Health Factors Associated with Cardiovascular Wellness

  • Mahmoud Al Rifai
  • Miguel Cainzos-Achirica
  • Michael J. Blaha
  • Kelly Arps
  • David A. Wood
  • Roger S. Blumenthal
  • John W. McEvoyEmail author
Evidence-Based Medicine, Clinical Trials and Their Interpretations (L. Roever, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Evidence-Based Medicine, Clinical Trials and Their Interpretations


Purpose of Review

In this review, we discuss a new paradigm for atherosclerotic cardiovascular disease (ASCVD) prevention that is focused on cultivating cardiovascular wellness through the promotion of “health factors.”

Recent Findings

Cardiovascular prevention efforts have contributed to falling rates of ASCVD over the past five decades. However, contemporary increases in obesity and diabetes have led to a recent slowing in the annual decline of ASCVD death rates. This slowing represents an opportunity for new thinking to change the current ASCVD prevention paradigm, i.e., the identification and treatment or control of risk factors for disease. Indeed, a new paradigm focusing on cultivating cardiovascular wellness in addition to preventing disease is gaining increased traction. With this approach, the goal of ASCVD prevention is shifting to include consideration of both treating “risk factors” and cultivating health factors. Importantly, cardiovascular wellness is more than just the absence of disease and, therefore, risk factors and health factors are not always mere opposites.


We review healthy lifestyle tools such as the American Heart Association Life’s simple 7 and Fuster-BEWAT score. We summarize landmark studies of interventions aimed at improving adherence to health factors. We highlight the inherent limitations of current studies to adequately examine cardiovascular wellness. We propose new study designs that are required to identify novel health factors and measures of wellness. We conclude with recommendations regarding the utility of health factors and cardiovascular wellness in current practice.


Wellness Cardiovascular health Health factors Cardiovascular disease prevention 


Compliance with Ethical Standards

Conflict of Interest

Mahmoud Al Rifai, Miguel Cainzos-Achirica, Michael J. Blaha, Kelly Arps, David A. Wood, Roger S. Blumenthal, and John W. McEvoy declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–492.CrossRefGoogle Scholar
  2. 2.
    Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med. 2007;356:2388–98.CrossRefGoogle Scholar
  3. 3.
    Capewell S, Morrison CE, McMurray JJ. Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart. 1999;81:380–6.CrossRefGoogle Scholar
  4. 4.
    Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J. Factors of risk in the development of coronary heart disease—six year follow-up experience The Framingham Study. Ann Intern Med. 1961;55:33–50.CrossRefGoogle Scholar
  5. 5.
    Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002. J Am Coll Cardiol. 2007;50:2128–32.CrossRefGoogle Scholar
  6. 6.
    Sidney S, Quesenberry CP, Jaffe MG, et al. Recent trends in cardiovascular mortality in the United States and public health goals. JAMA Cardiol. 2016;1:594–9.CrossRefGoogle Scholar
  7. 7.
    Lawler PR, Akinkuolie AO, Harada P, et al. Residual risk of atherosclerotic cardiovascular events in relation to reductions in very-low-density lipoproteins. J Am Heart Assoc. 2017;6:e007402.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Sampson UK, Fazio S, Linton MF. Residual cardiovascular risk despite optimal LDL cholesterol reduction with statins: the evidence, etiology, and therapeutic challenges. Curr Atheroscler Rep. 2012;14:1–10.CrossRefGoogle Scholar
  9. 9.
    • Al Rifai M, Greenland P, Blaha MJ, et al. Factors of health in the protection against death and cardiovascular disease among adults with subclinical atherosclerosis. Am Heart J. 2018;198:180–8. An important study examining the association of novel health factors and delayed onset of cardiovascular diseaese among adults with advanced subclinical atherosclerosis. CrossRefPubMedGoogle Scholar
  10. 10.
    •• Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121:586–613 One of the earliest concerted efforts by a national organization to address health factors for cardiovascular disease prevention and promotion of cardiovascular health. CrossRefGoogle Scholar
  11. 11.
    Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. J Am Coll Cardiol. 2018.
  12. 12.
    Blumenthal RS, Ambinder DI, McEvoy JW. Cardiovascular health Simplified. J Am Coll Cardiol. 2017;70:2474–5.CrossRefGoogle Scholar
  13. 13.
    Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;129:S76–99.CrossRefGoogle Scholar
  14. 14.
    Daviglus ML, Liu K, Greenland P, Dyer AR, Garside DB, Manheim L, et al. Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs. N Engl J Med. 1998;339:1122–9.CrossRefGoogle Scholar
  15. 15.
    Daviglus ML, Liu K, Pirzada A, Yan LL, Garside DB, Feinglass J, et al. Favorable cardiovascular risk profile in middle age and health-related quality of life in older age. Arch Intern Med. 2003;163:2460–8.CrossRefGoogle Scholar
  16. 16.
    Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343:16–22.CrossRefGoogle Scholar
  17. 17.
    Terry DF, Pencina MJ, Vasan RS, Murabito JM, Wolf PA, Hayes MK, et al. Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham heart study participants. J Am Geriatr Soc. 2005;53:1944–50.CrossRefGoogle Scholar
  18. 18.
    Hozawa A, Folsom AR, Sharrett AR, Chambless LE. Absolute and attributable risks of cardiovascular disease incidence in relation to optimal and borderline risk factors: comparison of African American with white subjects—atherosclerosis risk in communities study. Arch Intern Med. 2007;167:573–9.CrossRefGoogle Scholar
  19. 19.
    Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation. 2006;114:160–7.CrossRefGoogle Scholar
  20. 20.
    Åkesson A, Weismayer C, Newby PK, Wolk A. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med. 2007;167:2122–7.CrossRefGoogle Scholar
  21. 21.
    Vita AJ, Terry RB, Hubert HB, Fries JF. Aging, health risks, and cumulative disability. N Engl J Med. 1998;338:1035–41.CrossRefGoogle Scholar
  22. 22.
    Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, Beiser A, Wilson PWF, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006;113:791–8.CrossRefGoogle Scholar
  23. 23.
    Stamler J, Stamler R, Neaton JD, Wentworth D, Daviglus ML, Garside D, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999;282:2012–8.CrossRefGoogle Scholar
  24. 24.
    Fernández-Alvira JM, Fuster V, Pocock S, Sanz J, Fernández-Friera L, Laclaustra M, et al. Predicting subclinical atherosclerosis in low-risk individuals. J Am Coll Cardiol. 2017;70:2463–73.CrossRefGoogle Scholar
  25. 25.
    Ahmed HM, Blaha MJ, Nasir K, Jones SR, Rivera JJ, Agatston A, et al. Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: results from MESA. Am J Epidemiol. 2013;178:12–21.CrossRefGoogle Scholar
  26. 26.
    Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med. 2008;358:1336–45.CrossRefGoogle Scholar
  27. 27.
    Allen NB, Zhao L, Liu L, Daviglus M, Liu K, Fries J, et al. Favorable cardiovascular health, compression of morbidity, and healthcare costs: forty-year follow-up of the CHA study (Chicago heart association detection project in industry). Circulation. 2017;135:1693–701.CrossRefGoogle Scholar
  28. 28.
    Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2935–59.CrossRefGoogle Scholar
  29. 29.
    Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;129:S1–45.CrossRefGoogle Scholar
  30. 30.
    Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for americans. JAMA. 2018;320(19):2020–8. published online Nov 12. Scholar
  31. 31.
    •• Wood DA, Kotseva K, Connolly S, et al. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlle. Lancet (London, England). 2008;371:1999–2012 An important randomized controlled study showing the efficacy of a multidisciplanary cardiovascular disease prevention program aimed at promoting health factors. CrossRefGoogle Scholar
  32. 32.
    Jennings C, Kotseva K, De Bacquer D, et al. Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial. Eur Heart J. 2014;35:1411–20.CrossRefGoogle Scholar
  33. 33.
    Connolly SB, Kotseva K, Jennings C, et al. Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme. Heart. 2017;103:840 LP–847.CrossRefGoogle Scholar
  34. 34.
    Gibson I, Flaherty G, Cormican S, et al. Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland. Eur J Prev Cardiol. 2013;21:366–76.CrossRefGoogle Scholar
  35. 35.
    Gómez-Pardo E, Fernández-Alvira JM, Vilanova M, Haro D, Martínez R, Carvajal I, et al. A comprehensive lifestyle peer group–based intervention on cardiovascular risk factors. J Am Coll Cardiol. 2016;67:476–85.CrossRefGoogle Scholar
  36. 36.
    Schoenthaler AM, Lancaster KJ, Chaplin W, Butler M, Forsyth J, Ogedegbe G. Cluster randomized clinical trial of FAITH (FAITH-based approaches in the treatment of hypertension) in blacks. Circ Cardiovasc Qual Outcomes. 2018;11:e004691.CrossRefGoogle Scholar
  37. 37.
    Aneni EC, Roberson LL, Maziak W, Agatston AS, Feldman T, Rouseff M, et al. A systematic review of internet-based worksite wellness approaches for cardiovascular disease risk management: outcomes, challenges & opportunities. PLoS One. 2014;9:e83594.CrossRefGoogle Scholar
  38. 38.
    Feldman DI, Theodore Robison W, Pacor JM, Caddell LC, Feldman EB, Deitz RL, et al. Harnessing mHealth technologies to increase physical activity and prevent cardiovascular disease. Clin Cardiol. 2018;41:985–91.CrossRefGoogle Scholar
  39. 39.
    Martin SS, Feldman DI, Blumenthal RS, Jones SR, Post WS, McKibben RA, et al. mActive: a randomized clinical trial of an automated mHealth intervention for physical activity promotion. J Am Heart Assoc. 2015;4:e002239. Scholar
  40. 40.
    Shameer K, Johnson KW, Glicksberg BS, Dudley JT, Sengupta PP. Machine learning in cardiovascular medicine: are we there yet? Heart. 2018;104:1156–64.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Mahmoud Al Rifai
    • 1
    • 2
  • Miguel Cainzos-Achirica
    • 2
    • 3
  • Michael J. Blaha
    • 2
  • Kelly Arps
    • 2
  • David A. Wood
    • 4
    • 5
    • 6
  • Roger S. Blumenthal
    • 2
  • John W. McEvoy
    • 2
    • 5
    • 6
    Email author
  1. 1.Department of Internal MedicineUniversity of Kansas School of MedicineWichitaUSA
  2. 2.Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of CardiologyJohns Hopkins Medical InstitutionsBaltimoreUSA
  3. 3.Bellvitge University Hospital and Bellvitge Biomedical Research Institute (IDIBELL)L’Hospitalet de LlobregatBarcelonaSpain
  4. 4.Department of Cardiovascular Medicine, National Heart and Lung InstituteImperial College LondonLondonUK
  5. 5.National University of IrelandGalwayIreland
  6. 6.National Institute for Preventive Cardiology; and Saolta University Healthcare GroupUniversity College Hospital GalwayGalwayIreland

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