- Graham I.
- Atar D.
- Borch-Johnsen K.
- Boysen G.
- Burell G.
- Cifkova R.
- Dallongeville J.
- De Backer G.
- Ebrahim S.
- Gjelsvik B.
- Herrmann-Lingen C.
- Hoes A.
- Humphries S.
- Knapton M.
- Perk J.
- Priori S.G.
- Pyorala K.
- Reiner Z.
- Ruilope L.
- Sans-Menendez S.
- Op Reimer W.S.
- Weissberg P.
- Wood D.
- Yarnell J.
- Zamorano J.L.
- Walma E.
- Fitzgerald T.
- Cooney M.T.
- Dudina A.
- Vahanian A.
- Camm J.
- De Caterina R.
- Dean V.
- Dickstein K.
- Funck-Brentano C.
- Filippatos G.
- Hellemans I.
- Kristensen S.D.
- McGregor K.
- Sechtem U.
- Silber S.
- Tendera M.
- Widimsky P.
- Zamorano J.L.
- Altiner A.
- Bonora E.
- Durrington P.N.
- Fagard R.
- Giampaoli S.
- Hemingway H.
- Hakansson J.
- Kjeldsen S.E.
- Larsen M.L.
- Mancia G.
- Manolis A.J.
- Orth-Gomer K.
- Pedersen T.
- Rayner M.
- Ryden L.
- Sammut M.
- Schneiderman N.
- Stalenhoef A.F.
- Tokgozoglu L.
- Wiklund O.
- Zampelas A.
European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
- Smith Jr., S.C.
- Benjamin E.J.
- Bonow R.O.
- Braun L.T.
- Creager M.A.
- Franklin B.A.
- Gibbons R.J.
- Grundy S.M.
- Hiratzka L.F.
- Jones D.W.
- Lloyd-Jones D.M.
- Minissian M.
- Mosca L.
- Peterson E.D.
- Sacco R.L.
- Spertus J.
- Stein J.H.
- Taubert K.A.
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
- Leon A.S.
- Franklin B.A.
- Costa F.
- Balady G.J.
- Berra K.A.
- Stewart K.J.
- Thompson P.D.
- Williams M.A.
- Lauer M.S.
Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
- Arena R.
- Williams M.
- Forman D.E.
- Cahalin L.P.
- Coke L.
- Myers J.
- Hamm L.
- Kris-Etherton P.
- Humphrey R.
- Bittner V.
- Lavie C.J.
Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association.
- Graham I.
- Atar D.
- Borch-Johnsen K.
- Boysen G.
- Burell G.
- Cifkova R.
- Dallongeville J.
- De Backer G.
- Ebrahim S.
- Gjelsvik B.
- Herrmann-Lingen C.
- Hoes A.
- Humphries S.
- Knapton M.
- Perk J.
- Priori S.G.
- Pyorala K.
- Reiner Z.
- Ruilope L.
- Sans-Menendez S.
- Op Reimer W.S.
- Weissberg P.
- Wood D.
- Yarnell J.
- Zamorano J.L.
- Walma E.
- Fitzgerald T.
- Cooney M.T.
- Dudina A.
- Vahanian A.
- Camm J.
- De Caterina R.
- Dean V.
- Dickstein K.
- Funck-Brentano C.
- Filippatos G.
- Hellemans I.
- Kristensen S.D.
- McGregor K.
- Sechtem U.
- Silber S.
- Tendera M.
- Widimsky P.
- Zamorano J.L.
- Altiner A.
- Bonora E.
- Durrington P.N.
- Fagard R.
- Giampaoli S.
- Hemingway H.
- Hakansson J.
- Kjeldsen S.E.
- Larsen M.L.
- Mancia G.
- Manolis A.J.
- Orth-Gomer K.
- Pedersen T.
- Rayner M.
- Ryden L.
- Sammut M.
- Schneiderman N.
- Stalenhoef A.F.
- Tokgozoglu L.
- Wiklund O.
- Zampelas A.
European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
- Smith Jr., S.C.
- Benjamin E.J.
- Bonow R.O.
- Braun L.T.
- Creager M.A.
- Franklin B.A.
- Gibbons R.J.
- Grundy S.M.
- Hiratzka L.F.
- Jones D.W.
- Lloyd-Jones D.M.
- Minissian M.
- Mosca L.
- Peterson E.D.
- Sacco R.L.
- Spertus J.
- Stein J.H.
- Taubert K.A.
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
- Leon A.S.
- Franklin B.A.
- Costa F.
- Balady G.J.
- Berra K.A.
- Stewart K.J.
- Thompson P.D.
- Williams M.A.
- Lauer M.S.
Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
Methods
- Czernichow S.
- Kengne A.P.
- Stamatakis E.
- Hamer M.
- Batty G.D.
- Luepker R.V.
- Apple F.S.
- Christenson R.H.
- Crow R.S.
- Fortmann S.P.
- Goff D.
- Goldberg R.J.
- Hand M.M.
- Jaffe A.S.
- Julian D.G.
- Levy D.
- Manolio T.
- Mendis S.
- Mensah G.
- Pajak A.
- Prineas R.J.
- Reddy K.S.
- Roger V.L.
- Rosamond W.D.
- Shahar E.
- Sharrett A.R.
- Sorlie P.
- Tunstall-Pedoe H.
Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute.
- Safford M.M.
- Brown T.M.
- Muntner P.M.
- Durant R.W.
- Glasser S.
- Halanych J.H.
- Shikany J.M.
- Prineas R.J.
- Samdarshi T.
- Bittner V.A.
- Lewis C.E.
- Gamboa C.
- Cushman M.
- Howard V.
- Howard G.
- Investigators R.
Results
Participant characteristic | Number of Ideal Lifestyle Factors | |||
---|---|---|---|---|
0 (n = 240) | 1 (n = 1,383) | 2 (n = 1,452) | 3 – 4 (n = 1,100) | |
Percentage of sample | 5.7% | 33.1% | 34.8% | 26.4% |
Age (years) | 64.8 (0.5) | 67.2 (0.3) | 69.7 (0.3) | 70.4 (0.3) |
Female | 57.1% | 47.2% | 32.5% | 21.6% |
Black | 40.9% | 39.8% | 33.9% | 25.9% |
Less than a high school education | 25.1% | 20.0% | 17.0% | 12.5% |
Household Income <$20,000 | 37.3% | 28.8% | 20.2% | 12.7% |
Geographic Region | ||||
Stroke belt | 36.4% | 35.3% | 34.1% | 33.5% |
Stroke buckle | 18.9% | 21.5% | 22.2% | 20.4% |
Other region | 44.7% | 43.2% | 43.7% | 46.1% |
Diabetes mellitus | 46.9% | 45.4% | 33.2% | 23.9% |
Systolic blood pressure (mm Hg) | 130.9 (1.2) | 131.6 (0.5) | 129.5 (0.5) | 128.0 (0.6) |
Diastolic blood pressure (mm Hg) | 75.8 (0.6) | 76.1 (0.3) | 75.0 (0.3) | 74.0 (0.3) |
Low estimated GFR (<60 ml/min/1.73 m2) | 22.1% | 24.4% | 25.1% | 17.1% |
High albumin to creatinine ratio (≥30 mg/g) | 32.2% | 28.7% | 23.9% | 17.4% |
Aspirin Use | 74.6% | 74.4% | 75.0% | 82.6% |
Clopidogrel Use | 20.0% | 19.0% | 19.5% | 17.2% |
Statin Use | 58.2% | 62.3% | 65.7% | 68.6% |
Beta blocker use | 55.3% | 53.9% | 53.1% | 51.9% |
ACE inhibitor use | 44.4% | 39.9% | 40.1% | 36.8% |
Angiotensin receptor blocker use | 15.2% | 22.2% | 18.3% | 15.8% |
Abdominal obesity | 100.0% | 86.8% | 44.1% | 12.2% |
Serum LDL-cholesterol (mg/dL) | 103.5 (2.6) | 100.6 (1.0) | 98.7 (1.0) | 95.1 (1.1) |
C-reactive protein mg/L | 4.8 (4.7 – 4.9) | 3.3 (3.2 – 3.3) | 2.4 (2.4 – 2.4) | 1.6 (1.6 – 1.6) |
Individual lifestyle factors | Events/persons at risk | Incidence Rate (95% CI) | Hazard Ratio (95% CI) | |
---|---|---|---|---|
Crude (per 1,000 person-years) | Model 1 | Model 2 | ||
Abdominal obesity | ||||
Yes | 241/2,215 | 27.2 (23.7 – 30.6) | 1 (reference) | 1 (reference) |
No | 206/1,959 | 25.7 (22.2 – 29.2) | 0.88 (0.73 – 1.07) | 1.07 (0.87 – 1.31) |
p-value | - | - | 0.207 | 0.503 |
Physical Activity | ||||
None | 225/1,611 | 36.7 (31.8 – 41.5) | 1 (reference) | 1 (reference) |
1 – 3 times/week | 119/1,308 | 21.6 (17.7 – 25.6) | 0.59 (0.47 – 0.75) | 0.72 (0.57 – 0.90) |
4+ times/week | 104/1,255 | 19.7 (15.9 – 23.5) | 0.53 (0.42 – 0.68) | 0.69 (0.54 – 0.89) |
p-trend | - | - | <0.001 | 0.002 |
Mediterranean diet score | ||||
Quartile 1 (lowest - worse score) | 175/1,385 | 32.2 (26.8 – 37.6) | 1 (reference) | 1 (reference) |
Quartile 2 | 91/884 | 25.5 (19.2 – 37.8) | 0.79 (0.60 – 1.03) | 0.85 (0.65 – 1.12) |
Quartile 3 | 85/845 | 24.1 (18.1 – 30.2) | 0.73 (0.53 – 1.03) | 0.76 (0.54 – 1.07) |
Quartile 4 (highest - better score) | 96/1,060 | 21.9 (16.9 – 26.9) | 0.66 (0.48 – 0.90) | 0.77 (0.55 – 1.06) |
p-trend | - | - | 0.011 | 0.084 |
Current Smoker | ||||
Yes | 102/642 | 43.9 (35.4 – 52.4) | 1 (reference) | 1 (reference) |
No | 345/3,532 | 23.7 (21.2 – 26.2) | 0.47 (0.37 – 0.56) | 0.50 (0.39 – 0.64) |
p-value | - | - | <0.001 | <0.001 |
Individual lifestyle factors | Events/persons at risk | Incidence Rate (95% CI) | Hazard Ratio (95% CI) | |
---|---|---|---|---|
Crude (per 1,000 person-years) | Model 1 | Model 2 | ||
Abdominal obesity | ||||
Yes | 382/2,215 | 41.8 (37.6 – 46.0) | 1 (reference) | 1 (reference) |
No | 363/1,959 | 43.7 (39.2 – 48.2) | 0.93 (0.80 – 1.08) | 1.15 (0.98 – 1.35) |
p-value | - | - | 0.320 | 0.090 |
Physical Activity | ||||
None | 409/1,613 | 64.0 (57.8 – 70.2) | 1 (reference) | 1 (reference) |
1 – 3 times/week | 166/1,308 | 29.2 (24.7 – 33.7) | 0.48 (0.40 – 0.58) | 0.61 (0.50 – 0.73) |
4+ times/week | 171/1,254 | 31.7 (26.9 – 36.5) | 0.50 (0.42 – 0.61) | 0.71 (0.59 – 0.86) |
p-trend | - | - | <0.001 | <0.001 |
Mediterranean diet score | ||||
Quartile 1 (lowest - worse score) | 274/1,385 | 48.3 (42.3 – 54.3) | 1 (reference) | 1 (reference) |
Quartile 2 | 165/884 | 45.6 (37.8 – 53.4) | 0.92 (0.75 – 1.14) | 1.02 (0.82 – 1.27) |
Quartile 3 | 145/845 | 40.0 (32.0 – 48.0) | 0.78 (0.61 – 1.00) | 0.83 (0.63 – 1.08) |
Quartile 4 (highest - better score) | 161/1,060 | 35.6 (29.4 – 41.7) | 0.68 (0.55 – 0.86) | 0.84 (0.66 – 1.07) |
p-trend | - | - | <0.001 | 0.061 |
Current Smoker | ||||
Yes | 156/642 | 63.4 (53.4 – 73.3) | 1 (reference) | 1 (reference) |
No | 589/3,532 | 39.3 (36.1 – 42.5) | 0.46 (0.38 – 0.55) | 0.53 (0.44 – 0.65) |
p-value | - | - | <0.001 | <0.001 |


Number of ideal lifestyle factors | Events/persons at risk | Incidence Rate (95% CI) | Hazard Ratio (95% CI) | |
---|---|---|---|---|
Crude (per 1,000 person-years) | Model 1 | Model 2 | ||
0 | 71/422 | 46.2 (35.1 – 57.2) | 1 (reference) | 1 (reference) |
1 | 230/2,011 | 28.8 (24.8 – 32.7) | 0.56 (0.42 – 0.75) | 0.60 (0.44 – 0.81) |
2 | 124/1,386 | 21.2 (17.3 – 25.0) | 0.40 (0.30 – 0.55) | 0.49 (0.36 – 0.67) |
3 | 23/355 | 15.0 (7.7 – 22.2) | 0.28 (0.16 – 0.49) | 0.38 (0.21 – 0.67) |
p-trend | - | - | <0.001 | <0.001 |
Number of ideal lifestyle factors | Events/persons at risk | Incidence Rate (95% CI) | Hazard Ratio (95% CI) | |
---|---|---|---|---|
Crude (per 1,000 person-years) | Model 1 | Model 2 | ||
0 | 106/422 | 64.8 (52.0 – 77.6) | 1 (reference) | 1 (reference) |
1 | 392/2,011 | 47.4 (42.2 – 52.6) | 0.58 (0.46 – 0.73) | 0.65 (0.51 – 0.83) |
2 | 213/1,386 | 35.5 (29.9 – 41.1) | 0.42 (0.32 – 0.54) | 0.57 (0.43 – 0.74) |
3 | 35/355 | 22.3 (14.1 – 30.6) | 0.26 (0.17 – 0.41) | 0.41 (0.26 – 0.64) |
p-trend | - | - | <0.001 | <0.001 |
Discussion
- Graham I.
- Atar D.
- Borch-Johnsen K.
- Boysen G.
- Burell G.
- Cifkova R.
- Dallongeville J.
- De Backer G.
- Ebrahim S.
- Gjelsvik B.
- Herrmann-Lingen C.
- Hoes A.
- Humphries S.
- Knapton M.
- Perk J.
- Priori S.G.
- Pyorala K.
- Reiner Z.
- Ruilope L.
- Sans-Menendez S.
- Op Reimer W.S.
- Weissberg P.
- Wood D.
- Yarnell J.
- Zamorano J.L.
- Walma E.
- Fitzgerald T.
- Cooney M.T.
- Dudina A.
- Vahanian A.
- Camm J.
- De Caterina R.
- Dean V.
- Dickstein K.
- Funck-Brentano C.
- Filippatos G.
- Hellemans I.
- Kristensen S.D.
- McGregor K.
- Sechtem U.
- Silber S.
- Tendera M.
- Widimsky P.
- Zamorano J.L.
- Altiner A.
- Bonora E.
- Durrington P.N.
- Fagard R.
- Giampaoli S.
- Hemingway H.
- Hakansson J.
- Kjeldsen S.E.
- Larsen M.L.
- Mancia G.
- Manolis A.J.
- Orth-Gomer K.
- Pedersen T.
- Rayner M.
- Ryden L.
- Sammut M.
- Schneiderman N.
- Stalenhoef A.F.
- Tokgozoglu L.
- Wiklund O.
- Zampelas A.
European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
- Balady G.J.
- Ades P.A.
- Comoss P.
- Limacher M.
- Pina I.L.
- Southard D.
- Williams M.A.
- Bazzarre T.
- Smith Jr., S.C.
- Benjamin E.J.
- Bonow R.O.
- Braun L.T.
- Creager M.A.
- Franklin B.A.
- Gibbons R.J.
- Grundy S.M.
- Hiratzka L.F.
- Jones D.W.
- Lloyd-Jones D.M.
- Minissian M.
- Mosca L.
- Peterson E.D.
- Sacco R.L.
- Spertus J.
- Stein J.H.
- Taubert K.A.
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
- Go A.S.
- Mozaffarian D.
- Roger V.L.
- Benjamin E.J.
- Berry J.D.
- Borden W.B.
- Bravata D.M.
- Dai S.
- Ford E.S.
- Fox C.S.
- Franco S.
- Fullerton H.J.
- Gillespie C.
- Hailpern S.M.
- Heit J.A.
- Howard V.J.
- Huffman M.D.
- Kissela B.M.
- Kittner S.J.
- Lackland D.T.
- Lichtman J.H.
- Lisabeth L.D.
- Magid D.
- Marcus G.M.
- Marelli A.
- Matchar D.B.
- McGuire D.K.
- Mohler E.R.
- Moy C.S.
- Mussolino M.E.
- Nichol G.
- Paynter N.P.
- Schreiner P.J.
- Sorlie P.D.
- Stein J.
- Turan T.N.
- Virani S.S.
- Wong N.D.
- Woo D.
- Turner M.B.
Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
- Perk J.
- De Backer G.
- Gohlke H.
- Graham I.
- Reiner Z.
- Verschuren M.
- Albus C.
- Benlian P.
- Boysen G.
- Cifkova R.
- Deaton C.
- Ebrahim S.
- Fisher M.
- Germano G.
- Hobbs R.
- Hoes A.
- Karadeniz S.
- Mezzani A.
- Prescott E.
- Ryden L.
- Scherer M.
- Syvanne M.
- Scholte op Reimer W.J.
- Vrints C.
- Wood D.
- Zamorano J.L.
- Zannad F.
European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).
- Estruch R.
- Ros E.
- Salas-Salvado J.
- Covas M.I.
- Corella D.
- Aros F.
- Gomez-Gracia E.
- Ruiz-Gutierrez V.
- Fiol M.
- Lapetra J.
- Lamuela-Raventos R.M.
- Serra-Majem L.
- Pinto X.
- Basora J.
- Munoz M.A.
- Sorli J.V.
- Martinez J.A.
- Martinez-Gonzalez M.A.
- Investigators P.S.
- Klein S.
- Burke L.E.
- Bray G.A.
- Blair S.
- Allison D.B.
- Pi-Sunyer X.
- Hong Y.
- Eckel R.H.
Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
- Smith Jr., S.C.
- Benjamin E.J.
- Bonow R.O.
- Braun L.T.
- Creager M.A.
- Franklin B.A.
- Gibbons R.J.
- Grundy S.M.
- Hiratzka L.F.
- Jones D.W.
- Lloyd-Jones D.M.
- Minissian M.
- Mosca L.
- Peterson E.D.
- Sacco R.L.
- Spertus J.
- Stein J.H.
- Taubert K.A.
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
- Go A.S.
- Mozaffarian D.
- Roger V.L.
- Benjamin E.J.
- Berry J.D.
- Borden W.B.
- Bravata D.M.
- Dai S.
- Ford E.S.
- Fox C.S.
- Franco S.
- Fullerton H.J.
- Gillespie C.
- Hailpern S.M.
- Heit J.A.
- Howard V.J.
- Huffman M.D.
- Kissela B.M.
- Kittner S.J.
- Lackland D.T.
- Lichtman J.H.
- Lisabeth L.D.
- Magid D.
- Marcus G.M.
- Marelli A.
- Matchar D.B.
- McGuire D.K.
- Mohler E.R.
- Moy C.S.
- Mussolino M.E.
- Nichol G.
- Paynter N.P.
- Schreiner P.J.
- Sorlie P.D.
- Stein J.
- Turan T.N.
- Virani S.S.
- Wong N.D.
- Woo D.
- Turner M.B.
Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
- Balady G.J.
- Ades P.A.
- Comoss P.
- Limacher M.
- Pina I.L.
- Southard D.
- Williams M.A.
- Bazzarre T.
- Mihaylova B.
- Emberson J.
- Blackwell L.
- Keech A.
- Simes J.
- Barnes E.H.
- Voysey M.
- Gray A.
- Collins R.
- Baigent C.
The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials.
Acknowledgment
Disclosures
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This research project is supported by a cooperative agreement U01 NS041588 from the National Institute of Neurological Disorders and Stroke and grants R01 HL080477 and K24 HL111154 from the National Heart, Lung, and Blood Institute; National Institutes of Health, Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Neurological Disorders and Stroke; the National Heart, Lung, and Blood Institute; or the National Institutes of Health. Representatives of the funding agency have been involved in the review of the manuscript but not directly involved in the collection, management, analysis, or interpretation of the data. A full list of participating REGARDS investigators and institutions can be found at http://www.regardsstudy.org.
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