Objective
Despite race- and sex-specific differences in risk of heart failure (HF), there are
limited data comparing the contribution of major modifiable risk factors to the population
burden of HF in each race-sex group. In addition, studies have not used a competing
risk framework to account for death in the absence of HF, to provide a more accurate
risk estimate for each risk factor. We determined the contribution of modifiable risk
factors, specifically hypertension, diabetes, obesity, current smoking, and hyperlipidemia,
to the population burden of HF, as measured by population attributable fraction (PAF),
stratified by race and sex.
Methods
A pooled cohort was created using harmonized data from six longitudinal US-based cohorts
(Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young
Adults Study, Cardiovascular Health Study, Framingham Heart Study starting from 1970,
Framingham Offspring Study, and the Multi-Ethnic Study of Atherosclerosis). Baseline
measurements of the risk factors were used to determine prevalence. Relative risk
of incident HF for each risk factor was determined using a piecewise constant hazards
model adjusted for age, education, other modifiable risk factors, and the competing
risk of non-HF death. PAF for HF was then calculated for each risk factor in each
race-sex group.
Results
Hypertension had the highest adjusted PAF in black men (28.3%, 95% CI 18.7, 36.7%)
and black women (25.8%, 95% CI 16.3, 34.2%). In contrast, obesity had the highest
adjusted PAF in white men (21.0%, 95% CI 14.6, 27.0%) and white women (17.9%, 95%
CI 12.8, 22.6%). Diabetes disproportionately contributed to HF in black women (PAF
16.4%, 95% CI 12.7, 19.9%). Current smoking made a modest contribution and hyperlipidemia
contributed minimally to HF risk. The cumulative PAF for all risk factors was highest
in black women (51.9%, 95% CI 39.3, 61.8%) and lowest in white women (39.3%, 95% CI
33.9, 44.4%).
Conclusions
Our findings extend insights into the contribution of modifiable risk factors to population
HF burden by using a competing risk model and providing race and sex-specific contemporary
PAF estimates (Figure 1). Our results highlight the growing impact of hypertension
and diabetes on HF burden, especially in black women. These results can guide public
health policies aimed at reducing the population burden of HF.
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Identification
Copyright
© 2020 Published by Elsevier Inc.
