Cardiovascular Health Score and Atherosclerotic Cardiovascular Disease in the Million Veteran Program

Abstract

Importance: The American Heart Association proposed Life's Essential 8 (LE8) as an enhanced measurement tool for cardiovascular health.

Objective: To examine the association of LE8 with risk of atherosclerotic cardiovascular disease (ASCVD) incidence and prognosis in veterans.

Design, setting, and participants: This was a prospective cohort study of US veterans enrolled in the Department of Veterans Affairs (VA) Million Veteran Program (MVP) between 2011 and 2022. Data were analyzed from 2023 to 2024.

Exposure: LE8 score ranged from 0 to 100, with higher score indicating better cardiovascular health.

Main outcomes and measures: The primary outcome was total ASCVD incidence in veterans without baseline ASCVD, and the secondary outcome was incidence of a major adverse cardiovascular event (MACE) among veterans with and without ASCVD at baseline.

Results: A total of 413 052 veterans (mean [SD] age, 65.8 [12.1] years; 378 162 [91.6%] male) were included. Based on 1.7 million person-years of follow-up of 279 868 veterans without any ASCVD at baseline, 45 067 veterans had an ASCVD event during follow-up. Total LE8 score and each component LE8 factor score was associated with incident ASCVD in an inverse, linear, dose-response manner. For veterans without prior ASCVD, those with an LE8 score between 80 and 100 had lower risk of ASCVD compared with those with an LE8 score of 0 to 49 (adjusted hazard ratio [aHR], 0.36 [95% CI, 0.35-0.38]). Similarly, risk of MACE was significantly lower among veterans with an LE8 score of 80 to 100 regardless of baseline ASCVD status (with ASCVD: aHR, 0.52 [95% CI, 0.48-0.56]; without ASCVD: aHR, 0.14 [95% CI, 0.13-0.15]) compared with those with ASCVD and an LE8 score of 0 to 49.

Conclusions and relevance: In this cohort study of US veterans, higher LE8 scores were associated with significantly lower ASCVD incidence risk and lower likelihood of developing adverse cardiovascular events regardless of ASCVD status at baseline. These results support the utility of LE8 for health promotion and ASCVD prevention.

Figure 1.. Incident Rates and Hazard of Major Adverse Cardiovascular Events (MACE) Among Veterans With and Without Atherosclerotic Cardiovascular Disease (ASCVD) at Baseline

MACE were defined as experiencing a nonfatal stroke (either ischemic or hemorrhagic), nonfatal myocardial infarction, or cardiovascular disease death. Hazard ratios (HRs) are adjusted for age, sex, race and ethnicity, education level, income level, marriage status, family history of cardiovascular disease, diagnosis of atrial fibrillation, heart failure, or cancer (excluding nonmelanoma skin cancer) at or before baseline, duration since ASCVD diagnosis, and use of cardiovascular medications. IRR indicates incidence rate ratio; LE8, Life’s Essential 8; PY, person-year.

Figure 2.. Incident Rates and Hazard of All-Cause Mortality Among Veterans With and Without Atherosclerotic Cardiovascular Disease (ASCVD) at Baseline

Hazard ratios (HRs) are adjusted for age, sex, race and ethnicity, education level, income level, marriage status, family history of cardiovascular disease, and diagnosis of atrial fibrillation, heart failure, or cancer (excluding nonmelanoma skin cancer) at or before baseline. IRR indicates incidence rate ratio; LE8, Life’s Essential 8; PY, person-year.

Figure 3.. Hazard of Adverse Cardiovascular Outcomes by Life’s Essential 8 Score

Hazard ratios are adjusted for age, sex, race and ethnicity, education level, income level, marriage status, family history of cardiovascular disease, and diagnosis of atrial fibrillation, heart failure, or cancer (excluding nonmelanoma skin cancer) at or before baseline. The lowest score group (0-49) was the reference group. ASCVD indicates atherosclerotic cardiovascular disease; CVD, cardiovascular death; MI, myocardial infarction; PAD, peripheral arterial disease.