were also associated with lower brachial-ankle pulse wave velocity values at baseline and slower increments of brachial-ankle pulse wave velocity during follow-up (Ptrend≤0.001 for both). Arterial stiffness mediated 9.07% (95% CI, 5.83%-15.0%) of the total association between CVH and incident stroke. The pooled hazard ratio comparing 2 extreme CVH categories for stroke was 0.45 (95% CI, 0.35-0.59) when including 10 published studies and the current study.

CONCLUSIONS

The CVH score as assessed by the Life's Essential 8 metrics significantly predicted future stroke risk and arterial stiffness status.

Life's Essential 8 and Mortality in US Adults with Chronic Kidney Disease

INTRODUCTION

The current prevalence of chronic kidney disease (CKD) is substantial, and CKD individuals face a heightened risk of mortality, encompassing both all-cause and cause-specific outcomes. The current study aims to investigate the potential impact of adhering to Life's Essential 8 (LE8) on reducing mortality among CKD individuals.

METHODS

Using the National Health and Nutrition Survey (NHANES) data from 2005 to 2018, we analyzed 22,420 US adults (≥20 years old). CKD is defined by urinary albumin-to-creatinine ratio (≥30 mg/g or 3 mg/mmol) and estimated glomerular filtration rate (<60 mL/min/1.73 m2). The components of LE8, including diet, physical activity (PA), nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure (BP), were measured and given a score of 0-100. The total LE8 score was the unweighted average of all components and was divided into low cardiovascular health (CVH) (0-49), moderate CVH (50-79), and high CVH (80-100). A Cox proportional hazards regression model was used to explore the associations of LE8 with all-cause, cardiovascular disease (CVD), and cancer mortality, which were followed prospectively by the National Center for Health Statistics until December 31, 2019.

RESULTS

In the overall population, individuals with moderate CVH had a 47% lower risk of CKD, while high CVH was linked to a 55% lower risk compared to low CVH. During a median follow-up of 7.58 years, CKD individuals had a 93% higher all-cause mortality rate and a 149% higher CVD mortality rate compared to those without CKD. Among the CKD individuals, every 10-point increase in the LE8 score was associated with reduced risks of 17% for all-cause mortality (especially PA, nicotine exposure, blood glucose, and BP), 18% for CVD mortality (especially PA), and 12% for cancer mortality (especially PA and sleep health). In additional and sensitivity analysis, the results remained significant after further consideration of potential confounding of renal function. Additionally, LE8 demonstrated superior risk stratification for CVD mortality among CKD patients compared with LS7. Interaction was observed between LE8 and age, education level, marital status, and drinking status.

CONCLUSION

The current study demonstrates that adherence to higher LE8 levels within CKD individuals is associated with a reduced risk of both all-cause and cause-specific mortality.

Inflammation biomarkers are associated with the incidence of cardiovascular disease: a meta-analysis

Background

Inflammation is a risk factor for cardiovascular disease (CVD), and particular inflammatory parameters can be used to predict the incidence of CVD. The aim of this study was to assess the association between fibrinogen (FIB), interleukin-6 (IL-6), C-reactive protein (CRP) and galectin-3 (Gal-3) and the risk of cardiovascular disease using meta-analysis.

Methods

PubMed, Embase, Scopus, and Web of Science databases were searched with the appropriate strategies to identify observational studies relevant to this meta-analysis. A random-effects model was used to combine inflammation factor-associated outcomes and cardiovascular disease outcomes, except in the case of galectin-3, where a fixed-effects model was used because of less heterogeneity. Location, age, type of cardiovascular disease, and sample size factors were used to explore heterogeneity in stratification and metaregression for subgroup analysis. A case-by-case literature exclusion approach was used for sensitivity analysis. The funnel plot and Begg's test were combined to assess publication bias.

Results

Thirty-three papers out of 11,456 were screened for inclusion in the analysis. Four inflammation biomarkers were significantly associated with the development of CVD: FIB (OR: 1.21, 95% CI: 1.15-1.27, P < 0.001; HR: 1.04, 95% CI: 1.00-1.07, P < 0.05), IL-6 (HR: 1.16, 95% CI: 1.10-1.22, P < 0.001), CRP (OR: 1.25, 95% CI: 1.15-1.35, P < 0.001; HR: 1.20, 95% CI: 1.14-1.25, P < 0.001) and Gal-3 (HR: 1.09, 95% CI: 1.05-1.14, P < 0.001). Location factors help explain the source of heterogeneity, and there is publication bias in the Gal-3 related literature.

Conclusion

Taken together, the current research evidence suggests that high levels of fibrinogen, interleukin-6, C-reactive protein and galectin-3 are risk factors for cardiovascular disease and can be used as biomarkers to predict the development of cardiovascular disease to some extent.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023391844.

Ideal Cardiovascular Health and Risk of Cardiovascular Events or Mortality: A Systematic Review and Meta-Analysis of Prospective Studies

Cardiovascular diseases (CVD) remain the leading cause of morbidity and mortality worldwide, hence significant efforts have been made to establish behavior and risk factors associated with CVD. The American Heart Association proposed a 7-metric tool to promote ideal cardiovascular health (CVH). Recent data demonstrated that a higher number of ideal CVH metrics was associated with a lower risk of CVD, stroke, and mortality. Our study aimed to perform a systematic review and meta-analysis of prospective studies investigating the association of ideal CVH metrics and CVD, stroke, and cardiovascular mortality (CVM) in the general population. Medline and Scopus databases were searched from January 2010 to June 2022 for prospective studies reporting CVH metrics and outcomes on composite-CVD, coronary heart disease, myocardial infarction, stroke, and CVM. Each CVH metrics group was compared to another. Twenty-two studies totaling 3,240,660 adults (57.8% men) were analyzed. The follow-up duration was 12.0 ± 7.2 years. Our analysis confirmed that a higher number of ideal CVH metrics led to lower risk for CVD and CVM (statistically significant for composite-CVD, stroke, and CVM; p < 0.05). Conclusion: Even modest improvements in CVH are associated with CV-morbidity and mortality benefits, providing a strong public health message about the importance of a healthier lifestyle.

Metabolite Signature of Life's Essential 8 and Risk of Coronary Heart Disease among Low-Income Black and White Americans

Background and Aims

Life's Essential 8 (LE8) is a comprehensive construct of cardiovascular health. Yet, little is known about LE8 score, its metabolic correlates, and their predictive implications among Black Americans and low-income individuals.

Methods

In a nested case-control study of coronary heart disease (CHD) among 598 Black and 596 White low-income Americans, we estimated LE8 score, conducted untargeted plasma metabolites profiling, and used elastic net with leave-one-out cross-validation to identify metabolite signature (MetaSig) of LE8. Associations of LE8 score and MetaSig with incident CHD were examined using conditional logistic regression. Mediation effect of MetaSig on the LE8-CHD association was also examined. The external validity of MetaSig was evaluated in another nested CHD case-control study among 598 Chinese adults.

Results

Higher LE8 score was associated with lower CHD risk [standardized OR (95% CI)=0.61 (0.53-0.69)]. The identified MetaSig, consisting of 133 metabolites, showed strong correlation with LE8 score ( r =0.61) and inverse association with CHD risk [OR (95% CI)=0.57 (0.49-0.65)], robust to adjustment for LE8 score and across participants with different sociodemographic and health status (ORs: 0.42-0.69; all P <0.05). MetaSig mediated a large portion of the LE8-CHD association: 53% (32%-80%) ( P <0.001). Significant associations of MetaSig with LE8 score and CHD risk were found in validation cohort [ r =0.49; OR (95% CI)=0.57 (0.46-0.69)].

Conclusions

Higher LE8 score and its MetaSig were associated with lower CHD risk among low-income Black and White Americans. Metabolomics may offer an objective and comprehensive measure of LE8 score and its metabolic phenotype relevant to CHD prevention among diverse populations.

The Role of Aldosterone and Ideal Cardiovascular Health in Incident Cardiovascular Disease: The Jackson Heart Study

Background

Higher levels of ideal cardiovascular health (ICH) are associated with lower levels of aldosterone and incidence of cardiovascular disease (CVD). However, the degree to which aldosterone mediates the association between ICH and CVD incidence has not been explored. Thus, we investigated the mediational role of aldosterone in the association of 5 components of ICH (cholesterol, body mass index (BMI), physical activity, diet and smoking) with incident CVD and the mediational role of blood pressure (BP) and glucose in the association of aldosterone with incident CVD in a cohort of African Americans (AA).

Methods

The Jackson Heart Study is a prospective cohort of AAs adults with data on CVD outcomes. Aldosterone, ICH metrics and baseline characteristics were collected at exam 1 (2000-2004). ICH score was developed by summing 5 ICH metrics (smoking, dietary intake, physical activity, BMI, and total cholesterol) and grouped into two categories (0-2 and ≥3 metrics). Incident CVD was defined as stroke, coronary heart disease, or heart failure. Cox proportional hazard regression models were used to model the association of categorical ICH score with incident CVD. The R Package Mediation was utilized to examine: 1) The mediational role of aldosterone in the association of ICH with incident CVD and 2) The mediational role of blood pressure and glucose in the association of aldosterone with incident CVD.

Results

Among 3,274 individuals (mean age: 54±12.4 years, 65% female), there were 368 cases of incident CVD over a median of 12.7 years. The risk of incident CVD was 46% lower (HR: 0.54; 95%CI 0.36, 0.80) in those with ≥3 ICH metrics at baseline compared to 0-2. Aldosterone mediated 5.4% (p = 0.006) of the effect of ICH on incident CVD. A 1-unit increase in log-aldosterone was associated with a 38% higher risk of incident CVD (HR 1.38, 95%CI: 1.19, 1.61) with BP and glucose mediating 25.6% (p<0.001) and 4.8% (p = 0.048), respectively.

Conclusion

Aldosterone partially mediates the association of ICH with incident CVD and both blood pressure and glucose partially mediate the association of aldosterone with incident CVD, emphasizing the potential importance of aldosterone and ICH in risk of CVD among AAs.

Differences in Ideal Cardiovascular Health Between Sexual Minority and Heterosexual Adults

Importance

Research on the cardiovascular health (CVH) of sexual minority adults has primarily examined differences in the prevalence of individual CVH metrics rather than comprehensive measures, which has limited development of behavioral interventions.

Objective

To investigate sexual identity differences in CVH, measured using the American Heart Association's revised measure of ideal CVH, among adults in the US.

Design, Setting, and Participants

This cross-sectional study analyzed population-based data from the National Health and Nutrition Examination Survey (NHANES; 2007-2016) in June 2022. Participants included noninstitutional adults aged 18 to 59 years. We excluded individuals who were pregnant at the time of their interview and those with a history of atherosclerotic cardiovascular disease or heart failure.

Exposures

Self-identified sexual identity categorized as heterosexual, gay/lesbian, bisexual, or something else.

Main Outcomes and Measures

The main outcome was ideal CVH (assessed using questionnaire, dietary, and physical examination data). Participants received a score from 0 to 100 for each CVH metric, with higher scores indicating a more favorable CVH profile. An unweighted average was calculated to determine cumulative CVH (range, 0-100), which was recoded as low, moderate, or high. Sex-stratified regression models were performed to examine sexual identity differences in CVH metrics, disease awareness, and medication use.

Results

The sample included 12 180 participants (mean [SD] age, 39.6 [11.7] years; 6147 male individuals [50.5%]). Lesbian (B = -17.21; 95% CI, -31.98 to -2.44) and bisexual (B = -13.76; 95% CI, -20.54 to -6.99) female individuals had less favorable nicotine scores than heterosexual female individuals. Bisexual female individuals had less favorable body mass index scores (B = -7.47; 95% CI, -12.89 to -1.97) and lower cumulative ideal CVH scores (B = -2.59; 95% CI, -4.84 to -0.33) than heterosexual female individuals. Compared with heterosexual male individuals, gay male individuals had less favorable nicotine scores (B = -11.43; 95% CI, -21.87 to -0.99) but more favorable diet (B = 9.65; 95% CI, 2.38-16.92), body mass index (B = 9.75; 95% CI, 1.25-18.25), and glycemic status scores (B = 5.28; 95% CI, 0.59-9.97). Bisexual male individuals were twice as likely as heterosexual male individuals to report a diagnosis of hypertension (adjusted odds ratio [aOR], 1.98; 95% CI, 1.10-3.56) and use of antihypertensive medication (aOR, 2.20; 95% CI, 1.12-4.32). No differences in CVH were found between participants who reported their sexual identity as something else and heterosexual participants.

Conclusion and Relevance

Results of this cross-sectional study suggest that bisexual female individuals had worse cumulative CVH scores than heterosexual female individuals, whereas gay male individuals generally had better CVH than heterosexual male individuals. There is a need for tailored interventions to improve the CVH of sexual minority adults, particularly bisexual female individuals. Future longitudinal research is needed to examine factors that might contribute to CVH disparities among bisexual female individuals.

Changes in ideal cardiovascular health among Malawian adults from 2009 to 2017

Ideal Cardiovascular Health (CVH) is a concept defined by the American Heart Association (AHA) as part of its 2020 Impact Goals. Until now, changes in ideal CVH have been poorly evaluated in Sub-Saharan African populations. We aimed to investigate changes in the prevalence of ideal CVH and its components in a population of Malawian adults. Secondary analysis was done on cross-sectional data from 2009 to 2017, obtained from the Malawi STEPS surveys which included 5730 participants aged 25-64 years. CVH metrics categorized into "ideal (6-7 ideal metrics)", "intermediate (3-5 ideal metrics)" and "poor (0-2 ideal metrics)" were computed using blood pressure, body mass index (BMI), fasting glycaemia, fruit and vegetable intake, physical activity, smoking, and total cholesterol. Sampling weights were used to account for the sampling design, and all estimates were standardised by age and sex using the direct method. The mean participant age across both periods was 40.1 ± 12.4 years. The prevalence of meeting ≥ 6 ideal CVH metrics increased substantially from 9.4% in 2009 to 33.3% in 2017, whereas having ≤ 2 ideal CVH metrics decreased from 7.6% to 0.5% over this time. For the individual metrics, desirable levels of smoking, fruit and vegetable intake, physical activity, blood pressure (BP), total cholesterol and fasting glucose all increased during the study period whilst achievable levels of BMI (< 25 kg/m²) declined. From 2009 to 2017, the mean number of ideal CVH metrics was higher in women compared to men (from 2.1% to 5.1% vs 2.0% to 5.0%). However, poor levels of smoking and fruit and vegetable intake were higher in men compared to women (from 27.9% to 23.6% vs. 7.4%% to 1.9% , and from 33.7% to 42.9% vs 30.8% to 34.6%, respectively). Also, whilst achievable levels of BMI rose in men (from 84.4% to 86.2%) the proportion reduced in women (from 72.1% to 67.5% ). Overall, CVH improved in Malawian adults from 2009 to 2017 and was highest in women. However, the prevalence of poor fruit and vegetable intake, and poor smoking remained high in men whilst optimal levels of BMI was declined in women. To improve this situation, individual and population-based strategies that address body mass, smoking and fruit and vegetable intake are warranted for maximal health gains in stemming the development of cardiovascular events.

Life's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association

In 2010, the American Heart Association defined a novel construct of cardiovascular health to promote a paradigm shift from a focus solely on disease treatment to one inclusive of positive health promotion and preservation across the life course in populations and individuals. Extensive subsequent evidence has provided insights into strengths and limitations of the original approach to defining and quantifying cardiovascular health. In response, the American Heart Association convened a writing group to recommend enhancements and updates. The definition and quantification of each of the original metrics (Life's Simple 7) were evaluated for responsiveness to interindividual variation and intraindividual change. New metrics were considered, and the age spectrum was expanded to include the entire life course. The foundational contexts of social determinants of health and psychological health were addressed as crucial factors in optimizing and preserving cardiovascular health. This presidential advisory introduces an enhanced approach to assessing cardiovascular health: Life's Essential 8. The components of Life's Essential 8 include diet (updated), physical activity, nicotine exposure (updated), sleep health (new), body mass index, blood lipids (updated), blood glucose (updated), and blood pressure. Each metric has a new scoring algorithm ranging from 0 to 100 points, allowing generation of a new composite cardiovascular health score (the unweighted average of all components) that also varies from 0 to 100 points. Methods for implementing cardiovascular health assessment and longitudinal monitoring are discussed, as are potential data sources and tools to promote widespread adoption in policy, public health, clinical, institutional, and community settings.

A System-Wide Investigation and Stratification of the Hemostatic Proteome in Premature Myocardial Infarction

Introduction

Advancing understanding of key factors that determine the magnitude of the hemostatic response may facilitate the identification of individuals at risk of generating an occlusive thrombus as a result of an atherothrombotic event such as an acute Myocardial Infarction (MI). While fibrinogen levels are a recognized risk factor for MI, the association of thrombotic risk with other coagulation proteins is inconsistent. This is likely due to the complex balance of pro- and anticoagulant factors in any individual.

Methods

We compared measured levels of pro- and anticoagulant proteins in plasma from 162 patients who suffered an MI at an early age (MI <50 y) and 186 age- and gender-matched healthy controls with no history of CAD. We then used the measurements from these individuals as inputs for an established mathematical model to investigate how small variations in hemostatic factors affect the overall amplitude of the hemostatic response and to identify differential key drivers of the hemostatic response in male and female patients and controls.

Results

Plasma from the MI patients contained significantly higher levels of Tissue Factor (P = 0.007), the components of the tenase (FIX and FVIII; P < 0.0001 for both) and the prothrombinase complexes (FX; P = 0.003), and lower levels of Tissue Factor Pathway Inhibitor (TFPI; P = 0.033) than controls. The mathematical model, which generates time-dependent predictions describing the depletion, activation, and interaction of the main procoagulant factors and inhibitors, identified different patterns of hemostatic response between MI patients and controls, and additionally, between males and females. Whereas, in males, TF, FVIII, FIX, and the inhibitor TFPI contribute to the differences seen between case and controls, and in females, FII, FVIII, and FIX had the greatest influence on the generation of thrombin. We additionally show that further donor stratification may be possible according to the predicted donor response to anticoagulant therapy.

Conclusions

We suggest that modeling could be of value in enhancing our prediction of risk of premature MI, recurrent risk, and therapeutic efficacy.

Investigating the associations between childhood trauma and cardiovascular health in midlife

Growing evidence suggests that childhood trauma is associated with poorer cardiovascular health in adulthood, but few studies have examined potential mediators of these associations. We examined the links between different forms of childhood trauma (i.e., abuse, neglect, cumulative trauma) and cardiovascular health and explored potential mediators. Cross-sectional data from 1,251 participants in the National Survey of Midlife Development in the United States' II Biomarker Project were analyzed. Path analyses were conducted to examine the associations between childhood trauma and cardiovascular health (i.e., American Heart Association's Life's Simple 7 [LS7] score). Depressive symptoms and sleep quality were explored as potential mediators, and exploratory analyses examined whether these associations were moderated by sex. Women reported more severe childhood emotional and sexual abuse and emotional neglect, p < .001 to p = .018, and higher LS7 scores, p = .027, than men. Path analyses demonstrated the total effects of increasing severity of all forms of childhood trauma with LS7 scores were significant, and cumulative childhood trauma was inversely associated with LS7 score Bs = -0.306- -0.076, p < .001-p = .048. The range of total effects of different forms of childhood trauma on LS7 scores mediated by depressive symptoms and sleep quality was 26.8%-57.5%. Sex moderated the associations between all forms of childhood trauma and cardiovascular health. Longitudinal studies are needed that examine mediators of the associations between childhood trauma and cardiovascular health. Findings suggest sex-specific, trauma-informed approaches for cardiovascular disease prevention in adults exposed to childhood trauma may be needed.

Absolute and Relative Agreement between the Current and Modified Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) and the American Heart Association Healthy Diet Score (AHA-DS) in Post Myocardial Infarction Patients

The American Heart Association Diet Score (AHA-DS) defines the cardiovascular health, and the Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) was designed to evaluate diet quality in secondary cardiovascular prevention settings. Our aim was to assess the absolute and relative agreement between both tools in Brazilian adults after a myocardial infarction (MI). In this cross-sectional study, 473 individuals were included and had their diet assessed by a 24 h food recall and a semi-quantitative Food Frequency Questionnaire. The weighted Kappa between BALANCE DI and primary AHA-DS was 0.66 (95% CI: 0.08-0.21), and between BALANCE DI and total AHA-DS was 0.70 (95% CI: 0.20-0.32). To improve the agreement between the tools, modifications were made to the BALANCE DI scoring system. The weighted Kappa between New BALANCE DI and primary AHA-DS was 0.77 (95% CI: 0.36-0.48), and between BALANCE DI and total AHA-DS was 0.76 (95% CI: 0.34-0.46). The mean bias observed between the New BALANCE DI as compared to the primary and total AHA-DS was -16% (-51 to 19) and -8% (-41 to 24), respectively. Our results suggest that the New BALANCE DI may be a useful tool to evaluate diet quality in post MI patients.

Mediation effect of arterial stiffness on ideal cardiovascular health and stroke

BACKGROUND AND AIMS

Ideal cardiovascular health (CVH) metrics was associated with stroke, but the causal pathway was poorly investigated. Arterial stiffness was a major factor associated with both ideal CVH metrics and stroke. This study aimed to investigate whether the effect of ideal CVH metrics on stroke was mediated and enhanced by arterial stiffness.

METHODS AND RESULTS

A total of 15,297 participants were included in current study. Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV). Causal mediation analyses were used to separate the overall effects of ideal CVH metrics on stroke into indirect effects (mediated by arterial stiffness) and direct effects (mediated through pathways other than arterial stiffness). After a median follow-up of 5.88 years, 324 total stroke events (292 ischemic stroke and 31 hemorrhagic stroke) occurred. Mediation analysis showed 23.94% of the relation between ideal CVH and total stroke was mediated by baPWV (95% confidence interval [CI] of the indirect effect: 0.93-0.95). Further analysis showed the ideal CVH < median combined with baPWV ≥1400 cm/s was associated with the highest risk of total stroke (hazard ratio: 5.62; 95% CI, 3.53-8.96), compared with CVH ≥ median combined with baPWV < 1400 cm/s. Similar results were observed for ischemic stroke, but not for hemorrhagic stroke.

CONCLUSIONS

Arterial stiffness played a mediating role in the associations between ideal CVH metrics and risk of total and ischemic stroke. Combined ideal CVH metrics and baPWV is a reasonable and useful tool for the assessment and prevention of stroke.

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.

Ideal cardiovascular health in women with systemic lupus erythematosus: Association with arterial stiffness, inflammation, and fitness

BACKGROUND

Systemic Lupus Erythematosus (SLE) is closely related to cardiovascular morbidity and mortality. We aimed to examine the association of ideal cardiovascular health (ICH) with arterial stiffness, inflammation, and physical fitness in women with SLE.

METHODS

This cross-sectional study included 76 women with SLE (age 43.4±13.8 years old). Ideal levels of 7 health metrics (smoking, body mass index, physical activity, healthy diet, blood pressure, cholesterol, and glucose) were used to define the ICH score (ranging from 0 to 7 ideal metrics) and the ICH status ( defined as presenting ≥4 ideal metrics). Arterial stiffness was measured through pulse wave velocity (PWV) and inflammation through serum high sensitivity C-reactive protein (hs-CRP). Cardiorespiratory fitness (CRF) was measured by 6-min walk test (6MWT), and Siconolfi step test and muscular strength by handgrip strength and 30-s chair stand, and range of motion (ROM) by the back-scratch test.

RESULTS

Higher ICH score was associated with lower PWV (β = -0.122, p = 0.002), lower hs-CRP (β = -0.234, p = 0.056), higher CRF [6MWT (β = 0.263, p = 0.041); Siconolfi step test (β = 0.330, p < 0.001)], higher ROM (β = 0.278, p = 0.013) and higher relative handgrip strength (β = 0.248, p = 0.024). Women with ICH status presented lower PWV (mean difference 0.40 m/s, 95% CI 0.17 to 0.63, p = 0.001), and higher CRF [assessed by 6MWT (mean difference 43.9 m, 95% CI 5.0 to 82.7, p = 0.028)], than women with non-ICH status. Sensitivity analyses using ICH score ranging 0-14 and considering ICH status with ≥5 metrics revealed consistent results.

CONCLUSION

ICH is associated with lower arterial stiffness, lower inflammation, and higher fitness in women with SLE. Although these results extend current knowledge about the potential role of ICH for primordial prevention of CVD in SLE, they are yet to be confirmed in future prospective research .

Association of Changes in Cardiovascular Health Metrics and Risk of Subsequent Cardiovascular Disease and Mortality

Background

The extent to which change in cardiovascular health (CVH) in midlife reduces risk of subsequent cardiovascular disease and mortality is unclear.

Methods and Results

CVH was computed at 2 ARIC (Atherosclerosis Risk in Communities) study visits in 1987 to 1989 and 1993 to 1995, using 7 metrics (smoking, body mass index, total cholesterol, blood glucose, blood pressure, physical activity, and diet), each classified as poor, intermediate, and ideal. Overall CVH was classified as poor, intermediate, and ideal to correspond to 0 to 2, 3 to 4, and 5 to 7 metrics at ideal levels. There 10 038 participants, aged 44 to 66 years that were eligible. From the first to the second study visit, there was an improvement in overall CVH for 17% of participants and a decrease in CVH for 21% of participants. At both study visits, 28%, 27%, and 6% had poor, intermediate, and ideal overall CVH, respectively. Compared with those with poor CVH at both visits, the risk of cardiovascular disease (hazard ratio [HR], 0.26; 95% CI, 0.20–0.34) and mortality (HR, 0.35; 95% CI, 0.29–0.44) was lowest in those with ideal CVH at both measures. Improvement from poor to intermediate/ideal CVH was also associated with a lower risk of cardiovascular disease (HR, 0.67; 95% CI, 0.59–0.75) and mortality (HR, 0.80; 95% CI, 0.72–0.89).

Conclusions

Improvement in CVH or stable ideal CVH, compared with those with poor CVH over time, is associated with a lower risk of incident cardiovascular disease and all‐cause mortality. The change in smoking status and cholesterol may have accounted for a large part of the observed association.

Sexual Identity, Adverse Life Experiences, and Cardiovascular Health in Women

BACKGROUND

Adverse life experiences (ALE; eg, discrimination and sexual abuse) may contribute to cardiovascular disease (CVD) risk in sexual minority women (SMW), but few studies have tested whether ALE explain the association of sexual identity with cardiovascular health (CVH) markers in women.

OBJECTIVE

The aim of this study was to examine sexual identity differences in CVH among women and the role of ALE.

METHODS

In the Epidemiologic Study of Risk in Women, we used multinomial logistic regression to assess sexual identity differences (SMW vs heterosexual women [reference group]) in CVH markers (ideal vs poor, intermediate vs poor) using the American Heart Association's Life's Simple 7 metric and the total score. Next, we tested whether the association of sexual identity with the total CVH score was attenuated by traditional CVD risk factors or ALE.

RESULTS

The sample consisted of 867 women (395 heterosexual, 472 SMW). Sexual minority women were more likely to have experienced discrimination (P < .001) and lifetime sexual abuse (P < .001) than heterosexual women. Sexual minority women were also less likely to meet ideal CVH criteria for current tobacco use (adjusted odds ratio, 0.43; 95% confidence interval, 0.24-0.73) or intermediate CVH criteria for body mass index (adjusted odds ratio, 0.60; 95% confidence interval, 0.40-0.92). Sexual minority women had a lower cumulative CVH score (B [SE] = -0.35 [0.14], P < .01) than heterosexual women. This difference was not explained by traditional CVD risk factors or ALE.

CONCLUSIONS

Smoking, body mass index, and fasting glucose accounted for much of the CVH disparity due to sexual identity, but those differences were not explained by ALE. Health behavior interventions tailored to SMW should be considered.

Sex differences in the association between ideal cardiovascular health and biomarkers of cardiovascular disease among adults in the United States: a cross-sectional analysis from the multiethnic study of atherosclerosis

OBJECTIVES

This study investigated the sex differences in the associations between ideal cardiovascular health (CVH), measured by the American Heart Association's Life's Simple 7 metrics, and cardiovascular disease (CVD)-related biomarkers among an ethnically diverse cohort of women and men free of clinical CVD at baseline.

SETTING

We analysed data from the Multi-Ethnic Study of Atherosclerosis conducted in six centres across the USA (Baltimore, Maryland; Chicago, Illinois; Forsyth County, North Carolina; Los Angeles, California; New York, New York; and St Paul, Minnesota).

PARTICIPANTS

This is a cross-sectional study of 5379 women and men, aged 45-84 years old. Mean age (SD) was 62 (10), 52% were women, 38% White, 11% Chinese American, 28% Black and 23% Hispanic.

PRIMARY MEASURES

The seven metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood pressure and blood glucose) were each scored as 0 points (poor), 1 point (intermediate) or 2 points (ideal). The total CVH score ranged from 0 to 14. The CVD-related biomarkers studied were high-sensitivity C-reactive protein, D-dimer, fibrinogen, homocysteine, high-sensitivity cardiac troponin T, N-terminal pro B-type natriuretic peptide (NT-proBNP) and interleukin 6. We examined the association between the CVH score and each biomarker using multivariable linear regression, adjusting for age, race/ethnicity, education, income and health insurance status.

RESULTS

Higher CVH scores were associated with lower concentrations of all biomarkers, except for NT-proBNP where we found a direct association. There were statistically significant interactions by sex for all biomarkers (p<0.001), but results were qualitatively similar between women and men.

CONCLUSION

A more favourable CVH score was associated with lower levels of multiple CVD-related biomarkers for women and men, except for NT-proBNP. These data suggest that promotion of ideal CVH would have similarly favourable impact on the reduction of biomarkers of CVD risk for both women and men.

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.

Frequent, short bouts of light-intensity exercises while standing decreases systolic blood pressure: Breaking Up Sitting Time after Stroke (BUST-Stroke) trial

Background

Stroke survivors sit for long periods each day. Uninterrupted sitting is associated with increased risk of cardiovascular disease. Breaking up uninterrupted sitting with frequent, short bouts of light-intensity physical activity has an immediate positive effect on blood pressure and plasma clotting factors in healthy, overweight, and type 2 diabetic populations.

Aim

We examined the effect of frequent, short bouts of light-intensity physical activity on blood pressure and plasma fibrinogen in stroke survivors.

Methods

Prespecified secondary analyses from a three-armed randomized, within-participant, crossover trial. Participants were 19 stroke survivors (nine female, aged 68 years old, 90% able to walk independently). The experimental conditions were sitting for 8 h uninterrupted, sitting with 3 min bouts of light-intensity exercise while standing every 30 min, or sitting with 3 min of walking every 30 min. Blood pressure was measured every 30 min over 8 h and plasma fibrinogen at the beginning, middle, and end of each day. Intention-to-treat analyses were performed using linear mixed models including fixed effects for condition, period, and order, and a random intercept for participant to account for repeated measures and missing data.

Results

Sitting with 3 min bouts of light-intensity exercise while standing every 30 min decreased systolic blood pressure by 3.5 mmHg (95% CI 1.7–5.4) compared with sitting for 8 h uninterrupted. For participants not taking antihypertensive medications, sitting with 3 min of walking every 30 min decreased systolic blood pressure by 5.0 mmHg (95% CI −7.9 to 2.0) and sitting with 3 min bouts light-intensity exercise while standing every 30 min decreased systolic blood pressure by 4.2 mmHg (95% CI −7.2 to −1.3) compared with sitting for 8 h uninterrupted. There was no effect of condition on diastolic blood pressure (p = 0.45) or plasma fibrinogen levels (p = 0.91).

Conclusion

Frequent, short bouts of light-intensity physical activity decreases systolic blood pressure in stroke survivors. However, before translation into clinical practice, the optimal duration and timing of physical activity bouts needs to be determined.

Clinical trial registration

Australian and New Zealand Clinical Trials Registry http://www.anzctr.org.au ANZTR12615001189516.