Less Than Ideal: Trends in Cardiovascular Health Among US Stroke Survivors

Amy M. Lin, BA; Michelle P. Lin, MD, MPH; Daniela Markovic, MS; Bruce Ovbiagele, MD, MSc, MAS; Nerses Sanossian, MD; Amytis Towfighi, MD


Stroke. 2019;50(1):5-12. 

In This Article

Abstract and Introduction


Background and Purpose: The American Heart Association's Life's Simple 7 (LS7) defines ideal cardiovascular health by 7 metrics: not smoking, regular physical activity, normal body mass index, blood pressure, plasma glucose, and total cholesterol levels, and a healthy diet. We assessed prevalence and predictors of ideal LS7 among US stroke survivors.

Methods: Among 67 514 participants in the National Health and Nutrition Examination Surveys from 1988 to 1994 and 1999 to 2014, 1597 adults (≥18 years) had self-reported history of stroke. LS7 metrics were categorized as poor, intermediate, and ideal; ideal LS7 scores were calculated (1 point for each ideal metric met). Trends in poor, intermediate, and ideal cardiovascular health were assessed. Odds of low (0–1) versus high (≥4) ideal LS7 scores were assessed according to sex, race, poverty income ratio, and education level, before and after adjusting for covariates.

Results: Only 1 participant met all ideal LS7 metrics. The proportion with low LS7 score increased from 17.9% in 1988 to 1994 to 35.4% in 2011 to 2014 (P<0.001). Over that time frame, prevalence of poor blood pressure (≥140/90 mm Hg) and poor cholesterol (≥240 mg/dL) decreased (45.2%–26.5% and 37.2%–10.3%), whereas prevalence of poor body mass index (≥30 kg/m2), poor diet (healthy eating index score <50), and poor physical activity (0 minutes moderate/vigorous activity per week) increased (26.9%–39.0%; 14.2%–50.6%; 44.6%–70.9%; all P<0.05). After adjustment, black race (odds ratio, 2.29; 95% CI, 1.17–4.48), poverty income ratio ≤200% (odds ratio, 2.20, 95% CI, 1.11–4.36), and ≤12th grade education (odds ratio, 4.50; 95% CI, 2.27–8.92) were associated with low ideal LS7 scores.

Conclusions: Over the past 3 decades, blood pressure and cholesterol control among stroke survivors improved, but rates of obesity, poor diet, and physical inactivity increased. Stroke survivors who are black, poor, or less educated are less likely to have ideal cardiovascular health.


In 1979, the United States Surgeon General committed to lowering mortality rates from stroke and coronary artery disease via preventive measures, including high blood pressure (BP) detection and control, smoking reduction, adoption of a prudent diet, increased exercise and fitness, and better stress management.[1] The resultant Healthy People campaigns over the past 40 years have coincided with declining stroke incidence,[2–4] recurrence,[5] and mortality.[6] Still, >7 million adults in the United States have had a stroke,[7] and the number of stroke survivors is expected to increase as the population ages.[8] Stroke survivors are at high risk for stroke recurrence.[9,10] Poor cardiovascular health has been associated with stroke recurrence and other poor outcomes among stroke survivors.[11]

In 2010, the American Heart Association (AHA) defined ideal cardiovascular health according to 7 metrics known as Life's Simple 7 (LS7).[12] These metrics include health behaviors (not smoking, maintaining a healthy body mass index [BMI], engaging in physical activity, and eating a healthy diet) and health factors (control of BP, total serum cholesterol, and blood glucose). Despite evidence that people who embrace heart-healthy lifestyles and control vascular risk factors have better health outcomes, few Americans meet all LS7 criteria.[13,14]

Stroke survivors meeting higher numbers of LS7 criteria have lower mortality rates.[15] Little is known about recent temporal trends in control of LS7 factors in stroke survivors. In this study, we examined trends in LS7 factors among US stroke survivors from 1988 to 2014 and determined factors associated with poor and ideal LS7.