Clinical Context

Cardiovascular disease is the number one cause of mortality in the United States, and the American Heart Association (AHA) has previously created a framework to help define cardiovascular health, using a model that can be functional for both individual patients and larger public health efforts. The Life's Simple 7 plan used 7 important domains to measure cardiovascular health:

1. Healthy diet
2. Physical activity
3. Avoidance of nicotine
4. Healthy weight
5. Healthy levels of blood lipids
6. Healthy levels of blood pressure
7. Healthy levels of blood glucose

The current AHA Presidential Advisory updates some of these objectives plus adds 1 extra domain to create a new framework for cardiovascular health: Life's Essential 8.

Study Synopsis and Perspective

About 80% of US adults have low to moderate cardiovascular health, according to the AHA checklist for optimal heart health, which now includes healthy sleep as an essential component for heart health.

With the addition of sleep, "Life's Essential 8" replaces the AHA's "Life's Simple 7" checklist.

"The new metric of sleep duration reflects the latest research findings: sleep impacts overall health, and people who have healthier sleep patterns manage health factors such as weight, blood pressure, or risk for type 2 diabetes more effectively," AHA President Donald M. Lloyd-Jones, MD, said in a news release.

"In addition, advances in ways to measure sleep now offer people the ability to reliably and routinely monitor their sleep habits at home," said Dr Lloyd-Jones, chair of the department of preventive medicine at Northwestern University's Feinberg School of Medicine in Chicago, Illinois.

The AHA Presidential Advisory--"Life's Essential 8: Updating and Enhancing the American Heart Association's Construct on Cardiovascular Health"--was published online June 29 in Circulation.^[1]

A companion paper published simultaneously in Circulation reports the first study using Life's Essential 8.^[2]

Refining Life's Simple 7

The AHA first defined the 7 metrics for optimal cardiovascular health in 2010. After 12 years and more than 2400 scientific papers on the topic, new discoveries in cardiovascular health and ways to measure it provided an opportunity to revisit each health component in more detail and provide updates as needed, the AHA explains.

Four of the original metrics have been redefined for consistency with newer clinical guidelines or compatibility with new measurement tools, and the scoring system can now also be applied to anyone aged 2 years and older. Here is a snapshot of Life's Essential 8 metrics, including updates:

1) Diet (updated): 

The tool includes a new guide to assess diet quality for adults and children at the individual and population level. At the population level, dietary assessment is based on daily intake of elements in the Dietary Approaches to Stop Hypertension eating pattern. For individuals, the Mediterranean Eating Pattern for Americans is used to assess and monitor cardiovascular health.

2) Physical activity (no changes):

Physical activity continues to be measured by the total number of minutes of moderate or vigorous physical activity per week, as defined by the US Physical Activity Guidelines for Americans (2nd edition). The optimal level is 150 minutes of moderate physical activity or more per week or 75 minutes per week of vigorous-intensity physical activity for adults, 420 minutes or more per week for children ages 6 and older, and age-specific modifications for younger children.

3) Nicotine exposure (updated):

Use of inhaled nicotine-delivery systems, which includes e-cigarettes or vaping devices, has been added, as the previous metric only monitored traditional, combustible cigarettes. This reflects their use by adults and youth and their implications on long-term health. Secondhand smoke exposure for children and adults has also been added.

4) Sleep duration (new):

Sleep duration is associated with cardiovascular health. Measured by average hours of sleep per night, the ideal level is 7 to 9 hours daily for adults. Ideal daily sleep ranges for children are 10 to 16 hours per 24 hours for ages 5 years and younger, 9 to 12 hours for ages 6 to 12 years, and 8 to 10 hours for ages 13 to 18 years.

5) Body mass index (no changes):

The AHA acknowledges that body mass index (BMI) is an imperfect metric. Yet, because it is easily calculated and widely available, BMI continues to be a "reasonable" gauge to assess weight categories that may lead to health problems. BMI of 18.5 to 24.9 kg/m² is associated with the highest levels of cardiovascular health. The AHA notes that BMI ranges and the subsequent health risks associated with them may differ among people from diverse racial or ethnic backgrounds or ancestry.

6) Blood lipids (updated):

The metric for blood lipids (cholesterol and triglycerides) is updated to use non-high-density lipoprotein (HDL) cholesterol as the preferred number to monitor, rather than total cholesterol. This shift is made because non-HDL cholesterol can be measured without fasting beforehand (thereby increasing its availability at any time of day and implementation at more appointments) and reliably calculated among all people.

7) Blood glucose (updated):

This metric is expanded to include the option of hemoglobin A1c readings or blood glucose levels for people with or without type 1 or 2 diabetes or prediabetes.

8) Blood pressure (no changes):

Blood pressure criteria remain unchanged from 2017 guidance that established levels less than 120/80 mm Hg as optimal, and defined hypertension as 130 to 139 mm Hg systolic pressure or 80 to 89 mm Hg diastolic pressure.^[3]

"Concerning" New Data

Results of the first study using Life's Essential 8 show that the overall cardiovascular health of the US population is "well below ideal," with 80% of adults scoring at a low or moderate level, the researchers report.

Data for the analysis came from 2013 to 2018 US National Health and Nutrition Examination surveys (NHANES) of more than 13,500 adults, ages 20 to 79 years, and nearly 9900 children, ages 2 to 19 years. Among the key findings:

• The average cardiovascular health score based on Life's Essential 8 was 64.7 for adults and 65.5 for children, which is in the moderate range on the 0 to 100 scale.
• Only 0.45% of adults had a perfect score of 100; 20% had high cardiovascular health (score of 80+), 63% moderate (score of 50-79), and 18% low cardiovascular health (score of less than 50).
• Adult women had higher average cardiovascular health scores (67) compared with men (62.5).
• In general, adults scored lowest in the areas of diet, physical activity, and BMI.
• Cardiovascular health scores were generally lower at older ages.
• Non-Hispanic Asian American people had a higher average CV health score than other racial/ethnic groups. Non-Hispanic White people had the second highest average cardiovascular health score, followed, in order, by Hispanic (other than Mexican), Mexican, and Non-Hispanic Black people.
• Adult sociodemographic groups varied notably in cardiovascular health scores for diet, nicotine exposure, blood glucose, and blood pressure.

"Analyses like this can help policy makers, communities, clinicians, and the public to understand the opportunities to intervene to improve and maintain optimal cardiovascular health across the life course," he said.

This research had no commercial funding. The authors have no reported no relevant financial relationships.

Circulation. Published online June 29, 2022.

Clinical Implications

• The previous Life's Simple 7 framework included the domains of healthy diet, physical activity, avoidance of nicotine, healthy weight, and healthy levels of blood lipids, blood glucose, and blood pressure.
• The current update for cardiovascular health has added sleep as a core domain.
• Implications for the healthcare team: The healthcare team can refer patients to the Life's Essential 8 domains when discussing optimizing cardiovascular health for patients.

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