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

Abstract

Context: Recent recommendations from the American Heart Association aim to improve cardiovascular health by encouraging the general population to meet 7 cardiovascular health metrics: not smoking; being physically active; having normal blood pressure, blood glucose and total cholesterol levels, and weight; and eating a healthy diet.

Objective: To examine time trends in cardiovascular health metrics and to estimate joint associations and population-attributable fractions of these metrics in relation to all-cause and cardiovascular disease (CVD) mortality risk.

Design, setting, and participants: Study of a nationally representative sample of 44,959 US adults (≥20 years), using data from the National Health and Nutrition Examination Survey (NHANES) 1988-1994, 1999-2004, and 2005-2010 and the NHANES III Linked Mortality File (through 2006).

Main outcome measures: All-cause, CVD, and ischemic heart disease (IHD) mortality.

Results: Few participants met all 7 cardiovascular health metrics (2.0% [95% CI, 1.5%-2.5%] in 1988-1994, 1.2% [95% CI, 0.8%-1.9%] in 2005-2010). Among NHANES III participants, 2673 all-cause, 1085 CVD, and 576 IHD deaths occurred (median follow-up, 14.5 years). Among participants who met 1 or fewer cardiovascular health metrics, age- and sex-standardized absolute risks were 14.8 (95% CI, 13.2-16.5) deaths per 1000 person-years for all-cause mortality, 6.5 (95% CI, 5.5-7.6) for CVD mortality, and 3.7 (95% CI, 2.8-4.5) for IHD mortality. Among those who met 6 or more metrics, corresponding risks were 5.4 (95% CI, 3.6-7.3) for all-cause mortality, 1.5 (95% CI, 0.5-2.5) for CVD mortality, and 1.1 (95% CI, 0.7-2.0) for IHD mortality. Adjusted hazard ratios were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.24 (95% CI, 0.13-0.47) for CVD mortality, and 0.30 (95% CI, 0.13-0.68) for IHD mortality, comparing participants who met 6 or more vs 1 or fewer cardiovascular health metrics. Adjusted population-attributable fractions were 59% (95% CI, 33%-76%) for all-cause mortality, 64% (95% CI, 28%-84%) for CVD mortality, and 63% (95% CI, 5%-89%) for IHD mortality.

Conclusion: Meeting a greater number of cardiovascular health metrics was associated with a lower risk of total and CVD mortality, but the prevalence of meeting all 7 cardiovascular health metrics was low in the study population.

Figure 1

Age- and Sex-Standardized Mortality Rates per 1000 Person-Years of All-Cause, CVD, and IHD Mortality, by Number of Cardiovascular Health Metrics—NHANES III Linked Mortality File Error bars indicate 95% CIs. Y-axis segments shown in blue indicate range from 0 to 8. CVD indicates cardiovascular disease; IHD, ischemic heart disease; NHANES, National Health and Nutrition Examination Survey.

Figure 2

Kaplan-Meier Curves for Cumulative All-Cause, CVD, and IHD Mortality, by Number of Cardiovascular Health Metrics—NHANES III Linked Mortality File Y-axis segments shown in blue indicate range from 0 to 0.2. CVD indicates cardiovascular disease; IHD, ischemic heart disease; NHANES, National Health and Nutrition Examination Survey.