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Original Investigation
March 11, 2020

Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis

Author Affiliations
  • 1Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Department of Medicine, University of Turku, Turku, Finland
  • 3Division of Medicine, Turku University Hospital, Turku, Finland
  • 4Murdoch Children’s Research Institute, Parkville, Victoria, Australia
  • 5Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center–Tampere, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
  • 6Department of Epidemiology, UtahHealth School of Public Health, Houston, Texas
  • 7Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
  • 8Division of Biostatistics, Washington University of Medicine in St Louis, St Louis, Missouri
  • 9Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
  • 10Paavo Nurmi Centre, Sports & Exercise Medicine Unit, Department of Health and Physical Activity, University of Turku, Turku, Finland
  • 11Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
JAMA Cardiol. 2020;5(5):557-566. doi:10.1001/jamacardio.2020.0140
Key Points

Question  Is there an association between long-term patterns in cardiovascular health starting in childhood and subclinical atherosclerosis in middle age?

Findings  In this cohort study of 9388 individuals, a significant number of children were classified as having an intermediate cardiovascular health score by 8 years of age. Many of these children experienced more rapid declines in cardiovascular health, had greater carotid intima-media thickness, and were more likely to have high carotid intima-media thickness by middle age.

Meaning  Increasing the proportion of children who reach adulthood in ideal cardiovascular health may be associated with reduced burden of cardiovascular disease at later age.


Importance  Cross-sectional measures of cardiovascular health (CVH) have been associated with cardiovascular disease in older age, but little is known about longitudinal trajectories in CVH and their association with subclinical atherosclerosis in middle age.

Objectives  To model long-term patterns in CVH starting in childhood and to assess their association with subclinical atherosclerosis in middle age.

Design, Setting, and Participants  This cohort study used data from 5 prospective cardiovascular cohort studies from the United States and Finland from 1973 to 2015. A total of 9388 participants aged 8 to 55 years had at least 3 examinations and were eligible for this study. Statistical analysis was performed from December 1, 2015, to June 1, 2019.

Exposures  Clinical CVH factors (body mass index, total cholesterol level, blood pressure, and glucose level) were classified as ideal, intermediate, or poor, and were summed as a clinical CVH score. Group-based latent class modeling identified trajectories in this score over time.

Main Outcomes and Measures  Carotid intima-media thickness (cIMT) was measured for participants in 3 cohorts, and high cIMT was defined as a value at or above the 90th percentile. The association between CVH trajectory and cIMT was modeled using both linear and logistic regression adjusted for demographics, baseline health behaviors, and baseline (or proximal) CVH score.

Results  Among 9388 participants (5146 [55%] female; 6228 [66%] white; baseline mean [SD] age, 17.5 [7.5] years), 5 distinct trajectory groups were identified: high-late decline (1518 participants [16%]), high-moderate decline (2403 [26%]), high-early decline (3066 [32%]), intermediate-late decline (1475 [16%]), and intermediate-early decline (926 [10%]). The high-late decline group had significantly lower adjusted cIMT vs other trajectory groups (high-late decline: 0.64 mm [95% CI, 0.63-0.65 mm] vs intermediate-early decline: 0.72 mm [95% CI, 0.69-0.75 mm] when adjusted for demographics and baseline smoking, diet, and physical activity; P < .01). The intermediate-early declining group had higher odds of high cIMT (odds ratio, 2.4; 95% CI, 1.3-4.5) compared with the high-late decline group, even after adjustment for baseline or proximal CVH score.

Conclusions and Relevance  In this study, CVH declined from childhood into adulthood. Promoting and preserving ideal CVH from early life onward may be associated with reduced CVD risk later in life.