Life's Essential 8 and 10-Year and Lifetime Risk of Atherosclerotic Cardiovascular Disease in China

Makarem N., Castro‐Diehl C., St‐Onge M., Redline S., Shea S., Lloyd‐Jones D., Ning H., Aggarwal B.

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

Lloyd-Jones D.M., Ning H., Labarthe D., Brewer L., Sharma G., Rosamond W., Foraker R.E., Black T., Grandner M.A., Allen N.B., Anderson C., Lavretsky H., Perak A.M.

Background: The American Heart Association recently published an updated algorithm for quantifying cardiovascular health (CVH)—the Life’s Essential 8 score. We quantified US levels of CVH using the new score. Methods: We included individuals ages 2 through 79 years (not pregnant or institutionalized) who were free of cardiovascular disease from the National Health and Nutrition Examination Surveys in 2013 through 2018. For all participants, we calculated the overall CVH score (range, 0 [lowest] to 100 [highest]), as well as the score for each component of diet, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose, and blood pressure, using published American Heart Association definitions. Sample weights and design were incorporated in calculating prevalence estimates and standard errors using standard survey procedures. CVH scores were assessed across strata of age, sex, race and ethnicity, family income, and depression. Results: There were 23 409 participants, representing 201 728 000 adults and 74 435 000 children. The overall mean CVH score was 64.7 (95% CI, 63.9–65.6) among adults using all 8 metrics and 65.5 (95% CI, 64.4–66.6) for the 3 metrics available (diet, physical activity, and body mass index) among children and adolescents ages 2 through 19 years. For adults, there were significant differences in mean overall CVH scores by sex (women, 67.0; men, 62.5), age (range of mean values, 62.2–68.7), and racial and ethnic group (range, 59.7–68.5). Mean scores were lowest for diet, physical activity, and body mass index metrics. There were large differences in mean scores across demographic groups for diet (range, 23.8–47.7), nicotine exposure (range, 63.1–85.0), blood glucose (range, 65.7–88.1), and blood pressure (range, 49.5–84.0). In children, diet scores were low (mean 40.6) and were progressively lower in higher age groups (from 61.1 at ages 2 through 5 to 28.5 at ages 12 through 19); large differences were also noted in mean physical activity (range, 63.1–88.3) and body mass index (range, 74.4–89.4) scores by sociodemographic group. Conclusions: The new Life’s Essential 8 score helps identify large group and individual differences in CVH. Overall CVH in the US population remains well below optimal levels and there are both broad and targeted opportunities to monitor, preserve, and improve CVH across the life course in individuals and the population.

Lloyd-Jones D.M., Allen N.B., Anderson C.A., Black T., Brewer L.C., Foraker R.E., Grandner M.A., Lavretsky H., Perak A.M., Sharma G., Rosamond W.

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.

Zhou Y., Chen S., Wang G., Chen S., Zhang Y., Chen J., Tu Z., Liu G., Wu S., Pan A.

Limited studies had investigated the potential benefits of workplace-based hypertension management programs on long-term blood pressure (BP) control and health outcomes. This study used the propensity score matching to examine the effectiveness of a workplace-based hypertension management program on BP control and risks of major adverse cardiovascular events and all-cause mortality. Within the Kailuan study, a workplace-based hypertension management program was initiated in 2009 among men with hypertension, which included regular BP measuring (twice a month), free antihypertensive medications, and individualized health consultation. Participants were followed until loss to follow-up, death, or December 31, 2019. Among 17 724 male hypertensives aged 18 to 60 years, 6400 participated in the program. The propensity score matching yielded 6120 participants in the management group and 6120 participants in the control group. Both systolic and diastolic BPs were significantly lower in the management group than in the control group over follow-up, and the mean between-group difference at the 10th year was −7.83 (95% CI, −9.06 to −6.62) mm Hg for systolic BP and −4.72 (95% CI, −5.46 to −3.97) mm Hg for diastolic BP. Participants in the program were more likely to achieve BP control (odds ratio, 1.70 [95% CI, 1.41–2.06]) and had significantly lower risks of major adverse cardiovascular events (hazard ratio, 0.83 [95% CI, 0.72–0.94]) and all-cause mortality (hazard ratio, 0.71 [95% CI, 0.58–0.86]), compared with those who were not in the program. A workplace-based hypertension management program was related to reduced BP levels and lower risks of major adverse cardiovascular events and mortality in Chinese men with hypertension.

Wang L., Song L., Li D., Zhou Z., Chen S., Yang Y., Hu Y., Wang Y., Wu S., Tian Y.

Background Cardiovascular health (CVH) status is associated with cardiovascular diseases (CVD). However, evidence for association of CVH change with risk of CVD is scarce. Methods and Results Seven metrics (smoking status, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting blood glucose) were used to evaluate the CVH status. Having 0 to 2, 3 to 4, and 5 to 7 ideal cardiovascular metrics were categorized as low, moderate, and high CVH status, respectively. Change in CVH status was assessed from 2006/2007 to 2010/2011. We calculated lifetime risk of CVD using a modified Kaplan–Meier method, and life expectancy was evaluated via the multistate lifetable method. There were 82 349 participants included in our analysis. At 35 years index age, the age‐adjusted incident rate and lifetime risk of CVD were increased with decreasing number of ideal CVH metrics. The direction of change in status of CVH was consistently associated with age‐adjusted incident rate and lifetime risk of CVD. At 35 years index age, improvement from low to moderate (37.6% [95% CI, 32.8%–42.4%]) or to high status (24.4% [95% CI, 12.7%–36.0%]) had lower lifetime risk of CVD compared with consistently low status (44.6% [95% CI, 40.8%–48.5%]). The improvement in CVH could prolong the years of life free from CVD. The pattern of incident rate and lifetime risk across change in CVH status was similar at 45 and 55 years index age. Conclusions Higher number of CVH metrics was associated with lower lifetime risk of CVD. The improvement of CVH status could reduce the lifetime risk of CVD and prolonged the year of life free from CVD.

Roth G.A., Mensah G.A., Johnson C.O., Addolorato G., Ammirati E., Baddour L.M., Barengo N.C., Beaton A.Z., Benjamin E.J., Benziger C.P., Bonny A., Brauer M., Brodmann M., Cahill T.J., Carapetis J., et. al.

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases.

Gaye B., Tajeu G.S., Vasan R.S., Lassale C., Allen N.B., Singh‐Manoux A., Jouven X.

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.

Ahmed A., Pinto Pereira S.M., Lennon L., Papacosta O., Whincup P., Wannamethee G.

Background and Purpose: Research exploring the utility of cardiovascular health (CVH) and its Life’s Simple 7 (LS7) components (body mass index, blood pressure [BP], glucose, cholesterol, physical activity, smoking, and diet) for prevention of stroke in older adults is limited. In the British Regional Heart Study, we explored (1) prospective associations of LS7 metrics and composite CVH scores with, and their impact on, stroke in middle and older age; and (2) if change in CVH was associated with subsequent stroke. Methods: Men without cardiovascular disease were followed from baseline recruitment (1978–1980), and again from re-examination 20 years later, for stroke over a median period of 20 years and 16 years, respectively. LS7 were measured at each time point except baseline diet. Cox models estimated hazard ratios (95% CI) of stroke for (1) ideal and intermediate versus poor levels of LS7; (2) composite CVH scores; and (3) 4 CVH trajectory groups (low-low, low-high, high-low, high-high) derived by dichotomising CVH scores from each time point across the median value. Population attributable fractions measured impact of LS7. Results: At baseline (n=7274, mean age 50 years), healthier levels of BP, physical activity, and smoking were associated with reduced stroke risk. At 20-year follow-up (n=3798, mean age 69 years) only BP displayed an association. Hazard ratios for intermediate and ideal (versus poor) levels of BP 0.65 (0.52–0.81) and 0.40 (0.24–0.65) at baseline; and 0.84 (0.67–1.05) and 0.57 (0.36–0.90) at 20-year follow-up. With reference to low-low trajectory, the low-high trajectory was associated with 40% reduced risk, hazard ratio 0.60 (0.44–0.83). Associations of CVH scores weakened, and population attributable fractions of LS7 reduced, from middle to old age; population attributable fraction of nonideal BP from 53% to 39%. Conclusions: Except for BP, CVH is weakly associated with stroke at older ages. Prevention strategies for older adults should prioritize BP control but also enhance focus beyond traditional risk factors.

Li X., Krumholz H.M., Yip W., Cheng K.K., De Maeseneer J., Meng Q., Mossialos E., Li C., Lu J., Su M., Zhang Q., Xu D.R., Li L., Normand S.T., Peto R., et. al.

Summary China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.

Zhou M., Wang H., Zeng X., Yin P., Zhu J., Chen W., Li X., Wang L., Wang L., Liu Y., Liu J., Zhang M., Qi J., Yu S., Afshin A., et. al.

Summary Background Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. Methods We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). Findings Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (–3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). Interpretation China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. Funding China National Key Research and Development Program and Bill & Melinda Gates Foundation.

Wu S., Wu B., Liu M., Chen Z., Wang W., Anderson C.S., Sandercock P., Wang Y., Huang Y., Cui L., Pu C., Jia J., Zhang T., Liu X., Zhang S., et. al.

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

Liu S., Li Y., Zeng X., Wang H., Yin P., Wang L., Liu Y., Liu J., Qi J., Ran S., Yang S., Zhou M.

Cardiovascular disease (CVD) remains the top cause of death in China. To our knowledge, no consistent and comparable assessments of CVD burden have been produced at subnational levels, and little is understood about the spatial patterns and temporal trends of CVD in China.To determine the national and province-level burden of CVD from 1990 to 2016 in China.Following the methodology framework and analytical strategies used in the 2016 Global Burden of Disease study, the mortality, prevalence, and disability-adjusted life-years (DALYs) of CVD in the Chinese population were examined by age, sex, and year and according to 10 subcategories. Estimates were produced for all province-level administrative units of mainland China, Hong Kong, and Macao.Residence in China.Mortality, prevalence, and DALYs of CVD.The annual number of deaths owing to CVD increased from 2.51 million to 3.97 million between 1990 and 2016; the age-standardized mortality rate fell by 28.7%, from 431.6 per 100 000 persons in 1990 to 307.9 per 100 000 in 2016. Prevalent cases of CVD doubled since 1990, reaching nearly 94 million in 2016. The age-standardized prevalence rate of CVD overall increased significantly from 1990 to 2016 by 14.7%, as did rates for ischemic heart disease (19.1%), ischemic stroke (36.6%), cardiomyopathy and myocarditis (23.1%), and endocarditis (26.7%). Substantial reduction in the CVD burden, as measured by age-standardized DALY rate, was observed from 1990 to 2016 nationally, with a greater reduction in women (43.7%) than men (24.7%). There were marked differences in the spatial patterns of mortality, prevalence, and DALYs of CVD overall as well as its main subcategories, including ischemic heart disease, hemorrhagic stroke, and ischemic stroke. The CVD burden appeared to be lower in coastal provinces with higher economic development. The between-province gap in relative burden of CVD increased from 1990 to 2016, with faster decline in economically developed provinces.Substantial discrepancies in the total CVD burden and burdens of CVD subcategories have persisted between provinces in China despite a relative decrease in the CVD burden. Geographically targeted considerations are needed to tailor future strategies to enhance CVD health throughout China and in specific provinces.

Zhao D., Liu J., Wang M., Zhang X., Zhou M.

Cardiovascular disease (CVD) is the leading cause of death in China. To develop effective and timely strategies to cope with the challenges of CVD epidemics, we need to understand the current epidemiological features of the major types of CVD and the implications of these features for the prevention and treatment of CVD. In this Review, we summarize eight important features of the epidemiology of CVD in China. Some features indicate a transition in CVD epidemiology owing to interrelated changes in demography, environment, lifestyle, and health care, including the rising burden from atherosclerotic CVD (ischaemic heart disease and ischaemic stroke), declining mortality from haemorrhage stroke, varied regional epidemiological trends in the subtypes of CVD, increasing numbers of patients with moderate types of ischaemic heart disease and ischaemic stroke, and increasing ageing of patients with CVD. Other features highlight the problems that need particular attention, including the high proportion of out-of-hospital death of patients with ischaemic heart disease with insufficient prehospital care; the wide gaps between guideline-recommended goals and levels of lifestyle indicators; and the huge number of patients with undiagnosed, untreated, or uncontrolled hypertension, hypercholesterolaemia, or diabetes mellitus. Cardiovascular disease (CVD) is the leading cause of death in China. In this Review, Zhao and colleagues summarize eight important features of the evolving epidemiology of CVD in China and discuss how this information can help to develop effective and timely strategies to prevent and treat CVD.

van Sloten T.T., Tafflet M., Périer M., Dugravot A., Climie R.E., Singh-Manoux A., Empana J.

Importance There is consistent evidence of the association between ideal cardiovascular health and lower incident cardiovascular disease (CVD); however, most studies used a single measure of cardiovascular health. Objective To examine how cardiovascular health changes over time and whether these changes are associated with incident CVD. Design, Setting, and Participants Prospective cohort study in a UK general community (Whitehall II), with examinations of cardiovascular health from 1985/1988 (baseline) and every 5 years thereafter until 2015/2016 and follow-up for incident CVD until March 2017. Exposures Using the 7 metrics of the American Heart Association (nonsmoking; and ideal levels of body mass index, physical activity, diet, blood pressure, fasting blood glucose, and total cholesterol), participants with 0 to 2, 3 to 4, and 5 to 7 ideal metrics were categorized as having low, moderate, and high cardiovascular health. Change in cardiovascular health over 10 years between 1985/1988 and 1997/1999 was considered. Main Outcome and Measure Incident CVD (coronary heart disease and stroke). Results The study population included 9256 participants without prior CVD (mean [SD] age at baseline, 44.8 [6.0] years; 2941 [32%] women), of whom 6326 had data about cardiovascular health change. Over a median follow-up of 18.9 years after 1997/1999, 1114 incident CVD events occurred. In multivariable analysis and compared with individuals with persistently low cardiovascular health (consistently low group, 13.5% of participants; CVD incident rate per 1000 person-years, 9.6 [95% CI, 8.4-10.9]), there was no significant association with CVD risk in the low to moderate group (6.8% of participants; absolute rate difference per 1000 person-years, −1.9 [95% CI, −3.9 to 0.1]; HR, 0.84 [95% CI, 0.66-1.08]), the low to high group, (0.3% of participants; absolute rate difference per 1000 person-years, −7.7 [95% CI, −11.5 to −3.9]; HR, 0.19 [95% CI, 0.03-1.35]), and the moderate to low group (18.0% of participants; absolute rate difference per 1000 person-years, −1.3 [95% CI, −3.0 to 0.3]; HR, 0.96 [95% CI, 0.80-1.15]). A lower CVD risk was observed in the consistently moderate group (38.9% of participants; absolute rate difference per 1000 person-years, −4.2 [95% CI, −5.5 to −2.8]; HR, 0.62 [95% CI, 0.53-0.74]), the moderate to high group (5.8% of participants; absolute rate difference per 1000 person-years, −6.4 [95% CI, −8.0 to −4.7]; HR, 0.39 [95% CI, 0.27-0.56]), the high to low group (1.9% of participants; absolute rate difference per 1000 person-years, −5.3 [95% CI, −7.8 to −2.8]; HR, 0.49 [95% CI, 0.29-0.83]), the high to moderate group (9.3% of participants; absolute rate difference per 1000 person-years, −4.5 [95% CI, −6.2 to −2.9]; HR, 0.66 [95% CI, 0.51-0.85]), and the consistently high group (5.5% of participants; absolute rate difference per 1000 person-years, −5.6 [95% CI, −7.4 to −3.9]; HR, 0.57 [95% CI, 0.40-0.80]). Conclusions and Relevance Among a group of participants without CVD who received follow-up over a median 18.9 years, there was no consistent relationship between direction of change in category of a composite metric of cardiovascular health and risk of CVD.

Enserro D.M., Vasan R.S., Xanthakis V.

Background Data on the temporal trends in ideal cardiovascular health ( CVH ) as well as on their association with subclinical/overt cardiovascular disease ( CVD ) and death are limited. Methods and Results This study included 3460 participants attending ≥1 of 4 consecutive exams of the Framingham Heart Study (1991–2008, mean age 55.4 years, CVH score ranged 0–14). We created 4 groups describing changes in CVH score between examination cycles 5 and 8, using first and last exams attended (high‐high: starting CVH score ≥8, last score of ≥8, referent; high‐low: ≥8 start and ≤7 last; low‐high: ≤7 start and ≥8 last; and low‐low: ≤7 start and ≤7 last) and related them to subclinical CVD cross‐sectionally, and incident CVD and death. Fewer people have ideal CVH scores over the past 20 years (8.5% for 1991–1995, 5.9% for 2005–2008, P =0.002), because of decreases in those with ideal status of body mass index, blood glucose, and serum cholesterol levels ( P <0.05 for all). The odds of subclinical disease and risk of CVD and death were higher for all compared with the high‐high group (428 CVD and 367 death events, median follow‐up 5.1 years, hazard ratios for CVD : 1.39, 1.73, 1.9 and death: 1.12, 1.57, 1.4 and odds ratios for subclinical disease: 1.61, 1.98, 2.86 for high‐low, low‐high, and low‐low, respectively). Conclusions The decreased presence of ideal CVH scores over the past 20 years resulted in increasing odds of subclinical disease and risk of CVD and death, emphasizing the importance of maintaining ideal CVH over the life course.

Shen W., Cai L., Wang B., Li J., Sun Y., Wang N., Lu Y.

Xu N., Lu X., Luo C., Chen J.

Martin S.S., Aday A.W., Allen N.B., Almarzooq Z.I., Anderson C.A., Arora P., Avery C.L., Baker-Smith C.M., Bansal N., Beaton A.Z., Commodore-Mensah Y., Currie M.E., Elkind M.S., Fan W., Generoso G., et. al.

BACKGROUND: The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year’s worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year’s edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year’s Statistical Update. RESULTS: Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Yao F., Zhang J., Li X., Sun M., Shih P., Li T.

ABSTRACTBackgroundLife's Essential 8 (LE8) is a recently updated algorithm for evaluating cardiovascular health (CVH). This study investigates the association between LE8 and mortality risk among individuals with arthritis in the United States.MethodsWe conducted a retrospective cohort study using data from the US National Health and Nutritional Examination Survey (NHANES) 2005–2018. Participants with arthritis were included. Mortality data, including underlying causes of death, were obtained through linkage to national death records up to December 31, 2019. LE8 components (diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, glucose, and pressure) were measured and scored from 0 to 100. The total LE8 score, calculated as the unweighted average of all components, was categorized into low (0–49), moderate (50–79), and high (80–100) CVH. We employed Kaplan–Meier curves to estimate survival probabilities and weighted Cox proportional hazards regression models to evaluate hazard ratios (HRs) with 95% confidence intervals (CIs) for all‐cause and cardiovascular disease (CVD) mortality. Stratified analyses and interaction tests were performed to explore potential effect modifications.ResultsAmong 4519 participants with arthritis (median follow‐up: 7.67 years), we observed 793 all‐cause deaths, including 213 CVD deaths. Every 10‐point increase in the LE8 score was associated with a 17% lower risk of all‐cause mortality (HR: 0.83, 95% CI: 0.77–0.89) and a 25% lower risk of CVD mortality (HR: 0.75, 95% CI: 0.66–0.85). Compared to the lowest CVH tertile, individuals in the highest tertile demonstrated a 38% lower risk of all‐cause mortality (HR: 0.62, 95% CI: 0.41–0.92) and a 62% lower risk of CVD mortality (HR: 0.38, 95% CI: 0.18–0.80). Kaplan–Meier survival curves revealed significantly higher survival probability for patients with high CVH compared to those with lower CVH (log‐rank p < 0.05). Stratified analyses confirmed consistent associations across various subgroups. Similar findings were observed in sensitivity analyses focusing on osteoarthritis and other arthritis subtypes.ConclusionHigher adherence to LE8 recommendations is associated with reduced risks of all‐cause and cardiovascular mortality among US adults with arthritis.

Wu S., Wang Y., Wang J., Feng J., Li F., Lin L., Ruan C., Nie Z., Tian J., Jin C.

Preventing cardiovascular disease (CVD) in adults with hypertension is essential, but it remains uncertain whether optimizing modifiable factors can eliminate the excess CVD risk associated with new-onset hypertension. In this prospective cohort study, 29,597 adults with new-onset hypertension and no prior CVD (from 2006–2016 surveys) were each matched by age and sex to a normotensive control. Eight modifiable factors were assessed using the American Heart Association’s Life’s Essential 8 algorithm. We followed participants for incident CVD until December 2020, estimating 10-year and lifetime (age 25–95) CVD risks using the Fine-Gray competing risks model. Over a median follow-up of 9.81 years, adults with new-onset hypertension had higher 10-year (8.97% vs. 6.31%) and lifetime CVD risks (45.55% vs. 34.98%) compared to normotensive controls. After adjusting for age, sex, and other unmodifiable factors, each additional favorable factor was associated with a stepwise reduction in CVD risk (P-trend < 0.05). Hypertensive participants with four or more favorable factors had a 17% lower 10-year CVD risk (HR 0.83; 95% CI 0.72–0.97) and a similar lifetime CVD risk (HR 0.90; 95% CI 0.78–1.05) compared to normotensive controls. Notably, the protective effect was weaker among those with early-onset (before age 45) hypertension than those with later-onset (age ≥ 60) hypertension (P-interaction < 0.05). In adults with new-onset hypertension, maintaining four or more modifiable factors at favorable levels was associated with a CVD risk comparable to that of normotensive individuals. However, young hypertensive adults may require more aggressive interventions to mitigate CVD risk.

Dai L., Jiang C., Cui Q., Huang L., Chen S., Zhang Y., Luo X., Zhang P., Li J., Zhang Y.

Moradi F., Zibaeenezhad M.J., Sayadi M., Jafari F., Javidi AL-e-Saadi S., Karami H., Jafarnezhad A., Rokhsari S., Gharghani A.A.

Guo H., Wang S., Peng H., Wang W., Hou T., Li Y., Zhang H., Jiang J., Ma B., Qin Y., Wang M., Li L., Huang J., Wu T.

Recently, the American Heart Association introduced Life's Essential 8 (LE8) as a new cardiovascular health (CVH) metric, and studies have reported associations between LE8 and CVH outcomes. However, there is limited understanding of LE8's impact on the risk of transitions between different stages of CVH. The current study investigated whether adhering to LE8 during a healthy stage could mitigate the progression from hypertension (HT) to cardiovascular diseases (CVDs), and consequent death.

Yang X., Ding S., Guo J., Peng S., Duan Z., Liu S.

INTRODUCTION: Few studies have investigated the association between Life's Essential 8 (LE8) and abnormal bowel health. We aimed to investigate the relationship between LE8 and diarrhea and constipation in the adult population of the United States. METHODS: This cross-sectional study, based on population data, used information from the National Health and Nutrition Examination Survey conducted between 2005 and 2010. Diarrhea and constipation were classified based on Bristol Stool Form Scale and stool frequency. LE8 score is composed of 4 health behaviors (diet, physical activity, nicotine exposure, and sleep health) and 4 health factors (body mass index, blood lipids, blood glucose, and blood pressure) and is classified into low (0–49), moderate (50–79), and high (80–100) cardiovascular health groups. Weighted logistic regression and restricted cubic splines were used to analyze the relationship between the LE8 score and abnormal bowel health. RESULTS: The study comprised 12,369 participants aged 20 years or older, among whom 1,279 (9.7%) had constipation and 1,097 (7.6%) had diarrhea. After adjusting for potential confounders, we observed negative associations between LE8 scores and diarrhea (odds ratio: 0.60, 95% confidence interval: 0.39–0.93), whereas the association between LE8 scores and constipation was not statistically significant (odds ratio: 0.82, 95% confidence interval: 0.59–1.13). In addition, health behavior scores and health factor scores were associated with constipation. DISCUSSION: Higher LE8 levels are associated with a lower incidence of diarrhea, but not constipation.

Nguyen X.T., Li Y., Gong Y., Houghton S., Ho Y., Pyatt M., Treu T., Li R., Akinosho K., Raghavan S., Gagnon D.R., Gaziano J.M., Wilson P.W., Cho K.

ImportanceThe American Heart Association proposed Life’s Essential 8 (LE8) as an enhanced measurement tool for cardiovascular health.ObjectiveTo examine the association of LE8 with risk of atherosclerotic cardiovascular disease (ASCVD) incidence and prognosis in veterans.Design, Setting, and ParticipantsThis was a prospective cohort study of US veterans enrolled in the Department of Veterans Affairs (VA) Million Veteran Program (MVP) between 2011 and 2022. Data were analyzed from 2023 to 2024.ExposureLE8 score ranged from 0 to 100, with higher score indicating better cardiovascular health.Main Outcomes and MeasuresThe primary outcome was total ASCVD incidence in veterans without baseline ASCVD, and the secondary outcome was incidence of a major adverse cardiovascular event (MACE) among veterans with and without ASCVD at baseline.ResultsA total of 413 052 veterans (mean [SD] age, 65.8 [12.1] years; 378 162 [91.6%] male) were included. Based on 1.7 million person-years of follow-up of 279 868 veterans without any ASCVD at baseline, 45 067 veterans had an ASCVD event during follow-up. Total LE8 score and each component LE8 factor score was associated with incident ASCVD in an inverse, linear, dose-response manner. For veterans without prior ASCVD, those with an LE8 score between 80 and 100 had lower risk of ASCVD compared with those with an LE8 score of 0 to 49 (adjusted hazard ratio [aHR], 0.36 [95% CI, 0.35-0.38]). Similarly, risk of MACE was significantly lower among veterans with an LE8 score of 80 to 100 regardless of baseline ASCVD status (with ASCVD: aHR, 0.52 [95% CI, 0.48-0.56]; without ASCVD: aHR, 0.14 [95% CI, 0.13-0.15]) compared with those with ASCVD and an LE8 score of 0 to 49.Conclusions and RelevanceIn this cohort study of US veterans, higher LE8 scores were associated with significantly lower ASCVD incidence risk and lower likelihood of developing adverse cardiovascular events regardless of ASCVD status at baseline. These results support the utility of LE8 for health promotion and ASCVD prevention.

Chen W., Tang Y., Si Y., Tu B., Xiao F., Bian X., Xu Y., Qin Y.

Abstract Background and Objectives The association between chronic kidney disease (CKD) and cardiovascular disease has been previously evaluated. This study aimed to evaluate the association between the American Heart Association’s Life’s Essential 8 (LE8) and the prevalence and all-cause mortality of CKD in a nationally representative population of adults in the US. Methods This retrospective analysis included participants from the National Health and Nutrition Examination Survey spanning 2015–2018. We used multivariable survey logistic regression model to calculate the adjusted odds ratios (AORs) of the LE8 score for the prevalence of CKD. Survey-weighted Cox proportional hazards models were used to calculate the adjusted hazards ratios (AHRs) of the LE8 score for the risk of all-cause mortality among participants with CKD. Results Of the 8907 included participants, 789 had stage 3 to 5 CKD, and 8118 were in the non-CKD group. The adjusted prevalence rate of CKD was 10.7% in the low LE8 score group, and lower in the moderate (7.9%) and high (7.7%) LE8 score groups. Compared with low LE8 scores, moderate LE8 score (adjusted odds ratio [AOR] 0.628, 95% confidence interval [CI]: 0.463 to 0.853, P = 0.004) and high LE8 scores (AOR 0.328, 95% CI: 0.142 to 0.759, P = 0.011) were associated with lower prevalence rates of CKD. A similar association was found for health factors scores. Additionally, an increase in the LE8 score was associated with a lower risk of all-cause mortality (adjusted hazard ratio [AHR] 0.702, 95% CI: 0.594 to 0.829, P < 0.001). Conclusion The results of this study suggest the association of higher LE8 and its subscale scores with a lower prevalence and all-cause mortality of CKD.

Hyde E.T., Nguyen S., LaMonte M., Di C., Bellettiere J., Tinker L.F., Foraker R., Tindle H., Stefanick M.L., LaCroix A.Z.

Liu Y., Qin X., Jiang J., Zhao M., Peng X., Cui F., Wang X., Feng J., Chen S., Wu S.

BACKGROUND: Evidence is lacking regarding long-term patterns of change in Life’s Essential 8 (LE8) and their association with the risk of stroke. We aim to evaluate LE8 trajectories and examine their association with the risk of stroke in China. METHODS: This study, conducted in a workplace setting, recruited 26 719 participants (average age, 46.02±11.27 years and a male population of 73.73%) who had no history of stroke and consecutively participated in 6 surveys from 2006 to 2016. Repeated LE8 measurements were determined by taking the unweighted average of the 8 component scores ranging from 0 to 100. People with higher scores had better overall cardiovascular health. By examining the medical records of the participants, stroke cases were identified for the period from 2016 to 2020. A latent mixture model was applied to classify the trajectory clusters of LE8 from 2006 to 2016, and Cox proportional hazard models were used to analyze the data. RESULTS: Five LE8 trajectories were detected between 2006 and 2016. Four hundred ninety-eight incident strokes including 55 (11.04%) hemorrhagic and 458 (91.97%) ischemic strokes were documented. After adjusting for covariates, the hazard ratios and 95% CIs for the association between stable-low, moderate-increasing, moderate-stable, and high-stable trajectories and incident stroke, compared with the moderate-decreasing trajectory, were 1.42 (1.11–1.84), 0.73 (0.56–0.96), 0.49 (0.39–0.62), and 0.19 (0.11–0.32), respectively. Individuals with high LE8 status (LE8≥80) exhibited a significantly reduced risk of stroke compared with those with low one (LE8≤49; P -trend <0.001). A faster annual growth in LE8 was related to a lower risk of stroke. CONCLUSIONS: Maintaining high LE8 over an extended period and high baseline LE8 status were related to a decreased risk of stroke. Despite the initial low level of LE8, improvement in LE8 attenuates or even reverses the risk of stroke.

Zhong J., Cai Q., Zheng W., Chen S., Wu S., Dong S.

We aimed to explore the association of socioeconomic status (SES) and life’s essential 8 (LE8) with cardiovascular disease (CVD) and all-cause mortality in north China. A total of 91,365 adults from the Kailuan study were included in this study. Comprehensive individual SES, mainly including monthly household income, education, Occupation position, and community environment, was confirmed by latent class analysis. Furthermore, the mediation and combination effects of SES and LE8 on CVD and all-cause mortality were further assessed. The Cox regression model was conducted to estimate HRs and 95% CI. During about 13 years of follow-up, 7,646 cardiovascular events and 11,749 deaths were recorded. Relative to the high SES, there were decreased risks of CVD [HR (95% CI): 1.57(1.43–1.72)] and high all-cause death [HR (95% CI): 1.43(1.31–1.53)] in the low SES. The associations between SES and CVD [Mediation % (95% CI): 22.3 (16.4–30.4)] and mortality [Mediation % (95% CI): 10.1 (7.1–14.0)] were partially mediated by LE8 when comparing medium SES to high SES. Meanwhile, relative to high LE8, the elevated risk of death [HR (95% CI): 1.72(1.56–1.89)], and incident CVD [HR (95% CI): 3.34(2.91–3.83)] were detected in low LE8. Compared to participants who had the high SES and LE8, participants who had both the low SES and LE8 further increased the risk of CVD [HR (95% CI): 7.76(5.21–11.55)] and all-cause mortality [HR (95% CI): 2.80(2.19–3.58)]. Low SES was related to a higher risk of CVD and mortality in low- and middle-income countries, which was partially mediated by LE8.

Liu S., Qian F., Lu Q., Deng Y., Qu W., Lin X., Li R., Li R., Guo T., Pan A., Liu G.

To examine the association of Life's Essential 8 (LE8) with the risk of recurrent cardiovascular events among patients with CHD.