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CV Health Score and ASCVD in the Million Veteran Program
Quick Takes
- In elderly US veterans, higher AHA Life’s Essential (LE8) component scores were associated a 75% lower risk of ASCVD, likelihood of developing MACE, and incidence of all-cause mortality. The relationship was continuous and graded.
- A healthy lifestyle aimed at promoting ideal CV health, such as LE8—supplemented by medication to help control lipids, glucose, and blood pressure—plays an important role not only in primary prevention of ASCVD but also in the prevention of major adverse events after diagnosis of ASCVD.
- Physician and patient knowledge of relatively simple target scores can be used to facilitate individual and community-based primary and secondary ASCVD prevention.
Study Questions:
Is the American Heart Association (AHA) Life’s Essential 8 (LE8) score predictive of lower atherosclerotic cardiovascular disease (ASCVD) risk in US military veterans as a first and/or subsequent incident ASCVD events?
Methods:
The study was conducted within the Veterans Affairs Million Veteran Program (MVP). MVP combines data from self-reported surveys (MVP Baseline and Lifestyle Surveys), electronic health records (EHRs), and biospecimen samples collected at enrollment, which began in 2011 and enrolled 913,319 veterans as of September 2022. The 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. The joint effects of ASCVD and LE8 score on MACE and total mortality were evaluated in a secondary analysis. MACE was defined as experiencing a nonfatal stroke (either ischemic or hemorrhagic), nonfatal myocardial infarction, or CVD death.
The LE8 score includes 8 components of CV health: healthy diet, staying physically active, avoiding nicotine exposure, maintaining sleep health, managing a healthy body mass index, blood lipid control, blood glucose control, and blood pressure control. An overall LE8 score was calculated for each study participant using the mean of the 8 metrics. An LE8 score of 80-100 was considered high CV health (CVH) and 0-49 was defined as low CVH. A Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of ASCVD and its subtypes according to LE8 score. Crude models were adjusted for age, sex, race and ethnicity, education, income, marital status, family history of CVD, history of heart failure, and cancer (except nonmelanoma skin cancer) at or before the time of the MVP Lifestyle Survey completion.
Results:
A 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 had an ASCVD event during follow-up. ASCVD was 3.91 per 100 person-years among veterans with low CVH and 1.31 per 100 person-years among veterans with high CVH, with a graded decrease in incidence with higher LE8 score. 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 0-49 (adjusted HR [aHR], 0.36 [95% CI, 0.35-0.38]). Similarly, risk of MACE was significantly lower among veterans with an LE8 score of 80-100 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 0-49. There was no difference in associations of LE8 with ASCVD between males and females or across race and ethnicity groups, but the association was significantly stronger among veterans aged <66 years compared with those aged ≥66 years (p for interaction < 0.001).
Conclusions:
In this cohort study of US veterans, higher LE8 scores were associated with significantly lower ASCVD incidence risk and lower likelihood of developing adverse CV events regardless of ASCVD status at baseline. These results support the utility of LE8 for health promotion and ASCVD prevention.
Perspective:
This is an important observational study conducted within the very large MVP, a prospective predominantly White cohort study of US veterans designed to examine genetic and nongenetic factors associated with chronic diseases. Among the strengths include size, use of EHR for biometrics and CVD outcomes, and implications for secondary prevention. In veterans with ASCVD, the absolute incidence rate of MACE was attenuated from 5.25% among those with low CVH to 2.48% among those with high CVH. The potential risk of MACE among these participants may be attenuated by about 50% if their LE8 score improved from low to high. While the trends of the findings are likely similar in the general population, LE8 does not address risk factors for noncompliance and the pathobiological influences of depression, post-traumatic stress disorder, and dental hygiene that are more prevalent in veterans.
Clinical Topics: Cardiovascular Care Team, Prevention
Keywords: Atherosclerosis, Healthy Lifestyle, Secondary Prevention, Veterans Health
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