Risk Factors and Predictors of Heart Failure: from Incidence to Prognosis

Background: Heart failure (HF) is a major public health problem affecting at least 26 million people worldwide and one of the leading causes of disability and death. Aims: To identify characteristics associated with improved or worsened prognosis in patients with established HF and to study factors associated with higher risk for the incidence of HF in the general population. Methods and Results: This thesis consists of four papers. Paper I was designed to study the impact of different dose levels of beta-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) on long-term mortality in elderly patients with HF with reduced ejection fraction (EF). The study cohort included 184 HF patients aged ≥80 years with EF ≤40%. The target ACEI/ARB dose was associated with reduced all-cause mortality compared to 3mg/L at age 50 years were associated with higher odds of incident HF. Paper IV studied and compared risk factors and incidence of HF in middle-aged men born 30 years apart. The study population consisted of a sample of men born in 1943 (described in Paper III) and a similar sample of men born in 1913. The impact of different factors on the risk of developing HF was examined. Eighty men born in 1913 (9.4%) and 42 men born in 1943 (5.3%) developed HF during follow-up with an adjusted hazard ratio comparing the two cohorts of 0.46 (95% confidence interval 0.28–0.74, p=0.002). In both cohorts, higher body mass index, higher diastolic blood pressure, treatment for hypertension, and onset of atrial fibrillation, ischemic heart disease, or diabetes mellitus were associated with higher risk of HF. Higher heart rate was associated with an increased risk only in men born in 1913, whereas higher systolic blood pressure, smoking, higher glucose, higher cholesterol, and physical inactivity were associated with an increased HF risk in men born in 1943. The relative importance of atrial fibrillation as a risk factor decreased, whereas that of systolic blood pressure and physical inactivity increased in men born in 1943 compared with men born in 1913. Conclusions: Titration to the target ACEI/ARB dose is beneficial with respect to mortality in elderly patients with HF. Non-cardiac comorbidities contribute significantly to mortality in both HF phenotypes with some notable differences. NT-proBNP and hs-CRP have a predictive value for the incidence of HF in middle-aged men. The incidence of HF in middle-aged men has decreased during the past 30 years and, in the meantime, the risk profile for HF has also changed

Non-cardiac comorbidities and mortality in patients with heart failure with reduced vs. preserved ejection fraction: a study using the Swedish Heart Failure Registry

Background Heart failure (HF) and non-cardiac comorbidities often coexist and are known to have an adverse effect on outcome. However, the prevalence and prognostic impact of non-cardiac comorbidities in patients with HF with reduced ejection fraction (HFrEF) vs. those with preserved (HFpEF) remain inadequately studied. Methods and results We used data from the Swedish Heart Failure Registry from 2000 to 2012. HFrEF was defined as EF amp;lt; 50% and HFpEF as EF amp;gt;= 50%. Of 31 344 patients available for analysis, 79.3% (n = 24 856) had HFrEF and 20.7% (n = 6 488) HFpEF. The outcome was all-cause mortality. We examined the association between ten non-cardiac comorbidities and mortality and its interaction with EF using adjusted hazard ratio (HR). Stroke, anemia, gout and cancer had a similar impact on mortality in both phenotypes, whereas diabetes (HR 1.57, 95% confidence interval [CI] [1.50-1.65] vs. HR 1.39 95% CI [1.27-1.51], p = 0.0002), renal failure (HR 1.65, 95% CI [1.57-1.73] vs. HR 1.44, 95% CI [1.32-1.57], p = 0.003) and liver disease (HR 2.13, 95% CI [1.83-2.47] vs. HR 1.42, 95% CI [1.09-1.85] p = 0.02) had a higher impact in the HFrEF patients. Moreover, pulmonary disease (HR 1.46, 95% CI [1.40-1.53] vs. HR 1.66 95% CI [1.54-1.80], p = 0.007) was more prominent in the HFpEF patients. Sleep apnea was not associated with worse prognosis in either group. No significant variation was found in the impact over the 12-year study period. Conclusions Non-cardiac comorbidities contribute significantly but differently to mortality, both in HFrEF and HFpEF. No significant variation was found in the impact over the 12-year study period. These results emphasize the importance of including the management of comorbidities as a part of a standardized heart failure care in both HF phenotypes.Funding Agencies|Swedish Heart-Lung Foundation [20170453]; Vastra Gotalands region [ALFGBG-721961]; University of Gothenburg [ALFGBG-721961]</p