Associations of Late Adolescent or Young Adult Cardiovascular Health With Premature Cardiovascular Disease and Mortality

Abstract

Background: When measured in adolescence or young adulthood, cardiovascular health (CVH) is associated with future subclinical cardiovascular disease (CVD), but data are lacking regarding CVD events or mortality.

Objectives: This study examined associations of CVH at ages 18 to 30 years with premature CVD and mortality.

Methods: This study analyzed data from the CARDIA (Coronary Artery Risk Development in Young Adults Study). CVH was scored at baseline (1985 to 1986) using Life's Simple 7 metrics and categorized as high (12 to 14 points), moderate (8 to 11), or low (0 to 7). CVD events and cause-specific mortality were adjudicated over 32 years of follow-up. Adjusted associations were estimated using Cox models and event rates and population attributable fractions were calculated by CVH category.

Results: Among 4,836 participants (mean age: 24.9 years, 54.8% female, 50.5% Black, mean education: 15.2 years), baseline CVH was high (favorable) in 28.8%, moderate in 65.0%, and low in 6.3%. During follow-up, 306 CVD events and 431 deaths occurred. The adjusted hazard ratios for high (vs. low) CVH were 0.14 (95% confidence interval [CI]: 0.09 to 0.22) for CVD and 0.07 (95% CI: 0.03 to 0.19) for CVD mortality, and the population attributable fractions for combined moderate or low (vs. high) CVH were 0.63 (95% CI: 0.47 to 0.74) for CVD and 0.81 (95% CI: 0.55 to 0.92) for CVD mortality. Among individuals with high CVH, event rates were low across sociodemographic subgroups (e.g., CVD rates per 1,000 person-years: age 18 to 24 years, 0.64; age 25 to 30 years, 0.65; men, 1.04; women, 0.36; Blacks, 0.90; Whites, 0.50; up to/through high-school education, 1.00; beyond high-school education, 0.61).

Conclusions: High CVH in late adolescence or young adulthood was associated with very low rates of premature CVD and mortality over 32 years, indicating the critical importance of maintaining high CVH.

Keywords: Life’s Simple 7; population attributable fraction; primordial prevention.

Figure 1.. Unadjusted Incident Premature CVD and Mortality Rates by Baseline CVH Category.

Incidence rates were very low during long-term follow-up among individuals with high baseline cardiovascular health (CVH) compared with rates among individuals with low or moderate baseline CVH, both overall and across sociodemographic subgroups. Cardiovascular disease (CVD) includes myocardial infarction, heart failure, stroke, transient ischemic attack, hospitalized unstable angina, carotid or peripheral arterial disease requiring intervention, or other fatal heart or atherosclerotic disease. For CVD death, underlying causes of death included coronary or other heart disease, stroke, or other definite atherosclerotic disease. HS, high school education.

Figure 2.. Adjusted CVD Cumulative Incidence Curves by CVH Level at Age 18–30 Years.

In Cox models adjusted for field center, sex, age, race, and total education, more favorable cardiovascular health (CVH) was associated with significantly lower probability of cardiovascular disease (CVD) over 30 years, overall and across sociodemographic subgroups. CVD was defined as in Figure 1. HS, high school.

Figure 3.. Adjusted Associations between Baseline CVH Score (per 1 Point Higher) and Incident Premature CVD and Mortality.

In Cox models adjusted for field center, sex, age, race, and total education, each 1-point higher baseline cardiovascular health (CVH) score was associated with 20–31% lower hazards for incident premature cardiovascular disease (CVD) and mortality. Findings were similar across sociodemographic subgroups. CVD and CVD death were defined as in Figure 1. Edu, education; HR, hazard ratio; HS; high school; yrs, years.

Central Illustration.. Implications of Cardiovascular Health at Age 18 to 30 Years for Incident Premature Cardiovascular Disease Over >30 Years.

In the bar graph (top), unadjusted cardiovascular disease (CVD) incidence rates were very low among individuals with high baseline cardiovascular health (CVH) in all sociodemographic subgroups. In the forest plot (bottom left), after adjustment for field center, sex, age, race, and total education, categorically moderate (vs low) CVH was associated with 58% lower hazard for CVD, and high (vs low) CVH was associated with 86% lower hazard for CVD. The population attributable fraction (bottom right) of CVD was 63% for moderate/low (vs high) baseline CVH. Findings were similar across sociodemographic subgroups. CVD was defined as in Figure 1. Edu, education; HR, hazard ratio; HS, high school; yrs, years.