Adding a psychological health metric to Life’s Essential 8 improves the heart health construct for predicting mortality risk

A cardiovascular health construct based on the American Heart Association’s Life’s Essential 8, but enhanced with a ninth psychological health metric, strongly predicts total and cardiovascular mortality, according to a new study from Columbia University’s Mailman School of Public Health. The findings are published in JACC: Progress.

“Psychological health is multidimensional and includes positive mental states such as optimism and a sense of purpose, which are linked to better heart health, as well as depression, which is linked to a higher risk of cardiovascular disease. Although psychological health is fundamental to maintaining cardiovascular health, it is not currently included as a measure of cardiovascular health in the Life’s Essential 8,” said Nour Makarem, Ph.D., assistant professor of Epidemiology at Columbia Mailman School and lead author of the study.

A 2022 study led by Makarem had shown that updating the original cardiovascular health construct “Life’s Simple 7” to “Life’s Essential 8” by adding an eighth sleep health metric improves the prediction of cardiovascular disease outcomes, and was cited in the AHA’s Presidential Advisory on Life’s Essential 8. Building on this work, she and her colleagues have now conducted the first study to evaluate whether including a ninth metric for psychological health would improve the Life’s Essential 8 score for predicting mortality outcomes relative to the original eight metrics. This study was led by Mailman School of Public Health alumna Vanessa Dinh, MPH.

In a sample of more than 20,000 U.S. adults with an average age of 48, the research team examined the association between a new cardiovascular health score consisting of the Life’s Essential 8 (diet, sleep health, physical activity, nicotine use, BMI, blood glucose, blood lipids and blood pressure) plus a measure of psychological health and well-being.

The study found that a high versus low cardiovascular health score, augmented by a psychological health metric based on achievable depression screening, was associated with up to a 70% and 77% lower risk of total and cardiovascular mortality, respectively. These associations with mortality were stronger than those observed for the Life’s Essential 8 score, which was associated with a 65% and 68% lower risk of total and cardiovascular mortality.

A dose-response relationship was observed, suggesting that substantial gains in longevity may be achievable with improvements in cardiovascular health, including aspects of psychological health, Makarem said. Overall, the cardiovascular health score, enhanced with a psychological health metric, demonstrated excellent performance in predicting mortality outcomes compared with the Life’s Essential 8 score.

“We found that even a simple two-question screening on the frequency of depressive symptoms can improve the cardiovascular health construct and may serve as a feasible measure of psychological health in clinical or public health settings where comprehensive assessments are not possible,” Makarem said.

A higher cardiovascular health score, reinforced by the psychological health measure, was associated with a lower risk of death in both sexes and in black and white adults, but not in Hispanic adults. Associations of the improved cardiovascular health score with mortality were stronger than those observed for the Life’s Essential 8 score, particularly among black and female populations. Notably, the strongest associations were observed among black adults, such that a high versus low improved cardiovascular health score was associated with a more than twofold lower risk of death.

“Indeed, a notable increase in the strength of the associations between cardiovascular health and mortality among black adults was observed when the cardiovascular health score was updated to include a measure of psychological health,” Makarem said.

“For example, our finding that a new enhanced cardiovascular health score that includes a ninth metric for psychological health strongly predicts mortality outcomes in US adults supports a future update of the guidelines from ‘Life’s Essential 8’ to ‘Life’s Necessary 9.’ Screening for depression and addressing psychological health and well-being could have far-reaching effects on promoting cardiovascular health equity and reducing mortality outcomes at the population level,” Makarem said.

The authors acknowledge that more research is needed to unravel the relationship between cardiovascular health scores, using more comprehensive definitions of psychological health and well-being on the one hand, and chronic disease and mortality on the other.

“A psychological health construct that encompasses aspects of psychological well-being, such as gratitude, optimism, mindfulness, and symptoms of depression, anxiety, and stress, may better capture the complexity of mental health and its role in shaping cardiovascular health,” Makarem notes. “Future studies should test a more comprehensive psychological health construct that is also pragmatic and easily captured, particularly during an annual clinician visit.”

The study is accompanied by commentary from a team of scientists from Johns Hopkins University School of Medicine and Albert Einstein College of Medicine/Jacobi Medical Center, highlighting the novelty and clinical implications of the study’s findings.

Co-authors are Vanessa T. Dinh, Rahul Hosalli, Columbia Mailman School of Public Health; Brooke Aggarwal, Columbia Irving Medical Center; Pricila H. Mullachery, Temple University College of Public Health; and Charles A. German, University of Chicago Pritzker School of Medicine.