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

https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106486Get rights and content

Abstract

Background

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

Methods

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

Results

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

Conclusions

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

Introduction

Cardiovascular disease (CVD), including stroke, is a major cause of morbidity and mortality in the United States (US) with direct and indirect costs exceeding $350 billion annually.1 The prevalence of stroke, a leading cause of disability, cognitive impairment and mortality among U.S. adults was 2.5% in 2016.1 By 2030, almost 4% of U.S. adults will have experienced a stroke, which will represent a 20.5% increase from 2012.2 Stroke causes impaired mobility in more than half of stroke survivors age 65 and over.1 Given the aging population and a higher risk of stroke with advancing age, the burden of disability among stroke survivors and economic burden will continue to rise if primary prevention strategies are not implemented.

Data from the Global Burden of Disease Study suggest that approximately 90% of CVD and stroke can be prevented through optimizing modifiable risk factors such as hypertension, obesity, hyperglycemia, hyperlipidemia, and that over 70% of strokes are attributable to health behaviors, such as smoking, sedentary lifestyle and unhealthy diet.3 Improving health behaviors can avert the occurrence and recurrence of stroke. Despite robust evidence on the contribution of a healthy lifestyle, most US adults eat unhealthy diets and have sedentary lifestyles.4,5

The American Heart Association (AHA) developed the “Life's Simple 7 (LS7)” metric which includes seven modifiable components, including 3 health factors (glucose, cholesterol, and blood pressure) and 4 health behaviors (body mass index, physical activity, diet, and cigarette smoking), with each of the 7 indices categorized into ideal, intermediate, and poor levels.6 Only 2% of adults in the U.S. meet all 7 CVH metrics.7,8 Prior studies, including adults free from CVD, have suggested that having ideal levels of the LS7 metric is associated with lower cardiovascular and all-cause mortality.9,10

In a study based on data from the Atherosclerosis Risk in Communities (ARIC) study11, LS7 scores at middle age were inversely associated with adverse outcomes after myocardial infarction (MI), independently of access to care and MI severity. However, pathophysiology and treatment of stroke are distinct from MI, and it is unknown whether a similar pattern holds for stroke.

Thus, we sought to characterize the associations of the LS7 metric at middle-age with the risk of incident stroke, as well as CVD, recurrent stroke, and all-cause mortality after an incident stroke. We hypothesized that stroke risk would be lower in individuals with better CVH in midlife, and stroke survivors with better CVH (higher LS7 scores) at midlife (pre-stroke) would have lower risk of post-stroke CVD, recurrent stroke, and all-cause mortality than those with poorer baseline CVH.

Section snippets

Study population and design

We used data from the ARIC study, an ongoing community-based cohort of 15,792 middle-aged men and women aged 45–64 years at baseline (1987–1989) selected from four U.S. communities (Forsyth County, North Carolina; the city of Jackson, Mississippi; eight northern suburbs of Minneapolis, Minnesota; and Washington County, Maryland).12 Follow-up of ARIC cohort participants is conducted through active surveillance of hospitalizations and vital status and repeat clinic visits. Of the 15,792

Association between Life's Simple 7 scores at midlife and incident stroke

The baseline characteristics of 13,508 participants free of prevalent stroke stratified by LS7 scores at midlife are summarized in Table 1. The baseline characteristics of participants who had incident stroke up to December 31, 2016, stratified by LS7 scores at Visit 1 are described in Table 2. The mean age at baseline among the 1,218 participants who had incident stroke was 56 years and 36% were black. Also, 57.4% of stroke survivors had LS7 scores ≥7 and 14.6 % had LS7 scores ≥10 at baseline (

Discussion

We undertook this investigation to determine whether cardiovascular health at midlife was associated with incident stroke and CVD after stroke and recurrent stroke in a community-based sample of Black and White adults. We observed an inverse association between LS7 scores at midlife and risk of incident stroke and adverse CVD outcomes among stroke survivors. Specifically, higher LS7 scores were associated with lower risk of MI and HF, but not recurrent stroke after adjusting for

Conclusion

In a large community-based prospective study of White and Black adults, better CVH in mid-life was associated with lower risk of incident stroke and recurrent CVD after stroke. Ideal levels of BP, fasting blood glucose and smoking status were associated with lower risk of CVD or death after incident stroke. Clinicians should emphasize the importance of good CVH at midlife for the primary prevention of stroke and recurrent adverse CVD outcomes including mortality.

Sources of funding

The ARIC Study has been funded in whole or in part with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under Contract Nos.HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700004I, and HHSN268201700005I. Support was received from the National Institute of Health (5KL2TR001077-05 to YCM).

Disclosures

None

Acknowledgments

The authors thank the staff and participants of the ARIC Study for their indispensable contributions.

References (28)

  • C Bambs et al.

    Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study

    Circulation

    (2011)
  • ES Ford et al.

    Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States

    Circulation

    (2012)
  • Q Yang et al.

    Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults

    JAMA

    (2012)
  • Mok Y, Sang Y, Ballew SH, et al. American Heart Association's Life's Simple 7 at Middle Age and Prognosis After...
  • Cited by (3)

    • The Future of Sport and Exercise Medicine

      2022, Sport and Exercise Medicine Switzerland Journal
    a

    Phone number: +001-410-614-1519

    b

    Phone: +001-443-287-1814

    c

    Phone: +001-410-550-0630

    d

    Phone: +001-919-966-4564

    e

    Phone: +001-443-287-8766

    f

    Phone: +001-212-304-7561

    g

    Phone: +001-919-962-3230

    h

    Phone: +011-233-24-344-8464

    i

    Phone: 410-955-0495

    j

    Phone: +972-03-6405427

    View full text