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Prevention Strategies in Heart Failure

List of key references prepared and regularly updated by the Heart Failure Association (HFA)



Relations of lipid concentrations to heart failure incidence: the Framingham Heart Study.

Velagaleti RS, Massaro J, Vasan RS, Robins SJ, Kannel WB, Levy D.
Circulation 2009;120(23):2345-51.

Synopsis:
The authors evaluated dyslipidemia-specific population burden of heart failure (HF) based on the data of 6860 Framingham Heart Study participants (mean age, 44 years, 54% women) free of baseline coronary heart disease during a mean follow-up of 26 years.  Even after an adjustment of clinical covariates and interim myocardial infarction, elevated non–HDL-C and decreased HDL-C were associated with increased risk of a HF of a new onset.  In particular, 15% of HF cases were attributable to low HDL-C concentrations.

Commentary:
Previous studies have identified dyslipidaemia as a risk factor of myocardial infarction and the subsequent development of symptomatic heart failure.  However, the presented study has demonstrated that high non-HDL-C and reduced HDL-C predict the occurrence of heart failure, irrespectively of the association with myocardial infarction.  It is suggested that the burden of HF might be reduced by targeting abnormal lipid concentrations for treatment.


Relation between modifiable lifestyle factors and lifetime risk of heart failure.

Djoussé L, Driver JA, Gaziano JM.
JAMA 2009; 302; 394-400

Synopsis:
Among 20 900 middle-aged healthy men from the Physicians’ Health Study I, the authors assessed prospectively the association between six modifiable lifestyle factors (body weight, smoking, exercise, alcohol intake, consumption of breakfast cereals, and consumption of fruits and vegetables) and the remaining lifetime risk of heart failure.  During a mean follow-up of 22.4 years, 1200 cases of de novo heart failure (5.7%) occurred.  Overall, the lifetime risk of heart failure was 13.8% at age 40 years, remained constant in men who survived free of heart failure through age of 70 years, and at age of 80 years the lifetime risk for heart failure reached 10.6%.  Healthy lifestyle habits (normal body weight, never smoking, regular exercise, moderate alcohol intake, consumption of breakfast cereal, consumption of fruits and vegetables) were individually and jointly associated with the lower lifetime risk of heart failure.  There was an inverse and graded association between the number of healthy lifestyle factors and lifetime risk of heart failure with the highest risk in men adhering to none of 6 lifestyle factors and the lowest risk in men adhering to 4 or more desirable factors.

Commentary:
The NHANES I Epidemiologic Follow-up Study identified unhealthy lifestyle habits (such as cigarette smoking and physical inactivity) as independent risk factors for heart failure.  The lifetime risk of heart failure at age 40 years is approximately 1 in 5 in the general population, however to date it has been unclear whether an adherence to healthy lifestyle factors could reduce a lifetime risk of heart failure.  The current study demonstrates that healthy lifestyle has a substantial favourable impact on the preventing of heart failure in a large group of healthy middle-aged men.  These data reinforces the concept that healthy lifestyle reduces the long-term cardiovascular risk, and emphasizes the need for incorporation of simple behaviours based on adherence to healthy lifestyle in prevention strategies against heart failure. 

Racial differences in incident heart failure among young adults.

Bibbins-Domingo K, Pletcher MJ, Lin F, Vittinghoff E, Gardin JM, Arynchyn A, Lewis CE, Williams OD, Hulley SB.N Engl J Med. 2009 Mar 19;360(12):1179-90.

Synopsis:
The demonstrated racial differences in the incidence of heart failure over a 20-year period among 5115 blacks and whites of both sexes aged 18-30 years age at baseline.  Heart failure was 20 times more likely to occur before the age of 50 years among blacks than whites.  The predictors of heart failure occurrence among blacks included: higher diastolic blood pressure, obesity, lower HDL, chronic kidney disease, depressed left ventricular systolic function, but not a history of myocardial infarction, drug or alcohol use.

Commentary:
The study provided evidence on racial differences in the incidence of heart failure and identified risk factors that prospectively may predict the development of heart failure.  The presented data are of the great importance for cardiovascular prevention programs worldwide.
 

Consistency with the DASH diet and incidence of heart failure.

Levitan EB, Wolk A, Mittleman MA.
Arch Intern Med. 2009 May 11;169(9):851-7.

Synopsis:
The paper demonstrates that during the prospective 7-year observation, the DASH diet (diet effectively reducing blood pressure) in a large general population comprising 36019 women aged 48-83 years without baseline heart failure, diabetes mellitus, or a history of myocardial infarction could lower an incidence of heart failure.

Commentary:
The DASH (Dietary Approaches to Stop Hypertension) diet is characterized by high intakes of fruits, vegetables, low-fat diary products, and whole grains, and has been previously shown to reduce blood pressure effectively.  The possible mechanisms of its beneficial effects may be related to a reduction in LDL cholesterol and fatty acids levels, estrogenic effects of phytochemicals, and a decrease in oxidative stress.  The presented study due to its observational nature could not prove a causal relationship, however this is the first study clearly showing that a change in lifestyle (i.e. diet) can modify the natural history of cardiovascular disease and prevent the development of heart failure.