Bye-Bye, ‘Life’s Simple 7’: AHA Redefines Cardiovascular Health by Adding Sleep

The American Heart Association (AHA) revised its checklist of what constitutes heart health after more than a decade promoting “Life’s Simple 7.”

The new “Life’s Essential 8” is scored on a 100-point scale and includes sleep health as a new component of cardiovascular health for individuals ages 2 years and up, said AHA President Donald Lloyd-Jones, MD, ScM, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues.

The AHA’s statement on “Life’s Essential 8” was published in Circulation and describes other changes from the previous checklist for cardiovascular health assessment, including:

• More generous scoring of diet for people who have DASH- and Mediterranean-style eating patterns
• An update to the nicotine exposure domain to include vaping and secondhand smoke
• New metrics favored for blood lipid and glucose assessment

Meanwhile, assessment of physical activity, BMI, and blood pressure remain unchanged from 2010’s “Life’s Simple 7” framework for defining and quantifying cardiovascular health.

“Life’s Essential 8” was designed to better capture differences between patients and changes in cardiovascular health over time. “The new metrics attempt to allow credit for a broader scope of health in each CVH [cardiovascular health] component,” the AHA writing group noted.

The eight domains are to be scored from 0 (least optimized) to 100 (most optimized) and averaged all together for an unweighted composite score. Overall scores below 50 indicate low cardiovascular health, scores of 50-79 indicate moderate cardiovascular health, and scores of 80 and above indicate high cardiovascular health.

By this scale, only about 20% of U.S. adults have high cardiovascular health, and over 60% have moderate cardiovascular health, based on an analysis of the National Health and Nutrition Examination Surveys (NHANES) from 2013-2018 by Lloyd-Jones and colleagues, who also reported on disparities in cardiovascular health by age, sex, and race.

In the new sleep domain, adults get full points for sleeping 7-9 hours daily, while children get full points when they are in the age-appropriate optimal range. However, the scientific basis for this continues to evolve.

“We still need to understand how we can best collect lifestyle data such as sleep and diet accurately and include it in our electronic health records [EHRs] to be able to track progress. Wearable technology can help but integrating it into [an] existing EHR is a struggle,” Neomi Shah, MD, a sleep medicine specialist at the Icahn School of Medicine at Mount Sinai in New York City, told MedPage Today.

“For example, we know that self-reported sleep is not always correlated with objective sleep duration and there may be false assurance that the sleep health score is in the optimal range, when epidemiological investigations that have quantified sleep duration consistently report nearly half of Americans do not get the required amount of sleep,” she noted.

“Although there is a paucity of evidence indicating that improving sleep duration or quality reduces CVD [cardiovascular disease] incidence, several other lines of evidence support its connection with CVH,” Lloyd-Jones and team maintained. “Research indicates that real-world manipulation of sleep time is possible and that therefore sleep time is modifiable.”

They pointed out that improving cardiovascular health at the population level will require more than individual change. Their roadmap illustrates the multilevel opportunities available through policy changes, for example, or by working directly with the food industry to change the food supply.

Robert Mentz, MD, heart failure section chief at Duke University Medical Center in Durham, North Carolina, said he welcomed the addition of sleep to “Life’s Essential 8” and highlighted the framework’s emphasis on psychological health and social determinants of health.

“This document truly represents the best of the current state of knowledge in the field and gives us a pathway and approach to improve the lives of individuals around the world,” he said.

For now, there is more work to be done on scoring cardiovascular health in pregnancy and early childhood. More research is also needed on how social determinants of health and psychological health factor into cardiovascular health, and how they may be measured for inclusion in future definitions, Lloyd-Jones suggested in an AHA press release.

“We also need to assess how [primary care providers] will track yet another metric in their already severely compromised and understaffed clinical practices. Physician well-being and ‘Life’s Essential 8’ [are] equally important,” Shah said.