Author + information
- Published online July 29, 2019.
- aDepartment of Medicine, Baylor College of Medicine, Center for Cardiometabolic Disease Prevention, Houston, Texas
- bMichael E. DeBakey Veterans Affairs Hospital, Houston, Texas
- ↵∗Address for correspondence:
Dr. Christie M. Ballantyne, Baylor College of Medicine, One Baylor Plaza, MS BCM285, Houston, Texas 77030.
With an aging population and advances in prevention of atherosclerotic cardiovascular disease (CVD), heart failure (HF) is poised to become the leading CVD in the near future. The treatment of HF after the onset of symptoms, despite many advances in therapy, is still associated with a poor prognosis. Hence, prevention of HF is critical. Recognizing this, the American Heart Association (AHA)/American College of Cardiology established the Stage A to D system of classifying HF, with Stages A and B including those at risk but without clinically manifest HF. However, to date, no therapies are approved for prevention of HF; the closest successes are treatment of hypertension and sodium glucose cotransporter 2 inhibitor treatment of diabetes. As with any other disease process, improved tools for identifying those at risk for HF, understanding pathways that lead to HF, and eventually developing trials in which HF prevention is the primary endpoint are all important. In this context, this analysis of the EPIC-NL (European Prospective Investigation into Cancer and Nutrition–Netherlands) data (1) adds to the published reports on the association of Life’s Simple 7 (LS7) from the AHA with incident HF.
LS7 was identified and promoted by the AHA to improve cardiovascular health and reduce deaths from CVD in Americans by 20% by 2020 (2). Initial studies evaluated the prevalence and associated outcomes of having ideal metrics of LS7 and reported a very low prevalence of ideal health metrics but significantly reduced incidence of adverse outcomes in those with ideal metrics. In this issue of JACC: Heart Failure, Uijl et al. (1) report the prevalence and association of LS7 with incident HF over 15.2-year follow-up in EPIC-NL (∼37,800 men and women; mean age 49.4 years, 74.7% women). An ideal health score (defined as summed score 11 to 14; each of the 7 metrics was graded as 0, 1, or 2, with 2 ideal) was prevalent in ∼23% of the population and was associated with a 55% reduction in incidence of HF compared with those with an inadequate LS7 score (0 to 8). The presence of ≥2 ideal LS7 components was associated with a 52% reduction in incident HF risk compared with those who had no ideal LS7 components.
The results of the study are not surprising given that several factors included in LS7 classify one as having Stage A HF and given that other epidemiological studies, including the ARIC (Atherosclerosis Risk In Communities) study, Framingham Offspring Study, Jackson Heart Study, and the MESA (Multi-Ethnic Study of Atherosclerosis), have described similar results. However, EPIC-NL is the largest of these cohorts and included a younger population. Furthermore, the authors of the EPIC-NL analysis studied the association of LS7 components alone and in clusters with incident HF and noted that of the LS7 metrics, ideal and intermediate scores of glucose, smoking, body mass index, and blood pressure were associated with decreased incidence of HF in fully adjusted models, as were several cluster combinations that included these components. Of the LS7 components, only cholesterol was not associated with incident HF. Although intermediate and ideal metrics of physical activity and diet were not associated with incident HF after adjustment for other factors, physical activity was included in several clusters associated with reduced HF risk. It is likely that the lack of individual association is reflective of the fact that the pathway from suboptimal physical activity and diet to HF is via other risk factors such as blood pressure, blood glucose, and body mass index. Indeed, physical activity has been associated with reduced incidence of HF and is among the few factors that reduced troponin, a powerful marker of incident HF (3).
While the authors are to be commended for an excellent analysis, some limitations merit discussion as well. Glucose measurements were unavailable (and hence imputed) in almost one-half the population, and nonfasting samples were used to measure serum cholesterol and glucose. Furthermore, although the population was large, only 1.8% had incident HF over the median follow-up of ∼15 years, likely reflective of a younger, largely female population with predominantly European ancestry, as compared to the United States, which has greater ethnic and socioeconomic diversity. Indeed, in the United States, the Hispanic and African American populations have been shown to have increased cardiometabolic risk factors especially in those with lower socioeconomic status, and the rapidly growing South and East Asian segments of the U.S. population have a higher prevalence of diabetes. Finally, while the authors present the reduction in incident HF with ideal versus inadequate LS7 scores, it would have also been useful to define the number of suboptimal LS7 components at which risk starts to increase.
HF is one of the more challenging CVDs to prevent because of the various pathways that can lead to its manifestation. Recently, several tools have been developed that use clinical characteristics and biomarkers (alone and in combination) to improve HF risk prediction (4). LS7 is a simple way to identify higher-risk individuals; however, this analysis and others indicate how few individuals have ideal cardiovascular health metrics in the western world (and likely other parts of the world as well). This emphasizes the increasing importance of “primordial prevention,” the prevention of the emergence of CVD risk factors. The pathophysiology of CVD has its roots in early childhood and adolescence, and CVD risk factors emerge at various stages of life, resulting from a complex interplay of genes, habits, and environment. Of LS7, diet- and activity-related habits can be influenced at an earlier stage in life, and therefore are the keys in the primordial prevention of CVD. Despite guidelines for physical activity and nutrition in children, the practical application of these guidelines is challenging given the politico-societal influence underlying such policies. Another important demographic group for primordial prevention is adolescents/young adults, whose decisions about diet, physical activity, smoking, and education have far-reaching consequences. Individuals with ideal LS7 scores were more than twice as likely to have higher education that those with inadequate scores.
As our efforts to prevent HF evolve, age group–specific approaches are required (Figure 1). In younger groups for whom primordial prevention is the focus, education and promotion of healthy lifestyle habits to the family at large should be emphasized. Efforts such as those championed by Dr. Valentin Fuster (or Valentin Ruster as his character is called in the Spanish version of Sesame Street) and healthy lunch programs in elementary schools in the United States are laudable and important. In young adulthood, a combination of education and incentives for healthy habits may help. In middle-aged and older adults, precision medicine approaches using biomarkers, imaging, proteomics, and metabolomics to guide both pharmacotherapy and intensity of lifestyle modifications combined with societal strategies to promote a healthy lifestyle may be useful.
In summary, the factors that constitute LS7 are simple to describe but very hard to achieve without a concerted effort across multiple fronts; public policy coupled with individual education is critical if we are to make progress in realizing the ideal metrics of LS7. Non-ideal metrics may be viewed as the 7 deadly sins that lead to CVD, of which HF is emerging as one of the most frequent. While development of medical therapies is important, prevention of the underlying adverse behaviors and clinical characteristics is essential to improve CVD outcomes. Engagement and education of those crafting and influencing public health policies are critical for advancing the prevention of HF and cardiometabolic diseases in general. Strategies developed by organizations such as AHA, American College of Cardiology, and the American Diabetes Association to reduce CVD events in those with diabetes and clinical CVD must go beyond secondary prevention and encompass primordial and primary prevention. Indeed, like the old adage, if we do not close the barn door before the horse has bolted, then the prevention of failure will become the failure of prevention (4).
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Ballantyne has received grants and personal fees from the National Institutes of Health (NIH R01-HL134320), Abbott, and Roche. Dr. Nambi is supported by a VA MERIT grant (1I01CX001112-01); and is a site Principal Investigator for study sponsored by Merck. Drs. Ballantyne and Nambi are coinventors on a provisional patent #61721475 (“Biomarkers to Improve Prediction of Heart Failure Risk”) filed by Roche and Baylor College of Medicine. The views expressed by the authors are not a representation of the views of the Department of Veterans Affairs.
- 2019 American College of Cardiology Foundation
- Uijl A.,
- Koudstaal S.,
- Vaartjes I.,
- et al.
- Lloyd-Jones D.M.,
- Hong Y.,
- Labarthe D.,
- et al.
- Nambi V.,
- Liu X.,
- Chambless L.E.,
- et al.
- Nambi V.,
- Deswal A.,
- Ballantyne C.M.