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Artículo Sueño y Corazón
Artículo Sueño y Corazón
ABSTRACT: In 2010, the American Heart Association defined a novel construct of cardiovascular health to promote a paradigm
shift from a focus solely on disease treatment to one inclusive of positive health promotion and preservation across the life
course in populations and individuals. Extensive subsequent evidence has provided insights into strengths and limitations
of the original approach to defining and quantifying cardiovascular health. In response, the American Heart Association
convened a writing group to recommend enhancements and updates. The definition and quantification of each of the original
metrics (Life’s Simple 7) were evaluated for responsiveness to interindividual variation and intraindividual change. New
metrics were considered, and the age spectrum was expanded to include the entire life course. The foundational contexts
of social determinants of health and psychological health were addressed as crucial factors in optimizing and preserving
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cardiovascular health. This presidential advisory introduces an enhanced approach to assessing cardiovascular health: Life’s
Essential 8. The components of Life’s Essential 8 include diet (updated), physical activity, nicotine exposure (updated), sleep
health (new), body mass index, blood lipids (updated), blood glucose (updated), and blood pressure. Each metric has a new
scoring algorithm ranging from 0 to 100 points, allowing generation of a new composite cardiovascular health score (the
unweighted average of all components) that also varies from 0 to 100 points. Methods for implementing cardiovascular
health assessment and longitudinal monitoring are discussed, as are potential data sources and tools to promote widespread
adoption in policy, public health, clinical, institutional, and community settings.
Key Words: AHA Scientific Statements ◼ health promotion ◼ healthy lifestyle ◼ life change events
◼ public health ◼ social determinants of health
Supplemental material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001078.
© 2022 American Heart Association, Inc.
Circulation is available at www.ahajournals.org/journal/circ
actionable components for individuals, practitioners, re- as a new CVH component—to catalyze ongoing efforts to
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searchers, and policymakers to focus efforts for improve- improve CVH in all individuals and the population.
ment in CVH for all. Readers are referred to that document
for a more detailed discussion of the rationale and genesis
of the CVH construct. The initial definition of CVH1 was
REVIEW OF KNOWLEDGE GAINED SINCE
based on 7 health behaviors and health factors that, when 2010
optimal, were associated with greater CVD-free survival To date, >2500 scientific articles have cited the original
and total longevity and higher quality of life. The 7 compo- 2010 document describing the AHA’s construct of CVH
nents of CVH, subsequently called Life’s Simple 7, included and explored the prevalence, determinants, outcomes,
indicators of dietary quality, participation in physical activ- and mechanisms of CVH in diverse populations across
ity (PA), exposure to cigarette smoking, and measures of the life course. A number of findings are highlighted here.
body mass index, fasting blood glucose, total cholesterol,
and blood pressure (BP) levels. Each metric was classified
as poor, intermediate, or ideal on the basis of accepted clini- Prevalence of CVH
cal thresholds. Overall, ideal CVH was defined as having all In the United States, the prevalence of ideal CVH is ex-
7 metrics at ideal levels. Ideal CVH also formed the basis of ceedingly low (<1%) for all age groups studied, including
a new definition of optimal brain health published in 2017.2 among individuals as young as 12 years of age.3 Overall
The rich experience with and evidence in support of CVH declines with age: The prevalence of having ≥5 met-
this powerful new health construct over the past 12 years rics at ideal levels is only 45% among US adolescents, 32%
have created an opportunity to update the measurement of among adults 20 to 39 years of age, 11% among adults
CVH in the current context. Now is the time to enhance the 40 to 59 years of age, and 4% among adults ≥60 years of
approach to quantifying the original metrics and to assess age.3 Thus, although some individuals can preserve higher
the potential value of additional metrics and data sources levels of CVH, most will require some attention to achieve
to better represent the full range of CVH and to further and maintain it into later life. The prevalence of ideal diet
motivate individual and population health improvement. (as defined in 2010) is consistently negligible (<1%)
This advisory presents an updated and enhanced approach across all age groups, driving the overall low prevalence of
to measuring, monitoring, and modifying CVH—now called ideal CVH. Population levels of CVH in the United States
Life’s Essential 8 (Figure 1) after the inclusion of sleep have been low and fairly stagnant over the past 15 to 20
years,4 but this overall observation conceals several impor- in determining CVH.24 Indeed, pursuing and sustaining
CLINICAL STATEMENTS
tant findings. First, although some segments of the popula- a healthier lifestyle from a young age is a successful
AND GUIDELINES
tion are experiencing modest improvements in CVH, other strategy for maintaining higher CVH into middle age.25–31
groups (generally those at a lower socioeconomic position) However, one’s ability to choose healthy lifestyles across
are experiencing worsening CVH, creating a bimodal dis- the life course is strongly influenced by psychological
tribution.5 Second, there are persistent differences in the health factors32,33 and social and structural determi-
prevalence of CVH levels by self-reported race and ethnic- nants,34 as addressed later in detail (in the Foundational
ity, and these disparities are larger at younger ages.3 The Factors for CVH: Psychological Health/Well-Being and
prevalence of high CVH also varies geographically6 and Social Determinants section).
is higher in those who live in urban7 areas compared with
those who live in rural areas. Furthermore, recent data in- Mechanisms of CVH
dicate that the prevalence of high CVH is <1 in 10 during
pregnancy,8 and poor CVH in pregnancy is associated with Investigations of mechanisms through which high-
poor CVH in offspring, suggesting that ideal CVH is not er CVH is associated with lower CVD risk (or lower
universal even at birth.9 CVH with higher risk) have identified several potential
pathways involving inflammation, endothelial function,
atherosclerosis, cardiac stress and remodeling, hemo-
Outcomes of CVH static factors, and epigenetics,35,36 among others.13,37,38
Numerous studies have shown strong, stepwise, inverse Two studies examined multiple potential pathways from
associations between the number of ideal CVH metrics or low CVH status to clinical CVD events and found only
overall CVH score and total CVD and CVD mortality, all- partial statistical attenuation of the relationship after
cause mortality, and a wide variety of non-CVD outcomes. adjustment for a wide array of subclinical disease mea-
In all studies, those with higher CVH have markedly lower sures and biomarkers presumed to be in the causal
risks for CVD events. In a meta-analysis of 9 prospective pathway.13,37 Thus, beyond known CVD risk pathways,
cohort studies, having the highest number of ideal CVH the protection conferred by optimal CVH may be “more
metrics (generally ≥5 versus 0 to 2) was associated with a than the sum of its parts.”39
relative risk of 0.20 for CVD (95% CI, 0.11–0.37), 0.31 for Taken together, the substantial body of knowledge
stroke (95% CI, 0.25–0.38), 0.25 for CVD mortality (95% gained about CVH indicates that it is uniquely positioned
CI, 0.10–0.63), and 0.55 for all-cause mortality (95% CI, as a health outcome itself related to upstream genetic,
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0.37–0.80).10 Similar associations are observed across all social, behavioral, and environmental factors, and as
age groups, down to as young as 8 years of age,11–15 and a determinant of major downstream health outcomes.
regardless of race and ethnicity or socioeconomic position. Across the life course, assessment of CVH status has
All 7 original CVH metrics contribute to risks for health been shown to be an effective means to monitor pub-
outcomes,12 and the importance of CVH behaviors is lic and individual health and a strong indicator of the
underscored by the association of optimal CVH behaviors extraordinary potential of primordial prevention strate-
with nearly 50% lower risk for coronary events among gies to improve and extend countless lives.
individuals at high genetic risk.16,17 It is never too late to
realize benefits from improvement in CVH.18–20 However, LESSONS LEARNED ABOUT CVH AND
the earlier that CVH is optimized, the better the outcomes
are. Having higher CVH is associated with favorable long- RATIONALE FOR REDEFINITION
term health outcomes at every age, and improvement in As is evident from the previous review, a number of les-
CVH over time is associated with lower risk for CVD.18–20 A sons have been learned about the original construct of
recent analysis estimated that if all US adults maintained CVH through its application and study in diverse settings.
high CVH (defined in that article as 12–14 of 14 points on The collective experience of the scientific and medical
the CVH score), 2.0 million CVD events would be prevented community in using the original CVH construct to mea-
each year.21 Better CVH has also been associated with sure and improve CVH suggested several important con-
lower risks for cancer, dementia, end-stage renal disease, siderations for this update.
and chronic obstructive pulmonary disease; better cogni- First, some features of CVH component definitions
tive function and quality of life; compression of morbidity may not have allowed appreciation of the full scope of
(longer health span); and lower health care costs despite a health behaviors and practices in the current environ-
longer life span, among many other positive outcomes.22,23 ment. For example, the original diet metric assessed
intake of only 5 foods or nutrients (fruit and vegeta-
bles, fish, whole grains, sugar-sweetened beverages,
Determinants of CVH and sodium). These dietary components were selected
The heritability of overall CVH is low, indicating that be- to represent an overall healthy eating pattern such as
havioral and environmental exposures are paramount the DASH (Dietary Approaches to Stop Hypertension)
eating pattern from variables available at the time in can lead to successful outcomes (as discussed in Imple-
CLINICAL STATEMENTS
NHANES (National Health and Nutrition Examination mentation of CVH in Clinical Practice section).
AND GUIDELINES
Surveys). However, those 5 components are not the only Last, the original writing group contemplated the
features of a contemporary healthful eating pattern. The inclusion of sleep, stress, and other factors as metrics
new metrics attempt to allow credit for a broader scope and acknowledged their contributions to overall CVH.
of health in each CVH component. However, at the time, the means for reliably measur-
Second, over time, application of the CVH construct ing these domains in individuals and populations were
has increasingly been used to assess individual- and limited. In the ensuing years, improved assessment
population-level CVH. This application has revealed techniques and emerging evidence have bolstered the
limitations in how the metrics are quantified. Specifi- importance of sleep and psychological health/well-being
cally, the original definitions of ideal, intermediate, and for CVH. In addition, there is increased awareness of the
poor CVH for each component are less sensitive to critical importance for CVH of social determinants of
interindividual differences and intraindividual change health (SDOH) and the underlying societal and structural
than is desirable. For example, the PA metric quantified issues that create them. These factors were of signifi-
intermediate CVH as 1 to 149 minutes of moderate cant importance in the deliberations of the writing group.
to vigorous activity per week. Thus, 2 distinct individu- In the next sections, we introduce the AHA’s new
als with widely different amounts (eg, 1 min/wk versus Life’s Essential 8, including affirmation of the founda-
149 min/wk) would be categorized as having interme- tional roles that psychological health/well-being and
diate PA, and an individual who changed their own PA SDOH play in achieving optimal and equitable CVH in
from 1 to 149 min/wk would receive no credit for the the population (in the Foundational Factors for CVH:
substantial improvement in this health behavior. The Psychological Health/Well-Being and Social Determi-
newer approach to quantification of CVH is designed nants section); a new CVH component metric related to
to be more sensitive and responsive to these consid- sleep (in the Sleep Health as a New Component of CVH
erations. There were also large shifts in some individu- section); and novel, updated methods for defining and
als’ CVH scores as they transitioned from childhood to quantifying CVH (in the Updated Definitions and Novel
adult metrics (some of which is unavoidable) that we Quantitative Assessment of CVH Metrics section).
have attempted to address.
Third, although CVH was designed to measure and
monitor health trajectories over time, a novel contribu- FOUNDATIONAL FACTORS FOR CVH:
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CLINICAL STATEMENTS
AND GUIDELINES
Figure 2. The foundational context of
CVH.
As depicted in the social-ecological model
in the base of the figure 8, a variety of
socioeconomic and structural determinants
of health provide the foundational framework
that affects an individual’s or a community’s
ability to optimize cardiovascular health (CVH).
Several interacting factors provide critical
context for CVH, including structures and
systems (general socioeconomic, cultural,
and environmental conditions), community
resources (ie, education, agriculture, food
production, employment, water and sanitation,
health care, and housing), institutions and
organizations (in which people learn, grow, eat,
sleep, play, and pray), interpersonal social and
community networks, and individual genetic
and behavioral factors. These foundational
social-ecological factors work through and
alongside an individual’s psychological health
(represented at the top of the 8 in the figure)
to provide the context for what is possible
in improving or maintaining CVH. There is
a continuous interplay of brain-mind-heart-
body connections that can positively and
negatively affect CVH, which is represented
by the 8 component metrics (diet, physical
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attempts to assess and improve CVH in any patient or ways (such as inflammatory response, glucose and lipid
population. We therefore highlight these 2 critical, foun- homeostasis, and coagulation) related to chronic stress,
dational factors first. indirect effects on health behaviors that influence CVH,
and changes in psychosocial resilience factors that pro-
mote or impair health or buffer detrimental effects of
Psychological Health and Well-Being stressful experiences.33,55–59 The preponderance of data
A growing body of evidence supports the brain-mind- suggests that interventions to improve psychological
heart-body connection that can positively or negatively af- health can have a beneficial impact on CVH.33 However,
fect CVH, individual CVD risk factors, and cardiovascular agreement on which psychological factors are the most
outcomes. A recent AHA scientific statement33 reviewed robust predictors and correlates of CVH is lacking. Rela-
a large number of studies that address a broad range of tively simple questionnaires can be used by clinicians to
positive (eg, optimism, sense of purpose, happiness) and assess psychological health status in the evaluation and
negative (eg, stress, depression, anxiety) psychological management of patients with or at risk for CVD.33
health factors and their significant associations with CVH On the basis of the reviewed evidence, the writing
and CVD risk. That statement guided much of the current group judged that psychological health and well-being
writing group’s deliberations on the interactions of psy- form a critical context and interact bidirectionally with
chological health and well-being with CVH. the potential for preserving and improving CVH. Psy-
There are multiple direct and indirect pathways by chological health is multidimensional, and at this time,
which psychological health and well-being may influence it is not clear how best to combine measures of psy-
CVH and CVD risk. These include physiological path- chological health or which indicator(s) may be most
important for influencing CVH. When the writing group SLEEP HEALTH AS A NEW COMPONENT
CLINICAL STATEMENTS
strata, including race and ethnicity, socioeconomic posi- health is also known to be associated with poor psycho-
tion, geography, and rurality, among others,63,64 and logical health111–114 and SDOH,84,115–120 important con-
inequities persist as a result of societal and structural textual drivers of CVH; therefore, for some individuals,
barriers.34,64 The need to address CVH disparities has sleep health assessment and intervention may require
recently received considerable attention because per- customized approaches that consider the surround-
sistence of these pervasive issues hinders achievement ing context. As with many of the other CVH component
of health equity.34,65,66 Prior CVD disparities–focused metrics, sleep may also serve to integrate and mediate
interventions and initiatives have not proactively incor- some of the effects of SDOH and psychological health
porated the full spectrum of complex psychosocial on CVH. Several organizations have adopted sleep dura-
influences on CVH.67–71 tion guidelines, recognizing the population health value
Substantial research activity is currently focused on of ≈7 to 8 hours of habitual sleep for adults and age-
discovering the best means for representing and measur- appropriate ranges of sleep duration for children.91,121–127
ing SDOH in individuals and neighborhood environments. Although there is a paucity of evidence indicating that
As with psychological health and well-being, the writing improving sleep duration or quality reduces CVD inci-
group judged that the best methods for measuring and dence, several other lines of evidence support its con-
quantifying SDOH are inadequately understood at this nection with CVH. For example, laboratory studies show
time, and the most important factors for preserving CVH that experimentally manipulated sleep affects BP, inflam-
in individuals and populations remain to be elucidated. mation, glucose homeostasis, and other relevant factors.
Likewise, SDOH factors underlie much of the ability to Larger observational studies show that small changes in
optimize CVH rather than forming a single component of sleep at the population level are associated with changes
CVH. Accordingly, the writing group encourages further in CVD-related risk factors. Research indicates that real-
research on SDOH and CVH and urges consideration world manipulation of sleep time is possible and that
of SDOH in individual clinical attempts to improve CVH therefore sleep time is modifiable. Last, a limited number
and in the design of community and population policies of studies demonstrate that real-world sleep manipula-
and interventions (see Implementation of CVH in Clini- tion is associated with changes in CVD-related risk fac-
cal Practice and Context and Opportunities for Improving tors.128,129 Nonetheless, overall, this is a research gap for
CVH Going Forward). which further investigation is warranted.
As a result of the above evidence, the ease and • Nicotine exposure: Use of inhaled nicotine-
CLINICAL STATEMENTS
increasing reliability of measurement, and its compa- delivery systems (eg, e-cigarettes or vaping
AND GUIDELINES
rable and independent contributions to overall and car- devices) has been added to the former metric,
diometabolic health and health outcomes, the writing which included only combustible cigarette use, to
group elected to add sleep duration as an eighth metric reflect adult and childhood use of these products
to the formal definition of CVH. Its measurement and and their implications for long-term health.137,138
quantification are described in the next section with the Secondhand tobacco smoke exposure has also
other metrics. been added to the definition to reflect its adverse
impact on health.135,139
• Sleep health: As noted, the writing group endorses
UPDATED DEFINITIONS AND NOVEL the systematic assessment and inclusion of sleep
duration as the current means for reflecting sleep
QUANTITATIVE ASSESSMENT OF CVH
health within the construct of CVH.
METRICS • Blood lipids: The metric for blood lipids has been
Here, we propose updated definitions and rescoring of updated to consider non–high-density lipoprotein
the original 7 CVH metrics and the new sleep metric on cholesterol as the metric of interest rather than
a more continuous scale to better account for interindi- total cholesterol because non–high-density lipopro-
vidual difference and intraindividual change (Table 1). The tein cholesterol can be measured in the nonfasting
table should not be used as the sole guide for individu- state and reliably calculated in all patients (unlike
als to shape prevention or health promotion strategies. low-density lipoprotein cholesterol) and because of
It is provided for the AHA, researchers, health systems, the lifelong associations demonstrated for differ-
and policymakers to create standardized tools to measure ent atherogenic lipoprotein fractions, all of which
and monitor CVH in individuals and populations. In the fol- are represented in the non–high-density lipoprotein
lowing paragraphs, descriptions of new or updated metric cholesterol measurement.
definitions are first presented, followed by a discussion of • Blood glucose: The metric for blood glucose has
new measurement and quantification techniques. been expanded to include hemoglobin A1c mea-
Several of the original 7 metrics have been redefined surement (in individuals with or without diabetes)
for consistency with newer clinical guidelines, to better and to better reflect glycemic control among dia-
represent their biological impact, or for compatibility with betic patients.
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new measurement tools, as summarized here: • PA, body mass index, and BP: The writing group dis-
• Diet: A new method is proposed for assessing cussed these metrics and elected to use the same
dietary quality for both rapid individual assessment metric definitions (but with updated scoring, as for
in clinical settings and population-level assess- all the metrics).
ment in other settings, along with a suggested Childhood metrics were updated to reflect current
means for linking and aligning these assessments, pediatric guidelines, to extend to younger ages when
when needed, through the Healthy Eating Index136 appropriate, and to better align with transitions to
(see Supplemental Material for full details). The adulthood. More detailed discussion of the approach
writing group supports the overall goal of pursu- to quantifying CVH in children, especially children <6
ing DASH- and Mediterranean-style eating pat- years of age, is provided in the Supplemental Material
terns as being most consistent with optimal CVH. Appendix 2.
That said, there is no one such eating pattern, and For ease of reference in clinical or research settings,
there are limited tools for assessing alignment the 8 metrics making up the new CVH definition have
with these eating patterns. The DASH-style eat- been grouped into the 2 domains of health behaviors
ing pattern is more easily assessed at the popula- (diet, PA, nicotine exposure, sleep) and health factors
tion level for the United States, although it is more (body mass index, blood lipids, blood glucose, BP).
difficult at the individual level. Therefore, a rapid For the approach to quantification of the metrics and
dietary assessment tool is suggested for individu- overall CVH, various methods were considered. Also
als that is a modified Mediterranean Eating Pattern considered was the desire for ease of programming
for Americans (MEPA). The writing group selected metric scores to create applications (apps) and online
what we judge to be the best available tools and CVH assessment tools, as well as for incorporation into
calls for directed research to advance the field and electronic health records (EHRs) and other platforms.
identify even better standardized and rapid assess- Because some metrics do not lend themselves to fully
ment tools. This new approach provides a focus continuous quantification scales and because some
on individuals’ eating patterns and intake of whole associations of metrics with health are nonlinear, the
foods, rather than nutrients, that should promote writing group judged that an ordinal point scoring system
implementation in clinical and research settings. for each metric (ranging from 0 to 100 points) was most
Table 1. New and Updated Metrics for Measurement and Quantitative Assessment of CVH (see Notes for implementation of
each metric; See Supplemental Material for additional information on scoring of the Diet Metric, scoring in children at different
CLINICAL STATEMENTS
40 30–59
60 240–299
20 1–29
40 120–239
0 0
20 1–119
0 0
Nicotine Measurement: Self-reported Metric: Combustible tobacco use or Metric: Combustible tobacco use or inhaled
exposure use of cigarettes or inhaled inhaled NDS use; or secondhand smoke NDS use at any age (per clinician discre-
NDS exposure tion); or secondhand smoke exposure
Example tools for measure- Scoring: Scoring:
ment: NHANES SMQ134 Points Status Points Status
(Continued )
Table 1. Continued
CLINICAL STATEMENTS
Quantification of CVH metric: adults Quantification of CVH metric: children
AND GUIDELINES
Domain CVH metric Method of measurement (≥20 y) (up to 19 y)
Health factors BMI Measurement: Body weight Metric: BMI (kg/m2) Metric: BMI percentiles for age and sex,
(kilograms) divided by height Scoring: starting in infancy; see Supplemental Mate-
squared (meters squared) rial for suggestions for age <2 y
Example tools for measure- Points Level
Scoring:
ment: Objective measurement 100 <25 Points Level
of height and weight 70 25.0–29.9 100 5th–<85th percentile
30 30.0–34.9 70 85th–<95th percentile
15 35.0–39.9 30 95th percentile–<120% of
0 ≥40.0 the 95th percentile
15 120% of the 95th percentile–
<140% of the 95th percentile
0 ≥140% of the 95th percentile
Blood lipids Measurement: Plasma total and Metric: Non–HDL cholesterol (mg/dL) Metric: Non–HDL cholesterol (mg/dL), start-
HDL cholesterol with calcula- Scoring: ing no later than age 9–11 y and earlier per
tion of non–HDL cholesterol clinician discretion
Points Level
Example tools for measurement: Scoring:
100 <130
Fasting or nonfasting blood Points Level
sample 60 130–159
100 <100
40 160–189
60 100–119
20 190–219
40 120–144
0 ≥220
20 145–189
If drug-treated level, subtract 20 points
0 ≥190
If drug-treated level, subtract 20 points
Blood glucose Measurement: FBG or casual Metric: FBG (mg/dL) or HbA1c (%) Metric: FBG (mg/dL) or HbA1c (%), symp-
HbA1c Scoring: tom-based screening at any age or risk-based
Example tools for measurement: screening starting at age ≥10 y of age or on-
Points Level
Fasting (FBG, HbA1c) or non- set of puberty per clinician discretion
100 N
o history of diabetes and
fasting (HbA1c) blood sample Scoring:
FBG <100 (or HbA1c <5.7)
Points Level
60 No diabetes and FBG
100–125 (or HbA1c 5.7–6.4) 100 No history of diabetes and
FBG <100 (or HbA1c < 5.7)
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(prediabetes)
40 Diabetes with HbA1c <7.0 60 No diabetes and FBG 100–125
(or HbA1c 5.7–6.4) (prediabetes)
30 Diabetes with HbA1c 7.0–7.9
40 Diabetes with HbA1c <7.0
20 Diabetes with HbA1c 8.0–8.9
30 Diabetes with HbA1c 7.0–7.9
10 Diabetes with Hb A1c 9.0–9.9
20 Diabetes with HbA1c 8.0–8.9
0 Diabetes with HbA1c ≥10.0
10 Diabetes with Hb A1c 9.0–9.9
0 Diabetes with HbA1c ≥10.0
BP Measurement: Appropriately Metric: Systolic and diastolic BPs Metric: Systolic and diastolic BP (mm Hg)
measured systolic and diastolic (mm Hg) percentiles for age through 12 y. For age
BPs Scoring: ≥13 y, use adult scoring. Screening should
Example tools for measurement: start no later than age 3 y and earlier per
Points Level
Appropriately sized BP cuff clinician discretion
100 <120/<80 (optimal)
Scoring:
75 120–129/<80 (elevated)
Points Level
50 1
30–139 or 80–89 (stage 1
100 Optimal (<90th percentile)
hypertension)
75 Elevated (≥90th–<95th per-
25 140–159 or 90–99
centile or ≥120/80 mm Hg to
0 ≥160 or ≥100 <95th percentile, whichever
Subtract 20 points if treated level is lower)
50 Stage 1 hypertension (≥95th–
<95th percentile+12 mm Hg,
or 130/80 to 139/89 mm Hg,
whichever is lower)
25 Stage 2 hypertension (≥95th
percentile+12 mm Hg, or
≥140/90 mm Hg, whichever
is lower)
0 Systolic BP ≥160 or ≥95th
percentile+30 mm Hg systolic
BP, whichever is lower; and/
or diastolic BP ≥100 or ≥95th
percentile+20 mm Hg dia-
stolic BP
Subtract 20 points if treated level
(Continued )
Table 1. Continued
CLINICAL STATEMENTS
BMI indicates body mass index; BP, blood pressure; CVH, cardiovascular health; DASH, Dietary Approaches to Stop Hypertension; FBG, fasting blood glucose;
AND GUIDELINES
HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HEI, Healthy Eating Index; MEPA, Mediterranean Eating Pattern for Americans; NDS, nicotine-delivery sys-
tem; NHANES, National Health and Nutrition Examination Surveys; PA, physical activity; PAQ-K, Physical Activity Questionnaire K; and SMQ, smoking assessment.
*Cannot meet these metrics until solid foods are being consumed.
Notes on implementation:
Diet: See Supplemental Material Appendix 1. For adults and children, a score of 100 points for the CVH diet metric should be assigned for the top (95th percentile)
or a score of 15 to 16 on the MEPA (for individuals) or for those in the ≥95th percentile on the DASH score or HEI-2015 (for populations). The 75th to 94th percentile
should be assigned 80 points, given that improvement likely can be made even among those in this top quartile. For individuals, the MEPA points are stratified for the
100-point scoring system approximately by quantiles. In children, a modified MEPA is suggested that is based on age-appropriate foods. The writing group recognizes
that the quantiles may need to be adjusted or recalibrated at intervals with population shifts in eating patterns. In children, the scoring applies only once solid foods
are being consumed. For now, the reference population for quantiles of HEI or DASH score should be the NHANES sample from 2015 to 2018. The writing group
acknowledges that this may need to change or be updated over time. Clinicians should use judgment in assigning points for culturally contextual healthy diets. For
additional notes on scoring in children, see Supplemental Material Appendix 2.
PA: Thresholds are based in part on US Physical Activity Guidelines. For adults, each minute of moderate activity should count as 1 minute and each minute of
vigorous activity should count as 2 minutes toward the total for the week. For children, each minute of moderate or vigorous activity should count as 1 minute. The
score for PA is not linear, given that there is a greater increase in health benefit for each minute of marginal exercise at the lower end of the range and the association
tends to approach an asymptote at the higher end of the range.
If scoring is desired for children ≤5 years of age, see Supplemental Material. For additional notes on scoring in children, see Supplemental Material Appendix 2.
Nicotine exposure: The writing group recommends subtracting 20 points for children and adults exposed to indoor secondhand smoke at home, given its potential
for long-term effects on cardiopulmonary health.135 For additional notes on scoring in children, see Supplemental Material Appendix 2.
Sleep health: Thresholds are based in part on sleep guidelines. Clinicians may consider subtracting 20 points from the sleep score for adults or children with
untreated or undertreated sleep apnea if information is available. Note that overall scoring reflects the inverse-U–shaped association of sleep duration with health
outcomes, such that excessive sleep duration is also considered to be suboptimal for CVH.
For children, age-appropriate optimal sleep durations are as follows121:
Age 4 to 12 months, 12 to 16 hours per 24 hours (includes naps);
Age 1 to 2 years, 11 to 14 hours per 24 hours;
Age 3 to 5 years, 10 to 13 hours per 24 hours;
Age 6 to 12 years, 9 to 12 hours; and
Age 13 to 18 years, 8 to 10 hours.
For additional notes on scoring in children, see Supplemental Material Appendix 2.
BMI: Thresholds are based in part on National Heart, Lung, and Blood Institute (NHLBI) guidelines. The writing group acknowledges that BMI is an imperfect
metric for determining healthy body weight and body composition. Nonetheless, it is widely available and routinely calculated in clinical and research settings. BMI
ranges may differ for individuals from diverse ancestries. For example, the World Health Organization has recommended different BMI ranges for individuals of Asian
or Pacific ancestry. For individuals in these groups, point scores should be aligned as appropriate:
Points Level (kg/m2)
100 18.5–22.9
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75 23.0–24.9
50 25.0–29.9
25 30.0–34.9
0 ≥35.0
Clinicians may want to assign 100 points for overweight individuals (BMI, 25.0–29.9 kg/m2) who are lean with higher muscle mass. For underweight individuals
(<18.5 kg/m2 in adults or below the fifth percentile in children), the writing group defers to clinician judgment in assigning points on the basis of individual assessment
as to whether the underweight BMI is healthy or unhealthy. Conditions that should be considered unhealthy include chronic catabolic illnesses (eg, cancer), eating
disorders, and growth failure (for children). For additional notes on scoring in children, see Supplemental Material Appendix 2.
Blood lipids: Thresholds are based in part on 2018 Cholesterol Clinical Practice Guideline.129a The levels of non–HDL cholesterol for adults were selected on the
basis of current guideline recommendations and in concert with the observation that non–HDL cholesterol levels are generally ≈30 mg/dL higher than low-density
lipoprotein cholesterol levels in normative ranges in the population. For children, thresholds for non–HDL cholesterol were chosen on the basis of NHLBI pediatric
guidelines, pediatric low-density lipoprotein cholesterol thresholds for diagnosis of familial hypercholesterolemia phenotypes (+30 mg/dL), and current distributions
of non–HDL cholesterol to smooth transitions to adult point scales. The writing group recommends subtracting 20 points from the blood lipid score if the level of
non–HDL-cholesterol represents a treated value, given the residual risk present in those who require treatment. There may be a modest shift in point scores for this
metric as individuals age from pediatric to adult metrics. For additional notes on scoring in children, see Supplemental Material Appendix 2.
Blood glucose: Thresholds are based in part on American Diabetes Association guidelines.129b If an individual patient with prediabetes (ie, not yet diagnosed for-
mally with diabetes) is being treated with metformin to prevent the onset of diabetes and has normoglycemic levels, the writing group recommends clinician judgment
for assigning point values (ie, consider subtracting 20 points). The maximal point value for patients with well-controlled diabetes was set at 40, given the residual risk
present in those with diabetes. For additional notes on scoring in children, see Supplemental Material Appendix 2.
BP: Thresholds are based in part on the 2017 Hypertension Clinical Practice Guidelines and the guidelines for children.129c The writing group recommends sub-
tracting 20 points from the BP score if the level of BP represents a treated value, given the residual risk present in those who require treatment. For additional notes
on scoring in children, see Supplemental Material Appendix 2.
appropriate. We used a modified Delphi approach among health. Final point scores for each metric are displayed
the expert panel members to arrive at point score levels, in Table 1. The writing group acknowledges that these
informed by health outcomes and risk associations. We point scores are somewhat arbitrary, but we judge that
also examined US population distributions (from recent this approach is a substantial improvement to be able
NHANES) and resulting effects on the metric-specific to detect interindividual differences and population and
and overall CVH scores to arrive at the final point assign- individual changes in CVH over time. Further research
ments for each metric. The group also strove to ensure is warranted to understand all of the implications of the
that, across metrics, similar point value differences algorithm. The writing group judged that use of categori-
were associated with approximately similar impacts on cal descriptors (ideal, intermediate, poor) for each metric
was no longer desirable, electing instead for less pejo- and populations going forward. Large health information
CLINICAL STATEMENTS
rative and more supportive presentations of the entire exchanges such as the National Patient-Centered Clinical
AND GUIDELINES
spectrum of each metric, from lower to higher, to encour- Research Network140 offer comprehensive EHR registries
age intervention and change for improvement. that can be used to track individuals over time. As these
For overall CVH, the writing group continues to endorse a health information exchanges have evolved, many now
composite, aggregate score for measuring, monitoring, and include large swaths of the United States and compre-
assessing change in CVH. The new aggregate score is also hensively cover most major metropolitan areas, although
scaled from 0 to 100 points, calculated as the unweighted information on CVH in rural populations may still be limited.
average of all 8 component metric scores. Examples of Notably, EHRs include only individuals who seek care; they
CVH calculation for different scenarios are shown in the miss individuals who have difficulty accessing or paying for
Supplemental Material. The writing group recommends that care, particularly well care. EHRs have been shown to pro-
presentation of CVH score or status for individuals and vide reliable prevalence rates for some chronic conditions
populations should consider images or icons that reflect such as diabetes that require routine care, although their
the entire spectrum of CVH, including some indication of validity and reliability for other conditions such as obesity141
more and less desirable states (such as red/yellow/green are lower. Although EHR systems have great potential, at
coloration; example shown in Figure 3) across a range of present, they typically contain limited behavioral and life-
0 to 100. For some purposes, it may continue to be use- style information; thus, they may need dedicated work to
ful to consider categorical consideration of overall CVH; the generate systematic and standardized inputs that include
writing group recommends that overall CVH scores of 80 diet, PA, smoking, and sleep metrics of CVH and to struc-
to 100 be considered high CVH; 50 to 79, moderate CVH; ture these data in useful formats. The AHA can continue to
and 0 to 49 points, low CVH. New research is encouraged lead in this arena by identifying brief and valid methods of
in samples from diverse populations, across the life course, assessing these lifestyle constructs that can then be docu-
and in diverse settings to assess the implications of the mented within the medical records. Several are suggested
new scoring of the metrics and overall CVH. Further discus- in this document (Table 1). In addition, understanding and
sion of implementation considerations in various contexts tracking the fundamental roles of SDOH and psychologi-
is provided below (see Implementation of CVH in Clinical cal health in CVH through EHRs remain challenging but
Practice and Context and Opportunities for Improving CVH important (see Implementation of CVH in Clinical Practice
Going Forward sections). section).
Combining EHR data with lifestyle data collected
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gauge at the top corresponds to the individual’s overall CVH score (which can range from 0–100 points), with higher scores shown toward the
right (a “full tank” of CVH) in green. The individual’s status for each of the 8 component metrics is shown below, thus identifying health behaviors
and risk factors on which the individual can focus to achieve and maintain a full tank of overall CVH. The overall CVH score is the unweighted
average of the 8 component metric scores.
data may ultimately assist the AHA and policymakers Implementing the CVH Metric in Diverse
in providing insight into population CVH metrics. Other Populations and Settings and Leveraging
opportunities may arise through existing or new large-
scale crowd-sourcing efforts to monitor health (eg, Proj-
Health Technologies for Pragmatic Data
ect Baseline, Health eHeart). Collection and CVH Intervention
Most CVH metrics (body mass index, BP, cholesterol, fast-
IMPLEMENTATION OF CVH IN CLINICAL ing glucose/hemoglobin A1c, and smoking status) are cap-
tured as structured fields in the EHR. Health systems are
PRACTICE well positioned to leverage the EHR for population health
In addition to the social-ecological context for CVH pro- monitoring, risk prediction, and intervening on CVH in patient
motion (Figure 2), clinical implementation is crucial. With populations across the life course.146 Examples of CVH data
the proliferation of health technologies noted previously, visualization tools that have been integrated with the EHR
health systems, individuals, and families can participate in in learning health care systems include Stroke Prevention
the pragmatic collection of CVH data. In turn, the AHA or in Healthcare Delivery Environments and Priorities Wizard,
health systems need to provide platforms that assist in- among others.147 Clinicians have the opportunity to use these
dividual patients and their health care teams in assessing tools with patients at the point of care to raise awareness of
their CVH and tracking their progress over time through CVH and use shared decision-making approaches to help
online websites or apps. These same health technology patients preserve or achieve optimal CVH.148 For greater
platforms can serve to aggregate CVH data for popula- success, it is suggested that clinicians use motivational inter-
tion health monitoring and risk prediction or for interven- viewing strategies to help patients identify those metrics that
ing in CVH by motivating behavior change among diverse would benefit from improvement and for which the patient
populations.145 expresses some motivation for change and can envision the
means to do so. Better skills training for clinicians in these aimed at preserving and improving population-wide CVH
CLINICAL STATEMENTS
areas is critical for success. Likewise, it may be helpful to across the life course. Taken together, these interven-
AND GUIDELINES
have the patient focus on a single health behavior or health tions can serve as road maps for policymakers, health
factor at a time for improvement rather than trying to change systems, institutions, clinicians, researchers, and com-
too many things at once, which may risk the patient feeling munities for the future development and translation of
overwhelmed or experiencing a sense of failure. SDOH-informed, equitable solutions to ensure attain-
Universal efforts and tailored, culturally appropriate ment of CVH equity for diverse populations.
methods will be needed to direct individuals to resources
for improving or maintaining CVH, potentially ameliorat-
ing the negative impacts of SDOH and psychological Policies
health and promoting positive social and psychological Over the past decade, the AHA has partnered with
assets.143,149 Ubiquitous health technology can put impor- other volunteer science organizations on presidential
tant CVH information in the hands of traditionally under- advisories, clinical practice guidelines, and health policy
served populations. However, contextual factors (SDOH, statements focused on primordial, primary, and second-
access to health care and health technology, health liter- ary prevention and promotion of optimal CVH through-
acy, and psychological health) mediate individuals’ access out the life course. These efforts have also increased
to health technology and information and can affect their awareness about the SDOH and their driving influence
ability to maintain or achieve optimal CVH.145 The AHA and on CVH disparities and have provided recommenda-
other stakeholders will need to be mindful of these issues tions for addressing them.2,33,71,147,161,188–192 Although
in the design of data collection and intervention tools. interventions focused on the entire construct of CVH
are exceedingly rare, health policy statements have fo-
cused on several important structural, contextual, and
Communication of the New CVH Score With intergenerational factors that can promote overall opti-
Patients mal CVH (Table 2), including but not limited to access to
Clinical and general populations alike are accustomed to quality health care, healthy foods, and recreational fa-
hearing health status framed as risk (implying negative cilities for leisure-time PA.193 Ongoing advocacy efforts
or bad) for a given disease or condition. When the new at the federal, state, and community levels must con-
CVH, Life’s Essential 8, is implemented in diverse settings, tinue for improvement in population-wide CVH. Indeed,
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it should be presented in a positive manner through a lay- policy-level solutions are often the only ways to address
friendly format to ensure accurate interpretation, to indicate issues such as health care reform (for CVH monitor-
its strong associations with favorable health outcomes, and ing and intervention), transformation of PA and healthy
to provide motivation for behavior change as needed. In- meal programs in schools, regulation of tobacco/
deed, high CVH is a positive outcome in and of itself and nicotine products, and accessibility to a healthier food
can bring about immediate health benefits for an individual. supply.
Each assessment and reassessment serve as reinforce- The writing group particularly acknowledges the
ment of CVH metrics that have remained favorable with an emerging evidence on the critical importance of precon-
opportunity to arrest decline in others. Tools from the AHA ception maternal health, gestational health, pregnancy
and its partners for clear communication will be needed outcomes, and follow-up peripartum care to improve
so that it can be delivered by health care professionals, the health of women and children to launch succes-
EHRs, and health technologies and accompanied by sug- sively healthier generations.161,194,195 Further research
gested steps one can take to improve CVH and monitor and expanded programs are needed, including better
progress over time. Health care system and government metrics for monitoring progress in addressing dispari-
programs should also be designed to catalyze implementa- ties in maternal health outcomes. Likewise, a number of
tion of CVH improvement strategies in venues beyond the successful policies for promoting and sustaining better
clinic such as through evidence-based individual, family, or health from childhood through adolescence have been
group interventions. Newer strategies of patient self-man- developed, demonstrated, and supported by the AHA
agement also show promise for engaging and empowering and its partners.193 Future efforts are needed, given
patients to improve aspects of their CVH.150 the COVID-19 pandemic and its associated worsening
health inequities.
Ecological level Selected examples Examples of key gaps and needed directions
AND GUIDELINES
Policies
Federal FDA regulation of tobacco products Premarket approval of newer tobacco products154
Robust school nutrition standards and healthy school meals Regulating synthetic nicotine155
for all Removing all characterizing flavors from all tobacco prod-
Active transportation infrastructure investment ucts156
Ensuring affordable, equitable, adequate access to health Continued support for implementation and increasing sodium
insurance for all151 reduction, promotion of whole grains; developing an added
Public health infrastructure investment, data modernization, sugars standard
and surveillance systems upgrade152,153 Ensuring that federal appropriations flow effectively to the
state and local levels for biking, walking, and rolling, reaching
all people equitably, particularly those in the most underserved
and underinvested communities157
Preserving and building on the Affordable Care Act
Optimizing value-based insurance design158,159
Continued federal investment of the data modernization and
surveillance systems upgrade to ensure seamless integration
across all levels of government and health systems
Protecting and expanding the public health workforce
State Tobacco end game strategies (eg, comprehensive smoke-free air Effective coordination and engagement across public health,
laws, tobacco excise taxes, comprehensive coverage and access social justice, and equity partners
to tobacco cessation services, tobacco retail strategies, and re- Need for robust public and private investment in the tobacco
moving all characterizing flavors from all tobacco products)138 end game, overcoming industry product innovation, targeted
Medicaid expansion and Medicaid coverage of extended post- marketing, and positioning
partum coverage, self-measured BP, telehealth160–162 Housing, income, and transportation issues for the Medicaid
population
Ensuring that states can use all means at their disposal to off-
set costs of expansion163 and to increase access to services
Local Sugar-sweetened beverage taxes164,165 Combatting industry opposition and preemption efforts
Increasing access to early care and education166 Significant commitment to funding for advocacy campaigns
and ground softening efforts
State preemption of local efforts
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Health care systems (eg, AHA Get With The Guidelines Broader implementation
insurance/payers, hospitals, SPHERE176
practitioners)
Neighborhoods and communities
(Continued )
Table 2. Continued
CLINICAL STATEMENTS
Ecological level Selected examples Examples of key gaps and needed directions
AND GUIDELINES
Community-serving programs Strong Hearts, Healthy Communities intervention 177,178
Outreach to broader rural communities with geographic bar-
AHA SFRN-funded Hearts & Parks/Bull City Fit intervention179 riers to access
CDC Prevention Research Centers
Private community settings Faith-based interventions (FAITH trial, FAITH!) Evaluation of design elements sufficient for large-scale dis-
Barbershop interventions semination and implementation in community settings and
broad population health impact180
Expansion of rigorously tested CVH promotion interventions
to other community venues (eg, hair salons,181 community
centers) in partnership with civic organizations182 (eg, sorori-
ties, fraternities)
Neighborhood environments Green space, corner store interventions183,184 Development of methods to increase consumer demand and
to foster sustainability of corner store interventions in various
neighborhood/environmental contexts (eg, urban vs rural)185
Specific assessment of impacts of green space interventions
on health equity and potential adverse effects (eg, gentrifica-
tion and reduced access)186
Virtual communities Interactive, group social media interventions187 Culturally responsive interventions to promote CVH
Families and individuals
Parents/children AHA Simple Cooking With Heart for Kids
AHA/Aramark Health for Life nutrition education curriculum
INSIGHT intervention
STRIP intervention
Adults Health-partner intervention
Mobile technology for stroke prevention
AHA indicates American Heart Association; BP, blood pressure; CDC, Centers for Disease Control and Prevention; CVH, cardiovascular health; ENRICH, Early
Intervention to Promote Cardiovascular Health of Mothers and Children; FAITH, Faith-Based Approaches in the Treatment of Hypertension; FAITH!, Fostering African-
American Improvement in Total Health; FDA, US Food and Drug Administration; INSIGHT, Intervention Nurses Start Infants Growing on Healthy Trajectories; NFL, Na-
tional Football League; NHLBI, National Heart, Lung, and Blood Institute; NIOSH, National Institute for Occupational Safety and Health; PA, physical activity; SFRN,
Strategically-Focused Research Network; SPHERE, Stroke Prevention in Healthcare Delivery Environments; STRIP, Special Turku Coronary Risk Factor Intervention
Project; and WISEWOMAN, Well-Integrated Screening and Evaluation for Women Across the Nation.
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types of workplaces, including those most relevant to in- Of utmost importance are collaborative, equitable com-
dividuals who may be socioeconomically impacted, needs munity health needs assessments to allow a better under-
focused attention. standing of community priorities/needs, socioeconomic
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CLINICAL STATEMENTS
Enhanced definition and scoring and potentially different metrics for CVH DIRECTIONS
AND GUIDELINES
in pregnancy, at birth, and during the earliest years of life (especially <2 y
of age); enhanced data collection at individual and population levels during The extensive knowledge gained about the construct of
these life stages
CVH since 2010 provided the basis for the current update
Assessment of the new CVH scoring algorithm across the life course and and enhancement. Nonetheless, numerous knowledge
in diverse populations to understand its utility for describing individual and
population health, strengths and limitations, and trends in CVH over time gaps and research opportunities remain to ensure that the
Focused research to tie classification of existing metrics at the youngest
utility, implementation, and impact of CVH can be optimized.
ages based on guidelines (eg, PA) to meaningful outcomes, eg, CVH or In addition, there is now need for study of this new approach
BMI at older ages in childhood or subclinical CVD in midlife to measuring and monitoring CVH in diverse settings. Some
Investigation of novel measures or biomarkers to represent overall CVH at research gaps and proposed future directions identified by
young age
the writing group are presented in Table 3.
Development and validation of short, clinically feasible surveys for each age
group/developmental stage in children
Utility of new CVH score for predicting diverse health outcomes, including
total mortality, healthy longevity (compression of morbidity), cardiovascular
events, and other chronic disease outcomes, especially in younger people
CONCLUSIONS AND VISION FOR LIFE’S
Research driving to consensus on best tools for assessment of health be- ESSENTIAL 8
haviors in clinical settings
The formal definition of CVH in 2010 represented the
Greater routine and standardized assessment of diet, PA, nicotine exposure, culmination of decades of evolution in epidemiology,
and sleep health in clinical and population settings to facilitate CVH mea-
surement and monitoring public health, clinical care, and prevention concepts.
Greater routine and standardized assessment of psychological health and
Supported by the AHA, the rapid uptake of the CVH
well-being and SDOH, as well as their associations with CVH in clinical and concept by researchers, policymakers, funding agen-
population settings cies, communities, and, to a certain extent, patients
Discovery, demonstration, and dissemination of successful strategies (eg, and clinicians has provided a road map for reenergizing
policies, clinical strategies, community interventions, individual behavioral
changes) to preserve or improve overall CVH in individuals and in diverse
individual and population health promotion strategies
settings and populations and reducing the ongoing substantial burden of CVD
Research on other metrics of sleep related to CVH and interventions to im- and other chronic health conditions. The CVH construct
prove CVH through improved sleep health provided the means for positive, actionable steps that
could be taken to measure, monitor, and modify CVH
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Enhanced medical education and training to equip clinicians with the tools
to assess CVH, to implement motivational interviewing, to assist patients through primordial, primary, and secondary prevention
with behavioral change or maintenance, to promote wellness strategies, and
to avoid bias and stigma around adverse health behaviors and factors (eg, approaches. The knowledge gained over the past 12
nicotine exposure or obesity) years has reinforced the need for addressing limita-
Deployment of apps, online tools, and code for implementation of CVH tions and enhancing utility to advance this construct
scoring in consumer-facing, clinical, population, and research settings
even further. The goal is to unite efforts around improv-
Optimization of broad-based communication strategies to promote and ing a wide array of health outcomes and quality of life
preserve CVH and tailored communication strategies for diverse cultural
settings and demographic groups through a positively framed, responsive health construct
of CVH used consistently across the life course and in
Apps indicates applications; BMI, body mass index; CVD, cardiovascular
disease; CVH, cardiovascular health; PA, physical activity; and SDOH, social diverse settings. Greater insight into the foundational
determinants of health. aspects of SDOH and psychological health in which
CVH occurs will likely lead to further refinements of
CVH definitions in the future.
and socially. The transition to full responsibility for self The present document presents a substantial update of
comes with competing priorities for limited resources of and enhancement to the means for measuring and moni-
attention, often including parenthood, and appears to be toring CVH to address the current context of public health
a sensitive period for CVH loss.248 Contexts outside of and to assist the AHA and its partners in efforts to achieve
the young adult’s own health care such as college, work- greater health equity by promoting better CVH for all. The
place, community, and family-based/child health care new means for defining and measuring CVH, Life’s Essen-
settings gain importance. Middle age may offer new per- tial 8, in individuals and populations represents a major
spectives and changing roles that can be leveraged by step forward in our ability to intervene by promoting and
workplace, community, and health care contexts to con- reinforcing healthy metrics while averting decline of those
trol risk factors, improve CVH, and prevent CVD events. with potential for unfavorable trajectories. It should help
In older age, access to well-being supports through com- re-energize efforts to develop, test, and disseminate inter-
munities, neighborhoods, and health care systems can ventions to maintain or improve CVH at every stage across
help prevent frailty, promote active living, extend healthy the life course, in diverse settings, and for all people. Pri-
longevity, and improve quality of life through CVH promo- mordial prevention efforts focused on early life are likely
tion. to have particularly beneficial effects in initiating healthier
trajectories of lifelong CVH and creating healthier parents Disclosure Questionnaire showing all such relationships that might be perceived
as real or potential conflicts of interest.
CLINICAL STATEMENTS
of healthier babies in future generations. This advisory was approved by the American Heart Association Science Advisory
AND GUIDELINES
In business management, it is often said that “if you can- and Coordinating Committee on May 9, 2022, and the American Heart Associa-
not measure it, you cannot improve it.” With this enhanced tion Executive Committee on May 16, 2022. A copy of the document is available at
https://professional.heart.org/statements by using either “Search for Guidelines &
measurement tool for CVH, the AHA and its numerous Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-
multisector partners in schools, communities, government, 356-2721 or email [email protected].
health care, business, and beyond have new opportunities The American Heart Association requests that this document be cited as fol-
lows: Lloyd-Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE,
to catalyze CVH improvement by raising awareness of its Grandner MA, Lavretsky H, Perak AM, Sharma G, Rosamond W; on behalf of
importance, promoting platforms for its measurement, fund- the American Heart Association. Life’s essential 8: updating and enhancing the
ing research on interventions, and disseminating successful American Heart Association’s construct of cardiovascular health: a presidential
advisory from the American Heart Association. Circulation. 2022;146:e•••–e•••.
strategies. Capitalizing on these opportunities will be a criti- doi: 10.1161/CIR.0000000000001078
cal step toward ensuring that every person has the oppor- The expert peer review of AHA-commissioned documents (eg, scientific
tunity for optimal CVH and a full, healthy life. statements, clinical practice guidelines, systematic reviews) is conducted by the
AHA Office of Science Operations. For more on AHA statements and guidelines
development, visit https://professional.heart.org/statements. Select the “Guide-
lines & Statements” drop-down menu, then click “Publication Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or
ARTICLE INFORMATION
distribution of this document are not permitted without the express permission of
The American Heart Association makes every effort to avoid any actual or poten- the American Heart Association. Instructions for obtaining permission are located
tial conflicts of interest that may arise as a result of an outside relationship or a at https://www.heart.org/permissions. A link to the “Copyright Permissions Re-
personal, professional, or business interest of a member of the writing panel. Spe- quest Form” appears in the second paragraph (https://www.heart.org/en/about-
cifically, all members of the writing group are required to complete and submit a us/statements-and-policies/copyright-request-form).
Disclosures
Writing Group Disclosures
Speak-
Other ers’ Consultant/
Writing group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Donald M. Northwestern University None None None None None None None
Lloyd-Jones Feinberg School of Medicine
Norrina B. Allen Northwestern University NIH†; AHA† None None None None None None
Feinberg School of Medicine
Downloaded from http://ahajournals.org by on July 1, 2022
Cheryl A.M. UCSD None None None None None WW†; None
Anderson McCormick
Science
Foundation†
Terrie Black University of Massachusetts None None None None None None None
College of Nursing
LaPrincess C. Mayo Clinic College of AHA*; NIH*; CDC*; ACC* None None None None None ABC*;
Brewer Medicine ACC*; Am
J Prev
Card*;
J Am Med
Assoc*
Randi E. Foraker Washington University in St. NIH/NCI (1R01CA226078)† None None None None None None
Louis, School of Medicine
Michael A. University of Arizona Col- None None None None None None None
Grandner lege of Medicine
Helen Lavretsky UCLA NIH (PI)†; PCORI (PI)†; None None None None None None
NCCIH†
Amanda Marma Lurie Children’s Hospital NHLBI (K23 grant that exam- None None None None None None
Perak and Northwestern Uni- ines molecular mechanisms of
versity CVH in children)†; Northwest-
ern University (multiple small
pilot grants investigating CVH
in pregnant people and youth)†
Wayne University of North Carolina None None None None None None None
Rosamond Gillings School of Global
Public Health
Garima Sharma Johns Hopkins University None None None None None None None
School of Medicine
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclo-
sure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives
$5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or
owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
CLINICAL STATEMENTS
Other Speakers’ Consultant/
AND GUIDELINES
Research research bureau/ Expert Ownership advisory
Reviewer Employment grant support honoraria witness interest board Other
Donna K. Arnett University of Kentucky None None None None None None None
Robert H. Eckel University of Colorado Anschutz Medical None None None None None None None
Campus
Heather M. Christine E. Lynn Women’s Health & Well- NIH/NHLBI None None None None None None
Johnson ness Institute Charles E. Schmidt College (coinvesti-
of Medicine, Florida Atlantic University gator)*
Amit Khera UT Southwestern Medical Center None None None None None None None
Latha P. Stanford University NIH (K24 None None None None None None
Palaniappan Award)†
Linda V. Van Horn Northwestern University, Feinberg School NIH† None None None None None None
of Medicine
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during
any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or
more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
10. Fang N, Jiang M, Fan Y. Ideal cardiovascular health metrics and risk
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