Physicians' Academy for Cardiovascular Education

Small life style changes can reduce stroke risk

Literature - Kulshreshtha A, Vaccarino V, Judd SE et al. - Stroke. 2013 Jun 6


Life's Simple 7 and Risk of Incident Stroke: The Reasons for Geographic and Racial Differences in Stroke Study.

 
Kulshreshtha A, Vaccarino V, Judd SE et al.
Stroke. 2013 Jun 6. [Epub ahead of print]
 

Background

The American Heart Association/American Stroke Association (AHA/ASA) has proposed a metric to be able to define and track the nation’s cardiovascular (CV) health over time [1]. This metric was released as a score called ‘Life’s Simple 7’(LS7). LS7 emphasises primordial prevention and includes 7 modifiable components, consisting of 3 health factors (glucose, cholesterol and blood pressure) and 4 health behaviours (body mass index, physical activity, diet, and cigarette smoking). Each of these factors are categorised into ideal, intermediate and poor levels, and are given scores of 2, 1 or 0 respectively, so the LS7 score can range from 0 to 14. An LS7 score of 0-4 was classified as inadequate, 5-9 as average, and 10-14 as optimum CV health [2, 3].
Recently, more ideal CV health factors from the LS7 metric were shown to be associated with lower CVD and all-cause mortality [4-6]. Less is known about the predictive value of a composite measure of biological and behavioural risk factors for stroke. Using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study the association between LS7 and incident stroke was investigated, and racial differences were examined. The REGARDS study is a population-based cohort study of US adults of >45 years old, with a large proportion of blacks. 22914 participants without previous CVD were included, 9553 of whom were blacks.
 

Main results

  • Male sex, low income, less education and current alcohol use were associated with poorer CV health in both blacks and whites.
  • More whites were in the optimum CV health category (19%) than blacks (7%), irrespective of age, sex, income, education and geographic region. Mean (+SD) overall LS7 score was 7.2 (2.2). Adjusting for age and sex, blacks had a lower mean score (6.5+2.0) than whites (7.6+2.1).
  • During 4.9 years of follow-up, there were 432 incident strokes, of which 232 occurred in whites. For some LS7 components stroke incidence was lowest in those with an ideal score, and highest in those with poor CV health status. Adjusted HRs for total cholesterol, blood pressure, blood glucose and smoking showed a graded relationship with stroke, in particular among whites.
  • Worse overall LS7 score was inversely correlated with incident stroke in a graded fashion. In a multivariate model, each better health category was associated with a 25% lower risk of incident stroke (HR: 0.75, 95%CI: 0.63-0.90).
    Although the association of LS7 category and stroke did not reach statistical significance in blacks, crude and adjusted HRs were similar for blacks and whites.
  • When considering total LS7 score on a continuous scale from 0-14, a 1 point higher LS7 score was associated with 8% lower risk of stroke (HR: 0.92, 95%CI: 0.88-0.95), which was similar in blacks and whites. An increasing number of ideal factors was inversely associated with risk of stroke in both blacks and whites, even when changing from 0 to 1 ideal factor (HR: 0.70, 95%CI: 0.42-1.19).
 

Conclusion

The LS7 metric was developed as part of AHA’s strategic impact goal to improve the CV health of all Americans. This study shows that it is a useful tool to describe the risk of incident stroke. Although blacks showed lower levels of ideal factors, the association of LS7 and stroke did not differ between blacks and whites. Improvement of a single health behaviour can reduce stroke risk. These findings support the hypothesis that small shifts in the population distribution of risk factors can have a dramatic impact on reducing the disease burden in populations.
 

References

1. Lloyd-Jones DM, 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.Circulation. 2010;121:586–613.
2. Goldstein LB, Bushnell CD, Adams RJ et al.; American Heart Association Stroke Council; Council on
Cardiovascular Nursing; Council on Epidemiology and Prevention; Council for High Blood Pressure Research, Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:517–584.
3. Huffman MD, Capewell S, Ning Het al. Cardiovascular Health Behavior and Health Factor Changes (1988–2008) and Projections to 2020: Results from the National Health and Nutrition Examination Surveys (NHANES). Circulation. 2012;125:2595–602.
4. Folsom AR, Yatsuya H, Nettleton JA, ARIC Study Investigators. Community prevalence of ideal cardiovascular
health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57:1690–1696.
5. Ford ES, Greenlund KJ, Hong Y. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation. 2012;125:987–995.
6. Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307:1273–1283.
 

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