Association of modified cardiovascular health with long-term all-cause mortality among adults with Ankle-Brachial Index-defined peripheral artery disease: a NHANES 1999-2004 cohort study

BACKGROUND: Whether an integrated cardiovascular health profile is associated with long-term mortality among adults with objectively defined peripheral artery disease (PAD) remains insufficiently characterized in nationally representative cohorts. METHODS: We analyzed National Health and Nutrition Examination Survey (NHANES) 1999-2004 participants aged ≥40 years with Ankle-Brachial Index (ABI) measurements and linked mortality follow-up through December 31, 2019. PAD was defined as a minimum ABI ≤0.90. Modified cardiovascular health (mCVH; range 0-12) was constructed from smoking, Body Mass Index, physical activity, blood pressure, total cholesterol, and glycemic status. Corrected six-year Mobile Examination Center weights and complex survey design variables were used. Weighted Cox models estimated hazard ratios (HRs) for all-cause mortality using sequential adjustment for demographic factors, socioeconomic factors, survey cycle, and minimum ABI. Additional analyses evaluated non-PAD participants and cardiovascular mortality. RESULTS: The primary PAD cohort included 554 adults, among whom 428 deaths occurred during a median follow-up of 123.5 months. PAD participants had a higher absolute all-cause mortality burden than non-PAD participants. Each 1-point higher mCVH score was associated with lower all-cause mortality in Model 1 (HR 0.888, 95% CI 0.842-0.937; P<0.001), Model 2 (HR 0.922, 95% CI 0.870-0.977; P=0.006), and Model 3 (HR 0.926, 95% CI 0.874-0.982; P=0.010). Among non-PAD participants, higher mCVH was also associated with lower all-cause mortality, and the mCVH × PAD status interaction was not statistically significant (P=0.122). In sensitivity analysis, higher mCVH was also associated with lower cardiovascular mortality (HR 0.863, 95% CI 0.786-0.948; P=0.002). Component-level analyses suggested that smoking was the most robust individual component. CONCLUSIONS: Among U.S. adults with ABI-defined PAD, higher baseline mCVH was associated with lower long-term all-cause mortality. These findings support the prognostic relevance of integrated cardiovascular health profiling after objective PAD identification, while highlighting smoking as the most consistent individual component.