In 2022, the American Heart Association (AHA) introduced an updated framework for assessing and quantifying cardiovascular health (CVH): the Life’s Essential 8 (LE8), which builds upon the earlier Life’s Simple 7.1 The LE8 offers a comprehensive evaluation of eight evidence-based CVH metrics, including four lifestyle behaviors (healthy diet, physical activity, non-smoking, and healthy sleep) and four physiological health factors (healthy body weight, and optimal levels of blood lipids, blood glucose, and blood pressure).1 This updated model represents a significant advancement in the paradigm of CVH assessment.2

The LE8 framework has been widely adopted in clinical and public health research, with growing evidence supporting its association with cardiovascular outcomes, dementia and all-cause mortality in diverse populations.2, 3, 4 Its multidimensional structure reflects a shift toward a more holistic view of health, integrating both lifestyle choices and physiological indicators.1 However, despite its comprehensiveness, the LE8 does not currently incorporate psychosocial or social environmental dimensions, which are increasingly recognized as central determinants of cardiovascular and overall health.5,6

One such factor is psychological health measures, a construct that encompasses depression, anxiety, social integration, and stress.7,8 Importantly, the LE8 model does not incorporate this dimension, even though it has been consistently recognized as a crucial determinant of health. Psychological health refers to an individual’s emotional state, cognitive functioning, and capacity to maintain positive social relationships and a sense of belonging.9 A robust body of evidence demonstrates that poor psychological health, including low social integration, is independently associated with increased risk of cardiovascular morbidity and mortality,10, 11, 12 as well as other adverse outcomes such as cognitive decline,13 depression,14,15 and reduced quality of life.16 Mechanistically, psychological health has been linked to chronic stress, inflammatory pathways, and decreased adherence to medical recommendations and healthy behaviors,17 factors that could interact with some components of the LE8.

A previous study8 attempted to incorporate depression as a proxy for psychological health within the LE8 score; however, this approach remains limited, as this dimension cannot be fully captured by a single variable. While the inclusion of depression represents an important step toward acknowledging the role of psychological health in cardiovascular outcomes, much more remains to be done. As has been emphasized, psychological health extends beyond depression and encompasses a broader set of factors, including anxiety, stress, social integration, and overall emotional well-being. Including different indicators of psychological health could improve the predictive validity of LE8 and contribute to a more equitable approach to CVH assessment by recognizing that cardiovascular health is not solely a function of individual behavior and biology but also shaped by social context.

This study assessed the longitudinal association between a modified version of the Life´s Crucial 9 (LC9) score and all-cause mortality in the general Chilean population and examined the potential added value of incorporating psychological health (including depression and social integration) into the LE8 framework as an additional dimension to enhance its predictive power for mortality.