Life's Essential 8 cardiovascular health, cardiovascular-kidney-metabolic syndrome stages, and incident cardiovascular events: a nationwide 10-year prospective cohort study in China

Abstract

Background: Definition and staging rationale of cardiovascular-kidney-metabolic syndrome were developed. The utility of cardiovascular-kidney-metabolic construct in risk stratification and target strategies of health and behavior modifications needs to be addressed. The study aims to investigate the individual and combined associations of cardiovascular-kidney-metabolic stage and cardiovascular health (CVH) by Life's Essential 8 (LE 8) with incident cardiovascular events (CVD), and determine the distribution and contribution of domain-specific CVH across cardiovascular-kidney-metabolic stages.

Methods: The study included 100,727 individuals in the China Cardiovascular Disease and Cancer Cohort with complete data on cardiovascular-kidney-metabolic factors and LE 8 metrics, with a median follow-up of 10.1 years. Cardiovascular-kidney-metabolic stages and CVH metrics (nicotine exposure, diet, physical activity, sleep, body mass index, blood lipids, blood pressure, blood glucose) were defined according to Presidential Advisory from the American Heart Association. Incident CVD events including cardiovascular death, myocardial infarction, and stroke were validated. The Fine-Gray hazard model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) of CKM stages or CVH status associated with CVD.

Results: Compared with cardiovascular-kidney-metabolic stage 0, the adjusted competing HRs and 95% CIs of CVD events were 1.20 (0.95-1.51), 2.45 (1.97-3.04), 4.43 (3.53-5.58), and 5.95 (4.75-7.45) from stage 1 to stage 4, respectively. Optimal CVH status and each optimal CVH metric presented a significantly decreased risk of CVD events. Variation was observed in the association between cardiovascular-kidney-metabolic stage and CVD events with different CVH status or numbers of optimal CVH metrics. Compared with those in stage 0, Participants in stage 1 or 2 with optimal CVH no longer had elevated risks for incident CVD events. Suboptimal health factor contributed larger population attributable fractions to CVD events in cardiovascular-kidney-metabolic stage 0-2 (51.2%) than in stage 3-4 (25.2%), whereas suboptimal health behavior exhibited larger contribution in advanced stages (13.1% in stage 0-2 and 18.2% in stage 3-4).

Conclusions: The study indicated that cardiovascular-kidney-metabolic stage was associated with cardiovascular events, and optimal cardiovascular health could attenuate this risk. Health factor contributed predominantly at the early-stage, whereas health behavior exhibited consistent and slightly increased contribution along the spectrum. These findings support the utility of cardiovascular-kidney-metabolic construct and highlight the importance of target health improvement based on LE 8 framework.

Keywords: Cardiovascular events; Cardiovascular health; Cardiovascular-kidney-metabolic syndrome; Health behavior; Health factor.

Fig. 1

Distribution of CVH status according to CKM stages

Fig. 2

HRs of incident CVD events according to individual optimal CVH metrics and population attributable fractions for incident CVD events associated with individual suboptimal CVH metrics. Multivariable models were adjusted for age, sex, educational attainment, each metric of Life’s Essential 8 including nicotine exposure, diet, physical activity, sleep health, body mass index, blood lipids, blood glucose and blood pressures. CVD cardiovascular disease; CVH cardiovascular health; HR hazard ratio; BMI body mass index; CI confidence interval

Fig. 3

Combined association of CKM stages and CVH status with the risk of incident CVD events. A HRs (95% CI) of incident CVD events for the combination of CKM stage and CVH strata, compared with participants in CKM stage 0 with optimal CVH. B HRs (95% CI) for incident CVD events for participants with CKM syndrome in relation to the number of optimal CVH metrics, compared with participants in CKM stage 0. HRs were adjusted for age, sex, and educational attainment (< 9 years vs. ≥ 9 years)

Fig. 4

Contributions of specific CVH domains on CVD events among different stages of CKM syndrome. A HRs (95% CI) of incident CVD events associated with CVH behavior score and factor score among different stages of CKM syndrome. B HRs (95% CI) for incident CVD events associated with optimal behavior status and optimal factor status among different stages of CKM syndrome. C Population attributable fractions for incident CVD events associated with suboptimal behavior status and optimal factor status among different stages of CKM syndrome. Models were adjusted for age, sex, educational attainment (< 9 years vs. ≥ 9 years), BMI, blood pressure, blood lipids, and blood glucose status for analysis of health behavior. Models were adjusted for age, sex, educational attainment (< 9 years vs. ≥ 9 years), nicotine exposure, diet, physical activity, and sleep status for analysis of health factor