*2.2. CVH Score*

We defined the CVH score to evaluate seven modifiable risk factors following LS7 (Figure 2). The total CVH score ranged from 0 (poor) to 14 (ideal) and was calculated as the sum of the individual scores on seven modifiable risk factors (patterns of eating schedule, obesity, physical activity, smoking status, blood pressure, total cholesterol, and blood glucose). Patterns of eating schedule was scored by three answers from the questionnaire (eating faster than ordinary, eating dinner within 2 h before sleep at least three times per week, and eating snacks after dinner at least three times per week). We scored 2 points (ideal) if answers applied to none of the three questions, 0 points (poor) if the answers applied to all three questions, and 1 point if the answers applied to one or two questions. Obesity was scored by body mass index (BMI). We scored 2 points if BMI was less than 25 kg/m2, 0 points if BMI was 30 kg/m2 or greater, and 1point if BMI was between 25 and 29.9 kg/m2. Physical activity was scored by three answers from the questionnaire (exercising for 30 min per day at least two times per week over 1 year, walking or exercising 1 h per day on a daily basis, walking faster than people of the same sex and age). We scored 2 points (ideal) if the answers applied to all three questions, 0 points (poor) if the answers applied to none of the questions, and 1 point if the answers applied to one or two questions. Smoking status was scored as 2 points for noncurrent smoker and 0 points for current smoker. Blood pressure was scored as 2 points if systolic blood pressure (SBP) was <120 mmHg and diastolic blood pressure (DBP) was <80 mmHg without antihypertensive drugs. It was scored as 0 points if SBP was greater than or equal to 140 mmHg or DBP was greater than or equal to 90 mmHg, and 1 point if it was not applied to either condition. Total cholesterol (TC) was scored as 2 points if the TC was <200 mg/dL without lipid-lowering drugs, 0 points if the TC was greater than or equal to 240 mg/dL, and 1 point if it was not applied to either condition. Blood glucose was scored as 2 points if the fasting blood glucose (FBG) was less than 100 mg/dL without oral hyperglycemic drugs or insulin, 0 points if the FBG was greater than or equal to 126 mg/dL, and 1 point if it was not applied to either condition.


**Figure 2.** Cardiovascular health (CVH) scoring. The CVH score included seven modifiable components (patterns of eating schedule, obesity, physical activity, smoking status, blood pressure, total cholesterol, and blood glucose). We referred to the data of health checkups from questionnaires, anthropometric measurements, and blood tests. BMI, body mass index.

#### *2.3. Statistical Analysis*

Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as number and percentage. Differences in the baseline characteristics were compared using Student's *t*-test for parametric data and the Mann–Whitney *U* test for nonparametric data. Categorical variables were compared using the chi-square or Fisher's exact tests. Cox proportional hazard models were used to identify independent associations with the outcomes.

A *p*-value of <0.05 was considered statistically significant. We used R statistical software for all analyses.

#### *2.4. Ethical Considerations*

The Ethics Committee of Kanazawa Medical Association (16000003) and Kanazawa University (2019-223) approved this study. The research was conducted in accordance with the Declaration of Helsinki (2008) by the World Medical Association. All procedures were performed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975 (as revised in 2008).

#### **3. Results**

#### *3.1. Study Characteristics*

Table 1 shows the basic characteristics of this study population. A total of 37,523 participants (mean age 72.3 ± 9.6 years, 36.8% men, and mean total CVH score 9 ± 1) were finally analyzed. During the median follow-up period of 5 years (interquartile range 3.99–5.02), 703 cases of incident AF were observed. There were significant differences in age, sex, SBP, BMI, history of coronary artery disease, stroke, alcohol intake, and estimated glomerular filtration rate (eGFR) between the AF group and the non-AF group. The AF group was significantly older, had a significantly higher proportion of men, and had a significantly greater BMI than the non-AF group. The AF group had a more frequent history of heart disease and stroke. The AF group had a more frequent regular alcohol intake and lower eGFR.

**Table 1.** Basic characteristics of the study population. Regular alcohol intake meant drinking every day. SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; eGFR, estimated glomerular filtration rate.


#### *3.2. Total CVH Score*

Total CVH scores were normally distributed and ranged from 1 to 14, with a mean value of 9.25 ± 1.66. We classified a total CVH score of 1–9 as the poor CVH group (N = 20,177), a total CVH score of 10 as the intermediate CVH group (N = 8819), and a total CVH score of 11–14 as the ideal CVH group (N = 8527), based on the number of individuals according to the distribution. (Figure 3A). We observed 420, 126, and 157 AF incidents among the poor (85,230 person-years), intermediate (37,534 person-years), and ideal (38,349 person-years) groups, respectively (Figure 3B). The incident rate of AF per 1000 was 4.9, 4.1, and 3.6 in the poor, intermediate, and ideal groups, respectively. Compared with the poor CVH group, the ideal CVH group had a significantly lower risk for incident AF (chi-squared test, *p* = 0.0002).

**Figure 3.** (**A**) Histogram of total cardiovascular health (CVH) score. The horizontal axis shows the total CVH score, and the vertical axis shows the number of participants. We classified a total CVH score of 1–9 as the poor CVH group (red), a total CVH score of 10 as the intermediate CVH group (yellow), and a total CVH score of 11–14 as the ideal CVH group (blue). (**B**) Incident rate of atrial fibrillation by three groups of total CVH scores.
