Association of Life’s Essential 8 and its components with adverse cardiovascular and kidney events in patients with atherosclerotic cardiovascular disease: a prospective cohort study

Background Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of global mortality. Despite advances in primary prevention and acute management, patients with established ASCVD face high residual risks for recurrent major adverse cardiovascular events (MACEs) and chronic kidney disease (CKD) progression. Life’s Essential 8 (LE8) metric has demonstrated inverse associations with cardiovascular outcomes in general populations and high-risk groups like diabetes or CKD patients. However, evidence on LE8 in secondary prevention for patients with ASCVD is limited, with no studies quantifying population attributable fractions (PAFs) for components or residual risks compared to non-ASCVD individuals. Purpose Patients with ASCVD have a high residual risk of recurrent MACEs and CKD progression. We evaluated the association of LE8 score and its eight components with MACEs and CKD in ASCVD patients, and determined whether optimal cardiovascular health can mitigate the excess risk compared to non-ASCVD patients. Methods This study included a large prospective cohort with ASCVD (n = 10,635, mean age 61.5 ± 6.2 years, 75.7% male). Participants were categorised into low, medium, and high cardiovascular health groups based on LE8 score categories. Cox proportional hazards models were used to evaluate the associations between these groups and study endpoints. PAFs were calculated to estimate the proportion of adverse events attributable to suboptimal levels of each LE8 component. Additionally, Cox models were applied to assess the effect of LE8 components control after matching participants with ASCVD to those without ASCVD (n = 17,878). Results Over a median follow-up of 12 years, 2,168 (20.4%) MACEs and 1,350 (12.7%) CKD events occurred. Compared with high cardiovascular health, the low group had about 133% higher risk for MACEs (hazard ratios (HRs) 2.33, 95% confidence interval (CI) 1.83–2.96, P < 0.001) and about 168% higher risk for CKD (HR 2.68, 95% CI 1.95–3.68, P < 0.001), respectively. The overall PAF for MACEs were associated with glucose control (13.7%, 95% CI 10%-17%, P < 0.001) and smoking (12.6%, 95% CI 7%-18%, P = 0.003); and glucose control (19.6%, 95% CI 15%-24%, P = 0.003), BMI (24.4%, 95% CI 11%-35%, P = 0.003) and smoking (13.9%, 95% CI 7%-20%, P = 0.003) for CKD. Compared with non-ASCVD individuals (n = 17,878), ASCVD patients in the highest LE8 score quartile can mitigate the risk of MACEs (HR 1.23, 95% CI 1.00–1.52, P = 0.055) and CKD risk (HR 1.16, 95% CI 0.88–1.53, P = 0.299). Conclusion Optimal Life’s Essential 8 cardiovascular health is associated with lower risk of MACEs and CKD progression in ASCVD patients, with smoking and glucose as primary modifiable drivers of residual risk for MACEs, and glucose, BMI and smoking for CKD. ASCVD patients who achieve optimal LE8 control may partially mitigate excess MACEs and CKD risk compared with matched non-ASCVD individuals.