Sex Differences in Self-Rated Health and Cardiovascular Disease Events

Importance: Clinical risk factors, lifestyle factors, and social determinants of health have established sex-specific associations with new-onset cardiovascular disease (CVD). However, little is known about the role of patient-reported health measures in individuals without CVD. Objective: To determine whether self-rated health is independently associated with the development of CVD and whether this association differs by sex. Design, Setting, and Participants: This retrospective cohort study included community-dwelling adults enrolled in the Ontario Health Study from March 1, 2009, to December 31, 2017, with no prior CVD or active cancer. Outcome ascertainment was via linkage to administrative databases for follow-up outcomes to March 31, 2024, and data were analyzed from January 5, 2025, to January 16, 2026. Exposure: Excellent, very good to good, and fair to poor self-rated health. Main Outcomes and Measures: The primary outcome was CVD events (hospitalization for myocardial infarction, stroke, heart failure, and cardiovascular death). Cause-specific hazard models with an interaction between self-rated health and sex were adjusted for age, traditional risk factors, lifestyle factors, social determinants of health, and family history of CVD. Results: The cohort consisted of 170 197 participants (104 789 [61.6%] women; median age, 48 [IQR, 36-58] years) followed up for a median of 12.1 (IQR, 12.0-12.3) years. Fair to poor health was reported in 11 661 women (11.1%) and 6381 (9.8%) men; very good to good health, in 75 819 (72.4%) women and 47 865 (73.2%) men; and excellent health, in 17 309 (16.5%) women and 11 162 (17.1%) men. After adjustment, poorer self-rated health was associated with a higher rate of CVD in both sexes. Compared with excellent self-rated health, the fully adjusted hazard ratios (HRs) for fair to poor self-rated health were 2.08 (95% CI, 1.80-2.40) in women and 1.45 (95% CI, 1.29-1.64) in men; the HRs for very good to good self-rated health compared with excellent health were 1.26 (95% CI, 1.11-1.43) in women and 1.04 (95% CI, 0.94-1.14) in men (P < .001 for interaction). Conclusions and Relevance: In this cohort study of individuals without CVD, as many as 1 in 10 rated their health as fair to poor. Fair to poor self-rated health was an independent risk factor associated with new CVD, and its relative hazard was greater in women than in men. These findings support the use of a simple self-assessment of health to aid in risk stratification in the primary prevention of CVD.