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