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A Systematic Review of the Prevalence and Outcomes of Ideal Cardiovascular Health in US and Non-US Populations

      Abstract

      Several population-based studies have examined the prevalence and trends of the American Heart Association's ideal cardiovascular health (CVH) metrics as well as its association with cardiovascular disease (CVD)–related morbidity and mortality and with non-CVD outcomes. However, no efforts have been made to aggregate these studies. Accordingly, we conducted a systematic review to synthesize available data on the distribution and outcomes associated with ideal CVH metrics in both US and non-US populations. We conducted a systematic search of relevant studies in the MEDLINE and CINAHL databases, as well as the Cochrane Register of Controlled Trials (CENTRAL). Search terms used included “life's simple 7”, “AHA 2020” and “ideal cardiovascular health”. We included articles published in English Language from January 1, 2010, to July 31, 2015. Of the 14 US cohorts, the prevalence of 6 to 7 ideal CVH metrics ranged from as low as 0.5% in a population of African Americans to 12% in workers in a South Florida health care organization. Outside the United States, the lowest prevalence was found in an Iranian study (0.3%) and the highest was found in a large Chinese corporation (15%). All 6 mortality studies reported a graded inverse association between the increasing number of ideal CVH metrics and the all-cause and CVD-related mortality risk. A similar relationship between ideal CVH metrics and incident cardiovascular events was found in 12 of 13 studies. Finally, an increasing number of ideal CVH metrics was associated with a lower prevalence and incidence of non-CVD outcomes such as cancer, depression, and cognitive impairment. The distribution of ideal CVH metrics in US and non-US populations is similar, with low proportions of persons achieving 6 or more ideal CVH metrics. Considering the strong association of CVH metrics with both CVD and non-CVD outcomes, a coordinated global effort for improving CVH should be considered a priority.

      Abbreviations and Acronyms:

      AHA (American Heart Association), BMI (body mass index), BP (blood pressure), FPG (fasting plasma glucose), MI (myocardial infarction), NHANES (National Health and Nutrition Examination Survey)
      Article Highlights
      • This systematic review highlights the low prevalence of ideal cardiovascular health (CVH) status within and outside the United States.
      • Overall distribution of ideal CVH metrics is similar in US and non-US studies, with low proportions of persons achieving 6 or more ideal CVH metrics.
      • Overall, the lowest ideal status was noted for diet and physical activity metrics.
      • The presence of favorable CVH status is associated with a considerably lower risk of incident cardiovascular disease as well as all-cause and cardiovascular disease–related mortality.
      • An increasing number of ideal CVH metrics were also associated with fewer noncardiovascular outcomes including cancer, depression, cognitive impairment, and incident diabetes in the general population.
      With about 800,000 deaths per year, cardiovascular disease (CVD) remains the leading cause of mortality in the United States, accounting for 1 in 3 deaths.
      • Mozaffarian D.
      • Benjamin E.J.
      • Go A.S.
      • et al.
      American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2015 update: a report from the American Heart Association.
      The high rate of mortality from CVD is driven by prevalent CVD risk factors. According to data from the 2014 heart disease and stroke statistical update of the American Heart Association (AHA), more than 30% of Americans have hypertension and approximately 54% of the 80 million Americans with hypertension have their blood pressure (BP) under control.
      • Mozaffarian D.
      • Benjamin E.J.
      • Go A.S.
      • et al.
      American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2015 update: a report from the American Heart Association.
      Moreover, 36% are unaware that they have elevated BP.
      • Wall H.K.
      • Hannan J.A.
      • Wright J.S.
      Patients with undiagnosed hypertension: hiding in plain sight.
      In 2010, the prevalence of obesity was 36%, a figure that has not changed considerably from previous years.
      • Flegal K.M.
      • Carroll M.D.
      • Kit B.K.
      • Ogden C.L.
      Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010.
      With prevention efforts, CVD mortality has declined by 11.5% from 2007 to 2011.
      • Mozaffarian D.
      • Benjamin E.J.
      • Go A.S.
      • et al.
      American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2015 update: a report from the American Heart Association.
      Despite this, CVD remains a huge burden both epidemiologically and economically, accounting for more than US$320 billion in health care expenditure.
      • Mozaffarian D.
      • Benjamin E.J.
      • Go A.S.
      • et al.
      American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2015 update: a report from the American Heart Association.
      In response to the increasing burden of CVD, the AHA established several strategic goals. In 1999, the AHA introduced the 2010 Impact Goal, which aimed for a 25% reduction in deaths from CVD by mitigating traditional CVD risk factors associated with CVD, such as smoking, physical inactivity, elevated blood cholesterol level, and uncontrolled high BP, along with obesity and diabetes.
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      By 2008, several targets had been achieved: a 31% reduction in coronary heart disease mortality and a 29% decline in stroke mortality.
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      In addition, there was a 29%, 25%, and 16% reduction in the prevalence of uncontrolled high BP, high cholesterol level, and smoking, respectively.
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      However, some shortcomings were evident. The prevalence of obesity and diabetes increased, and the prevalence of physical inactivity remained largely unchanged.
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      Recognizing the limitations of focusing only on CVD, in 2010 the AHA redefined its strategic impact goal for 2020. In addition to targeting an additional 20% reduction in CVD mortality, it aimed to improve ideal cardiovascular health (CVH) in all Americans by 20%.
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      To define CVH, the AHA used simple, easily reproducible metrics known as CVH metrics. The CVH metrics are derived from 7 components, often referred to as Life's Simple 7, and include 4 health behaviors (body mass index [BMI, calculated as the weight in kilograms divided by the height in meters squared], smoking, diet, and physical activity) and 3 health factors (cholesterol level, BP, and fasting glucose level). Each metric is categorized into ideal, intermediate, and poor levels (Supplemental Table 1, available online at http://www.mayoclinicproceedings.org).
      • Lloyd-Jones D.M.
      • Hong Y.
      • Labarthe D.
      • et al.
      American Heart Association Strategic Planning Task Force and Statistics Committee
      Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.
      Over the past 5 years, there have been several studies, both within and outside the United States, that have examined the CVH metrics, their trends over time, and their associations with multiple CVD and non-CVD end points. With this plethora of information, it is important to sort the evidence in such a manner as to inform policy and program planning and to highlight potential for future research. In this systematic review of CVH metrics, we aimed to synthesize the available evidence on the prevalence of ideal CVH metrics in US cohorts and highlight resemblances to non-US populations. We also systematically examine the relationship of ideal CVH metrics with health outcomes.

      Patients and Methods

      Data Sources and Study Selections

      A systematic review of the MEDLINE database was conducted using PubMed and OvidSP search engines. A systematic search was also undertaken using CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL). We included articles published in the English Language from January 1, 2010, to July 31, 2015. In PubMed, MeSH and relevant free text terms used included Life's Simple 7, AHA 2020, American Heart Association 2020, ideal cardiovascular health, and AHA 2020 cardiovascular diseases.
      To be included in the review of abstracts, studies had to assess the association between the prevalence of Life's Simple 7 or CVH as defined by the AHA and mortality, CVD, and/or non-CVD outcomes. Studies were included if the CVH metrics were measured, and they enrolled participants 18 years or older who were free of CVD. We manually scanned the references of articles for other relevant studies. Three researchers (A.Y., E.C.A., K.N.) reviewed the articles; discordances were discussed and a consensus was reached for each article included in the review. Articles were excluded if the abstract and full text were unavailable or if the studies were conducted in children. Review articles, letters, editorials, and case reports were also excluded. In all, a total of 50 studies met our search criteria and are included in the review. Figure 1 details the results of our literature search.
      Figure thumbnail gr1
      Figure 1PRISMA flowcharts detailing the search results.

      Quality Assessment/Evidence Appraisal

      We appraised the quality of each study using a standardized tool designed by the National Heart, Lung, and Blood Institute.
      National Heart, Lung, and Blood Institute
      Two reviewers (A.Y. and C.U.O.) independently appraised each study meeting our eligibility criteria and subsequently reached a consensus on the final ratings of quality for each study. Each study was rated either as good (most methodological criteria met, low risk of bias), fair (some criteria met, low risk of bias), or poor (few criteria met, high risk of bias). All studies in this review were rated as either fair or good and were included in the qualitative synthesis (Table 1).
      Table 1Description of Studies Included in the Systematic Review
      Reference, year, populationCountryStudy dateType of studyStudy qualityStudy populationFollow-up duration (y)Main outcome measure
      Crichton et al,
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • Alkerwi A.
      Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study.
      2014, MSLS
      United States1974Cross-sectional studyFair972 participants; age 23-98 yC/SCVH and cognitive function
      Folsom et al,
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      2011, ARIC
      United States1987-1989Prospective observational studyGood12,744 participants; 24% black; mean age 54 y; prevalence female 56%18.7Incident CHD, heart failure, stroke, and multiple outcomes simultaneously
      Folsom et al,
      • Folsom A.R.
      • Shah A.M.
      • Lutsey P.L.
      • et al.
      American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function.
      2015, ARIC
      United States1987-1989Prospective observational studyGood13,462 participants; 24% black; mean age 54 y; prevalence female 56%22.5Heart failure incidence in relation to Life's Simple 7
      Rasmussen-Torvik et al,
      • Rasmussen-Torvik L.J.
      • Shay C.M.
      • Abramson J.G.
      • et al.
      Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study.
      2013, ARIC
      United States1987-1989Prospective observational studyGood13,253 participants; 25% black; mean age 54 y; prevalence female 54%17-19Incident cancer
      España-Romero et al,
      • España-Romero V.
      • Artero E.G.
      • Lee D.C.
      • et al.
      A prospective study of ideal cardiovascular health and depressive symptoms.
      2013, ACLS
      United States1987-1998Prospective observational studyGood5110 participants; mean age 47 y; prevalence female 20.4%6.1Depressive symptoms
      Artero et al,
      • Artero E.G.
      • España-Romero V.
      • Lee D.C.
      • et al.
      Ideal cardiovascular health and mortality: Aerobics Center Longitudinal Study.
      2012, ACLS
      United States1987-1999Prospective observational studyGood11,993 participants; mean age 46 y; prevalence female 24.3%11.6Mortality from all-causes, CVD, and cancer
      Yang et al,
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      2012, NHANES
      United States1988-1994

      1988-2010
      Multiple cross-sectional surveysGood15,305 participants; 10.7% black; 4.8% Mexican Americans; 7.7% others; mean age 45 y; prevalence female 51.8%14.5All-cause mortality and CVD mortality

      Trends in CVH metrics
      Huffman et al,
      • Huffman M.D.
      • Capewell S.
      • Ning H.
      • Shay C.M.
      • Ford E.S.
      • Lloyd-Jones D.M.
      Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.
      2012, NHANES
      United States1988-2008Multiple cross-sectional surveysGood35,059 participants; mean age 44.4 y; prevalence female 51%C/SAHA 2020 CVH goal projections
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012, NOMAS
      United States1993-2001Prospective observational studyGood2981 participants; 25% black; 54% Hispanic; mean age 69 y; prevalence female 63.7%11Incident MI, stroke, and cardiovascular death
      Dhamoon et al,
      • Dhamoon M.S.
      • Dong C.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts functional status independently of vascular events: the Northern Manhattan Study.
      2015, NOMAS
      United States1993-2001Prospective observational studyGood3219 participants; 25% black; 54% Caribbean Hispanic; mean age 69 y; prevalence female 63%13Ideal CVH predicts functional status
      Xanthakis et al,
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      2014, Framingham Offspring Study
      United States1995-1998Prospective cohort studyGood2680 participants; mean age 58 y; prevalence female 55%16Association between ideal CVH and subclinical disease, biomarkers, and incidence of CVD
      Saleem et al,
      • Saleem Y.
      • DeFina L.F.
      • Radford N.B.
      • et al.
      Association of a favorable cardiovascular health profile with the presence of coronary artery calcification.
      2015, Cooper Center Longitudinal Study
      United States1997-2007Population-based cross-sectional studyFair3121 participants; prevalence female 17%C/SAssociation of ideal CVH metrics with the presence of coronary artery calcification
      Ford et al,
      • Ford E.S.
      • Greenlund K.J.
      • Hong Y.
      Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States.
      2012, NHANES
      United States1999-2002Prospective observational studyGood7622 participants; 17% black; 24% Mexican Americans; 8% others; mean age 43 y; prevalence female 52%5.8Mortality from all-causes and diseases of the circulatory system
      Caleyachetty et al,
      • Caleyachetty R.
      • Echouffo-Tcheugui J.B.
      • Muennig P.
      • Zhu W.
      • Muntner P.
      • Shimbo D.
      Association between cumulative social risk and ideal cardiovascular health in US adults: NHANES 1999-2006.
      2015, NHANES
      United States1999-2006Cross-sectional studyFair11,467 participants; age ≥25 y; prevalence female 51%C/SAssociation between cumulative social risk and ideal CVH in US adults
      Alman et al,
      • Alman A.C.
      • Maahs D.M.
      • Rewers M.J.
      • Snell-Bergeon J.K.
      Ideal cardiovascular health and the prevalence and progression of coronary artery calcification in adults with and without type 1 diabetes.
      2014, CACTI
      United States2000-2002Prospective observational studyGood1177 participants; mean age 38 y; prevalence female 52%6.1Prevalence of ideal CVH metrics and prevalence of subclinical atherosclerosis in adults with or without type 1 diabetes
      Unger et al,
      • Unger E.
      • Diez-Roux A.V.
      • Lloyd-Jones D.M.
      • et al.
      Association of neighborhood characteristics with cardiovascular health in the Multi-Ethnic Study of Atherosclerosis.
      2014, MESA
      United States2000-2002Cross-sectional studyFair5649 participants; 28% black; 12% Chinese American; 22% Hispanic; mean age 61.6 y; prevalence female 52%C/SAssociation of neighborhood characteristics with CVH
      Djoussé et al,
      • Djoussé L.
      • Petrone A.B.
      • Blackshear C.
      • et al.
      Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study.
      2015, The Jackson Heart Study
      United States2000-2004Prospective cohort studyGood5301 participants; 100% black; mean age 55 y; prevalence female 63%9Prevalence of CVH metrics
      Fretts et al,
      • Fretts A.M.
      • Howard B.V.
      • McKnight B.
      • et al.
      Life's Simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study.
      2014, SHFS
      United States2001-2003Prospective observational studyGood1639 participants; mean age 38 y; prevalence female 63%4-8Incidence of diabetes
      Crichton et al,
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • et al.
      Cardiovascular health: a cross-national comparison between the Maine Syracuse Study (Central New York, USA) and ORISCAV-LUX (Luxembourg).
      2014, ORISCAV-LUX
      United States, Luxembourg2001-2006

      2007-2009
      Cross-sectional studyGood1818 participants (673 from MSLS; prevalence female 59%; and 1145 from ORISCAV-LUX; prevalence female 51%; age 30-69 y)C/SCompare the pattern of CVH between 2 geographically and culturally distinct sites in the United States and Luxembourg
      Kulshreshtha et al,
      • Kulshreshtha A.
      • Goyal A.
      • Veledar E.
      • et al.
      Association between ideal cardiovascular health and carotid intima-media thickness: a twin study.
      2014, Emory Twin Study
      United States2002-2010Cross-sectional studyFair490 participants; mean age 55.4 y; monozygotic twins 61%C/SAssociation between ideal CVH and carotid intima-media thickness
      Robbins et al,
      • Robbins J.M.
      • Petrone A.B.
      • Carr J.J.
      • et al.
      Association of ideal cardiovascular health and calcified atherosclerotic plaque in the coronary arteries: the National Heart, Lung, and Blood Institute Family Heart Study.
      2015, NHLBI FHS
      United States2002-2003Cross-sectional studyFair1731 participants; mean age 57 y; prevalence female 59%C/SAssociation between ideal CVH and calcified atherosclerotic plaque
      Bambs et al,
      • Bambs C.
      • Kip K.E.
      • Dinga A.
      • Mulukutla S.R.
      • Aiyer A.N.
      • Reis S.E.
      Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
      2011, Heart SCORE study
      United States2003Cross-sectional studyGood1933 participants; 44% black; mean age 59 y; prevalence female 66%C/SPrevalence of ideal CVH in a community-based population
      Kulshreshtha et al,
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      2013, REGARDS
      United States2003-2007Prospective observational studyGood22,914 participants; 42% black; mean age 65 y; prevalence female 58%4.9Incident stroke
      Thacker et al,
      • Thacker E.L.
      • Gillett S.R.
      • Wadley V.G.
      • et al.
      The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
      2014, REGARDS
      United States2003-2007Prospective observational studyGood17,761 participants; 42% black; age ≥45 y; prevalence female 55%4Incident cognitive impairment
      Kronish et al,
      • Kronish I.M.
      • Carson A.P.
      • Davidson K.W.
      • Muntner P.
      • Safford M.M.
      Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      2012, REGARDS
      United States2003-2007Cross-sectional studyFair20,093 participants; 42% black; mean age 65 y; prevalence female 56%C/SPrevalent depressive symptoms
      Olson et al,
      • Olson N.C.
      • Cushman M.
      • Judd S.E.
      • et al.
      American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      2015, REGARDS
      United States2003-2007Prospective observational studyGood30,239 participants; 42% black; age ≥45 y; prevalence female 55%5Incident venous thromboembolism
      Shay et al,
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
      2012, NHANES
      United States2003-2008Cross-sectional studyGood14,515 participants; 11% black; 7% Mexican Americans; 4% Hispanics; 4.8% others; age ≥20 y; prevalence female 49.3%C/SPrevalence of CVH metrics
      Fang et al,
      • Fang J.
      • Yang Q.
      • Hong Y.
      • Loustalot F.
      Status of cardiovascular health among adult Americans in the 50 States and the District of Columbia, 2009.
      2012, BRFSS
      United States2009Cross-sectional studyGood356,441 participants; 8% black; 6% Hispanic; 3% others; age ≥18 y; prevalence female 63%C/SPrevalence of CVH metrics in 50 states
      Short et al,
      • Short V.L.
      • Gamble A.
      • Mendy V.
      Racial differences in ideal cardiovascular health metrics among Mississippi adults, 2009 Mississippi Behavioral Risk Factor Surveillance System.
      2013, BRFSS
      United States2009Cross-sectional studyGood7128 participants; 28% black; age ≥18 yC/SRacial differences in ideal CVH
      Bostean et al,
      • Bostean G.
      • Roberts C.K.
      • Crespi C.M.
      • et al.
      Cardiovascular health: associations with race-ethnicity, nativity, and education in a diverse, population-based sample of Californians.
      2013, CHIS
      United States2009Cross-sectional studyFair42,014 participants; age ≥25 yC/SRace/ethnicity, nativity, and education interact to affect disparities in CVH
      Kim et al,
      • Kim J.I.
      • Sillah A.
      • Boucher J.L.
      • Sidebottom A.C.
      • Knickelbine T.
      Prevalence of the American Heart Association's “ideal cardiovascular health” metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project.
      2013, HONU Project
      United States2009 and 2011Cross-sectional studyGood4754 participants; 4.1% others; mean age 52 y; prevalence female 58.3%C/SPrevalence of ideal CVH metrics
      Ogunmoroti et al,
      • Ogunmoroti O.
      • Younus A.
      • Rouseff M.
      • et al.
      Assessment of American Heart Association's ideal cardiovascular health metrics among employees of a large healthcare organization: the Baptist Health South Florida Employee Study.
      2015, BHSF Employee Study
      United States2014Cross-sectional studyGood9364 participants; mean age 43 y; prevalence female 74%C/SAssessment of ideal CVH metrics in employees of a large health care organization
      Aatola et al,
      • Aatola H.
      • Hutri-Kähönen N.
      • Juonala M.
      • et al.
      Prospective relationship of change in ideal cardiovascular health status and arterial stiffness: the Cardiovascular Risk in Young Finns Study.
      2014, Young Finns Study
      Finland1986Prospective cohort studyGood340 participants; age ≥21-24 y; prevalence female 56%21Ideal CVH status and arterial stiffness
      Kim et al,
      • Kim J.Y.
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      • et al.
      Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study.
      2013, Seoul Male Cohort Study
      Korea1993Prospective cohort studyGood12,538 participants; age ≥40 y18All-cause mortality and CVD mortality
      Maclagan et al,
      • Maclagan L.C.
      • Park J.
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      • et al.
      The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population.
      2014, CCHS
      Canada2003-2011 (excluding 2005)Cross-sectional studyGood464,883 participants; age ≥20 yC/STrends in the prevalence of 6 CVH metrics
      Zhang et al,
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      • et al.
      Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke.
      2013, KaiLuan Study
      China2006-2007Prospective cohort studyGood91,698 participants; mean age 52 y; prevalence female 21%4Incident stroke events
      Wu et al,
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      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      2012, KaiLuan Study
      China2006-2007Prospective cohort studyGood91,698 participants; mean age 52 y; prevalence female 21%4Prevalence of CVH metrics and CVD incidence
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      2014, KaiLuan Study
      China2006-2007Prospective cohort studyGood91,698 participants; mean age 52 y; prevalence female 21%4All-cause mortality and CVD mortality
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      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      2015, KaiLuan Study
      China2006-2007Prospective cohort studyGood91,598 participants; mean age 52 y; prevalence female 20%6.8CVH score and the risk of CVD
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      2015
      India2006-2010Cross-sectional studyFair6198 participants; age 20-75 y; prevalence female 45%C/SPrevalence of CVH metrics
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      2013, Nutrition and Cardiovascular Risk
      Spain2008-2010Cross-sectional studyGood11,408 participants; age ≥18 y; prevalence female 51%C/SPrevalence of CVH metrics
      Lee et al,
      • Lee H.J.
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      • Lee H.
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      Trends in cardiovascular health metrics among Korean adults.
      2013, KNHANES
      Korea2005-2009

      2009
      Cross-sectional studyGood7755 participants; mean age 49 y; prevalence female 54%C/STrends in CVH metrics in Korean adults

      Prevalence of CVH metrics
      Wu et al,
      • Wu H.Y.
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      Cardiovascular health status in Chinese adults in urban areas: analysis of the Chinese Health Examination Database 2010.
      2013, CHED
      China2009-2011Cross-sectional studyGood1,012,418 participants; mean age 42.4 y; prevalence female 46%C/SCVH status in Chinese adults in urban areas
      Moghaddam et al,
      • Moghaddam M.M.
      • Mohebi R.
      • Hosseini F.
      • et al.
      Distribution of ideal cardiovascular health in a community-based cohort of Middle East population.
      2014, TLGS
      Iran2009-2011Cross-sectional studyGood4865 participants; mean age 41.5 y; prevalence female 59%C/SPrevalence of CVH metrics
      Zeng et al,
      • Zeng Q.
      • Dong S.Y.
      • Song Z.Y.
      • Zheng Y.S.
      • Wu H.Y.
      • Mao L.N.
      Ideal cardiovascular health in Chinese urban population.
      2013, DREHM Study
      China2009-2012Cross-sectional studyGood9962 participants; mean age 47.1 y; prevalence female 44.2%C/SPrevalence of CVH metrics and psychological status
      Janković et al,
      • Janković S.
      • Stojisavljević D.
      • Janković J.
      • Erić M.
      • Marinković J.
      Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study.
      2014, National Health Survey
      Republic of Srpska, Bosnia/Herzegovina2010Cross-sectional studyFair4020 participants; mean age 50.2 y; prevalence female 54%C/SPrevalence of CVH metrics
      Bi et al,
      • Bi Y.
      • Jiang Y.
      • He J.
      • et al.
      2010 China Noncommunicable Disease Surveillance Group
      Status of cardiovascular health in Chinese adults.
      2015, China Noncommunicable Disease Surveillance
      China2010Cross-sectional studyGood96,121 participants; age ≥20 y; prevalence female 54%C/SPrevalence of CVH metrics
      Del Brutto et al,
      • Del Brutto O.H.
      • Dong C.
      • Rundek T.
      • Elkind M.S.
      • Del Brutto V.J.
      • Sacco R.L.
      Cardiovascular health status among Caribbean Hispanics living in Northern Manhattan and Ecuadorian natives/mestizos in rural coastal Ecuador: a comparative study.
      2013, Atahualpa, Ecuador
      Ecuador2012Cross-sectional studyGood616 participants; mean age 59 y; prevalence female 59%C/SPrevalence of CVH metrics
      Vetrano et al,
      • Vetrano D.L.
      • Martone A.M.
      • Mastropaolo S.
      • et al.
      Prevalence of the seven cardiovascular health metrics in a Mediterranean country: results from a cross-sectional study.
      2013
      Italy2012Cross-sectional studyGood1110 participants; mean age 56 y; prevalence female 56%C/SPrevalence of CVH metrics
      Li et al,
      • Li Z.
      • Yang X.
      • Wang A.
      • et al.
      Association between ideal cardiovascular health metrics and depression in Chinese population: a cross-sectional study.
      2015
      China2013Cross-sectional studyFair6851 participants; age ≥20 y; prevalence female 49%C/SAssociation between ideal CVH metrics and depression
      ACLS = Aerobics Center Longitudinal Study; ARIC = Atherosclerosis Risk in Communities; BHSF = Baptist Health South Florida; BRFSS = Behavioral Risk Factor Surveillance System; CACTI = Coronary Artery Calcification in Type 1 Diabetes; CCHS = Canadian Community Health Survey; CHD = coronary heart disease; CHED = Chinese Health Examination Database; CHIS = California Health Interview Survey; C/S = cross-sectional; CVD = cardiovascular disease; CVH = cardiovascular health; DREHM = Disease Risk Evaluation and Health Management; HONU = Heart of New Ulm; KNHANES = Korean National Health and Nutrition Examination Survey; MESA = Multi-Ethnic Study of Atherosclerosis; MI = myocardial infarction; MSLS = Maine-Syracuse Longitudinal Study; NHANES = National Health and Nutrition Examination Survey; NHLBI FHS = National Heart, Lung, and Blood Institute Family Heart Study; NOMAS = Northern Manhattan Study; ORISCAV-LUX = Observation of Cardiovascular Risk Factors in Luxembourg; REGARDS = Reasons for Geographic And Racial Differences in Stroke; SHFS = Strong Heart Family Study; TLGS = Tehran Lipid and Glucose Study.

      Data Extraction

      From studies selected for inclusion, the following data were extracted: number of study participants enrolled, study design, study date, age, sex, race, follow-up duration, and outcome. Pooled proportions were estimated for the prevalence of ideal CVH metrics, the frequency of persons achieving 0, 1, 2, 3, 4, 5, and 6 or more (maximum 7) ideal CVH metrics, and in the following categories: 0 to 1, 2 to 3, 4 to 5, and 6 to 7 ideal CVH metrics. Our study followed all PRISMA guidelines, as applicable, in the design, data collection, and analysis and reporting of this systematic review (Supplemental Table 2, available online at http://www.mayoclinicproceedings.org).

      Publication Bias

      We conducted an analysis of the prevalence of 6 to 7 frequencies. First, we created a funnel plot of the frequency of 6 to 7 ideal AHA criteria plotted against their standard errors for both US and non-US studies. Then, for each of these, we conducted the linear regression test and rank correlation test for funnel plot asymmetry.
      • Egger M.
      • Davey Smith G.
      • Schneider M.
      • Minder C.
      Bias in meta-analysis detected by a simple, graphical test.
      It is important to state that the test for funnel plot asymmetry cannot be interpreted as publication bias and there is no bias attached to presenting any of the prevalences in any of the studies.

      Results

      Of the 50 studies
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • Alkerwi A.
      Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study.
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      • Folsom A.R.
      • Shah A.M.
      • Lutsey P.L.
      • et al.
      American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function.
      • Rasmussen-Torvik L.J.
      • Shay C.M.
      • Abramson J.G.
      • et al.
      Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study.
      • España-Romero V.
      • Artero E.G.
      • Lee D.C.
      • et al.
      A prospective study of ideal cardiovascular health and depressive symptoms.
      • Artero E.G.
      • España-Romero V.
      • Lee D.C.
      • et al.
      Ideal cardiovascular health and mortality: Aerobics Center Longitudinal Study.
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      • Huffman M.D.
      • Capewell S.
      • Ning H.
      • Shay C.M.
      • Ford E.S.
      • Lloyd-Jones D.M.
      Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Dhamoon M.S.
      • Dong C.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts functional status independently of vascular events: the Northern Manhattan Study.
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      • Saleem Y.
      • DeFina L.F.
      • Radford N.B.
      • et al.
      Association of a favorable cardiovascular health profile with the presence of coronary artery calcification.
      • Ford E.S.
      • Greenlund K.J.
      • Hong Y.
      Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States.
      • Caleyachetty R.
      • Echouffo-Tcheugui J.B.
      • Muennig P.
      • Zhu W.
      • Muntner P.
      • Shimbo D.
      Association between cumulative social risk and ideal cardiovascular health in US adults: NHANES 1999-2006.
      • Alman A.C.
      • Maahs D.M.
      • Rewers M.J.
      • Snell-Bergeon J.K.
      Ideal cardiovascular health and the prevalence and progression of coronary artery calcification in adults with and without type 1 diabetes.
      • Unger E.
      • Diez-Roux A.V.
      • Lloyd-Jones D.M.
      • et al.
      Association of neighborhood characteristics with cardiovascular health in the Multi-Ethnic Study of Atherosclerosis.
      • Djoussé L.
      • Petrone A.B.
      • Blackshear C.
      • et al.
      Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study.
      • Fretts A.M.
      • Howard B.V.
      • McKnight B.
      • et al.
      Life's Simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study.
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • et al.
      Cardiovascular health: a cross-national comparison between the Maine Syracuse Study (Central New York, USA) and ORISCAV-LUX (Luxembourg).
      • Kulshreshtha A.
      • Goyal A.
      • Veledar E.
      • et al.
      Association between ideal cardiovascular health and carotid intima-media thickness: a twin study.
      • Robbins J.M.
      • Petrone A.B.
      • Carr J.J.
      • et al.
      Association of ideal cardiovascular health and calcified atherosclerotic plaque in the coronary arteries: the National Heart, Lung, and Blood Institute Family Heart Study.
      • Bambs C.
      • Kip K.E.
      • Dinga A.
      • Mulukutla S.R.
      • Aiyer A.N.
      • Reis S.E.
      Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      • Thacker E.L.
      • Gillett S.R.
      • Wadley V.G.
      • et al.
      The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
      • Kronish I.M.
      • Carson A.P.
      • Davidson K.W.
      • Muntner P.
      • Safford M.M.
      Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      • Olson N.C.
      • Cushman M.
      • Judd S.E.
      • et al.
      American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
      • Fang J.
      • Yang Q.
      • Hong Y.
      • Loustalot F.
      Status of cardiovascular health among adult Americans in the 50 States and the District of Columbia, 2009.
      • Short V.L.
      • Gamble A.
      • Mendy V.
      Racial differences in ideal cardiovascular health metrics among Mississippi adults, 2009 Mississippi Behavioral Risk Factor Surveillance System.
      • Bostean G.
      • Roberts C.K.
      • Crespi C.M.
      • et al.
      Cardiovascular health: associations with race-ethnicity, nativity, and education in a diverse, population-based sample of Californians.
      • Kim J.I.
      • Sillah A.
      • Boucher J.L.
      • Sidebottom A.C.
      • Knickelbine T.
      Prevalence of the American Heart Association's “ideal cardiovascular health” metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project.
      • Ogunmoroti O.
      • Younus A.
      • Rouseff M.
      • et al.
      Assessment of American Heart Association's ideal cardiovascular health metrics among employees of a large healthcare organization: the Baptist Health South Florida Employee Study.
      • Aatola H.
      • Hutri-Kähönen N.
      • Juonala M.
      • et al.
      Prospective relationship of change in ideal cardiovascular health status and arterial stiffness: the Cardiovascular Risk in Young Finns Study.
      • Kim J.Y.
      • Ko Y.J.
      • Rhee C.W.
      • et al.
      Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study.
      • Maclagan L.C.
      • Park J.
      • Sanmartin C.
      • et al.
      The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population.
      • Zhang Q.
      • Zhou Y.
      • Gao X.
      • et al.
      Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke.
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      • Liu Y.
      • Chi H.J.
      • Cui L.F.
      • et al.
      The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.

      Gupta B, Gupta R, Sharma KK, Gupta A, Mahanta TG, Deedwania PC. Low prevalence of AHA-defined ideal cardiovascular health factors among urban men and women in India [published online ahead of print March 26, 2015]. Glob Heart. doi:10.1016/j.gheart.2014.09.004.

      • Graciani A.
      • León-Muñoz L.M.
      • Guallar-Castillón P.
      • Rodríguez-Artalejo F.
      • Banegas J.R.
      Cardiovascular health in a southern Mediterranean European country: a nationwide population-based study.
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      • Wu H.Y.
      • Sun Z.H.
      • Cao D.P.
      • Wu L.X.
      • Zeng Q.
      Cardiovascular health status in Chinese adults in urban areas: analysis of the Chinese Health Examination Database 2010.
      • Moghaddam M.M.
      • Mohebi R.
      • Hosseini F.
      • et al.
      Distribution of ideal cardiovascular health in a community-based cohort of Middle East population.
      included in the review, about 21 were prospective studies; the others were cross-sectional in design (Table 1). Thirty-three studies were conducted in the United States using 17 cohorts. The non-US studies included 8 studies from China conducted in 5 cohorts, 2 studies from Korea conducted in 2 cohorts (one of which was based on a nationally representative sample), and 1 study from each of the following countries: Bosnia/Herzegovina, Canada, Ecuador, Finland, India, Iran, Italy, and Spain. The follow-up periods for the studies with outcomes ranged from 4 to 22.5 years, beginning as early as 1974. Table 1 lists all the studies included in this systematic review.

      Prevalence of Individual CVH Metrics

      In the studies conducted in the United States, the prevalence of ideal classification for smoking ranged from 29% to 98% (Figure 2, A). Only 3 of the 14 studies reported prevalence of ideal classification for smoking as less than 50%, making it the best CVH metric. Similar prevalence (range, 49%-98%) was seen for nonsmokers in non-US studies. By far the poorest metric was diet, with 8 of the 14 US studies reporting a prevalence of 1% or less (range, 0%-39%). Six of the 15 non-US studies reported less than 10% prevalence of ideal diet (range, 2%-76%). However, none was less than 1% (Figure 2, B).
      Figure thumbnail gr2a
      Figure 2Prevalence of the ideal levels of cardiovascular health factors in (A) US and (B) non-US studies. BMI = body mass index; NHANES = National Health and Nutrition Examination Survey. aNHANES 2003-2008. bNHANES 1988-1994. cProportions of ideal healthy diet reported as less than 1% using American Heart Association criteria. These are different from those used in the tables within the publication.
      Figure thumbnail gr2b
      Figure 2Prevalence of the ideal levels of cardiovascular health factors in (A) US and (B) non-US studies. BMI = body mass index; NHANES = National Health and Nutrition Examination Survey. aNHANES 2003-2008. bNHANES 1988-1994. cProportions of ideal healthy diet reported as less than 1% using American Heart Association criteria. These are different from those used in the tables within the publication.

      Clustering of Ideal CVH Metrics

      The proportions of persons achieving 0 to 7 ideal CVH metrics and the number achieving ideal for each metric for the 14 US and 11 non-US studies are described in Table 2 and Figure 3, respectively. In US studies, the prevalence of ideal CVH (defined here as achieving 6 or 7 ideal CVH metrics) was as low as 0.5% (Table 2, US Studies).
      • Djoussé L.
      • Petrone A.B.
      • Blackshear C.
      • et al.
      Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study.
      Only 1 of the 14 US studies had a prevalence of ideal CVH greater than 10%.
      • Ogunmoroti O.
      • Younus A.
      • Rouseff M.
      • et al.
      Assessment of American Heart Association's ideal cardiovascular health metrics among employees of a large healthcare organization: the Baptist Health South Florida Employee Study.
      Among non-US studies, an Iranian study reported the prevalence of ideal CVH to be as low as 0.3%; however, 3 other studies reported the prevalence of ideal CVH to be greater than 10% (Table 2, Non-US Studies).
      Table 2Prevalence and Pooled Estimates of Prevalence of the Ideal Number of CVH Factors
      B/H = Bosnia/Herzegovina; CVH = cardiovascular health.
      US studies
      Reference, yearFolsom et al,
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      2011
      Artero et al,
      • Artero E.G.
      • España-Romero V.
      • Lee D.C.
      • et al.
      Ideal cardiovascular health and mortality: Aerobics Center Longitudinal Study.
      2012
      Yang et al,
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      2012
      NHANES 1988-1994.
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012
      Xanthakis et al,
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      2014
      Saleem et al,
      • Saleem Y.
      • DeFina L.F.
      • Radford N.B.
      • et al.
      Association of a favorable cardiovascular health profile with the presence of coronary artery calcification.
      2015
      Ford et al,
      • Ford E.S.
      • Greenlund K.J.
      • Hong Y.
      Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States.
      2012
      NHANES 1999-2002.
      Djoussé et al,
      • Djoussé L.
      • Petrone A.B.
      • Blackshear C.
      • et al.
      Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study.
      2015
      Robbins et al,
      • Robbins J.M.
      • Petrone A.B.
      • Carr J.J.
      • et al.
      Association of ideal cardiovascular health and calcified atherosclerotic plaque in the coronary arteries: the National Heart, Lung, and Blood Institute Family Heart Study.
      2015
      Bambs et al,
      • Bambs C.
      • Kip K.E.
      • Dinga A.
      • Mulukutla S.R.
      • Aiyer A.N.
      • Reis S.E.
      Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
      2011
      Approximate values obtained from Figure 1 of the respective publications.
      Kulshreshtha et al,
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      2013
      Shay et al,
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
      2012
      Approximate values obtained from Figure 1 of the respective publications.
      ,
      NHANES 2003-2008.
      Kim et al,
      • Kim J.I.
      • Sillah A.
      • Boucher J.L.
      • Sidebottom A.C.
      • Knickelbine T.
      Prevalence of the American Heart Association's “ideal cardiovascular health” metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project.
      2013
      Ogunmoroti et al,
      • Ogunmoroti O.
      • Younus A.
      • Rouseff M.
      • et al.
      Assessment of American Heart Association's ideal cardiovascular health metrics among employees of a large healthcare organization: the Baptist Health South Florida Employee Study.
      2015
      Study date1987-19891987-19991988-19941993-20011995-19981997-20071999-20022000-20042002-200320032003-20072003-20082009-20112014
      Total population (N)12,74411,99315,305298126803121762241321731193322,91414,51547549364
      Prevalence of CVH factors (%)
       02.54121222583310
       114.5138178138251721191472
       22522193221272033242731.5252110
       32723263030282723.5232426.5252723
       41920241422192212181214212331
       59141541391441055101423
       6 or 735715270.53313812
      Non-US studies
      Reference, yearKim et al,
      • Kim J.Y.
      • Ko Y.J.
      • Rhee C.W.
      • et al.
      Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study.
      2013
      Wu et al,
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      2012
      Gupta et al,

      Gupta B, Gupta R, Sharma KK, Gupta A, Mahanta TG, Deedwania PC. Low prevalence of AHA-defined ideal cardiovascular health factors among urban men and women in India [published online ahead of print March 26, 2015]. Glob Heart. doi:10.1016/j.gheart.2014.09.004.

      2015
      Graciani et al,
      • Graciani A.
      • León-Muñoz L.M.
      • Guallar-Castillón P.
      • Rodríguez-Artalejo F.
      • Banegas J.R.
      Cardiovascular health in a southern Mediterranean European country: a nationwide population-based study.
      2013
      Lee et al,
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      2013
      Wu et al,
      • Wu H.Y.
      • Sun Z.H.
      • Cao D.P.
      • Wu L.X.
      • Zeng Q.
      Cardiovascular health status in Chinese adults in urban areas: analysis of the Chinese Health Examination Database 2010.
      2013
      Moghaddam et al,
      • Moghaddam M.M.
      • Mohebi R.
      • Hosseini F.
      • et al.
      Distribution of ideal cardiovascular health in a community-based cohort of Middle East population.
      2014
      Approximate values obtained from Figure 1 of the respective publications.
      Zeng et al,
      • Zeng Q.
      • Dong S.Y.
      • Song Z.Y.
      • Zheng Y.S.
      • Wu H.Y.
      • Mao L.N.
      Ideal cardiovascular health in Chinese urban population.
      2013
      Bi et al,
      • Bi Y.
      • Jiang Y.
      • He J.
      • et al.
      2010 China Noncommunicable Disease Surveillance Group
      Status of cardiovascular health in Chinese adults.
      2015
      Janković et al,
      • Janković S.
      • Stojisavljević D.
      • Janković J.
      • Erić M.
      • Marinković J.
      Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study.
      2014
      Del Brutto et al,
      • Del Brutto O.H.
      • Dong C.
      • Rundek T.
      • Elkind M.S.
      • Del Brutto V.J.
      • Sacco R.L.
      Cardiovascular health status among Caribbean Hispanics living in Northern Manhattan and Ecuadorian natives/mestizos in rural coastal Ecuador: a comparative study.
      2013
      Study date19932006-20072006-20102008-201020092009-20112009-20112009-2012201020102012
      Region/countryKoreaChinaIndiaSpainKoreaChinaIranChinaChinaB/HEcuador
      Total population (N)12,53891,698619811,40858981,012,4184865996296,1214020616
      Prevalence of CVH factors (%)
       00.042.5140.41120.330.3
       1111.58143.541293147
       252522231292017102625
       31831292422232922232831
       43421252026222223311923
       53181212222616212389
       6 or 71213414150.361024
      a B/H = Bosnia/Herzegovina; CVH = cardiovascular health.
      b NHANES 1988-1994.
      c NHANES 1999-2002.
      d Approximate values obtained from Figure 1 of the respective publications.
      e NHANES 2003-2008.
      Figure thumbnail gr3
      Figure 3Distribution of the ideal cardiovascular health status. 0-1 = poor CVH; 2-5 = average CVH; 6-7 = optimal CVH; NHANES = National Health and Nutrition Examination Survey. aNHANES 1988-1994. bNHANES 1999-2002. cApproximate values obtained of the respective studies. dNHANES 2003-2008.
      For US studies, the funnel plot is shown in Supplemental Figure 1 (available online at http://www.mayoclinicproceedings.org). Egger's linear regression test for funnel plot asymmetry in these studies suggested that the funnel plot may be asymmetrical (t=3.66; P=.003). Rank correlation test values were z=1.2591 and P=.208. For non-US studies, the funnel plot is shown in Supplemental Figure 2 (available online at http://www.mayoclinicproceedings.org). Both Egger's linear regression test and rank correlation test suggested that the funnel plot is symmetrical (t=−.34; P=.79 and z=.856; P=.39).

      Ideal CVH Trends in US and Non-US Populations

      We found 4 studies that examined the trends in CVH (Supplemental Table 3, available online at http://www.mayoclinicproceedings.org). Yang et al
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      comparing age-standardized CVH prevalence across the National Health and Nutrition Examination Survey (NHANES) from 1988 through 2010 reported that there was a significant increase in the frequency of persons with 0 to 1 ideal CVH metrics (P<.01), but no significant change in the prevalence of those with 6 or more ideal CVH metrics (P=.12). Furthermore, their study reported that the gains made by improving smoking and physical activity status were eroded by reduction in the prevalence of ideal BMI, blood glucose level, and scores for healthy diet. Huffman et al
      • Huffman M.D.
      • Capewell S.
      • Ning H.
      • Shay C.M.
      • Ford E.S.
      • Lloyd-Jones D.M.
      Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.
      comparing 2 waves of NHANES data from 1988 through 2008 had findings similar to those of Yang et al. In addition, they estimated a 6% improvement in CVH by 2020.
      Among non-US studies, in a Korean nationally representative survey, that is, Korean NHANES, Lee et al
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      found that there was no change in the prevalence of ideal CVH from 2005 to 2009. However, among individual metrics, improvements were seen in physical activity and BMI.
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      Using a 6-metric system each of which also have ideal, intermediate, and poor classifications, Maclagan et al
      • Maclagan L.C.
      • Park J.
      • Sanmartin C.
      • et al.
      The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population.
      found that the prevalence of ideal CVH (ideal for all 6 metrics) in Canadians remained stable from 2003 to 2011.

      Ideal CVH Prevalence and Ethnic/Racial Disparities

      Consistently, studies that examined ethnic and racial differences in CVH prevalence reported that there was a tendency for blacks to have a lower proportion of persons with 5 or more ideal CVH metrics and higher levels of 2 or less ideal CVH metrics than do non-Hispanic whites.
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Bambs C.
      • Kip K.E.
      • Dinga A.
      • Mulukutla S.R.
      • Aiyer A.N.
      • Reis S.E.
      Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
      • Fang J.
      • Yang Q.
      • Hong Y.
      • Loustalot F.
      Status of cardiovascular health among adult Americans in the 50 States and the District of Columbia, 2009.
      • Short V.L.
      • Gamble A.
      • Mendy V.
      Racial differences in ideal cardiovascular health metrics among Mississippi adults, 2009 Mississippi Behavioral Risk Factor Surveillance System.
      Other minority ethnicities are less well studied, but the available data show that Hispanics also have a substantially lower prevalence of ideal CVH than did whites as well as more likely to have poor CVH (<2 ideal CVH metrics) as detailed in Supplemental Table 4 (available online at http://www.mayoclinicproceedings.org).
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
      • Fang J.
      • Yang Q.
      • Hong Y.
      • Loustalot F.
      Status of cardiovascular health among adult Americans in the 50 States and the District of Columbia, 2009.

      CVH Metrics, All-Cause Mortality, and CVD Mortality

      Table 3 details the findings of the 6 studies that assessed the relationship between ideal CVH metrics and mortality. We grouped the findings into all-cause and CVD-related mortality. In all studies, persons with higher numbers of ideal CVH metrics (≥5) had lower mortality than did those with fewer ideal CVH metrics. Compared with persons with 0 to 1 CVH metrics, persons with 5 to 7 CVH metrics had a 23% to 79% reduction in the risk of all-cause mortality and a 42% to 90% reduction in the risk of CVD mortality. It should be noted that the study by Yang et al
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      examined this relationship in NHANES using a single cohort (1988-1994).
      Table 3Number of Ideal CVH Metrics and CVD or All-Cause Mortality
      Reference, yearArtero et al,
      • Artero E.G.
      • España-Romero V.
      • Lee D.C.
      • et al.
      Ideal cardiovascular health and mortality: Aerobics Center Longitudinal Study.
      2012
      Yang et al,
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      2012
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012
      Ford et al,
      • Ford E.S.
      • Greenlund K.J.
      • Hong Y.
      Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States.
      2012
      Kim et al,
      • Kim J.Y.
      • Ko Y.J.
      • Rhee C.W.
      • et al.
      Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study.
      2013
      Liu et al,
      • Liu Y.
      • Chi H.J.
      • Cui L.F.
      • et al.
      The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city.
      2014
      Follow-up duration (y)11.614.5115.8184
      OutcomeCVD mortality (HR [95% CI])
       0ReferentReferentReferentReferentReferentReferent
       10.13 (0.04-0.43)
       20.72 (0.58-0.89)0.70 (0.53-0.91)0.12 (0.04-0.35)0.89 (0.67-1.19)
       30.45 (0.27-0.77)0.55 (0.43-0.69)0.67 (0.51-0.87)0.12 (0.04-0.36)0.77 (0.46-1.29)0.76 (0.57-1.01)
       40.50 (0.40-0.62)0.51 (0.37-0.72)0.09 (0.03-0.25)0.46 (0.27-0.76)0.60 (0.44-0.83)
       50.37 (0.15-0.95)0.41 (0.29-0.60)0.48 (0.29-0.80)0.10 (0.02-0.47)0.31 (0.18-0.53)0.58 (0.37-0.92)
       6 or 70.22 (0.11-0.41)0.10 (0.03-0.29)
      OutcomeAll-cause mortality (HR [95% CI])
       0ReferentReferentReferentReferentReferentReferent
       10.59 (0.23-1.51)
       20.79 (0.67-0.94)0.87 (0.73-1.03)0.61 (0.24-1.55)0.99 (0.84-1.17)
       30.83 (0.65-1.06)0.69 (0.58-0.81)0.78 (0.66-0.93)0.54 (0.21-1.44)0.93 (0.73-1.21)0.91 (0.77-1.07)
       40.59 (0.51-0.69)0.72 (0.59-0.89)0.39 (0.14-1.09)0.76 (0.59-0.96)0.86 (0.73-1.03)
       50.77 (0.53-1.12)0.57 (0.44-0.73)0.59 (0.43-0.81)0.21 (0.07-0.59)0.65 (0.51-0.84)0.69 (0.54-0.89)
       6 or 70.41 (0.28-0.61)0.42 (0.31-0.59)
      Variables adjusted forAge, sex, examination year, alcohol use, and family history of CVDAge, sex, and race/ethnicityAge, sex, and race/ethnicityAge, sex, race/ethnicity, education, self-reported health status, health insurance, alcohol use, and cancer historyAge, educational attainment, alcohol use, and family history of CVDAge, sex, average income, education level, alcohol use, history of MI, stroke, and cancer
      P trendNRP<.001P<.001NRP<.001NR
      CVD = cardiovascular disease; CVH = cardiovascular health; HR = hazard ratio; MI = myocardial infarction; NR = not reported.

      Ideal CVH and Incident CVD Events

      Nine studies assessed the relationship between CVH metrics and incident CVD. The CVD spectrum included stroke,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      • Zhang Q.
      • Zhou Y.
      • Gao X.
      • et al.
      Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      myocardial infarction (MI),
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      incident heart failure,
      • Folsom A.R.
      • Shah A.M.
      • Lutsey P.L.
      • et al.
      American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function.
      venous thromboembolism,
      • Olson N.C.
      • Cushman M.
      • Judd S.E.
      • et al.
      American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      and a composite variable of CVD events (definitions for CVD events for each study can be found in the footnote in Table 4).
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      Similar to the findings on CVD mortality, an increasing number of ideal CVH metrics was associated with a reduced risk of CVD. Only 1 of the 4 studies assessing stroke as an outcome did not find an association with increasing numbers of CVH metrics. The risk of MI alone was reported by 2 studies, both of which found that higher numbers of ideal CVH factors was protective of MI.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      In a 2015 study, Folsom et al
      • Folsom A.R.
      • Shah A.M.
      • Lutsey P.L.
      • et al.
      American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function.
      found that ideal CVH protects against incident heart failure, whereas Olson et al
      • Olson N.C.
      • Cushman M.
      • Judd S.E.
      • et al.
      American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      (also in 2015) found that ideal CVH (having 6 or 7 ideal CVH metrics) was protective against venous thromboembolism.
      Table 4Incidence of CVD Events
      BNP = B-type natriuretic peptide; CHD = coronary heart disease; CRP = C-reactive protein; CVD = cardiovascular disease; CVH = cardiovascular health; GDF-15 = growth differentiation factor-15; HR = hazard ratio; MI = myocardial infarction; PAI-1 = plasminogen activator inhibitor-1; NR = not reported; VTE = venous thromboembolism.
      Reference, yearDuration (y)Outcome measureEffect measure0123456 or 7Variables adjusted for:P trend
      Folsom et al,
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      2011
      Incident CVD event defined as heart failure, definite or probable MI, fatal CHD, and definite or probable stroke.
      18.7Incident CVD eventsHR (95% CI)Referent0.65 (0.55-0.77)0.46 (0.39-0.54)0.34 (0.28-0.40)0.24 (0.20-0.29)0.18 (0.14-0.23)0.11 (0.07-0.17)Age, sex, and raceNR
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012
      CVD events include the first event of MI, stroke, or cardiovascular death.
      11Referent0.73 (0.60-0.89)0.61 (0.50-0.76)0.49 (0.38-0.63)0.41 (0.26-0.63)Age, sex, and race/ethnicityP<.001
      Xanthakis et al,
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      2014
      CVD events include MI, coronary insufficiency, angina pectoris, stroke, transient ischemic attack, intermittent claudication, and heart failure.
      160.87 (0.78-0.97) per unit increase in 7-point CVH score (1 point for each ideal CVH metric achieved)Age, sex, PAI-1, GDF-15, BNP, and subclinical diseaseNR
      Wu et al,
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      2012
      CVD events include MI, cerebral infarction, or cerebral hemorrhage.
      4Referent0.88 (0.68-1.13)0.63 (0.49-0.81)0.47 (0.36-0.60)0.34 (0.26-0.44)0.24 (0.17-0.34)0.18 (0.08-0.40)Age, sex, income, and education. Stratified for hospitalNR
      Miao et al,
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      2015
      CVD events include MI and stroke.
      6.8Referent0.56 (0.48-0.66)0.29 (0.24-0.35)Age, sex, alcohol consumption, income, education, history of cardiovascular disease, heart rate, uric acid, and high-sensitivity CRPP<.01
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012
      11Myocardial infarctionReferent0.78 (0.54-1.12)0.57 (0.38-0.84)0.53 (0.33-0.85)0.16 (0.05-0.52)Age, sex, and race/ethnicityP<.001
      Miao et al,
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      2015
      6.8Myocardial infarctionReferent0.52 (0.37-0.73)0.26 (0.18-0.38)Age, sex, alcohol consumption, income, education, history of cardiovascular disease, heart rate, uric acid, and high-sensitivity CRPP<.01
      Folsom et al,
      • Folsom A.R.
      • Shah A.M.
      • Lutsey P.L.
      • et al.
      American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function.
      2015
      22.5Incident heart failureReferent0.75 (0.43-0.64)0.52 (0.43-0.64)0.39 (0.31-0.48)0.27 (0.22-0.34)0.17 (0.13-0.23)0.17 (0.11-0.28)Age, sex, prevalent CHD, competing risk of death, and race (all)NR
      Dong et al,
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      2012
      11StrokeReferent0.71 (0.51-0.99)0.6 (0.42-0.84)0.49 (0.31-0.76)0.43 (0.21-0.91)Age, sex, and race/ethnicityP<.0002
      Kulshreshtha et al,
      • Kulshreshtha A.
      • Vaccarino V.
      • Judd S.E.
      • et al.
      Life's Simple 7 and risk of incident stroke: the Reasons for Geographic And Racial Differences in Stroke study.
      2013
      4.9StrokeReferent0.7 (0.42-1.19)0.67 (0.4-1.13)0.53 (0.31-0.90)0.4 (0.23-0.73)0.5 (0.25-1.0)0.34 (0.08-1.52)Age, sex, race, income, education, alcohol use, and geographic regionNR
      Zhang et al,
      • Zhang Q.
      • Zhou Y.
      • Gao X.
      • et al.
      Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke.
      2013
      Stroke events include ischemic and intracerebral hemorrhagic stroke.
      4Incident stroke eventsReferent0.92 (0.69-1.23)0.69 (0.52-0.92)0.52 (0.39-0.68)0.38 (0.28-0.51)0.27 (0.18-0.40)0.24 (0.11-0.54)Age, sex, hospital, education, and incomeP<.001
      Miao et al,
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      2015
      6.8StrokeReferent0.57 (0.48-0.69)0.30 (0.24-0.37)Age, sex, alcohol consumption, income, education, history of cardiovascular disease, heart rate, uric acid, and high-sensitivity CRPP<.01
      Olson et al,
      • Olson N.C.
      • Cushman M.
      • Judd S.E.
      • et al.
      American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      2015
      5Incident VTEReferent0.62 (0.43-0.89)0.56 (0.38-0.82)Age, sex, income, education, race, region, and Race × Region interactionNR
      a BNP = B-type natriuretic peptide; CHD = coronary heart disease; CRP = C-reactive protein; CVD = cardiovascular disease; CVH = cardiovascular health; GDF-15 = growth differentiation factor-15; HR = hazard ratio; MI = myocardial infarction; PAI-1 = plasminogen activator inhibitor-1; NR = not reported; VTE = venous thromboembolism.
      b Incident CVD event defined as heart failure, definite or probable MI, fatal CHD, and definite or probable stroke.
      c CVD events include the first event of MI, stroke, or cardiovascular death.
      d CVD events include MI, coronary insufficiency, angina pectoris, stroke, transient ischemic attack, intermittent claudication, and heart failure.
      e CVD events include MI, cerebral infarction, or cerebral hemorrhage.
      f CVD events include MI and stroke.
      g Stroke events include ischemic and intracerebral hemorrhagic stroke.
      Five studies
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      examined incident CVD events as a composite variable. Three
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
      • Dong C.
      • Rundek T.
      • Wright C.B.
      • Anwar Z.
      • Elkind M.S.
      • Sacco R.L.
      Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study.
      • Xanthakis V.
      • Enserro D.M.
      • Murabito J.M.
      • et al.
      Ideal cardiovascular health: associations with biomarkers and subclinical disease and impact on incidence of cardiovascular disease in the Framingham Offspring Study.
      of these studies were conducted in the United States, and 2 studies
      • Wu S.
      • Huang Z.
      • Yang X.
      • et al.
      Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.
      • Miao C.
      • Bao M.
      • Xing A.
      • et al.
      Cardiovascular health score and the risk of cardiovascular diseases.
      were conducted in China. All 5 studies reported significant reduction in the risk of CVD events with increasing ideal CVH metrics, with as high as 89% reduction in the risk of CVD events in persons with 6 to 7 ideal CVH metrics.
      • Folsom A.R.
      • Yatsuya H.
      • Nettleton J.A.
      • Lutsey P.L.
      • Cushman M.
      • Rosamond W.D.
      ARIC Study Investigators
      Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.

      Ideal CVH and Non-CVD Outcomes

      Table 5 summarizes studies examining the relationship between ideal CVH and non-CVD outcomes.
      Table 5Relationship Between Ideal CVH and Non-CVD Outcomes
      Reference, year, countryMain outcomeResultsVariables adjusted for:Notes
      Rasmussen-Torvik et al,
      • Rasmussen-Torvik L.J.
      • Shay C.M.
      • Abramson J.G.
      • et al.
      Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study.
      2013, United States
      Cancer (prospective observational study)0 ideal metrics: Referent

      1 ideal metric: HR (95% CI) 0.79 (0.64-0.98)

      2 ideal metrics: HR (95% CI) 0.79 (0.64-0.98)

      3 ideal metrics: HR (95% CI) 0.74 (0.59-0.91)

      4 ideal metrics: HR (95% CI) 0.67 (0.54-0.84)

      5 ideal metrics: HR (95% CI) 0.61 (0.48-0.79)

      6-7 ideal metrics: HR (95% CI) 0.49 (0.35-0.69)
      Age, sex, race, and ARIC centerCombined all incident cancer cases, except nonmelanoma skin cancer
      España-Romero et al,
      • España-Romero V.
      • Artero E.G.
      • Lee D.C.
      • et al.
      A prospective study of ideal cardiovascular health and depressive symptoms.
      2013, United States
      Depressive symptoms (prospective observational study)0-2 ideal metrics: Referent

      3-4 ideal metrics: OR (95% CI) 0.72 (0.59-0.87)

      5-7 ideal metrics: OR (95% CI) 0.64 (0.50-0.82)
      Age, sex, baseline examination, survey response year, and alcohol useThe 4-item Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms
      Kronish et al,
      • Kronish I.M.
      • Carson A.P.
      • Davidson K.W.
      • Muntner P.
      • Safford M.M.
      Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      2012, United States
      Depression (cross-sectional study)Persons without depression had a higher mean simple score of 7 (on a 21-point CVH metric scale; 14.6 vs 13.7; P<.001). Those with depression also had higher scores on the behavioral (7.9 vs 7.2; P<.001; using a 4- to 12-point scale) and biological (6.8 vs 6.6; P<.001; using a 3- to 9-point scale) subscalesAge, race, sex, geographic region of residence, education, and incomeThe 4-item Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms
      Li et al,
      • Li Z.
      • Yang X.
      • Wang A.
      • et al.
      Association between ideal cardiovascular health metrics and depression in Chinese population: a cross-sectional study.
      2015, China
      Depression (cross-sectional study)Quartile 1 (≤8): Referent

      Quartile 2 (9-10): OR (95% CI) 0.94 (0.75-1.19)

      Quartile 3 (11): OR (95% CI) 0.67 (0.50-0.91)

      Quartile 4 (12-14): OR (95% CI) 0.58 (0.43-0.78)
      Age, sex, marital status, heavy alcohol consumption, income level, education level, previous history of myocardial infarction, stroke, or cancerThe 4-item Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms
      Thacker et al,
      • Thacker E.L.
      • Gillett S.R.
      • Wadley V.G.
      • et al.
      The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
      2014, United States
      Incident cognitive impairment (prospective observational study)Lowest tertile: OR (95% CI) 0.65 (0.52-0.81)

      Highest tertile: OR (95% CI) 0.63 (0.51-0.79)
      Age, sex, race, education, income, region, atrial fibrillation, left ventricular hypertrophy, atherosclerotic disease, time interval from baseline to most recent 3-test measureA Six-Item Screener was administered to assess global cognitive status (score range, 0-6). Scoring below 5 points on the Six-Item Screener was defined cognitive impairment
      Crichton et al,
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • et al.
      Cardiovascular health: a cross-national comparison between the Maine Syracuse Study (Central New York, USA) and ORISCAV-LUX (Luxembourg).
      2014, United States
      Cognitive function (cross-sectional study)The mean global composite score for cognitive function was higher in the highest and middle tertiles of a 0-8 CVH score compared with the lowest tertile (0.131 vs 0.059 vs −0.109; P =.003 for trend)Age, education, and sexCognitive function was assessed using a thorough neuropsychological test battery that includes 20 individual tests designed to measure a wide range of cognitive abilities
      Fretts et al,
      • Fretts A.M.
      • Howard B.V.
      • McKnight B.
      • et al.
      Life's Simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study.
      2014, United States
      Incidence of diabetes (prospective observational study)0-1 ideal metrics: Referent

      2-3 ideal metrics: OR (95% CI) 0.40 (0.29-0.56)

      ≥4 ideal metrics: OR (95% CI) 0.11 (0.05-0.21)
      Age, sex, site, education, and family history of diabetesNot applicable
      CVD = cardiovascular disease; CVH = cardiovascular health; HR = hazard ratio; OR = odds ratio.

      Cancer Risk

      Rasmussen-Torvik et al
      • Rasmussen-Torvik L.J.
      • Shay C.M.
      • Abramson J.G.
      • et al.
      Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study.
      found that higher numbers of ideal CVH metrics were associated with a reduced risk of cancer. In this study, persons with 6 to 7 ideal CVH metrics had a 51% reduction in cancer risk as compared with those with 0 ideal CVH metrics.
      • Rasmussen-Torvik L.J.
      • Shay C.M.
      • Abramson J.G.
      • et al.
      Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study.

      Depressive Symptoms

      Two studies
      • España-Romero V.
      • Artero E.G.
      • Lee D.C.
      • et al.
      A prospective study of ideal cardiovascular health and depressive symptoms.
      • Kronish I.M.
      • Carson A.P.
      • Davidson K.W.
      • Muntner P.
      • Safford M.M.
      Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      assessed the relationship between CVH and depressive symptoms. España-Romero et al
      • España-Romero V.
      • Artero E.G.
      • Lee D.C.
      • et al.
      A prospective study of ideal cardiovascular health and depressive symptoms.
      found that compared with persons with 0 to 2 ideal CVH metrics, persons achieving 5 to 7 and 3 to 4 ideal metrics had 36% and 28% reduction in the odds of depressive symptoms, whereas Kronish et al
      • Kronish I.M.
      • Carson A.P.
      • Davidson K.W.
      • Muntner P.
      • Safford M.M.
      Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
      estimated that the mean score of Life's Simple 7 (on a 21-point scale) was modestly but significantly higher in persons without depression than in those with depression (14.6 vs 13.7; P<.001).

      Cognitive Impairment

      Two studies
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • Alkerwi A.
      Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study.
      • Thacker E.L.
      • Gillett S.R.
      • Wadley V.G.
      • et al.
      The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
      measured the relationship between CVH and cognitive impairment. Thacker et al
      • Thacker E.L.
      • Gillett S.R.
      • Wadley V.G.
      • et al.
      The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
      found that persons in the lowest and highest tertiles of ideal CVH scores, using a 14-point scoring system, had lower odds of incident cognitive impairment than did persons in the middle tertile. Similarly, Crichton et al
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • Alkerwi A.
      Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study.
      found that persons in the middle and highest tertiles of ideal CVH scores, using an 8-point scoring system, had lower mean global composite scores for cognitive function.

      Diabetes

      In a study of American Indians, Fretts et al
      • Fretts A.M.
      • Howard B.V.
      • McKnight B.
      • et al.
      Life's Simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study.
      found that persons with 4 or more ideal CVH metrics had an approximate 90% reduction in the risk of diabetes as compared with persons with 0 or 1 ideal CVH metrics.

      Discussion

      This comprehensive systematic review of published studies conducted in both US and non-US cohorts reports a consistently low prevalence of ideal CVH (6-7 metrics) across all the studies. Despite differences in the measures, healthy diet was the poorest metric in both US and non-US populations. Among both US and non-US studies, nearly all studies reported that more than 50% of the population achieved ideal metrics for smoking. This may be a reflection of the global tobacco use prevention efforts. In non-US cohorts, the fasting plasma glucose (FPG) metric was also excellent, with some studies showing normal FPG metrics as high as 99%.
      • Aatola H.
      • Hutri-Kähönen N.
      • Juonala M.
      • et al.
      Prospective relationship of change in ideal cardiovascular health status and arterial stiffness: the Cardiovascular Risk in Young Finns Study.
      The frequency of an ideal FPG metric was also high in the United States, but trend results suggest that this is on the decline.
      • Huffman M.D.
      • Capewell S.
      • Ning H.
      • Shay C.M.
      • Ford E.S.
      • Lloyd-Jones D.M.
      Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.
      Poor levels of healthy diet and low frequency of physical activity, 2 of the poorest CVH metrics, have been shown to be associated with poor BMI and BP metrics.
      • Barreira T.V.
      • Harrington D.M.
      • Katzmarzyk P.T.
      Cardiovascular health metrics and accelerometer-measured physical activity levels: National Health and Nutrition Examination Survey, 2003-2006.
      • Bazzano L.A.
      • Green T.
      • Harrison T.N.
      • Reynolds K.
      Dietary approaches to prevent hypertension.
      • Estruch R.
      • Martínez-González M.A.
      • Corella D.
      • et al.
      Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial.
      • Siervo M.
      • Lara J.
      • Chowdhury S.
      • Ashor A.
      • Oggioni C.
      • Mathers J.C.
      Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis.
      • Boggs D.A.
      • Rosenberg L.
      • Rodríguez-Bernal C.L.
      • Palmer J.R.
      Long-term diet quality is associated with lower obesity risk in young African American women with normal BMI at baseline.
      • Forman J.P.
      • Stampfer M.J.
      • Curhan G.C.
      Diet and lifestyle risk factors associated with incident hypertension in women.
      • Jankovic N.
      • Geelen A.
      • Streppel M.T.
      • et al.
      Adherence to a healthy diet according to the World Health Organization guidelines and all-cause mortality in elderly adults from Europe and the United States.
      • Estruch R.
      • Ros E.
      • Salas-Salvadó J.
      • et al.
      PREDIMED Study Investigators
      Primary prevention of cardiovascular disease with a Mediterranean diet.
      Similarly, healthy diet and increased physical activity are both associated with lower levels of fasting glucose and better insulin sensitivity.
      • Esposito K.
      • Giugliano D.
      Mediterranean diet and type 2 diabetes.
      • Nettleton J.A.
      • Hivert M.F.
      • Lemaitre R.N.
      • et al.
      Meta-analysis investigating associations between healthy diet and fasting glucose and insulin levels and modification by loci associated with glucose homeostasis in data from 15 cohorts.
      • Rynders C.A.
      • Weltman J.Y.
      • Jiang B.
      • et al.
      Effects of exercise intensity on postprandial improvement in glucose disposal and insulin sensitivity in prediabetic adults.
      • Buresh R.
      Exercise and glucose control.
      Thus, successful prevention efforts that improve healthy diet and physical activity should result in an improvement in BMI, BP, and fasting glucose metrics.
      Comparisons between US and non-US studies are difficult because of differences in the age and sex composition of the cohorts and in the time period over which data were collected. However, among the 7 national cohorts included in this study (Figure 4), the Bosnia/Herzegovina cohort had the lowest ideal CVH (6-7 metrics) (2%), closely followed by the US cohort (3%).
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • et al.
      Cardiovascular health: a cross-national comparison between the Maine Syracuse Study (Central New York, USA) and ORISCAV-LUX (Luxembourg).
      • Shay C.M.
      • Ning H.
      • Allen N.B.
      • et al.
      Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.

      Gupta B, Gupta R, Sharma KK, Gupta A, Mahanta TG, Deedwania PC. Low prevalence of AHA-defined ideal cardiovascular health factors among urban men and women in India [published online ahead of print March 26, 2015]. Glob Heart. doi:10.1016/j.gheart.2014.09.004.

      • Graciani A.
      • León-Muñoz L.M.
      • Guallar-Castillón P.
      • Rodríguez-Artalejo F.
      • Banegas J.R.
      Cardiovascular health in a southern Mediterranean European country: a nationwide population-based study.
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      • Janković S.
      • Stojisavljević D.
      • Janković J.
      • Erić M.
      • Marinković J.
      Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study.
      • Bi Y.
      • Jiang Y.
      • He J.
      • et al.
      2010 China Noncommunicable Disease Surveillance Group
      Status of cardiovascular health in Chinese adults.
      As observed in US studies, the poorest metric in other national surveys was diet, except for Luxembourgian and Korean surveys, which did not use the AHA 2020 estimation for ideal healthy diet.
      • Crichton G.E.
      • Elias M.F.
      • Davey A.
      • et al.
      Cardiovascular health: a cross-national comparison between the Maine Syracuse Study (Central New York, USA) and ORISCAV-LUX (Luxembourg).
      • Lee H.J.
      • Suh B.
      • Yoo T.G.
      • Lee H.
      • Shin D.W.
      Trends in cardiovascular health metrics among Korean adults.
      Across all the national surveys, the United States had the lowest prevalence of ideal diet, cholesterol level, and BMI and the highest prevalence of only ideal smoking (ie, nonsmokers for at least 1 year). Although non-US studies appear to have better CVH indices than do US studies, none of the non-US studies had up to 20% prevalence of ideal CVH (6-7 metrics), suggesting that the limited presence of ideal CVH is not only a US concern but also a global problem. It appears that the low frequency of ideal CVH is particularly dire in developing countries. Four studies

      Gupta B, Gupta R, Sharma KK, Gupta A, Mahanta TG, Deedwania PC. Low prevalence of AHA-defined ideal cardiovascular health factors among urban men and women in India [published online ahead of print March 26, 2015]. Glob Heart. doi:10.1016/j.gheart.2014.09.004.

      • Moghaddam M.M.
      • Mohebi R.
      • Hosseini F.
      • et al.
      Distribution of ideal cardiovascular health in a community-based cohort of Middle East population.
      • Janković S.
      • Stojisavljević D.
      • Janković J.
      • Erić M.
      • Marinković J.
      Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study.
      • Del Brutto O.H.
      • Dong C.
      • Rundek T.
      • Elkind M.S.
      • Del Brutto V.J.
      • Sacco R.L.
      Cardiovascular health status among Caribbean Hispanics living in Northern Manhattan and Ecuadorian natives/mestizos in rural coastal Ecuador: a comparative study.
      included in this review were conducted in cohorts residing in developing nations (India, Iran, Bosnia/Herzegovina, and Ecuador). Only 4% and 2% of participants in studies conducted, respectively, in Ecuador and Bosnia/Herzegovina achieved 6 or more of ideal CVH metrics, whereas in the Iranian study, this figure was less than 1%. It is noteworthy that only 4 of the 50 studies examined CVH in low- and middle-income countries. Considering that CVD is a global health problem with an increasing incidence in low- and middle-income countries and that the AHA Life's Simple 7 metric is a simple, cost-effective tool to assess and monitor population level CVH, assessing CVH in low- and middle-income countries should be a priority.
      National Academy of Sciences
      Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health.
      GBD 2013 Mortality and Causes of Death Collaborators
      Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
      • Krishnamurthi R.V.
      • Feigin V.L.
      • Forouzanfar M.H.
      • et al.
      Global Burden of Diseases, Injuries, Risk Factors Study 2010 (GBD 2010)GBD Stroke Experts Group
      Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.
      • Huffman M.D.
      Cardiovascular health in low- and middle-income countries.
      Figure thumbnail gr4
      Figure 4Cross-national comparisons of cardiovascular health (Life's Simple 7). AHA = American Heart Association; B/H = Bosnia/Herzegovina; BMI = body mass index. aDiet metrics in the Korean and Luxembourgian surveys are not comparable with the American Heart Association ideal metric for healthy diet. b8 metrics were used, and frequency of numerical scores was not reported. 0-1 metrics = poor CVH; 2-5 metrics = average CVH; 6-7 metrics = optimal CVH.
      The lack of substantial change in ideal CVH in the United States over the past 2 decades and a projected 6% improvement in CVH by 2020 underscores the emergent need for well-calculated steps to be taken to make the most gains in CVH in the shortest possible period.
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      • Huffman M.D.
      • Capewell S.
      • Ning H.
      • Shay C.M.
      • Ford E.S.
      • Lloyd-Jones D.M.
      Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys.
      Indeed, if there is to be a chance of altering the course of CVH in the next half decade, then aggressive population level interventions ought to be made. The results of our findings show that the metrics most likely to achieve the highest yield are healthy diet and physical activity because they are the least prevalent and have a substantial effect on the other CVH metrics except for cigarette smoking.
      The studies in this review consistently show that minority populations have disproportionately lower frequencies of ideal CVH. Tailoring CVH improvement interventions to these populations is crucial to improving CVH in the United States. Findings from our review also indicate a substantial lack of research into CVH in minority ethnoracial groups including Hispanics. There are about 54 million Hispanics living in the United States and representing about 17% of the US population.
      Centers for Disease Control and Prevention
      Minority Health: Hispanic or Latino Population.
      Hispanics are of diverse backgrounds and have been shown to have a substantial prevalence of CVD risk factors. In addition, it has been reported that the prevalence of CVD risk factors varies by background within Hispanics.
      • Daviglus M.L.
      • Talavera G.A.
      • Avilés-Santa M.L.
      • et al.
      Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States.
      Despite having a greater burden of CVD risk factors, Hispanics have lower CVD mortality and the protective mechanisms responsible are yet to be elucidated.
      • Medina-Inojosa J.
      • Jean N.
      • Cortes-Bergoderi M.
      • Lopez-Jimenez F.
      The Hispanic paradox in cardiovascular disease and total mortality.
      Thus, there is clearly a need to examine CVH across diverse Hispanic backgrounds and to investigate genetic and sociocultural influences on CVH in this population.
      • Rodriguez C.J.
      Disparities in ideal cardiovascular health: a challenge or an opportunity?.
      The most efficient and cost-effective methods of addressing CVH in minority populations are not known, and addressing this in CVH research will be beneficial.
      As shown, all the CVD and mortality studies reported that with increasing frequency of ideal CVH metrics, there was a reduction in the risk of CVD events and mortality in a dose-response fashion. Apart from strongly suggesting a protective effect of ideal CVH, these findings indicate that even minor improvement in CVH should result in beneficial reduction in the risk of CVD and death. This can and should be used to incentivize participants in lifestyle improvement programs aimed at improving CVH.
      Several recent studies (included in this review) have shown that ideal CVH is associated with protection from other non-CVD outcomes such as cognitive impairment, depression, diabetes, and cancer. The protective effect that ideal CVH extends to non-CVD outcomes should further strengthen the drive for lifestyle intervention programs aimed at improving CVH. However, more research efforts are needed to fully understand the extent of protection that ideal CVH confers on non-CVD outcomes and on the mechanisms that drive this protection. In particular, more noncardiovascular disorders need to be examined in a temporal fashion. In addition, the individual metrics that affect these outcomes and the cost benefits of implementing CVH improvement programs on improving non-CVD outcomes need to be investigated.
      The potential economic impact of improving CVH metrics on a population level can be enormous. Overall, costs associated with CVD in the United States are more than US$300 billion annually and are projected to rise to more than US$700 billion by 2020.
      • Heidenreich P.A.
      • Trogdon J.G.
      • Khavjou O.A.
      • et al.
      American Heart Association Advocacy Coordinating CommitteeStroke CouncilCouncil on Cardiovascular Radiology and InterventionCouncil on Clinical CardiologyCouncil on Epidemiology and PreventionCouncil on ArteriosclerosisThrombosis and Vascular BiologyCouncil on CardiopulmonaryCritical CarePerioperative and ResuscitationCouncil on Cardiovascular NursingCouncil on the Kidney in Cardiovascular DiseaseCouncil on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research
      Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
      Results from epidemiological studies
      • Maruthur N.M.
      • Wang N.Y.
      • Appel L.J.
      Lifestyle interventions reduce coronary heart disease risk: results from the PREMIER Trial.
      • Stampfer M.J.
      • Hu F.B.
      • Manson J.E.
      • Rimm E.B.
      • Willett W.C.
      Primary prevention of coronary heart disease in women through diet and lifestyle.
      have suggested that an improvement in lifestyle is associated with a significant reduction (P<.001) in the risk of heart disease and that achieving improved lifestyle is cost-effective. For instance, reducing dietary intake by 100 kcal/d will result in the elimination of about 71 million obesity cases and savings of about US$58 billion annually, while salt reduction for the control of hypertension will result in an annual saving of US$2 billion.
      • Dall T.M.
      • Fulgoni III, V.L.
      • Zhang Y.
      • Reimers K.J.
      • Packard P.T.
      • Astwood J.D.
      Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet.
      Thus, programs targeted at improving CVH should result in substantial cost-savings. The assertions in this paragraph are backed by a recent study by Willis et al.
      • Willis B.L.
      • DeFina L.F.
      • Bachmann J.M.
      • et al.
      Association of ideal cardiovascular health and long-term healthcare costs.
      In their study of about 5000 adults (mean age, 56 years) with Medicare, Willis et al found that favorable CVH (5-7 ideal CVH metrics) was associated with 25% lower CVD health care costs as compared with those with unfavorable CVH profile (1-2 ideal CVH factors). Surprisingly, there was greater savings on non–CVD-related expenditures than on CVD-related expenditures.
      • Willis B.L.
      • DeFina L.F.
      • Bachmann J.M.
      • et al.
      Association of ideal cardiovascular health and long-term healthcare costs.
      This study, which is the first to formally assess the economic benefits of ideal CVH, underscores the importance of CVH not only in the setting of CVD prevention but also in other health care settings, thus reiterating that ideal CVH attainment should be a priority.
      In this systematic review, we attempted to determine whether there was publication bias. The formal test for funnel plot asymmetry was significantly asymmetric in US studies (P<.01), which suggested that there may have been some reporting or publication bias. However, we interpret these findings with caution. First, there was no intervention in any of these studies and a simple observed proportion was reported. Therefore, it is likely that the asymmetry seen in US studies and not non-US studies may be due to other causes including differences in the study qualities with regard to the methods of ascertaining the ideal CVH factors (eg, nutrition). Such methodological differences have been shown in studies to be a source of funnel plot asymmetry. Second, the heterogeneous nature of the studies (different age groups, geography, and times) may also be reflected in funnel plot asymmetry. Finally, these findings may also be due to chance.
      • Egger M.
      • Juni P.
      • Bartlett C.
      • Holenstein F.
      • Sterne J.
      How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study.
      • Davey Smith G.
      • Egger M.
      Statistical problems.
      • Glasziou P.P.
      • Irwig L.M.
      An evidence based approach to individualising treatment.
      Our study is the most comprehensive review on the ideal CVH metrics, providing a detailed analysis of ideal CVH in the United States and beyond. This study brings together results on CVD, subclinical CVD, and non-CVD outcomes, all of which are essential for policy formulation.
      Despite the study strengths listed above, there are several important limitations. The studies conducted evaluated the AHA metrics at a single time period and for those with follow-up assessed their outcomes at a later date without consideration to repeat assessments of their CVH metrics. This assumes no change in the individual CVH characteristics over time, which is not always the case. For instance, persons who quit smoking less than a year ago (intermediate level for smoking metric) and remain so will become ideal in a year's time.
      Conducting a meta-analysis of proportions for the prevalences was not possible because the surveys were taken from different times, up to 30 years apart, and from populations that were contrasting in age, sex, and racial demographic characteristics. The inability to conduct a meta-analysis coupled with the fact that only a few non-US studies with nationally representative samples precludes definite conclusions on the comparison of ideal CVH in the United States and beyond.
      There are several sources of heterogeneity across studies in this systematic review. First, there is some between-study variance in the measurements of ideal CVH metrics. This is most pronounced with diet; several studies used a diet score of 2 or more as ideal,
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      whereas others used a score of 4 to 5. The difference in these 2 scores can be substantial as mentioned by Yang et al,
      • Yang Q.
      • Cogswell M.E.
      • Flanders W.D.
      • et al.
      Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
      who measured 33% as ideal diet if a score of 2 or more was used and less than 1% if 4 or more was used. Thus, for these studies, the prevalence of ideal for healthy diet is probably underestimated. Second, there is a considerable difference in the populations assessed across studies in terms of age, sex, geographic distribution (even within the United States), and distribution of socioeconomic status. Finally, a third source of heterogeneity may stem from the difference in survey years for each of the studies included in our review and ranging from 1974 to 2014. Although we do not attempt to control for this heterogeneity, we have reported that even in fairly homogeneous studies, the prevalence of ideal CVH is low and shows a racial predilection.
      The lack of a uniform referral group for CVD mortality and incidence precluded conducting a meta-analysis, but, as pointed out earlier in the discussion, the inverse association between ideal CVH metrics and CVD outcomes was linear and uniform across all the studies.

      Conclusion

      There is convincing evidence that ideal CVH, as described in the AHA 2020 goal, protects from CVDs, CVD mortality, and all-cause mortality. The evidence linking CVH with subclinical CVD risk prevention strongly supports that ideal CVH protects not only from CVD but also from CVD-related mortality by mitigating the processes involved in its development. It also appears that the benefits of ideal CVH extend beyond CVD prevention to non-CVD disorders including cancer, depression, and cognitive impairment. Indeed, the benefits of ideal CVH are strongly supported by scientific evidence; however, the frequency of persons achieving ideal or nearly ideal CVH is low globally. Current evidence suggests slow progress in improving CVH in the United States, and there is no evidence of improvement in other populations. In lieu of the comprehensive evidence generated in the past years, our review clearly delineates the need to improve current policies for enhancing CVH and sharpening focus on metrics that will achieve the highest returns. Ongoing efforts need to specifically focus on highlighting interventions that will yield the greatest improvement in ideal CVH metrics in the shortest time, and with a long-lasting effect.

      Acknowledgments

      Drs Younus and Aneni contributed equally to this work.

      Supplemental Online Material

      Figure thumbnail figs1
      Supplemental Figure 1US studies funnel plot.
      Figure thumbnail figs2
      Supplemental Figure 2Non-US studies funnel plot.

      Supplemental Online Material

      Supplemental material can be found online at: http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

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