第一部分 社区人群理想心血管健康与基线冠状动脉钙化的关系

目的：探讨社区人群理想心血管健康（CVH）指标与冠状动脉钙化（CAC）发生率和钙化程度的关系。

材料与方法：2009-2010和2012年，通过典型抽样的方法选择北京西山社区年龄35-75岁的居民参与心血管病危险因素调查及CT冠状动脉钙化（CAC）扫描。根据美国心脏病协会（AHA）的定义确定了七项理想CVH指标（包括吸烟、体质指数、体力活动、膳食习惯、总胆固醇、血压和空腹血糖）。所有参与者根据满足理想CVH指标数目分为三组：0-2、3-4、5-7。采用多排螺旋CT进行CAC扫描并采用Agatston评分计算冠状动脉钙化积分（CACS），弥漫钙化定义为冠状动脉累及支数≥3（包括左主干、前降支、回旋支和右冠状动脉）。

结果：1068例居民中， 427（39.98%）例存在冠状动脉钙化（CACS＞0），0-2、3-4、5-7项理想CVH指标亚组中，CAC发生率分别为61.26%、41.84%和22.92%。理想CVH指标越多，CAC负荷和弥漫程度越低。与0-2项理想CVH指标相比，具有3-4、5-7项理想CVH指标时，CACS＞0的风险分别降低56%、72%[OR=0.44（0.30,0.64），0.28（0.18,0.44），P均＜0.001]，CACS＞400的风险分别降低44%、78%[OR=0.56（0.32,0.97），P=0.037；0.22（0.09,0.54），P=0.001]，弥漫钙化的风险分别降低49%、78% [OR=0.51（0.32,0.79），P=0.003；0.22（0.11,0.44），P＜0.001]。

结论：理想CVH指标越多，CAC发生率越低，CAC负荷和弥漫程度越低。保持理想的CVH状态可对动脉粥样硬化性疾病的预防有一定价值。

关键字：心血管健康，冠状动脉钙化，动脉粥样硬化，社区人群

第二部分 社区人群心血管健康评分与冠状动脉钙化进展之间的关系

目的：探讨社区人群心血管健康（CVH）状况与冠状动脉钙化进展之间的关系。

材料与方法：通过典型抽样选择北京西山社区35-75岁居民参与研究。所有居民完成基线心血管危险因素问卷调查和两次CT冠状动脉钙化（CAC）扫描。根据美国心脏协会（AHA）建议和我国膳食指南推荐，我们定义了7项心血管健康指标，包括吸烟、体质指数、体力活动、膳食习惯、血压、总胆固醇和空腹血糖，根据控制情况对每项指标分别进行赋值：理想（2分），一般（1分），差（0分）。理想CVH指标数目为所有满足理想状态的CVH个数，心血管健康评分（CHS）为所有CVH指标的得分之和。CAC积分（CACS）以Agatston评分表示。根据基线心血管健康状况与两次CACS结果，比较不同理想CVH指标数目、CHS评分间的CAC进展比例和进展程度的不同。

结果：共纳入734例居民，平均年龄52.41±8.51岁，男性363（49.46%）例，基线CACS=0的有498（67.85%）例，两次CT检查间隔875（861,889）天，共258（35.15%）例发生CAC进展。不同理想CVH指标数目及不同的CHS，CAC进展比例及进展程度不同。Logistic回归分析显示CAC进展与理想CVH指标数目或CHS相关，优势比（OR）分别为0.65（0.56,0.75），0.77（0.71,0.84）（P均＜0.001）。以0-2项理想CVH指标数目为参考，3-4、5-7项理想CVH指标的冠状动脉钙化进展OR值分别为0.32（0.20,0.50）、0.22（0.13,0.38）（P均＜0.001）。以CHS=3-8分为参考，9-10、11-14分两组钙化进展的OR值分别为0.42（0.28,0.61）、0.37（0.24,0.58）（P均＜0.001）。满足0-2、3-4、5-7项理想指标的CACS年增长量分别为50.48±8.87、42.10±6.13、32.87±10.49，差异无统计学意义（P=0.436）。CHS评分为3-8、9-10、11-14分的CACS年增长量分别为50.94±6.20、41.42±8.25、20.49±10.51（P=0.046）。

结论：心血管健康状态与CAC进展相关，理想CVH指标越多或CHS评分越高，CAC进展比例越低；CHS越高，CAC进展程度越低；提示我们关注并积极改善心血管健康，可减缓亚临床冠状动脉粥样硬化的发展。

关键词：心血管健康；冠状动脉钙化；冠状动脉粥样硬化；社区人群

第三部分 社区人群心血管健康评分和冠状动脉钙化与心血管事件之间的关系--10年随访研究

目的：探讨在不同冠状动脉钙化积分（CACS）水平下，社区人群心血管健康（CVH）与10年主要不良心血管事件（MACEs）的关系，并探究心血管健康评分（CHS）能否在CACS的基础上提高未来心血管事件的预测价值。

材料与方法：通过典型抽样的方法选取2009-2010年长期居住在北京西山社区且无心血管疾病和脑卒中病史的居民参加心血管危险因素基线调查和CT冠状动脉钙化扫描。2010年美国心脏协会（AHA）提出了理想CVH的概念，它包含了7个健康指标：吸烟、体质指数、运动、健康膳食、血压、总胆固醇和血糖。每个健康指标根据控制情况分为三类：理想（2分）、一般（1分）和差（0分），将每个指标得分相加得到心血管健康评分（CHS），按照接近三等分原则，将CHS分为三组3-8、9-10、11-14。CACS采用Agatston评分。对所有参与者进行定期随访，并记录MACEs，包括全因死亡、心肌梗死、冠状动脉再血管化治疗（包括冠状动脉支架和搭桥手术）和卒中。采用Cox回归模型评估理想CVH指标数目和CHS对10年MACEs的影响。统计分析时，将参与者按照CACS分为三组（CACS=0，1-400，>400）。

结果：719例参与者完成随访，中位随访时间9.91（9.83,10.91）年，发生MACEs 61（8.48%）例。整体来说，理想CVH指标数目越多或CHS评分越高，MACEs发生率越低。CACS=0时，以CHS=3-8分为参考，CHS=9-10、11-14亚组的MACEs风险比（HRs）分别为0.237（0.070,0.799）（P=0.020），0.129（0.026,0.649）（P=0.013）；CACS=1-400时，CHS=9-10、11-14亚组的HRs分别为0.273（0.100,0.745）（P=0.011），0.091（0.012,0.705）（P=0.022）。但当CACS>400时，CHS=9-10、11-14两组的HRs与CHS=3-8相比差异无统计学意义[HRs=0.386 (0.117, 1.274)（P=0.118），0.295 (0.054,1.604)（P =0.158）]。CHS与CACS在预测MACEs风险时具有同等的价值，曲线下面积（AUC）为0.756（0.723,0.787）和 0.723（0.688,0.755）（P=0.441），同时使用CACS和CHS，AUC提高至0.818 （0.788,0.846）。

结论：总体来说，理想CVH与较低的MACEs相关，特别是在CACS=0和1-400时，但当CACS＞400时，CVH与MACEs的相关性不显著。CHS与CACS在预测10年心血管风险时具有同等的价值，两者同时使用，预测价值提高。

【关键字】心血管健康，冠状动脉钙化，主要不良心血管事件，心血管风险

Part I  The Association of Ideal Cardiovascular Health with Coronary Artery Calcium at Baseline in a Community-based Population

Objective：To evaluate the association of ideal cardiovascular health (CVH) with the presence and severity of subclinical atherosclerosis measured as coronary artery calcium (CAC) in Chinese community-based population.

Methods and materials: Residents aged 35-75 years old from Xishan community of Beijing were selected to participate in the cardiovascular disease risk factor survey and CT coronary artery calcium (CAC) scan by typical sampling method from 2009 to 2010 and 2012.  The ideal CVH metrics (including smoke, body mass index, physical activity, health diet, total cholesterol, blood pressure and fasting blood glucose) were determined based on the definition of the American Heart Association (AHA). All participants were grouped into three categories according to the number of ideal CVH metrics: 0-2, 3-4, and 5-7. Multi-slice CT was used for CAC scanning and Agatston score was used to calculate CAC scores (CACS). Diffuse calcification was defined as calcification involving more than 3 coronary arteries.

Results: Of 1068 participants, 427 (39.98%) showed CACS>0. The prevalence of CACS>0 in 0-2, 3-4 and 5-7 ideal CVH metrics subgroups was 61.26%, 41.84% and 22.92%, respectively. The more ideal CVH metrics, the lower CAC burden and diffusivity. Compared with 0-2 ideal CVH metrics, participants with 3-4, 5-7 ideal CVH metrics had a lower risk of CACS>0 [OR=0.44（0.30,0.64），0.28（0.18,0.44），all P＜0.001], a lower risk of CACS>400[OR=0.56（0.32,0.97），P=0.037；0.22（0.09,0.54），P=0.001], and a lower risk of diffuse calcification [OR=0.51（0.32,0.79），P=0.003；0.22（0.11,0.44），P＜0.001].

Conclusion: The participants with more ideal CVH metrics had a lower prevalence of CAC, as well as a lower burden and diffusivity of CAC. Maintaining an ideal CVH may be valuable in the prevention of atherosclerosis in the general population.

Key words: cardiovascular health, coronary artery calcium, atherosclerosis，community-based population

Part II  The Association of Cardiovascular Health Score with Progression of Coronary Artery Calcium in a Community-based Population

Objective: We examined the association of cardiovascular health (CVH) with the development and progression of coronary artery calcium (CAC) among community population.

Methods and Materials: Residents aged 35-75 in Beijing Xishan Community were invited to participate in the study through typical sampling. All participants completed a questionnaire about the baseline cardiovascular risk factor and two CT coronary artery calcium (CAC) scans. According to the American Heart Association (AHA) recommendation and Chinese dietary guidelines, we defined 7 CVH metrics, including smoking, body mass index, physical activity, dietary habits, blood pressure, total cholesterol, and fasting glucose. Levels of each metric were classified as ideal (2 points), intermediate (1 point), and poor (0 points). Points were summed to produce a CVH score (CHS). CAC score (CACS) was evaluated by Agatston score. The differences of incidence and severity of CAC progression were compared among different CVH status.

Results: A total of 734 patients were included, with an average age of 52.41±8.51 years and 363 (49.46%) males, and 498 (67.85%) participants had CACS=0 at baseline. During a median follow-up of 875 (861,889) days, 258 (35.15%) experienced CAC progression. The incidence and severity of CAC progression varied in different numbers of ideal CVH metrics or CHS. Logistic regression analysis showed that CAC progression was correlated with the number of ideal CVH metrics and CHS, and the odd ratios (ORs) were 0.65 (0.56,0.75) and 0.77(0.71,0.84) (all P < 0.001). Taking the number of 0-2 ideal CVH metrics as a reference, the ORs of 3-4 and 5-7 ideal CVH metrics for CAC progression were 0.32 (0.20,0.50) and 0.22(0.13,0.38) (P < 0.001). Compared with participants with CHS=3-8, the ORs of CAC progression in participants of CHS=9-10, 11-14 subgroups were 0.42(0.28,0.61) and 0.37 (0.24,0.58) (P < 0.001). The annualized progression of CACS with 0-2, 3-4 and 5-7 ideal metrics was 50.48±8.87, 42.10±6.13 and 32.87±10.49, respectively, with no significance (P=0.436). The annualized progression of CACS with CHS=3-8, 9-10, and 11-14 was 50.94±6.20, 41.42±8.25 and 20.49±10.51, respectively (P=0.046).

Conclusions: Cardiovascular health was correlated with the progression of CAC. The higher the ideal CVH metrics or CHS score, the lower incidence of CAC progression. The higher CHS was, the lower severity of CAC progression was. It is suggested that paying more attention to and actively improving cardiovascular health could slow down the development and progression of subclinical coronary atherosclerosis.

Key words: cardiovascular health, coronary artery calcium, coronary atherosclerosis, community population

Part III  Association of Ideal Cardiovascular Health and Coronary Artery Calcium with Cardiovascular Events—a 10-year Follow Up Study

Objectives: To examine the association of ideal cardiovascular health (CVH) with major adverse cardiovascular events (MACEs) at different degrees of coronary artery calcium (CAC), and whether cardiovascular health score (CHS) provides additional predictive value on MACEs over coronary calcium score (CACS).

Methods: 719 participants free of heart disease or stroke at baseline in a community-based cohort study during 2009–2010 were involved. The American Heart Association has proposed a definition of CVH, including 7 metrics, and each metric levels were classified as ideal (2 points), intermediate (1 point), and poor (0 points). Points were summed to produce a CHS (3-8, 9-10, 11-14). Cox regression models were used to estimate the hazard ratios (HRs) of CHS for the risk of MACEs. Analyses were stratified by CACS (0, 1-400, >400).

Results: 61(8.48%) MACEs were recorded during a median follow up of 9.91(9.83,10.91) years. Participants with higher CHS had lower incidence of MACEs. In CACS=0 group, participants with CHS=9-10, 11-14 had lower risks of MACEs compared with CHS=3-8 [HRs=0.237(0.070,0.799) and 0.129(0.026,0.649), P<0.05] after adjusting for age, gender, income, education level, drinking and family history of CVD. In CACS=1-400 group, HRs of CHS=9-10, 11-14 were 0.273(0.100,0.745), 0.091(0.012,0.705) (all P<0.05). In group of CACS >400, the HRs of CHS=9-10, 11-14 were nonsignificant compared with that of CHS=3-8 [HRs=0.386 (0.117, 1.274), 0.295 (0.054,1.604), all P >0.05]. CHS and CACS predicted risk of MACEs with similar value, and the area under curve (AUC) was 0.756 (0.723,0.787), 0.723 (0.688,0.755) (P=0.441). Using both scores together, the AUC increased to 0.818 (0.788,0.846).

Conclusions: Ideal CVH was associated with lower risk of mortality and CVD events overall, especially in participants with CACS=0 and 1-400, while the association was not significant in those with CACS>400. CACS and CHS had equal value in predicting 10-year risk of MACEs. Using both scores together can increase the predictive value.

Key words: cardiovascular health, coronary artery calcium, major adverse cardiovascular event, cardiovascular risk