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Few Adopt the 7 Behaviors That Reduces Cardiac Deaths

Having more of seven heart-healthy behaviors translates to a reduced risk of death from cardiovascular disease, but only 0.2 percent are meeting all seven criteria…. 

Enrique Artero, PhD, of the University of South Carolina, and colleagues reported that those who met three to four of the American Heart Association’s ‘Simple Seven’ heart-health criteria had a 55% lower risk of cardiovascular mortality than those who met no more than two of those practices over about 11 years.

They cautioned, however, that the overall prevalence of "ideal cardiovascular health was extremely low in this middle-aged cohort," with only 0.2% of patients meeting all seven criteria.

In 2010, the AHA developed this construct of "ideal cardiovascular health," targeting seven behaviors that raise the likelihood of not having to face cardiovascular disease or stroke. They include four core behaviors — no smoking, a normal body mass index (BMI), engaging in physical activity, and eating healthfully — and meeting at least three of the following criteria: cholesterol lower than 200 mg/dL, blood pressure lower than 120/80 mm Hg, not having diabetes, or being free of heart disease.

To assess the effects of meeting these targets on risk of death from cardiovascular disease, the researchers looked at data from the Aerobics Longitudinal Study, conducted in 11,993 patients between Oct. 9, 1987 and March 3, 1999.

Patients completed questionnaires about their physical activity and their diet was assessed via a 3-day food diary.

Mean baseline age was 46, and over a mean follow-up of 11.6 years, there were 305 deaths — 23% of which were due to cardiovascular disease and 41.6% from cancer.

Overall, only 29 patients — just 0.2% of the whole population — met all seven of the AHA criteria, and only 18.2% met at least five parameters. The majority fell between three and four criteria fulfilled.

Artero and colleagues saw absolutely no deaths among patients who met at least six of the cardiovascular ideals. They also found that risk of cardiovascular mortality was 55% lower for those who met three or four of the criteria compared with those who met none to two (HR 0.45, 95% CI 0.27 to 0.77). And it was 63% lower for those who fulfilled five to seven of the ideal criteria compared with those with the lowest scores (HR 0.37, 95% CI 0.15 to 0.95), they reported.

The researchers also saw a non-significant trend toward a lower risk of all-cause mortality with increasing fulfillment of the seven criteria. There was no association, however, between the AHA’s Simple Seven construct and risk of death due to cancer.

The researchers concluded that the AHA’s criteria "reflects the subsequent risk of cardiovascular disease as reflected by graded CVD mortality in relation to the number of ideal metrics."

They cautioned that the study may be limited in generalizability, given that the population was largely white, educated, and of middle to upper socioeconomic status. Nor could it take into account whether patients had changes in those seven metrics during follow-up, and there was no information on medication use or other treatments.

Francisco Lopez-Jimenez, MD, of the Mayo Clinic in Rochester, Minn., in an accompanying commentary, criticized the AHA Simple Seven initiative, fingering some of its "shortcomings." Lopez-Jimenez noted that the dietary component doesn’t specifically call for a reduction in intake of saturated and trans fats, and its recommendation to lower salt intake below 1,500 mg a day may be too strict for healthy patients. Also, using BMI to assess obesity may be incomplete, he said, since the measure has been criticized as an inaccurate representation of cardiovascular health, and that other parameters such as waist-to-hip ratio may offer a better assessment.

Lopez-Jimenez concluded that while patients are typically aware that they need to change their unhealthy behaviors to prevent heart disease, doing so is no easy task. Rather than simply being given more recommendations to improve their health, he wrote, researchers should work to "better understand the factors that trigger and maintain healthy behaviors and improve compliance with medical treatments."

Practice Pearls:
  • The study found that the actual prevalence of ideal cardiovascular health was extremely low, but there was a relationship between the number of metrics and cardiovascular mortality.
  • This study was designed to assess the relationship between healthy behaviors and cardiovascular health factors and death.

Artero EG, et al "Ideal cardiovascular health and mortality: aerobics center longitudinal study" Mayo Clin Proceedings 2012; 87(10): 944-952. Lopez-Jimenez F "The pursuit of ideal cardiovascular health: An individual and societal change" Mayo Clin Proceedings 2012; 87(10): 929-931.