Life's Essential 8 and Mortality Risk: Associations of an Enhanced Cardiovascular Health Construct With All-Cause, Cardiovascular, and Cancer Mortality in US Adults From the 2011-2018 National Health and Nutrition Examination Survey

Introduction: Cardiovascular health (CVH), measured using the AHA’s Life’s Simple 7, is linked to mortality. Associations of AHA’s Life’s Essential 8 (LE8), an enhanced approach to defining CVH, with mortality risk have not yet been evaluated in a nationally representative sample of US adults. Hypothesis: Lower CVH will be associated with higher risk for all-cause, CVD, and cancer mortality. Methods: We included 21,164 adults (mean age: 48y, 51% female, 11% Black, 15% Hispanic, 65% White) from the 2011-2018 NHANES whose mortality through 2019 was determined via linkage to the National Death Index. The CVH score (range: 0-100, high: 80-100, moderate: 50-79, low: 0-49) and component scores were computed consistent with the LE8 framework. The Kaplan-Maier method and multivariable Cox proportional hazards models were used to evaluate the CVH score and its component scores in relation to all-cause mortality (primary outcome) as well as CVD and cancer mortality (secondary outcomes), accounting for the complex stratified survey design of NHANES. Results: During a median follow-up of 5y, there were 1,397 deaths, including 414 and 329 deaths from CVD and cancer, respectively. Low vs. high CVH was related to 3-fold higher risk for all-cause mortality and >3-fold higher risk of CVD and cancer mortality, and a linear trend across CVH categories was detected (Figure). Lower scores for the diet, physical activity, nicotine exposure, sleep health, BMI, blood glucose, and blood pressure components predicted 25% to 2-fold higher mortality risk, and a gradient in risk was observed. Associations did not vary by sex, but there were differences by race and ethnicity (p-interaction<0.05); the magnitude of associations was strongest among Whites, while no relation was observed among Hispanics. Conclusions: CVH measured using the enhanced LE8 is a strong predictor of all-cause, CVD, and cancer mortality in US adults, with evidence of a dose-response relationship. Improving CVH could result in substantial population-level reductions in mortality.