Redefining Cardiovascular Health to Include Sleep: Prospective Associations With Cardiovascular Disease in the MESA Sleep Study

Abstract

Background Although sufficient and healthy sleep is inversely associated with cardiovascular disease (CVD) and its risk factors, the American Heart Association's Life's Simple 7 (LS7), as a measure of cardiovascular health (CVH), did not include sleep. We evaluated an expanded measure of CVH that includes sleep as an eighth metric in relation to CVD risk. Methods and Results The analytic sample consisted of MESA (Multi-Ethnic Study of Atherosclerosis) Sleep Study participants who had complete data on sleep characteristics from overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and the outcome. We computed the LS7 score and 4 iterations of a new CVH score: score 1 included sleep duration, score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea), scores 3 and 4 included sleep characteristics associated with CVD in MESA (score 3: sleep duration and efficiency, daytime sleepiness, and obstructive sleep apnea; score 4: score 3+sleep regularity). Multivariable-adjusted logistic and Cox proportional hazards models evaluated associations of the LS7 and CVH scores 1 to 4 with CVD prevalence and incidence. Among 1920 participants (mean age: 69±9 years; 54% female), there were 95 prevalent CVD events and 93 incident cases (mean follow-up, 4.4 years). Those in the highest versus lowest tertile of the LS7 score and CVH scores 1 to 4 had up to 80% lower odds of prevalent CVD. The LS7 score was not significantly associated with CVD incidence (hazard ratio, 0.62 [95% CI, 0.37-1.04]). Those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratio, 0.57 [95% CI, 0.33-0.97]; and hazard ratio, 0.53 [95% CI, 0.32-0.89]), respectively. Conclusions CVH scores that include sleep health predicted CVD risk in older US adults. The incorporation of sleep as a CVH metric, akin to other health behaviors, may enhance CVD primordial and primary prevention efforts. Findings warrant confirmation in larger cohorts over longer follow-up.

Keywords: Life's Essential 8; Life's Simple 7; cardiovascular diseases; cardiovascular health; health behaviors; primordial prevention; sleep.

Figure 1. The Life's Simple 7 and iterations of potential “Essential Eight” CVH scores that include sleep in relation to CVD.

The AHA's LS7 score and 4 iterations of potential “Essential Eight” scores, that include the same LS7 metrics but additionally incorporate sleep, were evaluated in relation to CVD risk. The upper panel shows the LS7 and alternate CVH scores in relation to prevalent CVD using multivariable logistic models in 1920 adults in the MESA Sleep Study. The lower panel shows associations of the LS7 score and alternate CVH scores with risk of developing new CVD using multivariable Cox proportional hazards models. Models were adjusted for age, sex, race and ethnicity, education, health insurance, and alcohol use. AHA indicates American Heart Association; CVD, cardiovascular disease; CVH, cardiovascular health; HR, hazard ratio; LS7, Life's Simple 7; MESA, Multi‐Ethnic Study of Atherosclerosis; and OR, odds ratio.