Low-Risk Lifestyle, Coronary Calcium, Cardiovascular Events, and Mortality: Results From MESA

Editor's Note: Commentary based on Ahmed HM, Blaha MJ, Nasir K, et al. Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: results from the MESA. Am J Epidemiol 2013;178:12-21.


Unhealthy lifestyle habits are a major contributor to coronary artery disease. In this study, the authors sought to investigate the association between four key habits (smoking, weight maintenance, physical activity, and diet), and each of coronary artery calcium (CAC), CAC progression, cardiovascular events, and mortality.


Adult men and women ages 44-84 (N=6,229) were studied from the Multi-Ethnic Study of Atherosclerosis (MESA), a multi-center, multi-ethnic prospective study of risk factors, prevalence, and progression of subclinical cardiovascular disease.1 All participants were free of clinical cardiovascular disease at time of enrollment. A lifestyle score ranging from 0-4 was created using Mediterranean-style diet, exercise, body-mass index (BMI), and smoking status. CAC was measured at baseline and mean 3.1 (standard deviation [SD] ±1.3) years later to assess calcium progression. Coronary events and mortality were followed for median 7.6 (SD ±1.5) years.


Participants with lifestyle scores 1, 2, 3, and 4 were found to have slower mean adjusted annual CAC progression by 3.5 (95% confidence interval (CI): 0.0-7.0); 4.2 (95% CI 0.6-7.9); 6.8 (95% CI 2.0-11.5); and 11.1 (95% CI 2.2-20.1) Agatston units/year relative to the reference group of lifestyle score of 0 (P=0.003). Participants with score 1 had unadjusted hazard ratio (HR) 0.79 (95% CI 0.61-1.03) for death; score 2: HR 0.61 (95% CI 0.46-0.81); score 3: HR 0.49 (95% CI 0.32-0.75); and score 4: HR 0.19 (95% CI 0.05-0.75). P<0.001 by log-rank test.


The combination of regular exercise, healthy diet, smoking avoidance, and normal weight maintenance was associated with lower CAC incidence, slower CAC progression, and lower all-cause mortality over 7.6 years.


This study showed that adoption of the healthy lifestyle habits above was associated with lower CAC incidence, slower CAC progression, a trend towards lower cardiovascular event risk, and significantly lower all-cause mortality over 7.6 years.2 To our knowledge, this is the first study to connect the protective effects of healthy lifestyle across baseline subclinical vascular disease, atherosclerotic progression, clinical coronary heart disease (CHD), and death in a single longitudinal evaluation.

Results of this study are consistent with those of prior authors who have investigated the effects of lifestyle on CHD and death independently. At least five large prospective studies have shown protective effects of smoking avoidance, weight maintenance, physical activity, and diet on mortality.3-8 However, inclusion of CAC as an additional measure of subclinical atherosclerosis along the intermediary pathway lends biologic credibility to the outcomes investigated in our study.

Much attention has been directed towards CAC, given its link to risk of CHD and death.9-12 Numerous reports have found significant associations between physical activity and CAC.13-17 Several other lifestyle variables, including diet, smoking, and waist circumference have also been associated with CAC.18,19 Results of this study further confirm the associations between these behavioral risk factors and subclinical disease.

CAC is a potent measure of subclinical vascular disease and biologic aging. The association between the studied lifestyle variables and CAC, as well as a trend towards lower CHD risk in just 7.6 years suggests that this effect will likely mature more over time. The stronger association with mortality suggests the importance of lifestyle in non-cardiac as well as cardiac disease processes. Further emphasis on the education and counseling about these lifestyle modifications will be critical for improving future individual and community health.

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Clinical Topics: Prevention, Diet

Keywords: Coronary Artery Disease, Coronary Disease, Diet, Habits, Life Style

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