Pooled Cohort Equation Bests Life's Essential 8, Simple 7 for Predicting Long-Term CVD Risk

Pankaj Arora, MD
Credit: UAB

Research from investigators at the University of Alabama at Birmingham (UAB) is offering clinicians a comparative understanding of the strengths and weaknesses of newer and more traditional equations for calculating long-term cardiovascular risk.

Using data from the National Health and Nutrition Examination Survey (NHANES), results of the study indicate use of scores such as Life’s Essential 8 and Life’s Simple 7 were useful for promoting healthy lifestyle, but inferior to pooled cohort equations in terms of risk discrimination in predicting all-cause mortality among older adults.¹

“The [Life’s Essential 8] and [Life’s Simple 7] scores are invaluable for broad public health surveillance and interventions aimed at enhancing community health outcomes,” said study investigator Pankaj Arora, MD, cardiologist at the UAB Cardiovascular Institute.²“However, when it comes to individual risk assessment in clinical practice, the current study highlights the comprehensive nature of the [pooled cohort equations], which makes it a superior choice due to its nuanced approach to mortality risk prediction. Therefore, the study calls for a shift of research efforts away from assessing the risk prediction value of the [Life’s Essential 8] and [Life’s Simple 7] scores and focusing on their intended use of characterizing and tracking cardiovascular health.”

As part of the organization’s continued efforts to mitigate cardiovascular risk on a population level, the American Heart Association has actively promoted healthy lifestyle choices through ongoing initiatives, with a particular focus on simplifying messaging. An example of this was the creation of Life’s Simple 7 in 2010, which aimed at promoting primary prevention of cardiovascular disease by recommending outlining 7 risk factors to optimize. In 2022, the AHA expanded on the 7 and debuted Life’s Essential 8, which added sleep as an integral factor to health but expanded on messaging around diet, nicotine exposure, and blood lipids.^1,2,3

Another key component of Life’s Essential 8 was the inclusion of a new scoring algorithm ranging from 0-100 points to allow for the creation of a composite cardiovascular health score. The day after the 2022 release, an NHANES analysis found just 1 in 5 individuals in the US had Life’s Essential 8 scores indicative of optimal health.³

Citing the growing number of risk scores and calculations of predicting long-term mortality, in the current study Arora and colleagues sought to compare the associations of the AHA’s Life’s Essential 8 and Life’s Simple 7 scores with the risk of all-cause and cardiovascular mortality as well as to compare associations between these scores and pooled cohort equations for the risk of all-cause mortality and cardiovascular mortality. With this in mind, investigators designed their study as an analysis of data from 6 NHANES cycles recording from 2007 to 2018, which offered investigators data related to 21,721 adults who were 18 years of age or older, not pregnant or breastfeeding, with full data for the components of the risk scores of interests, and no history of cardiovascular disease at baseline.¹

This cohort had median age of 45.4 (IQR, 31.9 to 58.1) years, 52.3% (95% CI, 51.5% to 53.0%) were females, and 68.2% (95% CI, 65.4% to 71.0%) were non-Hispanic White individuals. Investigators noted the cohort had median Life’s Essential 8 and Life’s Simple 7 scores of 66.4 (IQR, 55.2 to 85.5) and 7.8 (IQR, 6.2 to 9.4), respectively. During the follow-up period, which lasted a median of 6.5 (IQR, 3.6 to 9.7) years, the overall event rate for all-cause mortality was 4.7% (IQR, 4.3% to 5.2%) and the overall event rate of cardiovascular mortality was 0.9% (IQR, 0.8% to 1.0%).¹

Initial analyses revealed the risk of all-cause mortality was 0.72 (95% CI, 0.65 to 0.79) and 0.78 (95% CI, 0.71 to 0.85) per SD increase in the Life’s Essential 8 and Life’s Simple 7 scores, respectively. For cardiovascular mortality, the risk was 0.59 (95% CI, 0.49 to 0.70) and 0.64 (95% CI, 0.53 to 0.77) per SD increase in the Life’s Essential 8 and Life’s Simple 7 scores, respectively.¹

Analyses comparing the scores against pooled cohort equations included 12,943 individuals aged 40 to 79 years of age. Results of these analyses indicated the C-statistics for the outcome of all-cause mortality were 0.756 (95% CI, 0.732 to 0.779), 0.674 (95% CI, 0.646 to 0.701), and 0.681 (95% CI, 0.656 to 0.706) for the pooled cohort equation, Life’s Simple 7 score, and Life’s Essential 8 score-based models, respectively.¹

“Apart from including the cardiovascular risk factors, the [pooled cohort equations] integrate demographic factors such as age, sex and race and also provide separate risk estimation algorithms based on sex and race,” said lead investigator Naman S. Shetty, MD, research fellow in the UAB Division of Cardiovascular Disease.² “Furthermore, the [pooled cohort equations] also incorporate weights for each cardiovascular risk factor to accurately reflect the increase in risk of cardiovascular outcomes with changes in the risk factors. Our results underscore the [pooled cohort equation’s] enhanced utility in clinical environments, where precise risk assessment is critical to effective patient management and treatment planning.”

References:

1. Shetty NS, Gaonkar M, Patel N, Li P, Arora G, Arora P. Association of Life's Essential 8 and Simple 7 Scores With Mortality: Comparison With Pooled Cohort Equation. JACC Adv. 2024;3(6):100945. Published 2024 May 2. doi:10.1016/j.jacadv.2024.100945
2. University of Alabama at Birmingham. New UAB study evaluates cardiovascular health scores in predicting mortality risks. EurekAlert! July 22, 2024. Accessed July 24, 2024. https://www.eurekalert.org/news-releases/1052205.
3. Campbell P. Using AHA’s essential 8, new study details need for optimized cardiovascular health in US. HCP Live. June 30, 2022. Accessed July 24, 2024. https://www.hcplive.com/view/using-aha-essential-8-new-study-details-need-for-optimized-cardiovascular-health-in-us.