[PDF] - Life Course of Cardiovascular Health: Prevention Across the Ages PDF Document

SLIDE 1

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

SLIDE 2

Defining Cardiovascular Health (CVH)

10/1/2019

3

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

SLIDE 3

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 ____%.

SLIDE 4

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 Mortality All‐Cause Mortality Greater Life Expectancy MRFIT men 35‐39

‐ 85% ‐ 50% +6.3 years

CHA men 18‐39

‐ 80% ‐ 57% +9.5

MRFIT men 40‐57

‐ 76% ‐ 55% +5.9

CHA men 40‐59

‐ 72% ‐ 58% +6.0

CHA women 40‐59

‐ 73% ‐ 40% +5.8

Stamler, JAMA 1999

SLIDE 5

Lifetime Risk for ASCVD by RF Strata

Framingham Heart Study, Age 50

Attained Age Adjusted Cumulative Incidence

5% 36% 50% 69% 8% 27% 50%

Men Women

46% 39%

Lloyd‐Jones, Circulation 2006

2 Major RFs 1 Major RF 1 Elevated RF 1 Not Optimal RF Optimal RFs

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

SLIDE 6

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

SLIDE 7

AHA 2020 Strategic Impact Goals Defining cardiovascular health:

Each of the 7 metrics classified as “poor,” “intermediate”
r “ideal”

HEALTH BEHAVIORS HEALTH FACTORS

Smoking
Diet
Physical Activity
Body Weight
Glucose
Cholesterol
Blood Pressure

Cardiovascular Health Definition

LIFE’S SIMPLE 7 POOR INTERMEDIATE IDEAL

Smoking Status

Adults >20 years of age Children (12–19) Current Smoker Tried prior 30 days Former ≤ 12 mos Never /quit ≥ 12 mos

Physical Activity

Adults > 20 years of age Children 12‐19 years of age None None 1‐149 min/wk mod or 1‐74 min/wk vig

r 1‐149 min/wk mod + vig

>0 and <60 min of mod or vig every day 150+ min/wk mod or 75+ min/wk vig or 150+ min/wk mod + vig 60+ min of mod or vig every day

Healthy Diet

Adults >20 years of age Children 5‐19 years of age 0‐1 components 0‐1 components 2‐3 components 2‐3 components 4‐5 components 4‐5 components

Healthy Weight

Adults > 20 years of age Children 2‐19 years of age ≥30 kg/m2 >95th percentile 25‐29.9 kg/m2 85th‐95th percentile <25 kg/m2 <85th percentile

Blood Glucose

Adults >20 years of age Children 12‐19 years of age 126 mg/dL or more 126 mg/dL or more 100‐125 mg/dL or treated to goal 100‐125 mg/dL Less than 100 mg/dL Less than 100 mg/dL

Cholesterol

Adults >20 years of age Children 6‐19 years of age ≥240 mg/dL ≥200 mg/dL 200‐239 mg/dL or treated to goal 170‐199 mg/dL <170 mg/dL

Blood Pressure

Adults >20 years of age Children 8‐19 years of age SBP ≥140 or DBP ≥90 mm Hg >95th percentile SBP120‐139 or DBP 80‐89 mm Hg

r treated to goal

90th‐95th percentile or SBP ≥120

r DBP ≥80 mm Hg

<120/<80 mm Hg <90th percentile

Summarize as :

No. of Ideal CVH Metrics (0‐7)

Total CVH Score (0‐14)

SLIDE 8

2020

20%

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%.

AHA 2020 Impact Goal

Evidence Linking CV Health Status and Outcomes

CV Health status is associated with major health outcomes

Total mortality
Cardiovascular, coronary, and stroke

mortality

Fatal and non‐fatal CVD
CHD and stroke
In all race/sex groups
Incident cancer (!)
Venous thromboembolism/PE
End‐stage renal disease/CKD
Atrial fibrillation
Atherosclerosis and arterial stiffness

in children, young adults and middle age

Cognition in younger and older adults
Depression
QOL in adults
Healthy days now
QOL in future
Compression of morbidity
Healthcare costs

SLIDE 9

Life Course of Cardiovascular Health Stock of Health

0.2 0.4 0.6 0.8 1 20 40 60 80 100

18

Born with full “stock of health” Gotta die Normative aging

Squaring the curve AKA “compression of morbidity” Age Is normative aging our destiny? Preprogrammed? Or can we square the curve? If so, how early does it matter?

SLIDE 10

CV Health In Middle Age

Clinical CV Events and/or Death Subclinical CVD Genetics Young Adult Behaviors/Lifestyles Fetal exposures Early Life exposures

CVH Status and Outcomes

20

SLIDE 11

CVH Score and CV Events

21

Polonsky et al., JAHA 2017

Number of Ideal CV Health Metrics and 20‐Year Incidence of CVD: ARIC

No. of Ideal Metrics

HR (95% CI) for CVD

Folsom et al. JACC 2011

0.1% 2.8% 9.3% 18.6% 26.7% 25.3% 14.5% 2.5%

SLIDE 12

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

SLIDE 13

CVH Trajectories over 20 Years in CARDIA

Pool et al. Prev Med 2019

CVH Trajectories and HRQoL: CARDIA

Pool et al. Prev Med 2019

SLIDE 14 10/1/2019

Allen et al., Circulation 2017

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

SLIDE 15

Compression of CV Morbidity by CV Health Status in Younger Adulthood

5 10 15 20 25 All Favorable 2+ High none 1 2 3+ 76 yrs 84 yrs 8.3 yrs (43%) 83 yrs 88 yrs 5.3 yrs (23%) CV Morbidity Score 65 70 75 80 85 90 Age CVH Status in Younger Adulthood Healthspan Lifespan Allen et al., Circulation 2017

Greater compression of morbidity Lifespan 4 yrs longer Healthspan 7 yrs longer Compression of All‐Cause Morbidity by CV Health Status in Younger Adulthood

5 10 15 20 25 All Favorable 1 Elevated 1 High 2+ High none 1 2 3+ 75 yrs 84 yrs 9.7 yrs (50%) 79 yrs 88 yrs 9.1 yrs (39%) Morbidity Score 65 70 75 80 85 90 Age CVH Status in Younger Adulthood Allen et al., Circulation 2017

Greater compression of morbidity Lifespan 4 yrs longer Healthspan 4.5 yrs longer

SLIDE 16

But Don, if people live longer, they just cost us more, right?

31

Differences in Medicare Costs by CV Health Status at Younger Ages

$10,000.00 $12,000.00 $14,000.00 $16,000.00 $18,000.00 $20,000.00 $22,000.00 $24,000.00

All Favorable 1+ Elevated None High 1 high 2+ high

Avg Annual Costs

$150,000.00 $175,000.00 $200,000.00 $225,000.00 $250,000.00

All Favorable 1+ Elevated None High 1 high 2+ high

Cumulative Costs

Adjusted for age, sex, race, education and whether the individual died during follow-up

Allen et al., Circulation 2017

SLIDE 17

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

SLIDE 18

CV Health In Middle Age

Clinical CV Events and/or Death Subclinical CVD Genetics Young Adult Behaviors/Lifestyles Fetal exposures Early Life exposures

Loss of CV Health Across the Lifespan NHANES 2007‐2008

AHA Statistical Update 2012

Age Group

Percent with Ideal CVH Metrics

SLIDE 19

How to Achieve/Maintain CV Health into Middle Age

It seems we are all born with fairly ideal CV health
In Western societies, ideal CV health in middle age is rare
So, is it all just good genes?
Or are health behaviors at younger ages related to

maintenance of ideal CV health into middle age?

Offspring Study: 8 Exams

N = 5124 men & women (ages 5‐70) 1576 spouse pairs, 3514 biological offspring

1971 2008

Framingham Heart Study: 3 Generations

Original Cohort: 28 Exams

N = 5209 men and women (ages 28‐62) 1644 spouse pairs, 596 extended families

1948 2008 Gen3 Study

N=4095 men and women Grandchildren of original cohort

2002 2005

1948 1968 1988 2008

SLIDE 20

Heritability of Ideal CV Health

Ideal CV Health Definition Age group Clinical Clinical / Behavioral 40 ± 5 years 16.9% 10.6% 50 ± 5 years 17.0% 7.4%

All P values < 0.001

CARDIA Study

NHLBI‐sponsored multicenter longitudinal study
5,115 Black and White young adults aged 18‐30 years at

baseline (1985‐86)

Balanced on race, sex, education, and age within centers
Eight follow‐up exams at Years 2, 5, 7, 10, 15, 20, and 25
Study Sample

3,154 participants completed baseline, Y7, and Y20 exams Not pregnant at baseline, Y7, or Y20 exams

SLIDE 21

Healthy Lifestyle Factors (HLF)

Healthy lifestyle factors based on data from baseline, Y7, and Y20 defined by:

1. Average BMI < 25 kg/m2
2. Never smoking
3. No or low alcohol intake

‐ 0 to 15 g/day for women; 0 to 30 g/day for men

4. Highest 40%ile of sex‐ and race‐specific diet score

‐ Based on higher average intake of potassium, calcium, and fiber and lower intake of saturated fat

5. Highest 40th %ile of sex‐ and race‐specific average physical

activity score

Healthy Lifestyle through Young Adulthood and Ideal CVH in Middle Age: CARDIA

Liu, Circ 2012

42

SLIDE 22

Healthy Lifestyle through Young Adulthood and Ideal CVH Factors in Middle Age: CARDIA

Liu, Circ 2012

43

Summary and Take Home Points

Flipping the risk paradigm on its head

 More than the sum of the parts?

Maintaining CVH into middle age

 Optimizes healthspan, improves compression of morbidity, lowers healthcare costs

Lifestyle factors > genetics as determinants of higher CVH

 Primordial prevention is key

Mechanism may in part be through more benign athero, not just

avoidance of athero

We have lots of tools in our toolbox

10/1/2019

44

SLIDE 23

Case #1

22‐year‐old white male presents for evaluation

PMH: Healthy childhood
SH: denies tobacco, social alcohol
FHx: Father with MI at age 43; Mother with stroke at 48
Meds: None
BP 122/76 mm Hg; BMI 23; Waist 32”; +Arcus; + Xanthomata
Lipids (mg/dL): TC 334 HDL‐C 64 LDL‐C 250 TG 100
ASCVD 10‐year risk: N/A

Case #2

42‐year‐old female presents for evaluation

PMH: Very healthy lifestyle
SH: denies tobacco, rare alcohol
FHx: Father with MI at age 43; Mother healthy
Meds: None
Avid exerciser, no symptoms
BP 118/76 mm Hg; BMI 22; Waist 28”; ‐Arcus; ‐Xanthomata
Lipids (mg/dL): TC 226 HDL‐C 64 LDL‐C 152 TG 50
ASCVD 10‐year risk: 2.0%

SLIDE 24

Case #3

62‐year‐old AA female presents for evaluation

PMH: Suboptimal diet; sedentary
SH: denies tobacco, rare alcohol
FHx: Father and Mother with ASCVD in 60s; smokers
Meds: Lisinopril
BP 128/76 mm Hg; BMI 32; Waist 40”; ‐Arcus; ‐Xanthomata
Lipids (mg/dL): TC 216 HDL‐C 64 LDL‐C 142 TG 50
ASCVD 10‐year risk: 7.7%

Case #4

68‐year‐old male presents for evaluation

PMH: Optimal lifestyle; avid tennis player
SH: denies tobacco, rare alcohol
FHx: None
Meds: None
BP 124/78 mm Hg; BMI 23; Waist 36”; ‐Arcus; ‐Xanthomata
Lipids (mg/dL): TC 196 HDL‐C 64 LDL‐C 122 TG 50
ASCVD 10‐year risk: 13.2%

SLIDE 25

Questions

What other test(s) should we order?
What therapies should we consider?
Any risks to that therapy?