The American Heart Association (AHA) Strategic Planning Task Force has adopted the following as an Impact Goal: "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%".^1,2

To help achieve this goal, the AHA designed a tool consisting of seven cardiovascular health (CVH) metrics, AHA Life's Simple 7:² four health behaviors (smoking, weight, physical activity, and diet) and three health risk factors (total cholesterol, blood pressure, and fasting blood glucose). Ideal CVH was defined as free from cardiovascular disease (CVD) and meeting all seven ideal metric criteria of Life's Simple 7 (Table 1). Since publication of the AHA 2020 Strategic Impact Goal, several publications have shown a strong and inverse association between AHA Life's Simple 7 ideal metrics and incidents of myocardial infarction (MI), stroke, coronary heart disease (CHD), and other cardiovascular outcomes, as well as non-cardiovascular conditions like depression, cognitive function, and cancer.³

Table 1: American Heart Association's Life's Simple 7 Cardiovascular Health Scoring

CVH Metric	Ideal CVH definition (2 points)	Intermediate CVH definition (1 point)	Poor CVH definition (0 point)
Health Behaviors
Current Smoking Adult (>20 years):	Never or quit >12 months ago	Former ≤12 months	Yes
Current Smoking Children (8-19 years):	Never tried; never smoked whole cigarette		Tried prior 30 days
Body Mass Index Adult (>20 years):	<25 kg/m2	25–29.9 kg/m2	≥30 kg/m2
Body Mass IndexChildren (8-19 years):	<85th Percentile	85th–95th Percentile	>95th Percentile
Physical Activity Adult (>20 years):	Moderate-intensity activity ≥150 min/week or vigorous-intensity activity ≥75 min/week or combination	Moderate-intensity activity 1-149 min/week or vigorous-intensity activity 1-74 min/week or combination of moderate- and vigorous-intensity activity 1-149 min/week	None
Physical Activity Children (8-19 years):	≥60 min of moderate- or vigorous-intensity activity every day	1-59 min of moderate- or vigorous-intensity activity every day	None
Healthy Diet Score* Adult (>20 years):	4–5 components	2–3 components	0–1 component
Healthy Diet Score* Children (8-19 years):	4–5 components	2–3 components	0–1 component
Health Factors
Total Cholesterol Adult (>20 years):	<200 mg/dL¶	200–239 mg/dL or treated to goal	≥240 mg/dL
Total Cholesterol Children (8-19 years):	<170 mg/dL¶	170–199 mg/dL	≥200 mg/dL
Blood Pressure Adult (>20 years):	<120/<80 mmHg¶	SBP: 120–139 mmHg and/or DBP: 80–89 mmHg or treated to <120/<80 mmHg	SBP ≥140 mmHg and/or DBP ≥90 mmHg
Blood Pressure Children (8-19 years):	<90th percentile¶	90th–95th percentile or SBP ≥120 mmHg and/or DBP ≥80 mmHg	>95th percentile
Fasting Plasma Glucose Adult (>20 years):	<100 mg/dL¶	100–125 mg/dL or treated to goal	≥126 mg/dL
Fasting Plasma Glucose Children (8-19 years):	<100 mg/dL¶	100–125 mg/dL	≥126 mg/dL

Recently, Folsom et al. analyzed the Atherosclerosis Risk in Communities (ARIC) Study cohort for the association of adherence to ideal AHA Life's Simple 7 metrics and lifetime risk of developing heart failure (HF) and/or left ventricular hypertrophy (LVH), LV diastolic dysfunction, and LV systolic dysfunction (subclinical markers).⁴ ARIC is a prospective observational study that enrolled 15,792 middle-aged (45-64 years) men and women in 1987-1989, in four US communities.⁵ The ARIC cohort was followed with four subsequent examinations 3 years apart and a fifth examination between 2011 and 2013 to allow an overall follow-up of 25 years. After excluding those with baseline HF, ARIC investigators classified their cohort into three CVH subgroups according to Life's Simple 7 risk score, ranging from 0 to14, by assigning for each metric two points for ideal, one point for intermediate, and zero points for poor: optimal (10-14), average (5-9), or inadequate (0-4).⁴ Echocardiographic LVH was based on the LV mass indexed to body surface area (>95 g/m2 for women and >115 g/m2 for men), systolic dysfunction was defined as LV ejection fraction (LVEF) <50%, and diastolic dysfunction defined as the ratio of early diastolic mitral valve peak inflow velocity (E) to tissue Doppler-derived septal early mitral annulus relaxation (e') velocity (E/e') >15.⁴

Interestingly, Folsom et al. demonstrated that lifetime risk (through age 85) of incident HF in the middle-aged ARIC cohort was 25.5% over 25 years of follow up.⁴ There was a stepwise decrement in lifetime risk for HF with higher Life's Simple 7 scores: 48.6% among those with inadequate CVH, 26.8% for those with average CHV, and 14.4% for those with optimal CVH score.⁴ Similarly, in the Framingham Offspring cohort (average age 58 years) who were free of CVD, Xanthakis et al. showed a significant inverse association between ideal CVH metrics and the incidence of CVD (defined as CHD, HF, intermittent claudication, and cerebrovascular disease) over a 16-year follow-up period: age- and sex-adjusted hazard ratio for incident CVD per 1 unit increase in the CVH score was 0.77 (p<0.0001).⁶

There was an important disparity in the prevalence of ideal CVH between White and African American (AA) ARIC participants. 14.4% of AA vs. 4.7% of Whites had inadequate CVH scores (0-4); 11.8% of AA vs. 33.8% of Whites had optimal CVH scores.⁴ This ethnic disparity was consistent with findings in the Coronary Artery Risk Development in Young Adults (CARDIA) study:⁷ 78% of those with poor CVH (defined by a Life's Simple 7 score ≤8) and 28% of those with ideal CVH (Simple 7 score ≥12) were AA, whereas 22% of those with poor CVH scores and 72% of those with ideal CVH scores were Whites.

Folsom et al. also demonstrated a stepwise relationship of echocardiographic LV hypertrophy, diastolic function, and LVEF and the AHA Life's Simple 7 score. Among ARIC participants free of CHD at baseline who did not develop HF or MI by 2011-2013, lifetime risk of LVH among those with optimal Life's Simple 7 score was 6.7%—significantly lower than the 16.5% in those with inadequate scores (adjusted odds ratio = 0.37 [0.20-0.66]). Furthermore, lifetime risk of diastolic dysfunction was significantly lower among those with an optimal score compared to those with an inadequate score (16.2% vs. 27.1%, respectively, adjusted odds ratio = 0.43 [0.26-0.69]). Similarly, lifetime risk of LV systolic dysfunction was lower among those with an optimal score (1.2%) compared to those with an inadequate score (2.4%), but the adjusted odds ratio was non-significant.4

Desai et al. investigated the association of Life's Simple 7 score with ventricular structure and function later in life in the young adult (18-30 years) CARDIA cohort.⁷ Although odds of developing LV systolic dysfunction (defined by LVEF <50%) were not significantly different among different CVH score strata, there was a significant favorable association between baseline CVH score and odds of developing LVH and/or diastolic dysfunction at 25 years of follow-up.⁷ Similarly, Xanthakis et al. demonstrated in the Framingham Offspring cohort a significant inverse association between ideal CVH metrics and development of subclinical CVD parameters (increased carotid intima-media thickness or stenosis, LVH [by ECG or echocardiography], LV systolic dysfunction, microalbuminuria, and a reduced ankle-brachial index) with an age- and sex-adjusted odds ratio of 0.57 per 1 unit increase in ideal CVH metrics (p < 0.0001).⁶

The Folsom et al. study has a number of limitations, including its observational nature, the reliance on the use of ICD codes for the detection of incident HF, absence of information on the incidence of HF with reduced vs. preserved LV systolic function, and the use of septal E/e' >15 as a sole marker of LV diastolic dysfunction.⁴ The study also does not provide comparison data on the relative importance of the various risk factors in the Simple 7 score. However, previous studies have provided this information in various gender, race and age subgroups.

Nevertheless, Folsom et al. have shown convincingly in a large prospective study the role of AHA Life's Simple 7 Score in predicting lifetime risk of HF and greater preservation of LV structure and function, as well as the potential beneficial effect in later years of maintaining an optimal CVH score into middle age. This study also emphasizes the disparities that exist in the prevalence of ideal CVH parameters between AA and Whites, which contribute, in part, to explaining the overall health disparities between these ethnic groups.

References

1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016;133:447-54.
2. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's Strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586-613.
3. Younus A, Aneni EC, Spatz ES, et al. A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and Non-US populations. Mayo Clin Proc 2016;91:649-70.
4. Folsom AR, Shah AM, Lutsey PL, et al. American Heart Association's Life's Simple 7: Avoiding heart failure and preserving cardiac structure and function. Am J Med 2015;128:970-6.e2.
5. The ARIC Investigators. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. Am J Epidemiol 1989;129:687-702.
6. Xanthakis V, Enserro DM, Murabito JM, et al. Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study. Circulation 2014;130:1676-83.
7. Desai CS, Ning H, Liu K et al. Cardiovascular health in young adulthood and association with left ventricular structure and function later in life: The Coronary Artery Risk Development in Young Adults Study. J Am Soc Echocardiogr 2015;28:1452-61.

Keywords: American Heart Association, African Americans, Ankle Brachial Index, Atherosclerosis, Blood Glucose, Blood Pressure, Body Mass Index, Body Surface Area, Carotid Intima-Media Thickness, Cerebrovascular Disorders, Cholesterol, Constriction, Pathologic, Coronary Artery Disease, Echocardiography, Electrocardiography, Ethnic Groups, Health Behavior, Heart Failure, Hypertrophy, Left Ventricular, Intermittent Claudication, International Classification of Diseases, Mitral Valve, Myocardial Infarction, Neoplasms, Risk Factors, Smoke, Smoking, Stroke, Sweetening Agents, Systole, Vegetables

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