Interventions Using Heart Age for Cardiovascular Disease Risk Communication: Systematic Review of Psychological, Behavioral, and Clinical Effects

Abstract

Background Cardiovascular disease (CVD) risk communication is a challenge for clinical practice, where physicians find it difficult to explain the absolute risk of a CVD event to patients with varying health literacy. Converting the probability to heart age is increasingly used to promote lifestyle change, but a rapid review of biological age interventions found no clear evidence that they motivate behavior change. Objective In this review, we aim to identify the content and effects of heart age interventions. Methods We conducted a systematic review of studies presenting heart age interventions to adults for CVD risk communication in April 2020 (later updated in March 2021). The Johanna Briggs risk of bias assessment tool was applied to randomized studies. Behavior change techniques described in the intervention methods were coded. Results From a total of 7926 results, 16 eligible studies were identified; these included 5 randomized web-based experiments, 5 randomized clinical trials, 2 mixed methods studies with quantitative outcomes, and 4 studies with qualitative analysis. Direct comparisons between heart age and absolute risk in the 5 web-based experiments, comprising 5514 consumers, found that heart age increased positive or negative emotional responses (4/5 studies), increased risk perception (4/5 studies; but not necessarily more accurate) and recall (4/4 studies), reduced credibility (2/3 studies), and generally had no effect on lifestyle intentions (4/5 studies). One study compared heart age and absolute risk to fitness age and found reduced lifestyle intentions for fitness age. Heart age combined with additional strategies (eg, in-person or phone counseling) in applied settings for 9582 patients improved risk control (eg, reduced cholesterol levels and absolute risk) compared with usual care in most trials (4/5 studies) up to 1 year. However, clinical outcomes were no different when directly compared with absolute risk (1/1 study). Mixed methods studies identified consultation time and content as important outcomes in actual consultations using heart age tools. There were differences between people receiving an older heart age result and those receiving a younger or equal to current heart age result. The heart age interventions included a wide range of behavior change techniques, and conclusions were sometimes biased in favor of heart age with insufficient supporting evidence. The risk of bias assessment indicated issues with all randomized clinical trials. Conclusions The findings of this review provide little evidence that heart age motivates lifestyle behavior change more than absolute risk, but either format can improve clinical outcomes when combined with other behavior change strategies. The label for the heart age concept can affect outcomes and should be pretested with the intended audience. Future research should consider consultation time and differentiate between results of older and younger heart age. International Registered Report Identifier (IRRID) NPRR2-10.1101/2020.05.03.20089938

The Impact of Health Literacy–Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing

“…This study also replicated several heart age effects found in reviews of previous research, in that it leads to a more negative emotional response, increased gist and verbatim knowledge of heart age, but not percentage risk, and reduced credibility, but is neutral for lifestyle change overall [ 60 , 61 ]. Our subgroup analyses suggest that more nuanced study designs are required to better understand the effects of heart age.…”

Predicted heart age profile across 41 countries: A cross-sectional study of nationally representative surveys in six world regions

“…Emerging evidence indicates that PHA could have potential benefits in clinical practice. 15 For example, the concept of (high) absolute cardiovascular risk is better understood by patients when expressed as PHA. 15 Furthermore, communicating patients’ absolute cardiovascular risk as PHA elicits more emotional impact and risk perception than absolute risk predictions.…”

“…We selected the Framingham risk score 7 to be consistent with previous research, as previous studies of the clinical usefulness 15 and distribution of PHA across multiple countries (including LMICs) 18 , 19 , 23 , 24 have used the Framingham risk score. We used the following variables to compute PHA in people without history of CVD 7 : sex, age (years), SBP, BMI, treatment for hypertension, smoking and diabetes status.…”

“… 14 Simple concepts like predicted heart age (PHA) have emerged as potentially useful tools to simplify communicating the absolute CVD risk. 15 An individual's PHA represents the chronological age of someone with similar absolute CVD risk but with normal risk factors. 7 That is, if modifiable risk factors are elevated, the individual's PHA would be higher than his/her chronological age.…”

“… 16 Recent evidence indicates that PHA has the potential to reduce risk factor levels when combined with other techniques (e.g., counseling) to communicate CVD risk. 15 Nevertheless, few studies have characterized PHA across multiple populations, 17 , 18 and only one focused on six LMICs. 19 In addition, PHA has been proposed as a tool to inform the need for medication to prevent CVD in clinical guidelines.…”