Cardiovascular health trajectories before age 50 and subsequent cardiovascular disease, mortality, and CVD-free survival: implications for predictive, preventive, and personalized medicine in a Chinese community cohort.

OBJECTIVES: To examine how distinct cardiovascular health (CVH) trajectories before age 50, estimated by Life's Essential 8 (LE8), a composite measure comprising four behavioral and four biological components, relate to incident cardiovascular disease (CVD), all-cause mortality, and CVD-free survival in a Chinese population, from a predictive, preventive, and personalized medicine (PPPM) perspective. METHODS: We included 39,305 CVD-free participants (77.3% men) from the Kailuan Cohort with at least three LE8 assessments before age 50. Group-based trajectory modelling over 6-12 years was used to identify LE8 patterns, with model selection based on the lowest Bayesian Information Criterion, average posterior probabilities > 0.70, and a minimum of 5% of the sample per trajectory. Multivariable Cox models estimated hazard ratios (HRs) for CVD and all-cause mortality, and restricted mean survival time (RMST) at age 45 was calculated to quantify CVD-free survival. RESULTS: During a median follow-up of 6.05 years, 1,254 CVD events and 917 deaths occurred. Five trajectories were identified: Low-stable, Moderate-increasing, Moderate-decreasing, Moderate-stable, and High-stable. Compared with Moderate-stable, High-stable was associated with lower risks of CVD (HR 0.42, 95% CI 0.30-0.58, P < 0.001) and mortality (HR 0.67, 95% CI 0.50-0.90, P = 0.007). Using Moderate-decreasing as reference, Moderate-increasing showed a 24% lower CVD risk (HR 0.76, 95% CI 0.60-0.96, P = 0.028) despite initial lower scores. Both sex and age modified these associations (P for interaction < 0.001 and 0.003, respectively), with women and individuals maintaining high LE8 between ages 45 and 50 showing greater cardiovascular protection. RMST ranged from 18.06 years in Low-stable to 19.72 years in High-stable, a difference of 1.66 CVD-free years (95% CI 1.37-1.96, P < 0.001). CONCLUSIONS: CVH trajectories before age 50 predicted subsequent CVD risk and survival. Sustained or improving trajectories were associated with lower CVD risk and longer CVD-free survival. From a PPPM perspective, early identification and modification of adverse CVH trajectories may enable proactive intervention before irreversible vascular damage occurs. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at https://doi.org/10.1007/s13167-026-00459-2.