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Cardiovascular health metrics and all-cause mortality in osteoarthritis, inflammatory arthritis, and unclassified arthritis patients: a national prospective cohort study

Arthritis Research & Therapy volume 26, Article number: 179 (2024) Cite this article

Abstract

Background

Arthritis notably elevates mortality risk. It remains unclear whether the cardiovascular health (CVH) metrics improves the risk of all-cause mortality in patients with all types of arthritis.

Methods

This study data from the National Health and Nutrition Examination Survey to probe the link between CVH and all-cause mortality among arthritis sufferers in the United States. CVH evaluation employed the Life's Essential 8 metrics. Mortality outcomes were scrutinized using Cox proportional hazard regression models. Additionally, a restricted cubic spline analysis delineated the linear relationship between CVH and mortality. The study also delved into the singular impact of each CVH component on mortality.

Results

In the cohort of 5919 patients with arthritis, improved CVH was linked to lower all-cause mortality. Specifically, each 10-point increment in CVH score was associated with a substantial decline in all-cause mortality risk [unadjusted hazard ratio (HR): 0.77, 95% Confidence Interval (95% CI): 0.71–0.83, P < 0.001]. Adjustments for age, sex, race, and social determinants of health further refined the HR to 0.72 (95% CI: 0.67–0.79, P < 0.001). Higher versus lower CVH scores at baseline markedly reduced mortality risk, with the most substantial decrease seen in those with ideal CVH metrics (HR: 0.39, 95% CI: 0.26–0.59, P < 0.001). Similar results were not observed in patients with inflammatory arthritis, but were seen in those with osteoarthritis or degenerative arthritis, and unknown types of arthritis.

Conclusion

Ideal CVH substantially decreases all-cause mortality risk among patients with arthritis, confirming the critical role of CVH in arthritis management. This study advocates for CVH interventions as part of comprehensive arthritis treatment plans.

Introduction

Osteoarthritis (OA) and inflammatory arthritis (IA), including rheumatoid arthritis (RA) and psoriatic arthritis (PsA), are major causes of pain and disability worldwide, often leading to joint deformity, functional impairment, and a diminished quality of life [1]. Research has shown that patients with these conditions have higher mortality rates compared to the general population, with prevalence steadily rising over the past three decades [2,3,4]. Uncontrolled arthritis can lead to severe joint damage, disability, and a lower quality of life, along with an elevated risk of cardiovascular diseases (CVD) and other comorbidities [5, 6]. Both conventional synthetic and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) have demonstrated effectiveness in improving cardiovascular outcomes in patients with IA [7]. However, additional strategies may be necessary to manage ongoing cardiovascular risks and improve prognosis, even after DMARDs therapy. Misclassification of arthritis types in clinical practice can lead to inappropriate medication use. For instance, while Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and corticosteroids can effectively reduce inflammation and pain, they may also contribute to heightened cardiovascular risk [8]. Therefore, exploring nonpharmacologic approaches that could enhance long-term outcomes and mitigate cardiovascular risks is essential.

The American Heart Association introduced the concept of cardiovascular health (CVH), highlighting its widespread importance [9]. Research has shown that achieving ideal CVH is linked not only to a lower risk of CVD but also to a reduced prevalence of a range of other conditions [10, 11]. Significantly, studies have found a negative association between optimal CVH and the prevalence of arthritis [12], suggesting that maintaining good CVH could play a crucial role in managing or potentially reducing the risk of arthritis. The recent update to the concept of CVH, evolving from Life's Simple 7 (LS7) to Life's Essential 8 (LE8) by adding a health behavior, underscores the enhanced importance of CVH for the entire population [13]. However, there is still a lack of research to clarify whether ideal CVH metrics can specifically benefit the prognosis of all types of arthritis patients.

Therefore, this study aimed to investigate the association between CVH and all-cause mortality in arthritis patients using a nationally representative sample in the United States. We anticipate that the findings will provide strategies for the long-term management of arthritis patients and serve as a key reference for developing targeted interventions in the future.

Methods

Study populations

The National Health and Nutrition Examination Survey (NHANES), administered by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC), is a nationally representative health survey designed to reflect the civilian non-institutionalized U.S. population. Utilizing a complex multistage probability sampling methodology, NHANES aims to provide comprehensive health and nutrition data. The protocol for NHANES has been approved by the NCHS ethics review board, and written informed consent was obtained from each participant.

In this prospective cohort study, we focused on participants aged 20 years and older diagnosed with arthritis within the NHANES database from 2007 to 2018. To ensure the specificity of our analysis, we excluded individuals with missing CVH data (n = 847), those with prior cardiovascular disease (n = 1724), and participants lost to follow-up (n = 8), resulting in a cohort of 5919 patients eligible for inclusion in our analysis (Fig. 1).

Fig. 1
figure 1

Flow diagram of patient selection

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Definitions of arthritis

The diagnosis of arthritis was based on the participants’ responses to two key questions: "Has a doctor or other health professional ever told you that you had arthritis?" with a "Yes" answer, and "Which type of arthritis was it?" with the response being " OA or degenerative arthritis, RA, PsA, other, and Don't know " This diagnostic criterion aligns with that used in other studies [14]. The questionnaires were administered by professionally trained investigators under strict quality control measures. In our study, we categorized patients with arthritis into three groups: 1) OA or degenerative arthritis; 2) IA, including RA, PsA, and others; and 3) unknown types of arthritis for patients who responded with "Don't know".

CVH Measurements and Classification

CVH encompasses four health behaviors (diet, physical activity, nicotine exposure, and sleep) and four health factors (body mass index (BMI), cholesterol, blood glucose, and blood pressure). Detailed measurements of CVH are provided in eTable 1 of the Supplement. The total CVH score is the average of the eight health index scores, ranging from 0 to 100 [13]. CVH score of less than 50 is considered poor, while scores between 50 to 79 and 80 or above are deemed intermediate and ideal, respectively.

Mortality outcomes

Data on mortality outcomes were obtained from the NHANES public-use linked mortality file as of December 31, 2019, which was linked to the National Death Index by the NCHS. The case definitions for underlying causes of death were based on the International Classification of Diseases, Tenth Revision (ICD-10) [15].

Statistical analysis

All analyses were conducted following the NHANES analytic guidelines and using NHANES-recommended weights to ensure nationally representative estimates. Continuous variables were reported as means ± standard error (SE), and categorical variables were summarized by frequency counts and percentages.

We used Kaplan–Meier curves to analyze the relationship between CVH categories and mortality risk. The association between CVH levels and all-cause mortality in all patients and across different arthritis types was assessed using Cox proportional hazard regression models with trend tests. Three models were applied: Model 1 (unadjusted), Model 2 (adjusted for demographic variables including age, sex, and race), and Model 3 (further adjusted for sociodemographic factors). A restricted cubic spline analysis (RCS) was conducted to clarify the nonlinear relationship between CVH and all-cause mortality. Three knots at 25%, 50%, and 75% were fitted to the RCS models. Subgroup analyses by age, sex, and social determinants examined CVH's impact on mortality, incorporating interaction terms to explore differences across subgroups. We also analyzed each CVH component's individual relationship with mortality.

All analyses were performed using R software version 4.3.1, with two-sided P-values < 0.05 considered statistically significant.

Result

In our study involving 5919 patients, the weighted mean age was 58.9 years (SE 0.3). We observed that the mean age decreased with improved CVH (P = 0.005), accompanied by significant racial differences in CVH categories (P < 0.001). Socioeconomic factors, including employment status, family income-to-poverty ratio, and education level, were strongly associated with CVH among individuals with IA, with better socioeconomic status leading to positive cardiovascular outcomes (all P < 0.001; Table 1). Our study presents a comparison of CVH metrics across different types of arthritis, showing significant differences in diet (P = 0.025), sleep (P < 0.001), and blood lipids (P = 0.012), while other factors such as physical activity, BMI, blood glucose, and blood pressure showed no significant variation across the groups (eTable 2).

Table 1 Baseline of Adults with Self-reported Arthritis by the Cardiovascular Health, NHANES 2007–2018
Full size table

Over a follow-up period of up to 74 months, there were 803 deaths. Kaplan–Meier curves indicated that adherence to better CVH significantly improves survival chances (Fig. 2). Initially, without adjustments, a 10-unit increase in CVH score lowered the all-cause mortality risk to a hazard ratio (HR) of 0.77 [95% Confidence Interval (95% CI): 0.71–0.83, P < 0.001; Table 2]. Adjusting for age, sex, and race, the HR improved to 0.72 (95% CI: 0.67–0.79, P < 0.001). Further adjustments for factors like drinking status, cancer, and various social determinants of health, yielded an HR of 0.77 (95% CI: 0.71–0.84, P < 0.001). Significantly, higher versus lower CVH scores at baseline markedly reduced mortality risk, with the most substantial decrease seen in those with ideal CVH metrics (HR: 0.39, 95% CI: 0.26–0.59, P < 0.001). This trend was consistent across all models (P for trend < 0.001), and the CVH score not showed a nonlinear decrease in mortality risk when used as a continuous variable (P for overall < 0.001, P for nonlinear = 0.578; Fig. 3). Similar results were not observed in patients with IA, but were seen in those with OA or degenerative arthritis, and unknown types of arthritis.

Fig. 2
figure 2

Kaplan‒Meier Curve Analysis for All-Cause Mortality according to Cardiovascular Health Metrics Among Arthritis Patients

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Table 2 Associations of CVH metrics with all-cause mortality in adults with self-reported arthritis
Full size table
Fig. 3
figure 3

Hazard Ratios for All-Cause Mortality based on Restricted Cubic Spine Functions for Cardiovascular Health Score in Arthritis Patients

Full size image

Subgroup analysis revealed that improved CVH is associated with a lower risk of all-cause mortality across all examined factors, including age, gender, and socioeconomic status, except for food security which showed a significant interaction (P = 0.030; Fig. 4). In adults with IA, key CVH metrics such as diet, physical activity level, smoking status, and sleep quality were all significantly linked to reduced mortality risk. Intermediate blood pressure levels also indicated a decreased risk, while BMI, blood lipids, and ideal blood pressure levels did not show a significant association (Table 3).

Fig. 4
figure 4

Subgroup Analysis of Hazard Ratios for All-Cause Mortality in Arthritis Patients by Demographic and Socioeconomic Factors. Analysis was adjusted for age, sex, and race, drinking status, cancer, and social determinants of health (employment status, family income-to-poverty ratio, food security, education level, regular health-care access, type of health insurance, home ownership, and marital status)

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Table 3 Associations of individual cardiovascular health metrics with all-cause mortality in adults with self-reported arthritis
Full size table

Discussions

This study is the first to investigate the impact of CVH on all-cause mortality risk in patients with arthritis. It reveals that maintaining ideal CVH significantly reduces this risk, except for those with IA, with a clear linear dose–response relationship as CVH increased. Regardless of social determinants, CVH remains a crucial factor in reducing all-cause mortality in arthritis patients, and the positive effects of healthy behaviors on prognosis are even more pronounced.

IA, a group of systemic chronic inflammatory diseases, causes joint damage and functional decline and results in inflammation-related symptoms in other body areas [16]. In contrast, OA is a chronic joint disease characterized by degeneration and destruction of articular cartilage and bone proliferation [17]. Despite their distinct pathophysiological mechanisms and differing impacts on cardiovascular health, current research indicates that both are associated with an increased risk of CVD [6, 18]. In recent years, the American Heart Association expanded the definition of CVH from the "LS7" to the "LE8", incorporating considerations for healthy behaviors [13]. Previous studies have validated the effectiveness of LS7 in identifying arthritis [12]. Our study found that CVH reduces the risk of all-cause mortality in arthritis patients. Key factors affecting prognosis include a healthy diet, regular physical activity, good quality sleep, smoking cessation, and maintaining appropriate blood glucose levels. The well-established link between physical activity and various diseases highlights the importance of promoting increased physical activity in both healthy individuals and those with arthritis [19,20,21]. However, our study did not find a significant role for CVH in patients with IA. Due to the limitations of our sample size and the fact that nearly half of the patients in the IA group had unknown types of arthritis, we must be cautious in interpreting this result. A study with a larger sample size found that LE8 reduces all-cause mortality in patients with carcinoid, which supports our findings, although their definition of LE8 has some limitations [22].

Previous research has also found that sleep disorders are associated with the risk of arthritis, and our study likewise confirms the importance of sleep [20, 23, 24]. Furthermore, exercise may have positive benefits for the sleep of patients with arthritis, reflecting the interconnectedness of healthy behaviors and their positive effects [25,26,27]. Our study confirms that physical activity significantly positively affects the prognosis of patients already suffering from arthritis. A study in Switzerland showed that obese participants had a higher incidence of RA and significantly more pain compared to non-obese participants, possibly related to less physical activity among the obese population [28]. However, our study did not find that obesity directly affects the prognosis of arthritis patients. We also confirmed the association between blood sugar levels and the prognosis of arthritis patients. Although previous research did not find a direct link between diet and arthritis, our findings indicate that good dietary habits can significantly reduce all-cause mortality among arthritis patients. Consistent with our results, clinical trials have shown that diet control can alleviate OA symptoms more effectively than exercise alone [29]. Studies by Sajedeh Jandari and others also confirmed the correlation between the Dietary Inflammatory Index and the Healthy Eating Index with RA [30].

In delving into the impact of CVH on the all-cause mortality risk among patients with arthritis, the role of social determinants cannot be overlooked [31, 32]. Social determinants, including socioeconomic status, education level, family and community support, as well as living conditions, have been widely recognized for their significant impact on health outcomes [33]. These factors indirectly affect CVH and arthritis management by influencing the choices of health behaviors, accessibility and quality of healthcare, and an individual's ability to cope with stress. Previous studies have suggested that the relationship between CVH and RA could be influenced by social status, health insurance, lifestyle, and other factors [34]. We further observed that food security may modify the impact of CVH on mortality. A recent study confirmed that food insecurity is associated with lower ideal CVH [35]. In populations with higher food security, improvements in CVH are linked to a more pronounced reduction in mortality risk, likely because food security enables individuals to fully benefit from good CVH practices. This suggests that raising awareness about food security could enhance the impact of CVH on mortality in patients with arthritis. As a key social determinant, food security directly influences dietary quality and nutrient intake, significantly shaping how CVH moderates mortality risk [36]. While other social determinants, such as income and health insurance, may also affect health outcomes, their direct moderating effects on CVH are likely smaller or more complex. However, patients with arthritis from lower socioeconomic backgrounds face more challenges in achieving optimal CVH, likely due to barriers that hinder their health management [37,38,39]. Therefore, this underscores the importance of considering and addressing inequalities in social determinants within arthritis management and CVH intervention strategies.

Our study underscores the importance of creating personalized CVH improvement plans for patients with arthritis. Given the heightened risk of CVD and all-cause mortality among arthritis patients, actively promoting changes in healthy behaviors can not only enhance their CVH but also significantly improve their quality of life and extend longevity. Moreover, our findings support the integration of CVH interventions into arthritis management strategies, suggesting that healthcare providers should focus on improving patients' CVH and lifestyle modifications alongside treating arthritis.

Our study, while contributing valuable insights, is subject to certain limitations. First, despite utilizing a nationally representative sample, the sample size may still restrict our capability to conduct subgroup analyses. Second, although we accounted for a range of covariates, the potential for unmeasured confounding factors and measurement errors remains, which could bias our findings. Third, lifestyle factors such as diet and sleep duration were self-reported in the NHANES dataset, a method that inherently introduces measurement errors. Lastly, our analysis was limited to baseline information on CVH indicators, lacking an assessment of potential changes in CVH during the follow-up period. Future research could elucidate the relationship between changes in CVH over time and health outcomes. Nevertheless, this study holds significant implications for the nonpharmacologic treatments of arthritis.

Conclusion

This study reveals that maintaining good CVH significantly reduces all-cause mortality in patients with arthritis, independent of social determinants. It underscores the importance of non-pharmacological interventions, particularly healthy lifestyle behaviors, in improving arthritis patients' prognosis. Furthermore, our research advocates for integrating CVH improvement strategies into arthritis management to enhance patient outcomes.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

BMI:

Body Mass Index

CDC:

Centers for Disease Control and Prevention

CI:

Confidence Interval

CVD:

Cardiovascular Disease

CVH:

Cardiovascular Health

DMARDs:

Targeted Synthetic Disease-modifying Antirheumatic Drugs

HR:

Hazard Ratio

IA:

Inflammatory Arthritis

ICD-10:

International Classification of Diseases, Tenth Revision

LS7:

Life’s Simple 7

LE8:

Life’s Essential 8

NSAIDs:

Non-Steroidal Anti-Inflammatory Drugs

NCHS:

National Center for Health Statistics

NHANES:

National Health and Nutrition Examination Survey

OA:

Osteoarthritis

PsA:

Psoriatic Arthritis

RA:

Rheumatoid Arthritis

RCS:

Restricted Cubic Spline

SE:

Standard Error

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Acknowledgements

The authors thank the participants and staff of the NHANES database for their valuable contributions.

Funding

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Author notes

  1. Yu Zhu, Yang-Zhen Wang and Yi-tian Chen contributed equally to this work.

Authors and Affiliations

  1. Beijing Friendship Hospital, Capital Medical University, Beijing, 100053, China

    Yu Zhu & Yi-tian Chen

  2. Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China

    Yang-Zhen Wang & Jie Guo

  3. Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China

    Zhen-Zhong Wang

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Contributions

Dr Wang and Dr Guo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors. Acquisition, analysis, or interpretation of data: Yu Zhu. Drafting of the manuscript: Yu Zhu, Yang-Zhen Wang. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Jie Guo, Yi-tian Chen. Administrative, technical, or material support: Zhen-Zhong Wang. Supervision: All authors.

Corresponding authors

Correspondence to Jie Guo or Zhen-Zhong Wang.

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Ethics approval and consent to participate

The study received ethical approval from the National Center for Health Statistics Research Ethics Review Board for different cycles: NHANES 2007–2010 (Protocol #2005–06), and NHANES 2011–2018 (Protocol #2011–17 and Protocol #2018–01), which are the cycles from which the data for this analysis were derived.

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The authors declare no competing interests.

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Zhu, Y., Wang, YZ., Chen, Yt. et al. Cardiovascular health metrics and all-cause mortality in osteoarthritis, inflammatory arthritis, and unclassified arthritis patients: a national prospective cohort study. Arthritis Res Ther 26, 179 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13075-024-03410-w

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  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13075-024-03410-w

Keywords

Arthritis Research & Therapy

ISSN: 1478-6362

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