American Journal of Preventive Cardiology · Nov 2026
Lifestyle factors and the incidence of premature major adverse cardiovascular events in the VA Million Veteran Program
By Nguyen XMT, Salvati LR, Li Y et al.
Background Premature cardiovascular disease remains an important cause of mortality. Among US Veterans specifically, the association of combined low-risk lifestyle factors with premature major adverse cardiovascular events (MACE) is not yet characterized. Methods We analyzed 71,968 Million Veteran Program participants free of CVD at baseline, including 45,820 males aged 21–54 years and 26,148 females aged 19–64 years, with complete data on 8 low-risk lifestyle factors: higher-quality diet, physical activity, not smoking, restful sleep, no excessive alcohol intake, good stress management, social connection and support, and no opioid use disorder. Premature MACE was defined as nonfatal stroke, nonfatal myocardial infarction (MI), or CVD death before age 55 in males or 65 in females. Results During 358,835 person-years of follow-up, 1,161 premature MACE cases occurred, including 481 MI, 467 stroke, and 238 CVD deaths. All 8 low-risk lifestyle factors were associated with lower premature MACE risk. After multivariable adjustment, higher low-risk lifestyle scores were associated with lower risk of premature MACE [hazard ratio (HR) comparing 7–8 versus 0–2 factors = 0.37; 95% confidence interval (CI): 0.27–0.52; P trend <0.0001], MI [HR 0.45; 95% CI: 0.27–0.75], stroke [HR 0.54; 95% CI: 0.33–0.87], and CVD death [HR 0.18; 95% CI: 0.07–0.46]. Associations were consistent across sex, age, race, income, and obesity subgroups. Conclusions Greater adherence to a low-risk lifestyle was associated with a lower risk of premature MACE in a dose-response manner among US Veterans.