Application of a Lifestyle-Based Tool to Estimate Premature Cardiovascular Disease Events in Young Adults: The Coronary Artery Risk Development in Young Adults (CARDIA) Study | Adolescent Medicine | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Navigation Landing]
Original Investigation
September 2017

Application of a Lifestyle-Based Tool to Estimate Premature Cardiovascular Disease Events in Young Adults: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Author Affiliations
  • 1Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 3Division of Chronic Disease Research Across the Life Course, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
  • 4now affiliated with Office of the Director, Environmental Influences on Child Health Outcomes Program, National Institutes of Health, Bethesda, Maryland
  • 5Center for Health Metrics and Evaluation, American Heart Association, Dallas, Texas
  • 6Office of the Dean, Colorado School of Public Health, Denver
  • 7now affiliated with National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 8Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 9AbbVie, Inc, Pharmaceuticals, West Roxbury, Massachusetts
JAMA Intern Med. 2017;177(9):1354-1360. doi:10.1001/jamainternmed.2017.2922
Key Points

Question  How effective is a lifestyle-based risk tool at estimating atherosclerotic cardiovascular disease events that occur before 55 years of age?

Findings  In the Coronary Artery Risk Development in Young Adults cohort study, the Healthy Heart Score performed moderately well at estimating the 25-year risk for early atherosclerotic cardiovascular disease events when applied to healthy adults aged 18 to 30 years. The Healthy Heart Score did not perform as well in young adults who already had at least 1 clinical atherosclerotic cardiovascular disease risk factor, such as elevated blood pressure or cholesterol or glucose levels.

Meaning  The Healthy Heart Score is an attractive tool for risk assessment and counseling for primary prevention of atherosclerotic cardiovascular disease, especially in those who have not yet developed traditional clinical risk factors.


Importance  Few tools exist for assessing the risk for early atherosclerotic cardiovascular disease (ASCVD) events in young adults.

Objective  To assess the performance of the Healthy Heart Score (HHS), a lifestyle-based tool that estimates ASCVD events in older adults, for ASCVD events occurring before 55 years of age.

Design, Setting, and Participants  This prospective cohort study included 4893 US adults aged 18 to 30 years from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Participants underwent measurement of lifestyle factors from March 25, 1985, through June 7, 1986, and were followed up for a median of 27.1 years (interquartile range, 26.9-27.2 years). Data for this study were analyzed from February 24 through December 12, 2016.

Exposures  The HHS includes age, smoking status, body mass index, alcohol intake, exercise, and a diet score composed of self-reported daily intake of cereal fiber, fruits and/or vegetables, nuts, sugar-sweetened beverages, and red and/or processed meats. The HHS in the CARDIA study was calculated using sex-specific equations produced by its derivation cohorts.

Main Outcomes and Measures  The ability of the HHS to assess the 25-year risk for ASCVD (death from coronary heart disease, nonfatal myocardial infarction, and fatal or nonfatal ischemic stroke) in the total sample, in race- and sex-specific subgroups, and in those with and without clinical ASCVD risk factors at baseline. Model discrimination was assessed with the Harrell C statistic; model calibration, with Greenwood-Nam-D’Agostino statistics.

Results  The study population of 4893 participants included 2205 men (45.1%) and 2688 women (54.9%) with a mean (SD) age at baseline of 24.8 (3.6) years; 2483 (50.7%) were black; and 427 (8.7%) had at least 1 clinical ASCVD risk factor (hypertension, hyperlipidemia, or diabetes types 1 and 2). Among these participants, 64 premature ASCVD events occurred in women and 99 in men. The HHS showed moderate discrimination for ASCVD risk assessment in this diverse population of mostly healthy young adults (C statistic, 0.71; 95% CI, 0.66-0.76); it performed better in men (C statistic, 0.74; 95% CI, 0.68-0.79) than in women (C statistic, 0.69; 95% CI, 0.62-0.75); in white (C statistic, 0.77; 95% CI, 0.71-0.84) than in black (C statistic, 0.66; 95% CI, 0.60-0.72) participants; and in those without (C statistic, 0.71; 95% CI, 0.66-0.76) vs with (C statistic, 0.64; 95% CI, 0.55-0.73) clinical risk factors at baseline. The HHS was adequately calibrated overall and within each subgroup.

Conclusions and Relevance  The HHS, when measured in younger persons without ASCVD risk factors, performs moderately well in assessing risk for ASCVD events by early middle age. Its reliance on self-reported, modifiable lifestyle factors makes it an attractive tool for risk assessment and counseling for early ASCVD prevention.