Deans' stroke musings: Association of Life’s Crucial 9 with all-cause and cardiovascular mortality in stroke survivors and predictive value for mortality compared with Life’s Essential 8: evidence from NHANES 2005

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Monday, March 24, 2025

Association of Life’s Crucial 9 with all-cause and cardiovascular mortality in stroke survivors and predictive value for mortality compared with Life’s Essential 8: evidence from NHANES 2005–2018

NOTHING HERE GETS SURVIVORS RECOVERED! Predicting mortality is the height of stupidity; JUST MAYBE YOU WANT TO PREVENT THAT!

I'd have you all fired!

Association of Life’s Crucial 9 with all-cause and cardiovascular mortality in stroke survivors and predictive value for mortality compared with Life’s Essential 8: evidence from NHANES 2005–2018

Xupeng Wu¹^*^†

Xiaofeng Li^2,3^†

Hong Liu¹

¹Department of Neurology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
²The First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
³Department of General Medicine, Linfen City People’s Hospital, Linfen, Shanxi, China

Background: There is evidence of a positive correlation between depressive disorders and poor cardiovascular health (CVH). Recently, the inclusion of psychological health assessments into Life’s Essential 8 (LE8) has been put forward to enhance the foundation of CVH. We aimed to investigate the probable link between the innovative CVH assessment framework, Life’s Crucial 9 (LC9), and overall mortality as well as mortality associated with cardiovascular disease (CVD) among stroke survivors, while also assessing its prognostic relevance regarding mortality in comparison to LE8.

Methods: This study draws on a cohort of stroke survivors identified from the National Health and Nutrition Examination Survey (NHANES), spanning survey cycles from 2005 to 2018. The LE8 was assessed by the approach recommended by the American Heart Association. The LC9 framework incorporated an additional depression score, measured by Patient Health Questionnaire-9, into the LE8 assessment. To investigate the associations between LE8 and LC9 with all-cause and cardiovascular mortality in stroke survivors, we employed multivariable Cox proportional hazards regression analyses.

Results: After adjusting for covariates, each 10-point increase in LC9 was associated with a 24.5 and 30.1% reduction in all-cause and CVD mortality in stroke survivors, respectively. Participants in the highest quartile (Q4) of LC9 exhibited significantly lower mortality rates compared to those in the lowest quartile (Q1) (all-cause mortality: HR 0.412, p < 0.0001; CVD mortality: HR 0.327, p < 0.001). Similar associations were observed for LE8. Restricted cubic spline analysis indicated that both LC9 and LE8 demonstrated linearly associations with mortality post-stroke. Physical activity score, nicotine exposure score, and blood glucose score were significantly linked to all-cause and CVD mortality in stroke survivors. Adding depression score to LE8 significantly enhanced the prediction of all-cause mortality in stroke survivors (net reclassification improvement index = 9.6%, p = 0.033; ΔC index = 0.002, p = 0.0009; integrated discrimination improvement = 0.01, p = 0.007). The NRI of 9% (p = 0.086) for CVD mortality, while not statistically significant, suggests a trend toward improved classification.

Conclusion: LC9 exhibited both linear and inverse correlations with all-cause and cardiovascular mortality among stroke survivors. Adding a depression score to the LE8 framework may improve the predictive accuracy for all-cause mortality in stroke survivors.

1 Introduction

Stroke, characterized by acute focal neurological deficits, results from various cerebrovascular causes and is primarily categorized into hemorrhagic and ischemic types (1, 2). It presents significant morbidity, mortality, and disability, profoundly affecting individuals, families, and societies (3). The Global Burden of Disease Study 2019 indicates a 70% increase in incident and an 85% rise in prevalent stroke cases over the past 30 years, with significant age-standardized incidence and prevalence rates observed in individuals under 70 (4). Over the next 30 years, stroke mortality is projected to continue to increase by 50%, and disease-adjusted life years are also projected to increase significantly (5). In the United States, the average annual medical cost per stroke patient is approximately $60,000, which is the highest of all countries (6). Despite advancements, gaps remain in current primary stroke prevention services, highlighting the urgent need to identify modifiable and practicable risk factors and foster collaborative multistakeholder efforts to implement effective stroke prevention strategies (5, 7).

Recently, the American Heart Association (AHA) updated and introduced a new tool for cardiovascular health (CVH) assessment and quantification, the Life’s Essential 8 (LE8), based on the previous Life’s Simple 7 (LS7) (8). The LE8 comprehensively evaluates eight evidence-based CVH metrics encompassing four healthy lifestyle (e.g., diet and physical activity [PA]) and four health factors (e.g., blood glucose and blood pressure), representing a new paradigm for CVH assessment (8). Since the introduction of the LE8, numerous population-based observational studies have demonstrated inverse associations between the LE8 score and various adverse health outcomes, including cardiovascular disease (CVD), chronic kidney disease, and non-alcoholic fatty liver disease (9–11). Maintaining a higher CVH has been linked to increased life expectancy and reduced risk of mortality among both men and women compared to low CVH populations (12–14). In addition, while several studies have shown an inverse relationship between the LE8 score and stroke risk, findings remain contentious (15, 16). Importantly, large population-based studies have indicated that maintaining a higher LE8 may narrow socioeconomic health inequalities (13, 17).

The bidirectional association of psychological health, including depression, with CVH is increasingly being recognized. People with CVD are at a higher risk of developing depression compared to the general population, while those with depression are also more prone to developing CVD, creating a negative feedback loop that adversely affects outcomes (18). Notably, several cross-sectional and longitudinal cohort studies have demonstrated a considerable link between CVH, as determined by the LE8 metric, and the prevalence of major depression (19, 20). Thus, in a recently published perspective, Gaffey et al. (21) suggested integrating psychological health (e.g., depression) into the existing LE8 score framework by proposing a new Life’s Crucial 9 (LC9) score. As a foundation for achieving optimal and equitable CVH, psychological health was identified as a possible underpinning for the enhancement of the existing LE8 paradigm and as an important dimension in future integrated models of cardiovascular care (21). A recent prospective cohort investigation demonstrated that LC9 was independently associated with all-cause and cardiovascular mortality among adults in U.S.; however, there was limited improvement in the predictive power of LC9 compared with LE8 for mortality (22). Available observational evidence suggests that higher LE8 is associated with reduced risk of depression and mortality after stroke (23, 24). Nevertheless, the association of LC9 with mortality in stroke survivors remains largely unknown.

This study assessed the longitudinal relationships between LC9 score and all-cause and CVD mortality in stroke survivors, as well as to elucidate whether the predictive power of the LC9 (as compared to the LE8) was improved for mortality after stroke. In summary, our study emphasizes the importance of understanding how LC9 contributes to mortality risk in stroke survivors and evaluates the necessity of incorporating depression assessments into the existing LE8 framework to enhance mortality predictions in this cohort. Given the complex interplay between CVH and mortality in stroke survivors, we conducted stratified analyses to evaluate the impact of demographic variables on these relationships. Additionally, we will evaluate the individual contributions of each LE8/LC9 component score to mortality risk, providing a more nuanced understanding of the factors driving the observed associations.