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SCIENCE CHINA Life Sciences, Volume 61, Issue 5: 504-514(2018) https://doi.org/10.1007/s11427-018-9281-6

Ideal cardiovascular health and incidence of atherosclerotic cardiovascular disease among Chinese adults: the China-PAR project

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  • ReceivedJan 2, 2018
  • AcceptedFeb 26, 2018
  • PublishedMar 19, 2018

Abstract

Existing evidence on the relationship between cardiovascular health (CVH) metrics and cardiovascular disease (CVD) was primarily derived from western populations. We aimed to evaluate the benefits of ideal CVH metrics on preventing incident atherosclerotic CVD (ASCVD) in Chinese population. This study was conducted among 93,987 adults from the China-PAR project (Prediction for ASCVD Risk in China) who were followed up until 2015. Cox proportional hazard regression models were used to estimate the hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) of CVH metrics for the risk of ASCVD, including coronary heart disease (CHD), stroke and ASCVD death. We further estimated the population-attributable risk percentage (PAR%) of these metrics in relation to each outcome. We observed gradient inverse associations between the number of ideal CVH metrics and ASCVD incidence. Compared with participants having ≤2 ideal CVH metrics, the multivariable-adjusted HRs (95% CIs) of ASCVD for those with 3, 4, 5, 6 and 7 ideal CVH metrics were 0.83 (0.74–0.93), 0.66 (0.59–0.74), 0.55 (0.48–0.61), 0.44 (0.38–0.50) and 0.24 (0.18–0.31), respectively (P for trend <0.0001). Approximately 62.1% of total ASCVD, 38.7% of CHD, 66.4% of stroke, and 60.5% of ASCVD death were attributable to not achieving all the seven ideal CVH metrics. After adjusting effects of ideal health factors, having four ideal health behaviors could independently bring adults health benefits in preventing 17.4% of ASCVD, 18.0% of CHD, 16.7% of stroke, and 10.1% of ASCVD death. Among all the seven CVH metrics, to keep with ideal blood pressure (BP) implied the largest public health gains against various ASCVD events (PAR% between 33.0% and 47.2%), while ideal diet was the metric most difficult to be achieved in the long term. Our study indicates that the more ideal CVH metrics adults have, the less ASCVD burden there is in China. Special efforts of health education and behavior modification should be made on keeping ideal BP and dietary habits in general Chinese population to prevent the epidemic of ASCVD.


Funded by

grants from the CAMS Innovation Fund for Medical Sciences(2017-12M-1-004)

Ministry of Science and Technology of China(2017YFC0211700)

and National Natural Science Foundation of China(91643208)


Acknowledgment

The authors thank the staffs and participants of the China-PAR project for their important participation and contribution. This work was supported by grants from the CAMS Innovation Fund for Medical Sciences (2017-12M-1-004), Ministry of Science and Technology of China (2017YFC0211700), and National Natural Science Foundation of China (91643208).


Interest statement

The author(s) declare that they have no conflict of interest.


Supplement

SUPPORTING INFORMATION

Table S1 Adjusted hazard ratios for the risk of ASCVD events according to the number of ideal cardiovascular health metrics, stratified by cohorts of the China-PAR project

Table S2 Adjusted hazard ratios for the risk of ASCVD events according to the number of ideal cardiovascular health metrics when cases occurring in the first year after follow-up were removed

Table S3 Comparison of baseline characteristics between included individuals and those lost to follow up

Table S4 Definition of ideal cardiovascular health metrics (>20 years of age) in this study

Figure S1 Adjusted hazard ratios for total ASCVD events by the number of ideal cardiovascular health metrics and subgroups of sex, age group, living region, and urbanization.

Figure S2 Adjusted hazard ratios for CHD by the number of ideal cardiovascular health metrics and subgroups of sex, age group, living region, and urbanization.

Figure S3 Adjusted hazard ratios for stroke by the number of ideal cardiovascular health metrics and subgroups of sex, age group, living region, and urbanization.

Figure S4 Adjusted hazard ratios for ASCVD death by the number of ideal cardiovascular health metrics and subgroups of sex, age group, living region, and urbanization.

Figure S5 Age- and sex-adjusted incidence rates of ASCVD events according to the number of ideal health behaviors and ideal health factors.

Figure S6 Flowchart of the study.

The supporting information is available online at http://life.scichina.com and https://link.springer.com. The supporting materials are published as submitted, without typesetting or editing. The responsibility for scientific accuracy and content remains entirely with the authors.


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  • Figure 1

    Kaplan-Meier curves for cumulative incidence of ASCVD (A), CHD (B), stroke (C), and ASCVD death (D) according to six cardiovascular health metrics groups, the China-PAR project. ASCVD, atherosclerotic cardiovascular disease; CHD, coronary heart disease; China-PAR project, Prediction for ASCVD Risk in China.

  • Figure 2

    Multivariable-adjusted association between hazard ratio for ASCVD (A), CHD (B), stroke (C), and ASCVD death (D) and the number of ideal cardiovascular health metrics (modeled as continuous variable), the China-PAR project. ASCVD, atherosclerotic cardiovascular disease; CHD, coronary heart disease; China-PAR project, Prediction for ASCVD Risk in China.

  • Table 1   Baseline characteristics and distribution of each cardiovascular health metric in the study participants, the China-PAR project

    Characteristics

    Total (n=93,987)

    Men (n=37,805)

    Women (n=56,182)

    P value

    Age, mean (SD), y

    51.64±11.97

    52.03±12.05

    51.37±11.92

    <0.0001

    Northern, n (%)

    47,120 (50.13)

    19,071 (50.45)

    28,049 (49.93)

    0.1176

    Urban, n (%)

    9,109 (9.69)

    4,408 (11.66)

    4,701 (8.37)

    <0.0001

    Drinking, n (%)

    17,216 (18.32)

    15,228 (40.29)

    1,988 (3.54)

    <0.0001

    Education level beyond high school, n (%)

    12,856 (13.72)

    7,124 (18.89)

    5,732 (10.23)

    <0.0001

    Family history of ASCVD, n (%)

    9,644 (10.26)

    3,980 (10.53)

    5,664 (10.08)

    0.0271

    Smoking, n (%)

     

     

     

     

    Ideal

    72,352 (76.98)

    17,255 (45.64)

    55,097 (98.07)

    <0.0001

    Non-ideal

    21,635 (23.02)

    20,550 (54.36)

    1,085 (1.93)

     

    Body mass index, n (%)

     

     

     

     

    Ideal

    61,688 (65.63)

    26,098 (69.03)

    35,590 (63.35)

    <0.0001

    Non-ideal

    32,299 (34.37)

    11,707 (30.97)

    20,592 (36.65)

     

    Physical activity, n (%)

     

     

     

     

    Ideal

    62,284 (66.27)

    26,252 (69.44)

    36,032 (64.13)

    <0.0001

    Non-ideal

    31,703 (33.73)

    11,553 (30.56)

    20,150 (35.87)

     

    Healthy diet score, n (%)

     

     

     

     

    Ideal*

    64,820 (68.97)

    28,342 (74.97)

    36,478 (64.93)

    <0.0001

    Non-ideal

    29,167 (31.03)

    9,463 (25.03)

    19,704 (35.07)

     

    Total cholesterol, n (%)

     

     

     

     

    Ideal

    72,249 (76.87)

    29,947 (79.21)

    42,302 (75.29)

    <0.0001

    Non-ideal

    21,738 (23.13)

    7,858 (20.79)

    13,880 (24.71)

     

    Blood pressure, n (%)

     

     

     

     

    Ideal

    32,099 (34.15)

    11,316 (29.93)

    20,783 (36.99)

    <0.0001

    Non-ideal

    61,888 (65.85)

    26,489 (70.07)

    35,399 (63.01)

     

    Fasting plasma glucose, n (%)

     

     

     

     

    Ideal

    73,225 (77.91)

    29,451 (77.90)

    43,774 (77.91)

    0.9646

    Non-ideal

    20,762 (22.09)

    8,354 (22.10)

    12,408 (22.09)

     

    No. of ideal CVH metrics, n (%)

     

     

     

     

    0

    77 (0.08)

    71 (0.19)

    6 (0.01)

    <0.0001

    1

    980 (1.04)

    550 (1.45)

    430 (0.77)

     

    2

    4,545 (4.84)

    2,138 (5.66)

    2,407 (4.28)

     

    3

    12,288 (13.07)

    5,554 (14.69)

    6,734 (11.99)

     

    4

    22,324 (23.75)

    10,027 (26.52)

    12,297 (21.89)

     

    5

    27,066 (28.80)

    11,194 (29.61)

    15,872 (28.25)

     

    6

    19,792 (21.06)

    6,802 (17.99)

    12,990 (23.12)

     

    7

    6,915 (7.36)

    1,469 (3.89)

    5,446 (9.69)

     

  • Table 2   Adjusted hazard ratios and population-attributable risk percentage for ASCVD events according to the number of ideal cardiovascular health metrics, the China-PAR project

    Characteristics

    Total

    Number of ideal cardiovascular health metrics

    P value

    for trend

    Adjusted

    PAR%

    (95% CI)§

    0–2 (n=5,602)

    3 (n=12,288)

    4 (n=22,324)

    5 (n=27,066)

    6 (n=19,792)

    7 (n=6,915)

    ASCVD events*

     

    Cases

    3,457

    463

    750

    976

    811

    397

    60

     

    Total person-years

    680,413.64

    42,061.07

    88,821.06

    158,730.06

    193,944.80

    145,672.97

    51,183.68

     

    Age-, sex-adjusted incidence rate

    508.07

    898.13

    721.75

    579.40

    458.22

    364.07

    194.30

     

    Age-, sex-adjusted HR (95% CI)

    1 (reference)

    0.82 (0.73–0.92)

    0.64 (0.58–0.72)

    0.51 (0.46–0.58)

    0.39 (0.34–0.45)

    0.20 (0.15–0.26)

    <0.0001

     

    Fully adjusted HR (95% CI)

    1 (reference)

    0.83 (0.74–0.93)

    0.66 (0.59–0.74)

    0.55 (0.48–0.61)

    0.44 (0.38–0.50)

    0.24 (0.18–0.31)

    <0.0001

    62.1 (50.5–71.4)

    CHD

     

    Cases

    788

    135

    179

    201

    178

    76

    19

     

    Total person-years

    685,538.03

    42,863.85

    90,012.30

    160,211.13

    195,068.79

    146,135.98

    51,245.98

     

    Age-, sex-adjusted incidence rate

    114.95

    259.21

    168.95

    119.52

    100.03

    71.74

    65.11

     

    Age-, sex-adjusted HR (95% CI)

    1 (reference)

    0.68 (0.54–0.85)

    0.46 (0.37–0.58)

    0.40 (0.32–0.50)

    0.27 (0.21–0.36)

    0.24 (0.15–0.38)

    <0.0001

     

    Fully adjusted HR (95% CI)

    1 (reference)

    0.72 (0.57–0.90)

    0.52 (0.42–0.65)

    0.48 (0.38–0.61)

    0.36 (0.27–0.49)

    0.35 (0.22–0.58)

    <0.0001

    38.7 (5.5–64.2)

    Stroke

     

    Cases

    2,718

    339

    583

    785

    643

    325

    43

     

    Total person-years

    681,713.16

    42,311.08

    89,119.12

    159,076.90

    194,194.54

    145,781.57

    51,229.94

     

    Age-, sex-adjusted incidence rate

    398.70

    647.38

    556.40

    466.61

    362.41

    295.87

    138.30

     

    Age-, sex-adjusted HR (95% CI)

    1 (reference)

    0.88 (0.77–1.00)

    0.72 (0.63–0.82)

    0.56 (0.49–0.64)

    0.44 (0.38–0.51)

    0.19 (0.14–0.26)

    <0.0001

     

    Fully adjusted HR (95% CI)

    1 (reference)

    0.87 (0.76–0.99)

    0.71 (0.62–0.81)

    0.56 (0.49–0.65)

    0.45 (0.39–0.53)

    0.21 (0.15–0.28)

    <0.0001

    66.4 (54.1–75.9)

    ASCVD death

     

    Cases

    1,383

    198

    306

    378

    317

    162

    22

     

    Total person-years

    684,215.37

    42,910.47

    89,861.24

    159,918.42

    194,606.32

    145,760.31

    51,158.6

     

    Age-, sex-adjusted incidence rate

    202.13

    359.88

    280.60

    220.49

    181.31

    157.36

    81.33

     

    Age-, sex-adjusted HR (95% CI)

    1 (reference)

    0.79 (0.66–0.95)

    0.60 (0.51–0.72)

    0.51 (0.43–0.61)

    0.43 (0.35–0.52)

    0.21 (0.13–0.32)

    <0.0001

     

    Fully adjusted HR (95% CI)

    1 (reference)

    0.82 (0.68–0.98)

    0.64 (0.54–0.76)

    0.56 (0.46–0.67)

    0.49 (0.39–0.61)

    0.26 (0.16–0.40)

    <0.0001

    60.5 (39.8–75.3)

    Abbreviations: ASCVD, atherosclerotic cardiovascular disease; HR, hazard ratio; CI, confidence interval, PAR%, population-attributable risk percentage; China-PAR project, Prediction for ASCVD Risk in China. *, ASCVD events were defined as the first occurrence of nonfatal acute myocardial infarction (AMI), or coronary heart disease (CHD) death or fatal or non-fatal stroke. †, The age- and sex-adjusted incidence rates (per 100,000 person-years) were calculated by the number of ideal CVH metrics using Poisson regression model. ‡, Adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, and cohort sources. §, The PAR% adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, and cohort sources. It indicated the proportion of the outcome (e.g. ASCVD event/CHD/Stroke/ASCVD death) attributable to not achieving all the seven ideal CVH metrics.

  • Table 3   Adjusted hazard ratios for the risk of ASCVD events according to the number of ideal health behaviors or ideal health factors, the China-PAR project

    Characteristics

    Number of ideal health behaviors

    P value

    for trend

    Number of ideal health factors

    P value

    for trend

    Adjusted PAR%

    (95% CI)

    0–1 (n=7,068)

    2 (n=26,519)

    3 (n=40,079)

    4 (n=20,321)

    0 (n=6,087)

    1 (n=21,689)

    2 (n=42,749)

    3 (n=23,462)

    ASCVD events*

     

    Fully adjusted HR (95% CI)

    1(reference)

    0.97(0.87–1.09)

    0.86(0.77–0.97)

    0.74(0.65–0.85)

    <0.0001

    1(reference)

    0.75(0.67–0.83)

    0.58(0.52–0.65)

    0.33(0.29–0.39)

    <0.0001

    17.4(9.4, 25.2)

    CHD

     

    Fully adjusted HR (95% CI)

    1(reference)

    0.86(0.69–1.07)

    0.78(0.62–0.97)

    0.68(0.52–0.90)

    0.0042

    1(reference)

    0.70(0.57–0.87)

    0.49(0.40–0.61)

    0.40(0.30–0.53)

    <0.0001

    18.0(0.6, 34.3)

    Stroke

     

    Fully adjusted HR (95% CI)

    1(reference)

    1.01(0.88–1.15)

    0.88(0.77–1.00)

    0.75(0.65–0.88)

    <0.0001

    1(reference)

    0.75(0.67–0.85)

    0.60(0.53–0.68)

    0.31(0.26–0.37)

    <0.0001

    16.7(7.7, 25.3)

    ASCVD death

     

    Fully adjusted HR (95% CI)

    1(reference)

    0.98(0.83–1.17)

    0.87(0.73–1.04)

    0.84(0.68–1.04)

    0.0221

    1(reference)

    0.64(0.55–0.76)

    0.54(0.46–0.64)

    0.33(0.26–0.42)

    <0.0001

    10.1(–3.2, 23.0)

    Abbreviations: ASCVD, atherosclerotic cardiovascular disease; HR, hazard ratio; CI, confidence interval; PAR%, population-attributable risk percentage; China-PAR project, Prediction for ASCVD Risk in China. *, ASCVD events were defined as the first occurrence of nonfatal acute myocardial infarction (AMI), or coronary heart disease (CHD) death or fatal or non-fatal stroke. †, Adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, cohort sources, and number of ideal health behaviors/factors. ‡, The PAR% adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, cohort sources, and number of ideal health factors. It indicated the proportion of the outcome (e.g. ASCVD event/CHD/Stroke/ASCVD death) attributable to not achieving all the four ideal health behaviors, after adjusting for the effect of ideal health factors.

  • Table 4   Adjusted hazard ratios and population-attributable risk percentage for the ASCVD events according to the status of each cardiovascular health metric, the China-PAR project

    CVH metrics

    ASCVD events*

    CHD

    Stroke

    ASCVD death

    Adjusted incidence rate

    Fully

    adjusted

    HR

    (95% CI)

    Adjusted

    PAR%

    (95% CI)§

    Adjusted incidence rate

    Fully

    adjusted

    HR

    (95% CI)

    Adjusted

    PAR%

    (95% CI)§

    Adjusted incidence rate

    Fully

    adjusted

    HR

    (95% CI)

    Adjusted

    PAR%

    (95% CI)§

    Adjusted incidence rate

    Fully

    adjusted

    HR

    (95% CI)

    Adjusted

    PAR%

    (95% CI)§

    Smoking

     

    Non-ideal

    513.49

    1(reference)

    121.22

    1 (reference)

    405.01

    1 (reference)

    196.64

    1 (reference)

     

    Ideal

    506.29

    0.86(0.79–0.94)

    3.6(1.0–6.2)

    112.88

    0.81 (0.68–0.98)

    5.5 (0.2–10.8)

    396.63

    0.86 (0.78–0.95)

    3.5 (0.7–6.4)

    203.94

    0.98(0.85–1.12)

    0.3 (–3.7–4.3)

    Body mass index

     

     

     

     

    Non-ideal

    618.65

    1(reference)

    131.49

    1 (reference)

    490.29

    1 (reference)

    209.62

    1 (reference)

     

    Ideal

    452.38

    0.87(0.81–0.93)

    5.0(1.9–8.0)

    106.58

    1.00 (0.86–1.16)

    NA

    352.51

    0.84 (0.77–0.91)

    6.5 (3.1–9.9)

    198.33

    1.12(1.00–1.27)

    NA

    Physical activity

     

     

     

     

    Non-ideal

    544.05

    1(reference)

    143.37

    1 (reference)

    404.93

    1 (reference)

    227.97

    1 (reference)

     

    Ideal

    488.54

    0.99(0.92–1.06)

    1.4(–1.7–4.5)

    99.47

    0.83 (0.71–0.97)

    8.7 (1.7–15.6)

    395.32

    1.03 (0.95–1.12)

    NA

    188.12

    0.86(0.77–0.97)

    7.7 (2.6–12.7)

    Healthy diet score

     

     

     

     

    Non-ideal

    598.73

    1(reference)

    130.79

    1 (reference)

    472.67

    1 (reference)

    255.54

    1 (reference)

     

    Ideal

    469.86

    0.90(0.84–0.96)

    5.1(2.5–7.8)

    108.26

    0.93 (0.80–1.08)

    3.4 (–1.9–8.7)

    367.53

    0.89 (0.82–0.96)

    5.4 (2.5–8.3)

    179.58

    0.85(0.76–0.96)

    7.9 (3.6–12.2)

    Total cholesterol

     

     

     

     

    Non-ideal

    624.47

    1(reference)

    165.48

    1 (reference)

    466.30

    1 (reference)

    249.26

    1 (reference)

     

    Ideal

    469.76

    0.83(0.77–0.89)

    7.0(4.4–9.7)

    98.23

    0.70 (0.61–0.82)

    12.6 (6.8–18.3)

    376.41

    0.86 (0.79–0.94)

    5.3 (2.4–8.2)

    186.54

    0.80(0.71–0.90)

    8.0 (3.9–12.0)

    Blood pressure

     

     

     

     

    Non-ideal

    629.65

    1(reference)

    137.27

    1 (reference)

    497.43

    1 (reference)

    249.79

    1 (reference)

     

    Ideal

    297.89

    0.51(0.46–0.56)

    44.1(38.6–49.3)

    76.06

    0.63 (0.51–0.77)

    33.0 (20.4–44.4)

    227.74

    0.47 (0.42–0.53)

    46.0 (39.9–51.7)

    118.77

    0.48(0.41–0.57)

    47.2(38.4–55.1)

    Fasting plasma glucose

     

     

     

     

    Non-ideal

    694.14

    1(reference)

    169.27

    1 (reference)

    534.38

    1 (reference)

    276.05

    1 (reference)

     

    Ideal

    456.57

    0.78(0.72–0.84)

    8.0(5.3–10.6)

    99.83

    0.77 (0.66–0.90)

    8.8 (3.2–14.2)

    361.10

    0.78 (0.72–0.85)

    7.5 (4.5–10.4)

    181.49

    0.80(0.72–0.90)

    7.6 (3.5–11.8)

    Abbreviations: ASCVD, atherosclerotic cardiovascular disease; CVH, cardiovascular health; HR, hazard ratio; CI, confidence interval; PAR%, population-attributable risk percentage; NA, not available; China-PAR project, Prediction for ASCVD Risk in China. *, ASCVD events were defined as the first occurrence of nonfatal acute myocardial infarction (AMI), or coronary heart disease (CHD) death or fatal or non-fatal stroke. †, The age- and sex-adjusted incidence rates (per 100,000 person-years) were calculated by the status of each CVH metric using Poisson regression model. ‡, Adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, cohort sources, and other CVH metrics. §, The PAR% adjusted for age, sex, living region, urbanization, drinking status, education level, family history of ASCVD, cohort sources, and other CVH metrics. It indicated the proportion of the outcome (e.g. ASCVD event/CHD/Stroke/ASCVD death) attributable to not achieving ideal level for each CVH metric.

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