Life Course of Cardiovascular Health: Prevention Across the Ages - PDF document

Life Course of Cardiovascular Health: Prevention Across the Ages Donald M. Lloyd‐Jones, MD ScM FACC FAHA Eileen M. Foell Professor Chair, Dept. of Preventive Medicine Senior Associate Dean Director, NUCATS Institute Northwestern Feinberg School of Medicine Disclosures • Dr. Lloyd‐Jones has no RWI/COI  Grant funding: NIH, CMS, AHA

Defining Cardiovascular Health (CVH) 3 10/1/2019 Cardiovascular Risk vs. Cardiovascular Health • Major cardiovascular risk factors have been known since the 1960s/1970s • Since 2000, we have turned the risk paradigm on its head, focusing instead on individuals who have optimal levels of all risk factors preserved into middle age • Major step forward in 2010 with formal definition of cardiovascular health (CVH) by AHA

Circulation 2010; 121: 586-613 AHA 2020 Impact Goal: Charge By 2020, to improve the cardiovascular health of all Americans by ____%, while reducing deaths from cardiovascular disease and stroke by ____%.

Low Risk in MRFIT and CHA Cohorts • 366,000 US individuals (~ 40,000 in Chicago) • Low risk:  Serum cholesterol level <200 mg/dL  SBP/DBP  120/80 mm Hg  Not a current smoker  No history of diabetes  (No major ECG abnormalities) Stamler, JAMA 1999 Risk Reduction and Life Years Gained from Low Risk Status CVD All‐Cause Greater Life Mortality Mortality Expectancy MRFIT men ‐ 85% ‐ 50% +6.3 years 35‐39 CHA men ‐ 80% ‐ 57% +9.5 18‐39 MRFIT men ‐ 76% ‐ 55% +5.9 40‐57 CHA men ‐ 72% ‐ 58% +6.0 40‐59 CHA women ‐ 73% ‐ 40% +5.8 40‐59 Stamler, JAMA 1999

Lifetime Risk for ASCVD by RF Strata Framingham Heart Study, Age 50 Men Women 69%  2 Major RFs Adjusted Cumulative Incidence 1 Major RF  1 Elevated RF  1 Not Optimal RF 50% 50% Optimal RFs 46% 39% 36% 27% 8% 5% Attained Age Lloyd‐Jones, Circulation 2006 Healthy Behaviors in US Nurses • 84,129 mostly middle‐aged women followed for 14 years • 5 healthy lifestyle factors  Nonsmoker (never or quitter)   ½ hour per day of moderate/vigorous activity  BMI <25  Best 40% of dietary scores • Low trans fat, low glycemic load, high cereal fiber, high marine ω‐3 FAs, high folate, high PUFA/SFA   ½ glass of wine per day (or equivalent) Stampfer, NEJM 2000

Healthy Behaviors and Risk for CHD Risk Reduction for CHD 3 low RFs 57% 4 low RFs 66% 5 low RFs 83% Stampfer, NEJM 2000 Considerations in Defining CV Health • Health is a broader, more positive construct than just the absence of disease • Need for evidence base linked to CVD‐free survival, healthy longevity, and QOL • Simple and accessible to providers, payers and consumers  Allowing all subsets of the population to improve • Actionable items for individuals, practitioners and policy‐makers • 3M’s: measurable, monitored, modifiable

AHA 2020 Strategic Impact Goals Defining cardiovascular health: HEALTH BEHAVIORS HEALTH FACTORS • Smoking • Glucose • Diet • Cholesterol • Physical Activity • Blood Pressure • Body Weight • Each of the 7 metrics classified as “ poor ,” “ intermediate” or “ ideal” Cardiovascular Health Definition LIFE’S SIMPLE 7 POOR INTERMEDIATE IDEAL Smoking Status Current Smoker Former ≤ 12 mos Never /quit ≥ 12 mos Adults >20 years of age Tried prior 30 days Children (12–19) Physical Activity 1‐149 min/wk mod or 150+ min/wk mod or 75+ None 1‐74 min/wk vig min/wk vig or 150+ min/wk Adults > 20 years of age or 1‐149 min/wk mod + vig mod + vig None Children 12‐19 years of age >0 and <60 min of mod or vig every 60+ min of mod or vig every Summarize as : day day Healthy Diet 2‐3 components 0‐1 components 4‐5 components Adults >20 years of age No. of Ideal CVH Metrics (0‐7) 2‐3 components 0‐1 components 4‐5 components Children 5‐19 years of age Healthy Weight 25‐29.9 kg/m2 Total CVH Score (0‐14) ≥30 kg/m 2 <25 kg/m 2 Adults > 20 years of age >95 th percentile 85th‐95th percentile <85 th percentile Children 2‐19 years of age Blood Glucose 126 mg/dL or more 100‐125 mg/dL or treated to goal Less than 100 mg/dL Adults >20 years of age 126 mg/dL or more 100‐125 mg/dL Less than 100 mg/dL Children 12‐19 years of age Cholesterol ≥240 mg/dL 200‐239 mg/dL or treated to goal <170 mg/dL Adults >20 years of age ≥200 mg/dL 170‐199 mg/dL Children 6‐19 years of age SBP120‐139 or DBP 80‐89 mm Hg Blood Pressure SBP ≥140 or DBP ≥90 mm Hg or treated to goal <120/<80 mm Hg Adults >20 years of age >95th percentile 90th‐95th percentile or SBP ≥120 <90th percentile Children 8‐19 years of age or DBP ≥80 mm Hg

AHA 2020 Impact Goal By 2020, to impro ve the c ardio vasc ular health o f all Americ ans by 20%, while reduc ing deaths fro m c ardio vasc ular disease and stro ke by 20%. 2020 20% Evidence Linking CV Health Status and Outcomes CV Health status is associated with major health outcomes • Total mortality • Atherosclerosis and arterial stiffness • Cardiovascular, coronary, and stroke in children, young adults and middle age mortality • Cognition in younger and older adults • Fatal and non‐fatal CVD • Depression - CHD and stroke • QOL in adults - In all race/sex groups - Healthy days now • Incident cancer (!) - QOL in future • Venous thromboembolism/PE • Compression of morbidity • End‐stage renal disease/CKD • Healthcare costs • Atrial fibrillation

Life Course of Cardiovascular Health Stock of Health Born with full “stock of health” 1 AKA Squaring “compression of the curve 0.8 Normative morbidity” aging 0.6 Is normative aging our destiny? 0.4 Preprogrammed? Or can we square the curve? 0.2 Gotta die If so, how early does it matter? 0 0 20 40 60 80 100 Age 18

Early Life Fetal Genetics exposures exposures Young Adult Behaviors/Lifestyles CV Health In Middle Age Subclinical CVD Clinical CV Events and/or Death CVH Status and Outcomes 20

CVH Score and CV Events 21 Polonsky et al., JAHA 2017 Number of Ideal CV Health Metrics and 20‐Year Incidence of CVD: ARIC 2.5% 14.5% 25.3% 26.7% 18.6% 9.3% 2.8% 0.1% HR (95% CI) for CVD No. of Ideal Metrics Folsom et al. JACC 2011

Number of Ideal CV Health Factors and Behaviors and 20‐Year Incidence of CVD Folsom et al. JACC 2011 CVH and Incident Cancer ARIC Study Rasmussen‐Torvik et al., Circulation . 2013;127:1270‐1275

CVH Trajectories over 20 Years in CARDIA Pool et al. Prev Med 2019 CVH Trajectories and HRQoL: CARDIA Pool et al. Prev Med 2019

Allen et al., Circulation 2017 10/1/2019 Chicago Heart Association Detection Project in Industry (CHA) • Longitudinal cohort study  39,522 men and women  18‐74 years (mean age 42)  Baseline in 1967‐1973  Employed at 84 participating companies and organizations in the Chicago area • Health questionnaire, physical exam, phlebotomy • Followed through 2010 via National Death Index and Medicare‐ linked files Allen et al., Circulation 2017

Compression of CV Morbidity by CV Health Status in Younger Adulthood 8.3 yrs 76 yrs 84 yrs (43%) CVH Status in Younger Adulthood 2+ High CV Morbidity Healthspan Greater compression of morbidity Score Lifespan none Lifespan 4 yrs longer 1 83 yrs 88 yrs 2 Healthspan 7 yrs longer 5.3 yrs 3+ (23%) All Favorable 65 70 75 80 85 90 0 5 10 15 20 25 Age Allen et al., Circulation 2017 Compression of All‐Cause Morbidity by CV Health Status in Younger Adulthood 75 yrs 9.7 yrs 84 yrs (50%) CVH Status in Younger Adulthood 2+ High Morbidity Greater compression of morbidity Score 1 High none Lifespan 4 yrs longer 1 2 Healthspan 4.5 yrs longer 1 Elevated 79 yrs 9.1 yrs 88 yrs 3+ (39%) All Favorable 65 70 75 80 85 90 0 5 10 15 20 25 Age Allen et al., Circulation 2017

But Don, if people live longer, they just cost us more, right? 31 Differences in Medicare Costs by CV Health Status at Younger Ages Avg Annual Costs Cumulative Costs $24,000.00 $250,000.00 $22,000.00 $225,000.00 $20,000.00 $18,000.00 $200,000.00 $16,000.00 $14,000.00 $175,000.00 $12,000.00 $10,000.00 $150,000.00 All 1+ 1 high 2+ high All 1+ 1 high 2+ high Favorable Elevated Favorable Elevated None High None High Adjusted for age, sex, race, education and whether the individual died during follow-up Allen et al., Circulation 2017

Implications of Ideal CV Health Factor Pattern • Individuals with prevalent RFs in middle age merit intensive prevention • And this can reduce risk, but it does not restore low risk • To optimally prevent CVD and other chronic diseases of aging, and potentially realize major cost savings, we need to focus on prevention of RF development in children and younger and middle‐aged adults (i.e., primordial prevention) How Can We Achieve/Maintain Ideal Cardiovascular Health? Determinants 34

Early Life Fetal Genetics exposures exposures Young Adult Behaviors/Lifestyles CV Health In Middle Age Subclinical CVD Clinical CV Events and/or Death Loss of CV Health Across the Lifespan NHANES 2007‐2008 Percent with Ideal CVH Metrics Age Group AHA Statistical Update 2012