Life's Essential 8 and carotid artery plaques: the Swedish cardiopulmonary bioimage study

Background To quantify cardiovascular health (CVH), the American Heart Association (AHA) recently launched an updated construct of the “Life's Simple 7” (LS7) score, the “Life's Essential 8” (LE8) score. This study aims to analyse the association between both CVH scores and carotid artery plaques and to compare the predictive capacity of such scores for carotid plaques. Methods Randomly recruited participants aged 50–64 years from the Swedish CArdioPulmonary bioImage Study (SCAPIS) were analysed. According to the AHA definitions, two CVH scores were calculated: i) the LE8 score (0, worst CVH; 100, best CVH) and two different versions of the LS7 score [(0–7) and (0–14), 0 indicating the worst CVH]. Ultrasound-diagnosed carotid plaques were classified as no plaque, unilateral, and bilateral plaques. Associations were studied by adjusted multinomial logistic regression models and adjusted (marginal) prevalences, while comparison between LE8 and LS7 scores was performed through receiver operating characteristic (ROC) curves. Results After exclusions, 28,870 participants remained for analysis (50.3% women). The odds for bilateral carotid plaques were almost five times higher in the lowest LE8 (<50 points) group [OR: 4.93, (95% CI: 4.19–5.79); adjusted prevalence 40.5%, (95% CI: 37.9–43.2)] compared to the highest LE8 (≥80 points) group [adjusted prevalence 17.2%, (95% CI: 16.2–18.1)]. Also, the odds for unilateral carotid plaques were more than two times higher in the lowest LE8 group [OR: 2.14, (95% CI: 1.82–2.51); adjusted prevalence 31.5%, (95% CI: 28.9–34.2)] compared to the highest LE8 group [adjusted prevalence 29.4%, (95% CI: 28.3–30.5)]. The areas under ROC curves were similar between LE8 and LS7 (0–14) scores: for bilateral carotid plaques, 0.622 (95% CI: 0.614–0.630) vs. 0.621 (95% CI: 0.613–0.628), P = 0.578, respectively; and for any carotid plaque, 0.602 (95% CI: 0.596–0.609) vs. 0.600 (95% CI: 0.593–0.607), P = 0.194, respectively. Conclusion The new LE8 score showed inverse and dose-response associations with carotid plaques, particularly bilateral plaques. The LE8 did not outperform the conventional LS7 score, which showed similar ability to predict carotid plaques, especially when scored as 0–14 points. We conclude that both the LE8 and LS7 may be useful in clinical practice for monitoring CVH status in the adult population.


Measurement and calculation of health factors and health behaviors in Life´s Essential 8 Health factors
In brief, Life´s Essential 8 (LE8) factors were measured using standardized clinical and laboratory procedures. For blood glucose and lipids, baseline biochemistry levels were evaluated through the analysis of freshly obtained blood samples collected after an overnight fast, utilizing the Architect Abbott® and Cobas Rocher® analyzers at laboratories located within the specific university hospitals. Data about the prescription of antihypertensive (Anatomical Therapeutic Codes [ATC] codes C02, C03, C07, C08, and C09), lipid lowering (ATC code C10) and antidiabetic (ATC code A10) medications during the year prior to measurements were collected from the Swedish Prescribed Drug Register. This register is a database that records all prescription drugs dispensed to individuals in Sweden since July 2005, with an estimated national coverage rate of 100%.

Blood pressure
Systolic and diastolic brachial arterial pressures (SBP and DBP) were obtained by automatic measurement in both arms with the oscillometer Omron M10-IT® (Omron Health care Co, Kyoto, Japan) 2 . After 5 minutes rest in the supine position, the cuff-pressure was located at heart level and SBP and DBP were registered. The measurement was repeated with at least one minute between measurements. If the two results differed >10 mmHg in the same arm, either for SBP or DBP, the measurement was repeated until two subsequent results were within ±10 mmHg, with a maximum of four attempts. If the difference was still >10 mmHg, the last two measurements were considered. The measurements were performed before administration of beta-stimulants (for spirometry) or beta-blockers (for Computed Coronary Tomography Angiography [CCTA] evaluation) or on a different day. After measuring twice in each arm, the average pressure of the arm with the highest blood pressure was considered for the analysis. For blood pressure computation, the worst scenario is considered, e.g., a patient with SBP=145.0 mmHg and DBP=85.0 mmHg scores 25 points.

Health behaviors Diet
The evaluation of dietary habits was conducted using the web-based MiniMeal-Q questionnaire 3,4 . The scoring of dietary habits was aligned with the Mediterranean Eating Pattern for Americans (MEPA) 5 . Diet total score is corrected as follows: Corrected diet total score = (Diet total score x 16) / (16-Total subcomponents missed in diet total score).

Physical activity
Physical activity was measured through tri-axial accelerometry using the Actigraph GT3X+ (3% of participants), wGT3X+ (15% of participants) and wGT3X-BT (82% of participants) devices with low-frequency extension filter (ActiGraph LCC, Pensacola, FL, USA). Participants were instructed to wear the accelerometer on their right hip for a period of seven consecutive days during "all wake time", excluding water-based activities 6 . A categorical classification system was applied to assess physical activity levels, with the following criteria: lowintensity physical activity (200-2689 counts per minute), moderate-intensity physical activity (2690-6166 counts per minute), and vigorous-intensity physical activity (≥6167 counts per minute) 7 .
For the purpose of calculation, each minute of moderate activity was recorded as one minute and each minute of vigorous activity was recorded as two minutes.

Moderate (or greater) intensity activity per week (minutes)
Score

Score
Never smoker 100 Former smoker, quit ≥5 years 75 Former smoker, quit 1-<5 years 50 Former smoker, quit <1 years, or currently using inhaled NDS 25 Current smoker 0 Assumption: smokers who did not answer the questions on consumption of any type of tobacco were assumed to consume the median value for each category (6 for occasional smokers, 15 for all other current smokers, and 10 for ex-smokers). In those participants with cohabitant smoking (or who smoked) less than 10 years, 10-20 years and >20 years, 10, 15 and 20 points were subtracted to the nicotine exposure score, respectively.

Sleep health
Sleep patterns were evaluated through self-administered questionnaire which included the following aspects: hours of sleep per night, breathing problems during sleep (self-reported or others-reported), sleep apnea (doctor-diagnosed or self-reported), and sleep apnea treatment (self-reported) were reported from self-administered questionnaire.

Total Life´s Essential 8 score calculation
The determination of scores in LE8 aligns with the methodology published by the American Heart Association (AHA) 8 . In accordance with the AHA, the 8 components of LE8 are scored on a scale ranging from 0 (lowest possible level) to 100 (highest possible level). In this study, the calculation of LE8 was performed when either 8 or 7 components were available. The LE8 score was calculated as the unweighted mean of the present components, yielding a total score in the range of 0-100 that was adjusted for the number of missing components as follows: • For participants with 8 available components, LE8 = sum of all 8 components / 8.
Furthermore, two separate scores were determined for the LE8 factors and the LE8 behaviors. In both cases, the scores were calculated when 3 or 4 components were available and corrected for the missing components using the same methodology as previously described.

Measurement and calculation of health factors and health behaviors in Life´s Simple 7
Though the calculation of scores is different between LE8 and Life´s Simple 7 (LS7) scores, the measurements used in LS7 score were similar to those used in LE8 score (apart from sleep health that is not included in LS7).

Diet
The diet component was consistent with a Dietary Approaches to Stop Hypertension (DASH) eating plan, as the AHA recommended 9 .

Total Life´s Simple 7 score calculation
The calculation of scores in LS7 are consistent with those published by the AHA 9 . In the total score, only those participants with data in all 7 components are considered. Two scores of LS7 were created: • LS7 (0-7) score, we calculated the number of LS7 components at ideal level, thus creating a score ranging from 0 (the lowest cardiovascular health) to 7 (the highest cardiovascular health) points. • LS7 (0-14) score, we calculated a combined score of the 7 components which were rated as 0 (poor cardiovascular health), 1 (intermediate cardiovascular health), or 2 (ideal cardiovascular health), leaving a total score from 0 (the lowest CVH) to 14 (the highest CVH) points.