Road to the American Heart Association 2020 Impact Goals

HomeCirculation: Cardiovascular ImagingVol. 11, No. 1Road to the American Heart Association 2020 Impact Goals Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBRoad to the American Heart Association 2020 Impact GoalsThe Metric for Monitoring Progress Joseph Yeboah, MD, MS Joseph YeboahJoseph Yeboah From the Heart and Vascular Center of Excellence, Wake Forest School of Medicine, Winston-Salem, NC. Originally published5 Jan 2018https://doi.org/10.1161/CIRCIMAGING.117.007385Circulation: Cardiovascular Imaging. 2018;11:e007385In 2010, the Goals and Metric Committee of the Strategic Planning Task Force of the American Heart Association (AHA) developed the 2020 Impact Goals for the organization.1 The 2020 Impact Goal was to improve the cardiovascular health (CVH) of all Americans by 20% and reduce deaths from cardiovascular diseases (CVDs) and stroke by 20% by the year 2020.1 The Committee introduced a 7-item semiquantitative metric/concept of CVH and recommended its use for monitoring the changing prevalence of CVH status and defining achievement of the 2020 Impact Goals.See Article by Hwang et alIdeal CVH was defined by the presence of both ideal health behaviors (nonsmoking, body mass index <25 kg/m2, physical activity at goal levels, and pursuit of a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol <200 mg/dL, untreated blood pressure <120/80 mm Hg, and fasting blood glucose <100 mg/dL).1 Several studies have shown associations between this semiquantitative metric of CVH and cardiovascular outcomes or mortality.2–4 However, there are limited data showing that a change in this semiquantitative measure is associated with an appropriate change in cardiovascular outcomes, especially in low-risk populations.Atherosclerosis is the underlying pathophysiology of most clinical cardiovascular outcomes.5 Atherosclerotic plaques can be calcified or noncalcified. Coronary artery calcium (CAC) score is a quantitative measure of calcified atherosclerotic plaque burden and has the strongest association and predictive value for future clinical cardiovascular outcomes and mortality among all measures of subclinical atherosclerosis.6,7 Thus, using CAC as an intermediate outcome may help forecast clinical CVD outcomes and may be very helpful in situations where clinical outcomes are relatively rare and take longer to accrue. Factors that influence the initiation and progression of coronary artery calcification are not entirely clear.8 Nonetheless, prior studies consistently show an association between CAC and future clinical CVD outcomes.6,7 Despite evidence linking CAC progression and clinical CVD outcomes,9–11 some have questioned the clinical significance and use of CAC progression.10,11In this issue of Circulation: Cardiovascular Imaging, Hwang et al12 used data from the ongoing Framingham Heart Study to show an association between unfavorable CVH profiles and CAC progression in a low-risk white sample (low risk defined as baseline CAC of 0). Further, they suggest that their study supports public health measures to prevent CVD by promoting favorable CVH profiles in persons free of clinical and subclinical CVD. Although the baseline AHA CVH metric1 and Atherosclerotic Cardiovascular Disease (ASCVD) risk (Pooled Cohort Equation)13 were significantly associated with CAC progression, the association between change in the AHA CVH metric and CAC progression only showed a trend toward significance. Even more surprising is the finding that a change in a quantitative measure of CVD risk13 in their population was not independently associated with CAC progression. The authors should be commended for their study and the significant contribution it will make to this area of CVD research. However, the use and clinical implications of this study lie in how much inference can be drawn from their results to support use of the AHA CVH metric as a monitoring tool for achieving the AHA 2020 impact goals.The 2010 AHA document1 clearly states that the semiquantitative metric seeks to monitor the changing prevalence of CVH status and define attainment of the 2020 impact goals. For those goals to be achievable, the semiquantitative CVH metric must accurately measure change in population CVD risk, and this change should be associated with a change in the clinical CVD outcomes outlined in their document.1 Because the present study used an intermediate outcome, CAC, the change in population CVD risk assessed using the AHA CVH metric should be associated with change in CAC or CAC progression. So does it mean change in the ASCVD risk/AHA CVH metric is not associated with CAC progression? And if so, then what are the implications of their finding on the usefulness of AHA CVH metric for monitoring the changing prevalence of CVH status as stipulated in the AHA 2020 document?To put the results of the study by Hwang et al12 in perspective, one has to understand the epidemiological variables they used. Accurate measurement of change in any epidemiological variable is a challenge and often leads to increased imprecision/noise compared with the original variable.14,15 To measure change, one has to measure the same variable at least twice and then accurately assess any differences. Because measurement of most epidemiological variables has inherent inaccuracies, calculating the difference of multiple measures further increases the noise or reduces the precision of the changed variable compared with the original variable. The imprecision is even greater when assessing the association between one measure of change (change in AHA CVH metric/ASCVD risk) and another (CAC progression), as in this study.12Hwang et al12 report that both analyses of change in population CVD risk, assessed either using the AHA CVH metric or ASCVD risk with CAC progression, showed a trend toward significance or were not statistically significant. It can be inferred from existing data that improvement in cardiovascular risk behaviors and factors reduces cardiovascular risk of a population.16 This reduced cardiovascular risk should manifest itself as more favorable subclinical measures of atherosclerosis and ultimately fewer clinical cardiovascular outcomes. Thus, the null association between changes in the semiquantitative CVH metric or the quantitative ASCVD risk and CAC progression may be because of measurement errors significantly increasing the imprecision of the 2 variables involved.In addition, unlike the measurement of CAC, calculation of change in CAC or CAC progression is not standardized. Thus, the results and inferences may have been different if CAC progression had been calculated using other proposed methods in the literature. Despite the concerns with the variables used in this study, the association between change in the semiquantitative CVH metric and CAC progression did show a trend toward significance. It is therefore conceivable that, in the absence of these concerns, a clear and strong association may exist between changes in the AHA CVH metric and CAC progression.However, as Hwang et al12 acknowledge, this study has limitations that reduce the applicability and generalizability of their findings to the US population. This study involved only whites at low risk of CVD defined as CAC=0. It is also not feasible, in a widely deployed epidemiological concept such as the 2020 Impact goals, to measure CAC to determine the CVD risk status of the segment of the US population that their findings are applicable. The study by Hwang et al,12 therefore, barely provides the necessary assurances that the AHA CVH metric is adequate for monitoring population CVH status with the ultimate aim of achieving the 2020 Impact Goals.An ideal generalizable study validating the usefulness of the semiquantitative AHA CVH metric should involve a population more similar to that of the nation as a whole and assess the association of a change in the AHA CVH metric with actual adjudicated clinical cardiovascular outcomes in all CVD risk groups. In the absence of clinical CVD outcomes, using a validated and a more standardized intermediate outcome would be reassuring. Because CAC is presently the most informative subclinical measure of atherosclerosis, standardizing the measurement of CAC progression would help produce more reproducible results. As we approach the year 2020, there should be no ambiguity about the use of the yardstick for monitoring progress toward the set goals. A problematic yardstick may take us to a different destination from what was anticipated.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Reprint requests to Joseph Yeboah, MD, MS, Heart and Vascular Center of Excellence, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail [email protected]References1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Rosamond WD; American Heart Association Strategic Planning Task Force and Statistics Committee. 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January 2018Vol 11, Issue 1 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.117.007385PMID: 29305353 Originally publishedJanuary 5, 2018 Keywordsprevalencerisk factorscardiovascular diseasesEditorialslife styleepidemiologyPDF download Advertisement SubjectsCardiovascular DiseaseEpidemiology