| Citation: |
Please cite this article as: JIANG F, LIU XT, HU Z, LIAO W, LI SY, ZHU RF, MAO ZX, HOU J, Akhtar S, Ahmad F, Mehmood T, WANG CJ. Healthy life expectancy with cardiovascular disease among Chinese rural population based on the prospective cohort study. J Geriatr Cardiol 2024; 21(8): 799−806. DOI: 10.26599/1671-5411.2024.08.006.
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Limited research has explored the impact of cardiovascular disease (CVD) on healthy life expectancy (HLE) especially in resource-limited areas. This study aimed to investigate the association between CVD and HLE in Chinese rural population.
This study included 11,994 participants aged 45 years and older from the baseline and follow-up surveys of the Henan rural cohort study. Healthy status was measured via a Visual Analogue Scale. The multistate Markov model was applied to estimate the association between CVD and transitions in health, unhealthiness and death. Gender-specific total life expectancy, HLE and unhealthy life expectancy were calculated by the multistate life table method.
During a mean follow-up time of 3.85 (3.84–3.86) years, there were 588 deaths recorded. For individuals with CVD, the risk of switching from health to unhealthiness status was increased by 71% [hazard ratio (HR) = 1.71, 95% CI: 1.42–2.07], the chance of recovery was reduced by 30% (HR = 0.70, 95% CI: 0.60–0.82). Men aged 45 years without CVD could gain an extra 7.08 (4.15–10.01) years of HLE and lose 4.00 (1.60–6.40) years of unhealthy life expectancy compared to their peers with CVD, respectively. The corresponding estimates among women were 8.62 (5.55–11.68) years and 5.82 (2.59–9.04) years, respectively.
This study indicated that CVD was significantly associated with poorer health status and lower HLE among Chinese rural population. It is an important public health policy to adopt targeted measures to reduce the CVD burden and enhance the quality of life and HLE in resource-limited areas.
Cardiovascular disease (CVD) is the leading cause of morbidity, mortality, and premature death worldwide, which comprises a cluster of diseases such as stroke, coronary heart disease (CHD), and others.[1] Over the decades, prevalent cases of total CVD nearly doubled from 271 million in 1990 to 523 million in 2019, and the number of CVD deaths steadily increased from 12.1 million in 1990, reaching 18.6 million in 2019.[2] China has one of the heaviest burdens of CVD in the world, with CVD accounting for 40% of deaths in the Chinese population.[3]
With the economic growth and the improvement of medical conditions, life expectancy of the general population in China has increased significantly, and the quality of life is gradually paid more attention.[4] The question of whether the additional years of life gained are spent in good health or poor health has been increasingly relevant because of the potential policy implications, such as extending retirement ages and healthcare provisions, allocation.[5] Healthy life expectancy (HLE) defined as the average number of years that a person can expect to live in a healthy status, is a comprehensive summary measure of population health and reflects both the “quantity” and “quality” of lived years.[6] These indicators facilitate communication with health professionals, policymakers and the general public, and are more conducive to estimating future healthcare costs and healthcare needs.[7]
Despite the critical importance of understanding the impact of CVD on HLE, particularly in rural areas with high CVD burdens, there remains a dearth of research in this area. To address these important research gaps, this study utilized multistate life tables to investigate the association between CVD and HLE in the Chinese rural population, drawing the baseline and follow-up data from the Henan rural cohort study.
Henan rural cohort study comprised 39,259 participants aged 18–79 years from 2015 to 2017 in five rural areas (Yuzhou, Xinixiang, Tongxu, Yima and Suiping) of Henan province at baseline, with further details provided in a previous publication.[8] Subsequently, 35,995 participants participated in the second wave of the survey from 2018 to 2022, during which 1006 deaths occurred. Participants were included if they: (1) aged ≥ 45 years; (2) participated in Visual Analogue Scale (VAS) survey at baseline; and (3) participated in VAS survey or died during the follow-up period. Exclusion criteria for the present study were: (1) aged < 45 years (n = 7171); and (2) no participate in VAS survey in two waves of surveys (n = 20,094). Finally, the current study included 11,994 participants from the Henan rural cohort study.
The Henan rural cohort study received approval from the Zhengzhou University Life Science Ethics Committee ([2015] MEC (S128)). All participants provided written informed consent to participate in this study.
Information and data of participants were collected by face-to-face interview with a standard questionnaire, which included general demographic characteristics and individual history of diseases.[9] Covariates that were taken into account were age, gender, education, and income. The educational level of individuals was categorized into low (primary school or below), medium (junior high school), and high (senior high school or above).[10] Based on average monthly income, income level was segmented into three levels: low (< 500 RMB), medium (500–999 RMB), and high (≥ 1000 RMB).[10,11]
Participants were interviewed by well-trained investigators to collect their history of stroke and CHD. Stroke/CHD was diagnosed by physicians. Stroke was defined as a constellation of sudden or rapid onset of a neurologic deficit of vascular origin that persisted more than 24 h or until death.[12] CHD was defined as the first occurrence of nonfatal myocardial infarction, fatal CHD, stable and unstable angina, or coronary revascularization.[13] CVD was defined as a history of stroke and/or CHD.[14]
Mortality data were collected from family members (spouses and children) or primary caregivers, and all deaths during follow-up were verified through the death registries.[8]
The European Quality of Life Five Dimension Five Level Scale serves as a standardized tool for assessing the quality of life to offer a generic measure of health status for clinical and economic evaluations.[15] The European Quality of Life Five Dimension Five Level Scale includes a VAS, which reflects the self-rated healthy states of the participant on a scale from 0 (the worst healthy status) to 100 (the best healthy status).[16] In this study, the median VAS score for participants was 80 points, “health” was defined as VAS score ≥ 80, while other scores are considered “unhealthiness”.
The demographic characteristics of participants were described as mean ± SD for continuous variables and as counts (percentages) for categorical variables. Differences between groups were compared using the independent Student’s t-test or the Mann-Whitney U test (for continuous variables), and the Pearson’s chi-squared test (for categorical variables).
The multistate life table method was used to calculate the age and gender-specific total life expectancy and HLE for participants with and without CVD. The multistate life table method assumes that different health states are able to transition to each other, and constructs matrices based on the transition probabilities between different states obtained from dynamic tracking data, and thus more accurately reflects changes in population health and estimates the HLE.[17] With the baseline and follow-up survey data from the Henan rural cohort study, a Markov multistate transition model was fitted with three states using the “MSM” package[18]: health, unhealthiness, and death (Figure 1). Reverse transitions were allowed between health and unhealthiness, thus four transitions were taken into account: (1) from health to unhealthiness; (2) from health to death; (3) recovery from unhealthiness to health; and (4) from unhealthiness to death. Age was defined as a time-dependent covariate, and the model additionally adjusted gender, education and income. Transition-specific hazard ratio (HR) and 95% CI were evaluated for each transition. With the multivariate-adjusted model, total life expectancy, HLE and unhealthy life expectancy were calculated via the “ELECT” package, and the standard error was estimated by bootstrapping with 1000 replications.[17]
All analyses were performed with SPSS 21.0 (SPSS Inc., IBM, Chicago, IL, USA) and R statistical software 4.3.0 (The R Project for Statistical Computing, Vienna, Austria). Two-tailed P-value < 0.05 were considered statistically significant.
The characteristics of study populations according to CVD were reported in Table 1. Out of 11,994 participants, 1805 participants were identified as CVD, with a prevalence of 15.05%. In comparison to participants without CVD, those with CVD exhibited older age (59.86 ± 8.48 years vs. 63.48 ± 7.61 years) and were more likely to have lower education (49.76% vs. 58.17%) and lower monthly income (41.87% vs. 45.26%). During a mean follow-up time of 3.85 (3.84–3.86) years, 588 deaths were recorded. Of 7406 participants with healthy status at baseline, 285 deaths occurred, while 303 deaths developed among those with unhealthy status at baseline (Figure 1).
| Variables | Without CVD (n = 10,189) | With CVD (n = 1805) | P-value |
| Age, yrs | 59.86 ± 8.48 | 63.48 ± 7.61 | < 0.001 |
| Gender | 0.135 | ||
| Men | 4043 (39.68%) | 750 (41.55%) | |
| Women | 6146 (60.32%) | 1055 (58.45%) | |
| Education | < 0.001 | ||
| Low | 5070 (49.76%) | 1050 (58.17%) | |
| Medium | 3821 (37.50%) | 583 (32.30%) | |
| High | 1298 (12.74%) | 172 (9.53%) | |
| Income | 0.023 | ||
| Low | 4266 (41.87%) | 817 (45.26%) | |
| Medium | 3222 (31.62%) | 528 (29.25%) | |
| High | 2701 (26.51%) | 460 (25.48%) | |
| Data are presented as means ± SD or n (%). CVD: cardiovascular disease. | |||
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The association of CVD with the risk of transitions between health, unhealthiness and death was presented in Table 2. For individuals with CVD, the risk of switching from health to unhealthiness was increased by 71% (HR = 1.71, 95% CI: 1.42–2.07), the chance of recovery was reduced by 30% (HR = 0.70, 95% CI: 0.60–0.82). Compared to men, the risk of death was lower for women with healthy status (HR = 0.46, 95% CI: 0.31–0.67) and unhealthy status (HR = 0.43, 95% CI: 0.30–0.63). Additionally, for every annual increase in age, the risk of death increased by 10% (HR = 1.10, 95% CI: 1.07–1.13) for subjects with healthy status and 9% (HR = 1.09, 95% CI: 1.06–1.12) for those with unhealthy status.
| HR (95% CI) | ||||
| Health to unhealthiness | Health to death | Unhealthiness to health | Unhealthiness to death | |
| Age | 1.02 (1.01–1.03) | 1.10 (1.07–1.13) | 0.99 (0.98–1.00) | 1.09 (1.06–1.12) |
| Womena | 1.11 (0.95–1.28) | 0.46 (0.31–0.67) | 1.08 (0.95–1.21) | 0.43 (0.30–0.63) |
| Education | ||||
| Low | Reference | Reference | Reference | Reference |
| Medium | 0.85 (0.72–1.00) | 0.91 (0.61–1.36) | 1.04 (0.92–1.19) | 0.75 (0.49–1.16) |
| High | 0.79 (0.63–1.00) | 0.61 (0.30–1.26) | 1.01 (0.84–1.23) | 1.04 (0.57–1.88) |
| Income | ||||
| Low | Reference | Reference | Reference | Reference |
| Medium | 0.85 (0.71–1.00) | 1.07 (0.74–1.55) | 1.18 (1.03–1.34) | 1.38 (0.94–2.02) |
| High | 0.99 (0.84–1.18) | 0.70 (0.42–1.16) | 1.07 (0.92–1.24) | 1.15 (0.73–1.80) |
| CVDb | 1.71 (1.42–2.07) | 1.15 (0.65–2.03) | 0.70 (0.60–0.82) | 1.34 (0.94–1.91) |
| aRefers to men were the reference category. bRefers to participants without CVD were the reference category. CVD: cardiovascular disease. | ||||
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The total life expectancy, HLE and unhealthy life expectancy for participants with and without CVD were presented in Table 3 and Figure 2. Overall, compared to subjects with CVD, HLE was significantly higher but unhealthy life expectancy was lower for their peers without CVD, and similar result pattern was observed across age groups and gender. At age 45, the total life expectancy for men without CVD was 31.14 (29.50–32.78) years, of which 23.21 (21.88–24.53) years were HLE and 7.93 (7.10–8.77) years were unhealthy life expectancy. The corresponding estimates were 28.06 (25.81–30.31) years, 16.12 (14.51–17.73) years, and 11.94 (10.37–13.50) years for their peers with CVD. The total life expectancy for women without CVD at age 45 was 38.76 (36.64–40.88) years, of which 27.31 (25.80–28.81) years were spent with healthy status and 11.45 (10.32–12.59) years were live with unhealthy status, while the equivalent assessment for their peers with CVD was 35.96 (33.36–38.56) years, 18.69 (17.13–20.25) years and 17.27 (15.18–19.36) years. Namely, men aged 45 without CVD could gain an extra 7.08 (4.15–10.01) years of HLE and lose 4.00 (1.60–6.40) years of unhealthy life expectancy compared to their peers with CVD, respectively. The corresponding estimates among women were 8.62 (5.55–11.68) years and 5.82 (2.59–9.04) years, respectively.
| Life expectancy, yrs | Men | Women | |||
| Without CVD | With CVD | Without CVD | With CVD | ||
| Life expectancy | 31.14 (29.50–32.78) | 28.06 (25.81–30.31) | 38.76 (36.64–40.88) | 35.96 (33.36–38.56) | |
| Difference | Reference | −3.08 (−6.97–0.81) | Reference | −2.80 (−7.51–1.91) | |
| HLE | 23.21 (21.88–24.53) | 16.12 (14.51–17.73) | 27.31 (25.80–28.81) | 18.69 (17.13–20.25) | |
| Difference | Reference | −7.08 (−10.01–-4.15) | Reference | −8.62 (−11.68–-5.55) | |
| Unhealthy life expectancy | 7.93 (7.10–8.77) | 11.94 (10.37–13.50) | 11.45 (10.32–12.59) | 17.27 (15.18–19.36) | |
| Difference | Reference | 4.00 (1.60–6.40) | Reference | 5.82 (2.59–9.04) | |
| CVD: cardiovascular disease; HLE: healthy life expectancy. | |||||
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The proportion of HLE in life expectancy according to CVD was shown in Figure 3, and it was greatest among men without CVD and lowest among women with CVD in all age groups. The ratio of HLE to total life expectancy was 57.47% and 74.52% for men with and without CVD, respectively. And for women, the corresponding estimates were 51.98% and 70.46%, respectively. In addition, the proportion of HLE decreased with age. At age 75, the proportion of life expectancy spent with healthy status was 44.44% and 60.55% in men with and without CVD, while the equivalent assessment in women was 38.86% and 57.05%, respectively.
Utilizing data from prospective research in rural areas of China, this study provides quantitative insights into the effect of CVD on HLE and unhealthy life expectancy. The results indicated CVD was associated with fewer years lived with healthy status and longer years lived with unhealthy status. At age 45, men without CVD could gain an extra 7.08 (4.15–10.01) years of HLE and lose 4.00 (1.60–6.40) years of unhealthy life expectancy compared to their peers with CVD, respectively. And for women, the corresponding figure was 8.62 (5.55–11.68) and 5.82 (2.59–9.04) years. In addition, the proportion of HLE in total life expectancy was higher for men without CVD, while it was lower for women with CVD. This research sheds light on the nuanced impact of CVD on the length and quality of life, emphasizing the need for targeted interventions and healthcare strategies.
This study explored the association between CVD and transitions in health, unhealthiness and death among Chinese rural population. The results of the multistate Markov model showed that the risk of unhealthiness was increased, while the chance of recovery was reduced for individuals with CVD, and it was consistent with the results of several previous surveys.[19-21] Tehran Lipid and Glucose Study reported poorer self-rated health-related quality of life in those who experienced CVD compared to their healthy counterparts.[19] Compared with the general population, the EQ-5D VAS and index were significantly lower for subjects with CHD in Korea.[20] In a population-based prospective study, self-rated quality of life declined annually up to 5 years after stroke among survivors.[21] In addition, the study also found that the risk of mortality for women was significantly lower than for men, which was in line with previous studies.[22] The data from the Hispanic Established Populations revealed that men have a 27% higher risk of mortality than women.[22] A study about sex disparities in cancer mortality reported that age-adjusted mortality rates were higher among males than females for the vast majority of cancers.[23] The protective effects of estrogen for women and behavioral factors contributing to premature death for men are suggested as potential underlying mechanisms.[24]
Our results are consistent with previous studies that estimated the effect of CVD on HLE.[25-27] A study from Taiwan with a 13-year follow-up found that patients with stroke had an average loss of 8.3 quality-adjusted life-years.[25] Another cross-sectional study reported that the individual-level quality-adjusted life expectancy loss derived from stroke was 9.2 years for Americans aged 45 in 2009.[26] For those aged 65, quality-adjusted life expectancy among patients with stroke was 7.8 years lower than their peers without stroke in America.[27] Our study extended previous findings via the multistate life table method based on a prospective cohort study and provided broader estimates of longevity and the number of years in HLE and unhealthy life expectancy. In our study, the effect of CVD on total life expectancy was not as remarkably as on HLE and unhealthy life expectancy. The proportion of HLE in total life expectancy among subjects without CVD was always higher than their peers with CVD across gender and age groups. The findings imply that safe and effective interventions and treatments have reduced CVD mortality and prolonged the longevity of patients with CVD,[28] but did not significantly improve their quality of life. Considering the high prevalence of CVD in China, future clinical and public health policies focusing on the prognosis for patients with CVD to enhance their quality of life would result in significant gains for the Chinese health system. Healthy China 2030 set out the goal of improving the average life expectancy and HLE of Chinese population in 2030. Our study suggested that public health interventions for patients with CVD are critical to achieving this vision.
Compared to men, women gained a longer total life expectancy and HLE, resulting from the relatively lower mortality risk, as observed in our study. However, the proportion of HLE was lower for women in all age groups. It indicated that women had a worse quality of life despite having a higher life span, and similar sexual specificity was also reported in several studies.[27,29] One study conducted in Jiangxi of China showed that compared to men, life expectancy and self-rated HLE were longer while the quality of life was worse for women.[29] Previous research has reported that quality-adjusted life expectancy loss is commonly higher for women than for men, which is attributed to multiple chronic diseases including stroke.[27] Thus, HLE for women was higher than for men, more likely because of longer life expectancy rather than better quality of life. This suggested that future public health policies should be better directed at reducing mortality to improve life expectancy for men and enhancing the quality of life for women.
In addition, similar to other studies, the proportion of HLE decreased with age in our study.[29,30] A Chinese study showed that the proportion of self-rated life expectancy in total life expectancy continued to decline with age, regardless of gender and urban/rural location.[29] The result suggested the poor quality of life among Chinese elderly should be paid attention to. The Chinese population is aging rapidly owing to longer life expectancy coupled with a sharp decline in fertility rates.[31] Boosting the quality of life of the elderly is crucial to coping with the issue of population aging in China, where nearly one-fifth of the population is elderly.[31] Therefore, our findings had important implications for the proposal and implementation of healthy aging policies in China.
Few limitations should be considered when interpreting the results of this study. Firstly, there might exist reverse causality since the data analyses were based on an observational study with a relatively short follow-up duration. Future investigations with extended follow-up periods are warranted to strengthen the robustness of our findings. Secondly, as some information was collected via self-report, bias in this study was inevitable. However, potential bias was controlled due to favorable field implementation and the structured questionnaire with sound credibility and validity. Thirdly, there was an unavoidable ceiling effect in studies when calculating HLE and assessing the association between CVD and healthy status. Nevertheless, the VAS was used to evaluate the healthy status in this study, and the ceiling effect was less compared to other measures.[32] Last but not least, although a large sample was recruited in this study, the participants came from resource-limited areas, which may limit the generalizability of the findings.
In summary, this study indicated that CVD was significantly associated with poorer health status and lower HLE among Chinese rural population. Compared to men, women had longer life longevity and HLE, while their quality of life was worse. Bridging these health disparities is pivotal for formulating effective public health strategies in resource-limited areas. It is an important public health policy to adopt targeted measures to reduce the CVD burden and enhance the quality of life and HLE in resource-limited areas.
This study was supported by the Philosophy and Social Science Planning Project of Henan Province (No.2020BSH018), the Science and Technology Innovation Team Support Plan of Colleges and Universities in Henan Province (No.21IRTSTHN029), and the Foundation of National Key Program of Research and Development of China (No.2016YFC0900803). All authors had no conflicts of interest to disclose. The authors thank all of the participants, coordinators, and administrators for their support and help during the research.
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Figures(3) / Tables(3)
Supported by: Beijing Renhe Information Technology Co., Ltd. 
| Variables | Without CVD (n = 10,189) | With CVD (n = 1805) | P-value |
| Age, yrs | 59.86 ± 8.48 | 63.48 ± 7.61 | < 0.001 |
| Gender | 0.135 | ||
| Men | 4043 (39.68%) | 750 (41.55%) | |
| Women | 6146 (60.32%) | 1055 (58.45%) | |
| Education | < 0.001 | ||
| Low | 5070 (49.76%) | 1050 (58.17%) | |
| Medium | 3821 (37.50%) | 583 (32.30%) | |
| High | 1298 (12.74%) | 172 (9.53%) | |
| Income | 0.023 | ||
| Low | 4266 (41.87%) | 817 (45.26%) | |
| Medium | 3222 (31.62%) | 528 (29.25%) | |
| High | 2701 (26.51%) | 460 (25.48%) | |
| Data are presented as means ± SD or n (%). CVD: cardiovascular disease. | |||
DownLoad:
CSV
| HR (95% CI) | ||||
| Health to unhealthiness | Health to death | Unhealthiness to health | Unhealthiness to death | |
| Age | 1.02 (1.01–1.03) | 1.10 (1.07–1.13) | 0.99 (0.98–1.00) | 1.09 (1.06–1.12) |
| Womena | 1.11 (0.95–1.28) | 0.46 (0.31–0.67) | 1.08 (0.95–1.21) | 0.43 (0.30–0.63) |
| Education | ||||
| Low | Reference | Reference | Reference | Reference |
| Medium | 0.85 (0.72–1.00) | 0.91 (0.61–1.36) | 1.04 (0.92–1.19) | 0.75 (0.49–1.16) |
| High | 0.79 (0.63–1.00) | 0.61 (0.30–1.26) | 1.01 (0.84–1.23) | 1.04 (0.57–1.88) |
| Income | ||||
| Low | Reference | Reference | Reference | Reference |
| Medium | 0.85 (0.71–1.00) | 1.07 (0.74–1.55) | 1.18 (1.03–1.34) | 1.38 (0.94–2.02) |
| High | 0.99 (0.84–1.18) | 0.70 (0.42–1.16) | 1.07 (0.92–1.24) | 1.15 (0.73–1.80) |
| CVDb | 1.71 (1.42–2.07) | 1.15 (0.65–2.03) | 0.70 (0.60–0.82) | 1.34 (0.94–1.91) |
| aRefers to men were the reference category. bRefers to participants without CVD were the reference category. CVD: cardiovascular disease. | ||||
DownLoad:
CSV
| Life expectancy, yrs | Men | Women | |||
| Without CVD | With CVD | Without CVD | With CVD | ||
| Life expectancy | 31.14 (29.50–32.78) | 28.06 (25.81–30.31) | 38.76 (36.64–40.88) | 35.96 (33.36–38.56) | |
| Difference | Reference | −3.08 (−6.97–0.81) | Reference | −2.80 (−7.51–1.91) | |
| HLE | 23.21 (21.88–24.53) | 16.12 (14.51–17.73) | 27.31 (25.80–28.81) | 18.69 (17.13–20.25) | |
| Difference | Reference | −7.08 (−10.01–-4.15) | Reference | −8.62 (−11.68–-5.55) | |
| Unhealthy life expectancy | 7.93 (7.10–8.77) | 11.94 (10.37–13.50) | 11.45 (10.32–12.59) | 17.27 (15.18–19.36) | |
| Difference | Reference | 4.00 (1.60–6.40) | Reference | 5.82 (2.59–9.04) | |
| CVD: cardiovascular disease; HLE: healthy life expectancy. | |||||
DownLoad:
CSV
