Hongyan Ning

Lifetime Risks of Cardiovascular Disease

BACKGROUND The lifetime risks of cardiovascular disease have not been reported across the age spectrum in black adults and white adults. METHODS We conducted a meta-analysis at the individual level using data from 18 cohort studies involving a total of 257,384 black men and women and white men and women whose risk factors for cardiovascular disease were measured at the ages of 45, 55, 65, and 75 years. Blood pressure, cholesterol level, smoking status, and diabetes status were used to stratify participants according to risk factors into five mutually exclusive categories. The remaining lifetime risks of cardiovascular events were estimated for participants in each category at each age, with death free of cardiovascular disease treated as a competing event. RESULTS We observed marked differences in the lifetime risks of cardiovascular disease across risk-factor strata. Among participants who were 55 years of age, those with an optimal risk-factor profile (total cholesterol level, <180 mg per deciliter [4.7 mmol per liter]; blood pressure, <120 mm Hg systolic and 80 mm Hg diastolic; nonsmoking status; and nondiabetic status) had substantially lower risks of death from cardiovascular disease through the age of 80 years than participants with two or more major risk factors (4.7% vs. 29.6% among men, 6.4% vs. 20.5% among women). Those with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women). Similar trends within risk-factor strata were observed among blacks and whites and across diverse birth cohorts. CONCLUSIONS Differences in risk-factor burden translate into marked differences in the lifetime risk of cardiovascular disease, and these differences are consistent across race and birth cohorts. (Funded by the National Heart, Lung, and Blood Institute.).

Status of Cardiovascular Health in US Adults Prevalence Estimates From the National Health and Nutrition Examination Surveys (NHANES) 2003–2008

Background— The American Heart Associations 2020 Strategic Impact Goals define a new concept, cardiovascular (CV) health; however, current prevalence estimates of the status of CV health in US adults according to age, sex, and race/ethnicity have not been published. Methods and Results— We included 14 515 adults (≥20 years of age) from the 2003 to 2008 National Health and Nutrition Examination Surveys. Participants were stratified by young (20–39 years), middle (40–64 years), and older (≥65 years) ages. CV health behaviors (diet, physical activity, body mass index, smoking) and CV health factors (blood pressure, total cholesterol, fasting blood glucose, smoking) were defined as poor, intermediate, or ideal. Fewer than 1% of adults exhibited ideal CV health for all 7 metrics. For CV health behaviors, nonsmoking was most prevalent (range, 60.2%–90.4%), whereas ideal Healthy Diet Score was least prevalent (range, 0.2%–2.6%) across groups. Prevalences of ideal body mass index (range, 36.5%–45.3%) and ideal physical activity levels (range, 50.2%–58.8%) were higher in young adults compared with middle or older ages. Ideal total cholesterol (range, 23.7%–36.2%), blood pressure (range, 11.9%–16.3%), and fasting blood glucose (range, 31.2%–42.9%) were lower in older adults compared with young and middle-aged adults. Prevalence of poor CV health factors was lowest in young age but higher at middle and older ages. Prevalence estimates by age and sex were consistent across race/ethnic groups. Conclusions— These prevalence estimates of CV health represent a starting point from which effectiveness of efforts to promote CV health and prevent CV disease can be monitored and compared in US adult populations.

Cardiovascular Health Behavior and Health Factor Changes (1988–2008) and Projections to 2020 Results From the National Health and Nutrition Examination Surveys

Background— The American Heart Associations 2020 Strategic Impact Goals target a 20% relative improvement in overall cardiovascular health with the use of 4 health behavior (smoking, diet, physical activity, body mass) and 3 health factor (plasma glucose, cholesterol, blood pressure) metrics. We sought to define current trends and forward projections to 2020 in cardiovascular health. Methods and Results— We included 35 059 cardiovascular disease–free adults (aged ≥20 years) from the National Health and Nutrition Examination Survey 1988–1994 and subsequent 2-year cycles during 1999–2008. We calculated population prevalence of poor, intermediate, and ideal health behaviors and factors and also computed a composite, individual-level Cardiovascular Health Score for all 7 metrics (poor=0 points; intermediate=1 point; ideal=2 points; total range, 0–14 points). Prevalence of current and former smoking, hypercholesterolemia, and hypertension declined, whereas prevalence of obesity and dysglycemia increased through 2008. Physical activity levels and low diet quality scores changed minimally. Projections to 2020 suggest that obesity and impaired fasting glucose/diabetes mellitus could increase to affect 43% and 77% of US men and 42% and 53% of US women, respectively. Overall, population-level cardiovascular health is projected to improve by 6% overall by 2020 if current trends continue. Individual-level Cardiovascular Health Score projections to 2020 (men=7.4 [95% confidence interval, 5.7–9.1]; women=8.8 [95% confidence interval, 7.6–9.9]) fall well below the level needed to achieve a 20% improvement (men=9.4; women=10.1). Conclusions— The American Heart Association 2020 target of improving cardiovascular health by 20% by 2020 will not be reached if current trends continue. # Clinical Perspective {#article-title-25}Background— The American Heart Associations 2020 Strategic Impact Goals target a 20% relative improvement in overall cardiovascular health with the use of 4 health behavior (smoking, diet, physical activity, body mass) and 3 health factor (plasma glucose, cholesterol, blood pressure) metrics. We sought to define current trends and forward projections to 2020 in cardiovascular health. Methods and Results— We included 35 059 cardiovascular disease–free adults (aged ≥20 years) from the National Health and Nutrition Examination Survey 1988–1994 and subsequent 2-year cycles during 1999–2008. We calculated population prevalence of poor, intermediate, and ideal health behaviors and factors and also computed a composite, individual-level Cardiovascular Health Score for all 7 metrics (poor=0 points; intermediate=1 point; ideal=2 points; total range, 0–14 points). Prevalence of current and former smoking, hypercholesterolemia, and hypertension declined, whereas prevalence of obesity and dysglycemia increased through 2008. Physical activity levels and low diet quality scores changed minimally. Projections to 2020 suggest that obesity and impaired fasting glucose/diabetes mellitus could increase to affect 43% and 77% of US men and 42% and 53% of US women, respectively. Overall, population-level cardiovascular health is projected to improve by 6% overall by 2020 if current trends continue. Individual-level Cardiovascular Health Score projections to 2020 (men=7.4 [95% confidence interval, 5.7–9.1]; women=8.8 [95% confidence interval, 7.6–9.9]) fall well below the level needed to achieve a 20% improvement (men=9.4; women=10.1). Conclusions— The American Heart Association 2020 target of improving cardiovascular health by 20% by 2020 will not be reached if current trends continue.

Lifetime Risk and Years Lived Free of Total Cardiovascular Disease

CONTEXT Estimates of lifetime risk for total cardiovascular disease (CVD) may provide projections of the future population burden of CVD and may assist in clinician-patient risk communication. To date, no lifetime risk estimates of total CVD have been reported. OBJECTIVES To calculate lifetime risk estimates of total CVD by index age (45, 55, 65, 75 years) and risk factor strata and to estimate years lived free of CVD across risk factor strata. DESIGN, SETTING, AND PARTICIPANTS Pooled survival analysis of as many as 905,115 person-years of data from 1964 through 2008 from 5 National Heart, Lung, and Blood Institute-funded community-based cohorts: Framingham Heart Study, Framingham Offspring Study, Atherosclerosis Risk in Communities Study, Chicago Heart Association Detection Project in Industry Study, and Cardiovascular Health Study. All participants were free of CVD at baseline with risk factor data (blood pressure [BP], total cholesterol [TC], diabetes, and smoking status) and total CVD outcome data. MAIN OUTCOME MEASURES Any total CVD event (including fatal and nonfatal coronary heart disease, all forms of stroke, congestive heart failure, and other CVD deaths). RESULTS At an index age of 45 years, overall lifetime risk for total CVD was 60.3% (95% CI, 59.3%-61.2%) for men and 55.6% (95% CI, 54.5%-56.7%) for women. Men had higher lifetime risk estimates than women across all index ages. At index ages 55 and 65 years, men and women with at least 1 elevated risk factor (BP, 140-149/90-99 mm Hg; or TC, 200-239 mg/dL; but no diabetes or smoking), 1 major risk factor, or at least 2 major risk factors (BP, ≥160/100 mm Hg or receiving treatment; TC, ≥240 mg/dL or receiving treatment; diabetes mellitus; or current smoking) had lifetime risk estimates to age 95 years that exceeded 50%. Despite an optimal risk factor profile (BP, <120/80 mm Hg; TC, <180 mg/dL; and no smoking or diabetes), men and women at the index age of 55 years had lifetime risks (through 85 years of age) for total CVD of greater than 40% and 30%, respectively. Compared with participants with at least 2 major risk factors, those with an optimal risk factor profile lived up to 14 years longer free of total CVD. CONCLUSIONS Lifetime risk estimates for total CVD were high (>30%) for all individuals, even those with optimal risk factors in middle age. However, maintenance of optimal risk factor levels in middle age was associated with substantially longer morbidity-free survival.

Distribution of 10-Year and Lifetime Predicted Risks for Cardiovascular Disease in US Adults Findings From the National Health and Nutrition Examination Survey 2003 to 2006

Background—National guidelines for primary prevention suggest consideration of lifetime risk for cardiovascular disease in addition to 10-year risk, but it is currently unknown how many US adults would be identified as having low short-term but high lifetime predicted risk if stepwise stratification were used. Methods and Results—We included 6329 cardiovascular disease–free and nonpregnant individuals ages 20 to 79 years, representing approximately 156 million US adults, from the National Health and Nutrition Examination Survey 2003 to 2004 and 2005 to 2006. We assigned 10-year and lifetime predicted risks to stratify participants into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10%) predicted risk or diagnosed diabetes. The majority of US adults (56%, or 87 million individuals) are at low short-term but high lifetime predicted risk for cardiovascular disease. Twenty-six percent (41 million adults) are at low short-term and low lifetime predicted risk, and only 18% (28 million individuals) are at high short-term predicted risk. The addition of lifetime risk estimation to 10-year risk estimation identifies higher-risk women and younger men in particular. Conclusions—Whereas 82% of US adults are at low short-term risk, two thirds of this group, or 87 million people, are at high lifetime predicted risk for cardiovascular disease. These results provide support for use of a stepwise stratification system aimed at improving risk communication, and they provide a baseline for public health efforts aimed at increasing the proportion of Americans with low short-term and low lifetime risk for cardiovascular disease.

Status of Cardiovascular Health in US Adolescents

Background— The American Heart Association recently developed definitions and metrics for monitoring the spectrum of cardiovascular health in adolescents and children. Current nationally representative prevalence estimates according to sex and race/ethnicity are unavailable. Methods and Results— We examined the components of cardiovascular health in 4673 participants aged 12 to 19 years (representing ≈33.2 million US adolescents) from the 2005–2010 National Health and Nutrition Examination Surveys. Population prevalence of individual cardiovascular health behaviors and factors was estimated according to American Heart Association criteria for poor, intermediate, and ideal levels. Ideal blood pressure was most prevalent (males, 78%; females, 90%), whereas a dramatically low prevalence of ideal Healthy Diet Score was observed (males, <1%; females, <1%). Females exhibited a lower prevalence of ideal total cholesterol (65% versus 72%, respectively) and ideal physical activity levels (44% versus 67%, respectively) yet a higher prevalence of ideal blood glucose (89% versus 74%, respectively) compared with males. Approximately two thirds of adolescents exhibited ideal body mass index (males, 66%; females, 67%) and ideal smoking status (males, 66%; females, 70%). Less than 50% of adolescents exhibited ≥5 ideal cardiovascular health components (45%, males; 50%, females). Prevalence estimates according to sex were consistent across race/ethnic groups. Conclusions— The low prevalence of ideal cardiovascular health behaviors in US adolescents, particularly physical activity and dietary intake, will likely contribute to a worsening prevalence of obesity, hypertension, hypercholesterolemia, and dysglycemia as the current US adolescent population reaches adulthood. Population-wide emphasis on establishment of ideal cardiovascular health behaviors early in life is essential for maintenance of ideal cardiovascular health throughout the lifespan.Background— The American Heart Association recently developed definitions and metrics for monitoring the spectrum of cardiovascular health in adolescents and children. Current nationally representative prevalence estimates according to sex and race/ethnicity are unavailable. Methods and Results— We examined the components of cardiovascular health in 4673 participants aged 12 to 19 years (representing ≈33.2 million US adolescents) from the 2005–2010 National Health and Nutrition Examination Surveys. Population prevalence of individual cardiovascular health behaviors and factors was estimated according to American Heart Association criteria for poor, intermediate, and ideal levels. Ideal blood pressure was most prevalent (males, 78%; females, 90%), whereas a dramatically low prevalence of ideal Healthy Diet Score was observed (males, <1%; females, <1%). Females exhibited a lower prevalence of ideal total cholesterol (65% versus 72%, respectively) and ideal physical activity levels (44% versus 67%, respectively) yet a higher prevalence of ideal blood glucose (89% versus 74%, respectively) compared with males. Approximately two thirds of adolescents exhibited ideal body mass index (males, 66%; females, 67%) and ideal smoking status (males, 66%; females, 70%). Less than 50% of adolescents exhibited ≥5 ideal cardiovascular health components (45%, males; 50%, females). Prevalence estimates according to sex were consistent across race/ethnic groups. Conclusions— The low prevalence of ideal cardiovascular health behaviors in US adolescents, particularly physical activity and dietary intake, will likely contribute to a worsening prevalence of obesity, hypertension, hypercholesterolemia, and dysglycemia as the current US adolescent population reaches adulthood. Population-wide emphasis on establishment of ideal cardiovascular health behaviors early in life is essential for maintenance of ideal cardiovascular health throughout the lifespan. # Clinical Perspective {#article-title-48}

Distribution of coronary artery calcium scores by Framingham 10-year risk strata in the MESA (Multi-Ethnic Study of Atherosclerosis) potential implications for coronary risk assessment.

OBJECTIVES By examining the distribution of coronary artery calcium (CAC) levels across Framingham risk score (FRS) strata in a large, multiethnic, community-based sample of men and women, we sought to determine if lower-risk persons could benefit from CAC screening. BACKGROUND The 10-year FRS and CAC levels are predictors of coronary heart disease. A CAC level of 300 or more is associated with the highest risk for coronary heart disease even in low-risk persons (FRS, <10%); however, expert groups have suggested CAC screening only in intermediate-risk groups (FRS, 10% to 20%). METHODS We included 5,660 Multi-Ethnic Study of Atherosclerosis participants. The number needed to screen (number of people that need to be screened to detect 1 person with CAC level above the specified cutoff point) was used to assess the yield of screening for CAC. CAC prevalence was compared across FRS strata using chi-square tests. RESULTS CAC levels of more than 0, of 100 or more, and of 300 or more were present in 46.4%, 20.6%, and 10.1% of participants, respectively. The prevalence and amount of CAC increased with higher FRS. A CAC level of 300 or more was observed in 1.7% and 4.4% of those with FRS of 0% to 2.5% and of 2.6% to 5%, respectively (number needed to screen, 59.7 and 22.7, respectively). Likewise, a CAC level of 300 or more was observed in 24% and 30% of those with FRS of 15.1% to 20% and more than 20%, respectively (number needed to screen, 4.2 and 3.3, respectively). Trends were similar when stratified by age, sex, and race or ethnicity. CONCLUSIONS Our study suggests that in very low-risk individuals (FRS ≤5%), the yield of screening and probability of identifying persons with clinically significant levels of CAC is low, but becomes greater in low- and intermediate-risk persons (FRS 5.1% to 20%).

Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: the cardiovascular lifetime risk pooling project.

Background— Prior estimates of lifetime risk (LTR) for cardiovascular disease (CVD) examined the impact of blood pressure (BP) at the index age and did not account for changes in BP over time. We examined how changes in BP during middle age affect LTR for CVD, coronary heart disease, and stroke. Methods and Results— Data from 7 diverse US cohort studies were pooled. Remaining LTRs for CVD, coronary heart disease, and stroke were estimated for white and black men and women with death free of CVD as a competing event. LTRs for CVD by BP strata and by changes in BP over an average of 14 years were estimated. Starting at 55 years of age, we followed up 61 585 men and women for 700 000 person-years. LTR for CVD was 52.5% (95% confidence interval, 51.3–53.7) for men and 39.9% (95% confidence interval, 38.7–41.0) for women. LTR for CVD was higher for blacks and increased with increasing BP at index age. Individuals who maintained or decreased their BP to normal levels had the lowest remaining LTR for CVD, 22% to 41%, compared with individuals who had or developed hypertension by 55 years of age, 42% to 69%, suggesting a dose-response effect for the length of time at high BP levels. Conclusions— Individuals who experience increases or decreases in BP in middle age have associated higher and lower remaining LTR for CVD. Prevention efforts should continue to emphasize the importance of lowering BP and avoiding or delaying the incidence of hypertension to reduce the LTR for CVD.

A Systematic Examination of the 2013 ACC/AHA Pooled Cohort Risk Assessment Tool for Atherosclerotic Cardiovascular Disease

BACKGROUND The 2013 American College of Cardiology/American Heart Association updated cholesterol guidelines recommend the use of Pooled Cohort Equations to estimate 10-year absolute risk for atherosclerotic cardiovascular disease (ASCVD) in primary prevention. OBJECTIVES This study sought to systematically examine the Pooled Cohort Equations to determine risk factor levels required to exceed risk thresholds outlined in new cholesterol guidelines. METHODS We entered continuous risk factor levels in isolation and in specified combinations with the risk tool, and we observed predicted risk output patterns. We used the 10-year ASCVD risk threshold of ≥7.5% as a clinically relevant risk threshold. RESULTS We demonstrated that a hypothetical man or woman can reach clinically relevant risk thresholds throughout the eligible age spectrum of 40 to 79 years of age, depending on the associated risk factor burden in all race-sex groups. Age continues to be a major determinant of 10-year ASCVD risk for both men and women. Compared with the previous risk assessment tool used in cholesterol guidelines, the inclusion of a stroke endpoint and use of race-specific coefficients permit identification of at-risk African Americans and non-Hispanic white women at much younger ages and lower risk factor levels. CONCLUSIONS These data provide context of specific risk factor levels and groups of individuals who are likely to have 10-year ASCVD risk estimates ≥7.5%. Age continues to be a major driver of risk, which highlights the importance of the clinician-patient discussion before statin therapy is initiated.

Lifetime Risk for Heart Failure Among White and Black Americans: Cardiovascular Lifetime Risk Pooling Project

OBJECTIVES This study sought to estimate lifetime risk for heart failure (HF) by sex and race. BACKGROUND Prior estimates of lifetime risk for developing HF range from 20% to 33% in predominantly white cohorts. Short-term risks for HF appear higher for blacks than whites, but only limited comparisons of lifetime risk for HF have been made. METHODS Using public-release and internal datasets from National Heart, Lung, and Blood Institute-sponsored cohorts, we estimated lifetime risks for developing HF to age 95 years, with death free of HF as the competing event, among participants in the CHA (Chicago Heart Association Detection Project in Industry), ARIC (Atherosclerosis Risk in Communities), and CHS (Cardiovascular Health Study) cohorts. RESULTS There were 39,578 participants (33,652 [85%] white; 5,926 [15%] black) followed for 716,976 person-years; 5,983 participants developed HF. At age 45 years, lifetime risks for HF through age 95 years in CHA and CHS were 30% to 42% in white men, 20% to 29% in black men, 32% to 39% in white women, and 24% to 46% in black women. Results for ARIC demonstrated similar lifetime risks for HF in blacks and whites through age 75 years (limit of follow-up). Lifetime risk for HF was higher with higher blood pressure and body mass index at all ages in both blacks and whites, and did not diminish substantially with advancing index age. CONCLUSIONS These are among the first data to compare lifetime risks for HF between blacks and whites. Lifetime risks for HF are high and appear similar for black and white women, yet are somewhat lower for black compared with white men due to competing risks.