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.
- Bild DE, Bluemke DA, Burke GL, et al. Multi-Ethnic Study of Atherosclerosis: objectives and design. Am J Epidemiol 2002;156:871-81.
- Ahmed HM, Blaha MJ, Nasir K, et al. Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: results from the MESA. Am J of Epidemiol 2013;178:12-21.
- Ford ES, Greenlund KJ, Hong Yulig. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation 2012;125:987-95.
- Van Dam RM, Li T, Spiegelman D, et al. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ 2008;337:a1440.
- Ford ES, Zhao G, Tsai J, et al. Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health. 2011;101(10):1922-1929.
- Gopinath B, Flood VM, Burlutsky G, et al. Combined influence of health behaviors on total and cause-specific mortality. Arch Intern Med 2010;170:1605-7.
- Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly european men and women: the HALE Project. JAMA 2004;292:1433-9.
- Chiuve SE, Fung TT, Rexrode KM, et al. Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA 2011;306:62-9.
- Newman AB, Naydeck BL, Ives DG, et al. Coronary artery calcium, carotid artery wall thickness, and cardiovascular disease outcomes in adults 70 to 99 years old. Am J Cardiol 2008;101:186-92.
- Budoff MJ, Hokansen JE, Nasir K, et al. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging 2011;3:1229-36.
- Blaha M, Budoff MJ, Shaw LJ. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging 2009;2:692-700.
- McEvoy JW, Blaha MJ, DeFilippis, et al.Coronary artery calcium progression: an important clinical measurement? a review of published reports. J Am Coll Cardiol 2010;56:1613-22.
- Ahmed HM, Blaha MJ, Nasir K, et al. Effects of physical activity on cardiovascular disease. Am J Cardiol. 2012;109:288-95.
- Bishop FK, Maahs DM, Snell-Bergeon JK, et al. Lifestyle risk factors for atherosclerosis in adults with type 1 diabetes. Diab Vasc Dis Res 2009;6:269-75.
- Storti KL, Pettee Gabriel KK, Underwood DA, et al. Physical activity and coronary artery calcification in two cohorts of women representing early and late postmenopause. Menopause 2010;17:1146-51.
- Hamer M, Kivimaki M, Lahiri A,et al. Walking speed and subclinical atherosclerosis in healthy older adults: the Whitehall II Study. Heart 2010;96:380-4.
- Pettee KK, Larouere BM, Kriska AM, et al. associations among walking performance, physical activity, and subclinical cardiovascular disease. Prev Cardiol 2007;10(3):134-140.
- Diaz VA, Mainous AG 3rd, Everett CJ, et al. Effect of healthy lifestyle behaviors on the association between leukocyte telomere length and coronary artery calcium. Am J Cardiol 2010;106:659-63.
- Michos ED, Santos RD, Narla V, et al. Favorable cardiovascular risk factor profile is associated with reduced prevalence of coronary artery calcification and inflammation in asymptomatic nondiabetic white men. Prev Cardiol 2008;11:189-94.
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