Life's Simple 7 at Midlife and Risk of Recurrent Cardiovascular Disease and Mortality after Stroke: The ARIC study



      Stroke is a leading cause of morbidity and mortality among adults in the U.S. Ideal levels of the Life's Simple 7 (LS7) are associated with lower cardiovascular disease (CVD) and all-cause mortality. However, the association of LS7 with CVD, recurrent stroke, and all-cause mortality after incident stroke is unknown.


      We used data from the ARIC study, a cohort of 13,508 adults from four US communities, 45–64 years old at baseline (1987–1989). Cardiovascular hospitalizations and mortality were ascertained in follow-up through December 31st, 2017. We defined cardiovascular health (CVH) based on AHA definitions for LS7 (range 0-14) and categorized CVH into four levels: LS7 0-3, 4-6, 7-9, and ≥10 (ideal LS7), according to prior studies. Outcomes included incident stroke, CVD, recurrent stroke, all-cause mortality, and a composite outcome including all the above. Adjusted hazard ratios (95% CI) were estimated with Cox proportional hazards regression models.


      Median (25%-75%) follow-up for incident stroke was 28 (18.6-29.2) years. Participants with incident stroke were 55.7 (SD 5.6) years-old at baseline, 53% were women and 35% Black. Individuals with LS7 score ≥10 had 65% lower risk (HR: 0.35; 95% CI: 0.29-0.41) of incident stroke than those with LS7 4-6 (reference group). Of 1,218 participants with incident stroke, 41.2% (n=502) had composite CVD and 68.3% (n=832) died during a median (25%-75%) follow-up of 4.0 (0.76-9.95) years. Adjusted HR (95% CI) for stroke survivors with LS7≥10 at baseline were 0.74 (0.58-0.94) for the composite outcome, 0.38(0.17-0.85) for myocardial infarction, 0.60 (0.40-0.90) for heart failure, 0.63 (0.48-0.84) for all-cause mortality, and 0.65 (0.39-1.08) for recurrent stroke.


      Good and excellent midlife cardiovascular health are associated with lower risks of incident stroke and CVD after stroke. Clinicians should stress the importance of a healthy lifestyle for primary and secondary CVD prevention.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Virani SS
        • Alonso A
        • Benjamin EJ
        • et al.
        Heart disease and stroke statistics-2020 update: a report from the American Heart Association.
        Circulation. 2020; 141: e139-e596
        • Ovbiagele B
        • Goldstein LB
        • Higashida RT
        • et al.
        Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association.
        Stroke. 2013; 44: 2361-2375
      1. Feigin VL, Roth GA, Naghavi M, et al. Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol. 2016;15(9):913-924.: S1474-4422(16)30073-4 [pii].

      2. Huffman MD, Capewell S, Ning H, Shay CM, Ford ES, Lloyd-Jones DM. Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys. Circulation. 2012;125(21):2595-2602.oi:

      3. 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(12):e67-e492.

      4. 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(4):586-613.oi:

        • Bambs C
        • Kip KE
        • Dinga A
        • Mulukutla SR
        • Aiyer AN
        • Reis SE
        Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
        Circulation. 2011; 123: 850-857
        • Folsom AR
        • Yatsuya H
        • Nettleton JA
        • et al.
        Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
        J Am Coll Cardiol. 2011; 57: 1690-1696
        • Ford ES
        • Greenlund KJ
        • Hong Y
        Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States.
        Circulation. 2012; 125: 987-995
        • Yang Q
        • Cogswell ME
        • Flanders WD
        • et al.
        Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.
        JAMA. 2012; 307: 1273-1283
      5. Mok Y, Sang Y, Ballew SH, et al. American Heart Association's Life's Simple 7 at Middle Age and Prognosis After Myocardial Infarction in Later Life. J Am Heart Assoc. 2018;7(4):e007658 [pii].

      6. The Atherosclerosis Risk in Communities (ARIC) Study: Design and Objectives. The ARIC Investigators.
        Am J Epidemiol. 1989; 129: 687-702
        • Folsom AR
        • Yatsuya H
        • Nettleton JA
        • et al.
        Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
        J Am Coll Cardiol. 2011; 57: 1690-1696
      7. Ogunmoroti O, Oni E, Michos ED, et al. Life's Simple 7 and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc. 2017;6(6):e005180 [pii].

      8. Olson NC, Cushman M, Judd SE, et al. American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. J Am Heart Assoc. 2015;4(3):e001494:

      9. White AD, Folsom AR, Chambless LE, et al. Community surveillance of coronary heartisease in the Atherosclerosis Risk in Communities (ARIC) Study: methods and initial two years' experience. J Clin Epidemiol. 1996;49(2):223-233.: 0895435695000410 [pii].

        • Rosamond WD
        • Folsom AR
        • Chambless LE
        • et al.
        Stroke Incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk In Communities (ARIC) cohort.
        Stroke. 1999; 30: 736-743
        • Koton S
        • Schneider AL
        • Rosamond WD
        • et al.
        Stroke incidence and mortality trends in US communities, 1987 to 2011.
        JAMA. 2014; 312: 259-268
      10. Loehr LR, Rosamond WD, Chang PP, Folsom AR, Chambless LE. Heart failure Incidence and survival (from the Atherosclerosis Risk in Communities study). Am J Cardiol. 2008;101(7):1016-1022:

        • Gonzalez HM
        • Tarraf W
        • Rodriguez CJ
        • et al.
        Cardiovascular health among diverse Hispanics/Latinos: Hispanic Community Health Study/Study of Latinos (HCHS/SOL) results.
        Am Heart J. 2016; 176: 134-144
        • Kulshreshtha A
        • Vaccarino V
        • Judd SE
        • et al.
        Life’s Simple 7 and risk of incident stroke: the Reasons for Geographic and Racial Differences in stroke study.
        Stroke. 2013; 44: 1909-1914
      11. Ommerborn MJ, Blackshear CT, Hickson DA, et al. Ideal Cardiovascular Health and Incident Cardiovascular Events: The Jackson Heart Study. Am J Prev Med. 2016;51(4):502-506.

      12. Sacco RL, Kargman DE, Gu Q, Zamanillo MC. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke. 1995;26(1):14-20.

        • Sacco RL
        • Foulkes MA
        • Mohr JP
        • Wolf PA
        • Hier DB
        • Price TR
        Determinants of early recurrence of cerebral infarction. The Stroke Data Bank.
        Stroke. 1989; 20: 983-989
        • Shou J
        • Zhou L
        • Zhu S
        • Zhang X
        Diabetes as an Independent Risk Factor for Stroke Recurrence in Stroke Patients: A Meta-analysis.
        J Stroke Cerebrovasc Dis. 2015; 24: 1961-1968
      13. Boulanger M, Bejot Y, Rothwell PM, Touze E. Long-Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta-Analysis. J Am Heart Assoc. 2018;7(2):e007267 [pii].

      14. Deijle IA, Van Schaik SM, Van Wegen EE, Weinstein HC, Kwakkel G, Vanen Berg-Vos RM. Lifestyle Interventions to Prevent Cardiovascular Events After Stroke and Transient Ischemic Attack: Systematic Review and Meta-Analysis. Stroke. 2017;48(1):174-179:

      15. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236: