Risk Factors for Congestive Heart Failure in US Men and Women: NHANES I Epidemiologic Follow-up Study
Abstract
BACKGROUND: The incidence of congestive heart failure (CHF) has been increasing steadily in the United States during the past 2 decades. We studied risk factors for CHF and their corresponding attributable risk in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. PARTICIPANTS AND METHODS: A total of 13 643 men and women without a history of CHF at baseline examination were included in this prospective cohort study. Risk factors were measured using standard methods between 1971 and 1975. Incidence of CHF was assessed using medical records and death certificates obtained between 1982 and 1984 and in 1986, 1987, and 1992. RESULTS: During average follow-up of 19 years, 1382 CHF cases were documented. Incidence of CHF was positively and significantly associated with male sex (relative risk [RR], 1.24; 95% confidence interval [CI], 1.10-1.39; P<.001; population attributable risk [PAR], 8.9%), less than a high school education (RR, 1.22; 95% CI, 1.04-1.42; P =.01; PAR, 8.9%), low physical activity (RR, 1.23; 95% CI, 1.09-1.38; P<.001; PAR, 9.2%), cigarette smoking (RR, 1.59; 95% CI, 1.39-1.83; P<.001; PAR, 17.1%), overweight (RR, 1.30; 95% CI, 1.12-1.52; P =.001; PAR, 8.0%), hypertension (RR, 1.40; 95% CI, 1.24-1.59; P<.001; PAR, 10.1%), diabetes (RR, 1.85; 95% CI, 1.51-2.28; P<.001; PAR, 3.1%), valvular heart disease (RR, 1.46; 95% CI, 1.17-1.82; P =.001; PAR, 2.2%), and coronary heart disease (RR, 8.11; 95% CI, 6.95-9.46; P<.001; PAR, 61.6%). CONCLUSIONS: Male sex, less education, physical inactivity, cigarette smoking, overweight, diabetes, hypertension, valvular heart disease, and coronary heart disease are all independent risk factors for CHF. More than 60% of the CHF that occurs in the US general population might be attributable to coronary heart disease.
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In observational studies (NHANES and ARIC), the incidence of HF in patients with T2DM was higher than in those without T2DM, with hazard ratios of 1.85 and 3.54.
“Similarly, in observational studies (NHANES 64 and ARIC 65 ), the incidence of HF in patients with T2DM was higher than in those without T2DM, with the corresponding hazard ratios (HRs) of 1.85 and 3.54.”
From Type 2 diabetes mellitus and heart failure: A position statement from the Heart Failure Association of the European Society of Cardiology (2018) · cites this paper as [64]
In human studies, conclusions are not firm regarding the direct role of obesity in the development of heart failure.
“However, in human studies, we mainly have to rely on cross-sectional data at this time, and the conclusions are not firm regarding the direct role of obesity in the development of heart failure (14, 46, 132, 376).”
From Cardiac remodeling in obesity (2008) · cites this paper as [132]
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BackgroundInfluentialDifferences in the Incidence of Congestive Heart Failure by Ethnicity
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“Also, although the CHF incidence rates are lower in women without RA than in men without RA, as would be expected based on reports from the general population (36), the difference in CHF incidence rates between the sexes seems to be attenuated in patients with RA.”
BackgroundThe Empirical Foundations of Telemedicine Interventions for Chronic Disease Management
Bashshur, R. L., Shannon, G. W., Smith, B. R., Alverson, D. C., Antoniotti, N., Barsan, W. G., Bashshur, N., Brown, E. M., Coye, M. J., Doarn, C. R., et al. (2014) · Telemedicine and e-Health · doi:10.1089/tmj.2014.9981 · Cited by 452 · see citing works
“In 2001, He et al. 37 observed that ‘‘during the past several decades, the incidence of and mortality from coronary heart disease have been continuously declining.”
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M. L., Konstam, M. A., MANCINI, D. M., Michl, K., et al. (2005) · Circulation · doi:10.1161/circulationaha.105.167587 · Cited by 461 · see citing works
“The presence of clinical diabetes mellitus markedly increases the likelihood of HF in patients without structural heart disease (29) and adversely affects the outcomes of patients with established HF (38,39).”
Reduced Kidney Function as a Risk Factor for Incident Heart Failure
Köttgen, A., Russell, S. D., Loehr, L. R., Crainiceanu, C. M., Rosamond, W. D., Chang, P. P., Chambless, L. E., & Coresh, J. (2007) · Journal of the American Society of Nephrology · doi:10.1681/asn.2006101159 · Cited by 459 · see citing works
“0% of our study population experienced incident HF hospitalization/HF death during the course of follow-up corresponds well to data from other large US prospective studies of community-dwelling individuals of comparable age (38,39).”
ResultHFSA 2006 Comprehensive Heart Failure Practice Guideline: Introduction and Table of Contents
Heart Failure Society of America (2006) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2005.11.005 · Cited by 447 · see citing works
Pathophysiology of heart failure
Schwinger, R. H. G. (2021) · Cardiovascular Diagnosis and Therapy · doi:10.21037/cdt-20-302 · Cited by 435 · see citing works
Administration of Cardiac Stem Cells in Patients With Ischemic Cardiomyopathy: The SCIPIO Trial
Chugh, A. R., Beache, G. M., Loughran, J. H., Mewton, N., Elmore, J. B., Kajstura, J., Pappas, P., Tatooles, A. J., Stoddard, M. F., Lima, J. A. C., et al. (2012) · Circulation · doi:10.1161/circulationaha.112.092627 · Cited by 432 · see citing works
“6 EF units) 12 months later, accompanied by a parallel increase in regional contractile function in the infarcted regions that were infused with CSCs; (4) this improvement in LV function was coupled with a concomitant decrease in infarct size, which was consistently observed with three different CMR methods (reduction…”
ResultInfluentialAtherton, J. J., Sindone, A. P., Pasquale, C. G. D., Driscoll, A. L., Macdonald, P. S., Hopper, I., Kistler, P. M., Briffa, T. G., Wong, J., Abhayaratna, W. P., et al. (2018) · Heart Lung and Circulation · doi:10.1016/j.hlc.2018.06.1042 · Cited by 431 · see citing works
“The recommendation for smoking cessation is based on observational studies reporting an association between smoking and the risk of developing cardiovascular disease and heart failure [36].”
BackgroundEffects of Tobacco Smoking on Cardiovascular Disease
Kondo, T., Nakano, Y., Adachi, S., & Murohara, T. (2019) · Circulation Journal · doi:10.1253/circj.cj-19-0323 · Cited by 425 · see citing works
Waging war on physical inactivity: using modern molecular ammunition against an ancient enemy.
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“(97), physical inactivity can account for 9.”
BackgroundInfluentialBody Mass Index and Prognosis in Patients With Chronic Heart Failure
Kenchaiah, S., Pocock, S., Wang, D., Finn, P. V., Zornoff, L. A. M., Skali, H., Pfeffer, M. A., Yusuf, S., Swedberg, K. B., Michelson, E. L., et al. (2007) · Circulation · doi:10.1161/circulationaha.106.679779 · Cited by 409 · see citing works
“In multivariable analyses evaluating the shape of the association between BMI and all-cause death, linear plus quadratic BMI terms had the best goodness of fit ( 2 [2] 54.”
Bazzano, L., He, J., Muntner, P., Vupputuri, S. X., & Whelton, P. K. (2003) · Annals of Internal Medicine · doi:10.7326/0003-4819-138-11-200306030-00010 · Cited by 406 · see citing works
“Cigarette smoking is a major modifiable risk factor for cardiovascular disease, including coronary heart disease, stroke, peripheral vascular disease, and congestive heart failure (3, 4).”
BackgroundSelf-citationPop‐Busui, R., Januzzi, J. L., Bruemmer, D., Butalia, S., Green, J. B., Horton, W. B., Knight, C. M., Levi, M., Rasouli, N., & Richardson, C. R. (2022) · Diabetes Care · doi:10.2337/dci22-0014 · Cited by 424 · see citing works
“Results of several longitudinal observational studies of population-based cohorts with diabetes and prediabetes, including Framingham Heart Study (8), First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (9), Reykjavik Study (10), and the Scottish diabetes mellitus register (…”
BackgroundHao, G., Wang, X., Chen, Z., Zhang, L., Zhang, Y., Wei, B.-Q., Zheng, C., Kang, Y., Jiang, L., Zhu, Z., et al. (2019) · European Journal of Heart Failure · doi:10.1002/ejhf.1629 · Cited by 399 · see citing works
10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2024</i>
American Diabetes Association Professional Practice Committee, ElSayed, N. A., Aleppo, G., Bannuru, R. R., Bruemmer, D., Collins, B. S., Das, S. R., Ekhlaspour, L., Hilliard, M. E., Johnson, E. L., et al. (2024) · Diabetes Care · doi:10.2337/dc24-s010 · Cited by 438 · see citing works
Relationship between physical activity, body mass index, and risk of heart failure
Pandey, A., LaMonte, M., Klein, L., Ayers, C., Psaty, B. M., Eaton, C. B., Allen, N. B., de Lemos, J. A., Carnethon, M., Greenland, P., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2016.11.081 · Cited by 398 · see citing works
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“HFpEF is preceded by chronic comorbidities, such as hypertension, type 2 diabetes mellitus (T2DM), obesity, and renal insufficiency, whereas HFrEF is often preceded by the acute or chronic loss of cardiomyocytes due to ischemia, a genetic mutation, myocarditis, or valvular disease [5,6].”
BackgroundBody Mass Index, Abdominal Fatness, and Heart Failure Incidence and Mortality
Aune, D., Sen, A., Norat, T., Janszky, I., Romundstad, P., Tonstad, S., & VATTEN, L. J. (2016) · Circulation · doi:10.1161/circulationaha.115.016801 · Cited by 381 · see citing works
Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care
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Leening, M. J. G., Ferket, B. S., Steyerberg, E. W., Kavousi, M., Deckers, J. W., Nieboer, D., Heeringa, J., Portegies, M. L. P., Hofman, A., Ikram, M. A., et al. (2014) · BMJ · doi:10.1136/bmj.g5992 · Cited by 352 · see citing works
Insulin-Resistant Cardiomyopathy
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Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women
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Bariatric surgery and cardiovascular outcomes: a systematic review
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“Data from the first National Health and Nutrition Examination Survey (NHANES I) indicate that coronary disease had the largest population attributable risk for heart failure at 62% compared to the other risk factors analyzed (hypertension, obesity, diabetes and smoking) [100].”
BackgroundCardiovascular Disease Projections in the United States Based on the 2020 Census Estimates
Mohebi, R., Chen, C., Ibrahim, N. E., McCarthy, C. P., Gaggin, H. K., Singer, D. E., Hyle, E. P., Wasfy, J. H., & Januzzi, J. L. (2022) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2022.05.033 · Cited by 319 · see citing works
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M. L., Konstam, M. A., MANCINI, D. M., Michl, K., et al. (2005) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2005.08.023 · Cited by 308 · see citing works
Dupre, M. E. (2007) · Journal of Health and Social Behavior · doi:10.1177/002214650704800101 · Cited by 298 · see citing works
MicroRNAs in cardiovascular disease: from pathogenesis to prevention and treatment
Quiat, D., & Olson, E. N. (2013) · Journal of Clinical Investigation · doi:10.1172/jci62876 · Cited by 302 · see citing works
“Patients with hypertension have an increased lifetime risk of cardiovascular disease and heart failure (15, 16), and those with high-normal blood pressure similarly demonstrate a heightened risk (17).”
Risk Factors for Heart Failure: A Population-Based Case-Control Study
Dunlay, S. M., Weston, S. A., Jacobsen, S. J., & Roger, V. L. (2009) · The American Journal of Medicine · doi:10.1016/j.amjmed.2009.04.022 · Cited by 302 · see citing works
Nutrition, metabolism, and the complex pathophysiology of cachexia in chronic heart failure
von Haehling, S., Doehner, W., & Anker, S. D. (2006) · Cardiovascular Research · doi:10.1016/j.cardiores.2006.08.018 · Cited by 299 · see citing works
“Diabetes mellitus has been shown to be a predisposing factor for the development of CHF [73,74].”
BackgroundMurphy, N. F., MacIntyre, K., Stewart, S., Hart, C. L., Hole, D., & McMurray, J. J. V. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehi506 · Cited by 298 · see citing works
Diabetes in heart failure: prevalence and impact on outcome in the population
From, A. M., Leibson, C. L., Bursi, F., Redfield, M. M., Weston, S. A., Jacobsen, S. J., Rodeheffer, R. J., & Roger, V. L. (2006) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.05.024 · Cited by 295 · see citing works
Doehner, W., Rauchhaus, M., Ponikowski, P., Godsland, I. F., von Haehling, S., Okonko, D. O., Leyva, F., Proudler, A. J., Coats, A. J. S., & Anker, S. D. (2005) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2005.02.093 · Cited by 294 · see citing works
Heart Failure and Socioeconomic Status: Accumulating Evidence of Inequality
Hawkins, N. M., Jhund, P. S., McMurray, J. J. V., & Capewell, S. (2012) · European Journal of Heart Failure · doi:10.1093/eurjhf/hfr168 · Cited by 295 · see citing works
“01].(29) Analysis of 11 022 individuals in the Atherosclerosis Risk in Communities (ARIC) study constructed different composite socioeconomic scores for each life epoch.”
BackgroundOhkuma, T., Komorita, Y., Peters, S. A. E., & Woodward, M. (2019) · Diabetologia · doi:10.1007/s00125-019-4926-x · Cited by 279 · see citing works
Dose–Response Relationship Between Physical Activity and Risk of Heart Failure: A Meta-Analysis
Pandey, A., Garg, S., Khunger, M., Darden, D., Ayers, C., Kumbhani, D. J., Mayo, H. G., de Lemos, J. A., & Berry, J. D. (2015) · Circulation · doi:10.1161/circulationaha.115.015853 · Cited by 272 · see citing works
Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline
Heart Failure Society of America (2010) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2010.04.005 · Cited by 274 · see citing works
Epidemiology, Pathophysiology, and Prognosis of Heart Failure in Older Adults
Dharmarajan, K., & Rich, M. W. (2017) · Heart Failure Clinics · doi:10.1016/j.hfc.2017.02.001 · Cited by 277 · see citing works
Daniels, L. B., Clopton, P., Bhalla, V., Krishnaswamy, P., Nowak, R. M., McCord, J., Hollander, J. E., Duc, P., Omland, T., Storrow, A. B., et al. (2006) · American Heart Journal · doi:10.1016/j.ahj.2005.10.011 · Cited by 271 · see citing works
Metabolic and Vascular Effect of the Mediterranean Diet
Tuttolomondo, A., Simonetta, I., Daidone, M., Mogavero, A., Ortello, A., & Pinto, A. V. (2019) · International Journal of Molecular Sciences · doi:10.3390/ijms20194716 · Cited by 269 · see citing works
“Among the dietary regimens that have been studied by these authors, there are the Mediterranean diet (MD) and Dietary Approach to Stop Hypertension (DASH); the DASH diet is one of the recommended dietary models, because it can influence blood pressure, which is positively correlated with functional changes in the card…”
Factors Associated With Hypertension Control in the General Population of the United States
He, J., Muntner, P., Chen, J., Roccella, E. J., Streiffer, R. H., & Whelton, P. K. (2002) · Archives of Internal Medicine · doi:10.1001/archinte.162.9.1051 · Cited by 261 · see citing works
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Incident Heart Failure Prediction in the Elderly
Butler, J., Kalogeropoulos, A. P., Georgiopoulou, V. V., BeLue, R., Rodondi, N., García, M., Bauer, D. C., Satterfield, S., Smith, A. L., Vaccarino, V., et al. (2008) · Circulation Heart Failure · doi:10.1161/circheartfailure.108.768457 · Cited by 257 · see citing works
“Heart rate, bpm 65 (11) 68 (12) 65 (11) 0.”
Resistin, Adiponectin, and Risk of Heart Failure
Frankel, D. S., Vasan, R. S., D’Agostino, R. B., Benjamin, E. J., Levy, D. A., Wang, T. J., & Meigs, J. B. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.07.073 · Cited by 256 · see citing works
“Numerous risk factors ave been well established, including age, coronary heart isease (CHD), hypertension, valvular heart disease, left entricular hypertrophy, diabetes, and obesity (3).”
BackgroundBody Mass Index and Vigorous Physical Activity and the Risk of Heart Failure Among Men
Kenchaiah, S., Sesso, H. D., & Gaziano, J. M. (2008) · Circulation · doi:10.1161/circulationaha.108.807289 · Cited by 249 · see citing works
Lifetime Risk for Heart Failure Among White and Black Americans
Huffman, M. D., Berry, J. D., Ning, H., Dyer, A. R., Garside, D. B., Cai, X., Daviglus, M. L., & Lloyd‐Jones, D. M. (2013) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2013.01.022 · Cited by 245 · see citing works
Obesity cardiomyopathy: pathogenesis and pathophysiology
Wong, C. Y., & Marwick, T. H. (2007) · Nature Clinical Practice Cardiovascular Medicine · doi:10.1038/ncpcardio0943 · Cited by 243 · see citing works
Understanding the Epidemic of Heart Failure: Past, Present, and Future
Dunlay, S. M., & Roger, V. L. (2014) · Current Heart Failure Reports · doi:10.1007/s11897-014-0220-x · Cited by 238 · see citing works
Chronic Heart Failure: Contemporary Diagnosis and Management
Ramani, G. V., Uber, P. A., & Mehra, M. R. (2010) · Mayo Clinic Proceedings · doi:10.4065/mcp.2009.0494 · Cited by 234 · see citing works
“Coronary artery disease (CAD) accounts for the vast majority of cases of systolic heart failure in the United States, followed by hypertensive and dilated cardiomyopathies.(10) In the acute setting of newly diagnosed cardiomyopathy, the exclusion of underlying CAD and potential “at-risk” myocardium that might benefit…”
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Effects of Bariatric Surgery on Cardiovascular Function
Ashrafian, H., le Roux, C. W., Darzi, A. W., & Athanasiou, T. (2008) · Circulation · doi:10.1161/circulationaha.107.721027 · Cited by 228 · see citing works
Chronic obstructive pulmonary disease and cardiovascular disease
Bhatt, S. P., & Dransfield, M. T. (2013) · Translational research · doi:10.1016/j.trsl.2013.05.001 · Cited by 229 · see citing works
Diabetes, left ventricular systolic dysfunction, and chronic heart failure
MacDonald, M. R., Petrie, M. C., Hawkins, N. M., Petrie, J. R., Fisher, M., McKelvie, R., Aguilar, D., Krum, H., & McMurray, J. J. V. (2008) · European Heart Journal · doi:10.1093/eurheartj/ehn156 · Cited by 227 · see citing works
“19), respectively.(10,11) In Iceland, the age-adjusted odds ratio (OR) for development of HF was 2.”
BackgroundMortality Associated With Heart Failure After Myocardial Infarction
Gerber, Y., Weston, S. A., Enriquez-Sarano, M. L., Berardi, C., Chamberlain, A. M., Manemann, S. M., Jiang, R., Dunlay, S. M., & Roger, V. L. (2015) · Circulation Heart Failure · doi:10.1161/circheartfailure.115.002460 · Cited by 221 · see citing works
Impact of obesity on cardiovascular disease
Zalesin, K. C., Franklin, B. A., Miller, W. M., Peterson, E. D., & McCullough, P. A. (2011) · Medical Clinics of North America · doi:10.1016/j.mcna.2011.06.005 · Cited by 231 · see citing works
“These pathologic changes may stem from the associated increases in blood volume, cardiac output, stroke volume, and filling pressures, culminating in left ventricular hypertrophy and dilation that may induce diastolic dysfunction through impairment in diastolic relaxation.26 The established metabolic consequences of o…”
InfluentialCardiovascular Health Disparities
Davis, A. M., Vinci, L. M., Okwuosa, T. M., Chase, A., & Huang, E. S. (2007) · Medical Care Research and Review · doi:10.1177/1077558707305416 · Cited by 218 · see citing works
Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes
Morris, P. B., Ference, B. A., Jahangir, E., Feldman, D. N., Ryan, J. J., Bahrami, H., El‐Chami, M. F., Bhakta, S., Winchester, D. E., Al-Mallah, M. H., et al. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2015.07.037 · Cited by 230 · see citing works
“Compared with lifelong nonsmokers, both prior smoking and current smoking increase the risk of developing heart failure by as much as 33% to 93% (90,91).”
BackgroundThe Predictive Capacity of Personal Genome Sequencing
Roberts, N. J., Vogelstein, J. T., Parmigiani, G., Kinzler, K. W., Vogelstein, B., & Velculescu, V. E. (2012) · Science Translational Medicine · doi:10.1126/scitranslmed.3003380 · Cited by 216 · see citing works
- Authors
- He, J., Ogden, L. G., Bazzano, L. A., Vupputuri, S., Loria, C., & Whelton, P. K.
- Affiliations
- Tulane University (US)
- Corresponding author
- He, Jiang
- Venue
- Archives of Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2001-04-09
- Volume
- 161
- Issue
- 7
- Pages
- 996
- ISSN
- 0003-9926 (ISSN-L)
- OpenAlex
- W2025266397
- Cited by
- 1,172
- References
- 24
- Citations by year
- 2026: 14 · 2025: 29 · 2024: 38 · 2023: 39 · 2022: 43 · 2021: 51 · 2020: 54 · 2019: 60 · 2018: 61 · 2017: 56 · 2016: 55 · 2015: 61 · 2014: 67 · 2013: 63 · 2012: 66
- FWCI
- 17.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Archives of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5r03hl061954-02, 5r01hl060300-05)
- National Heart, Lung, and Blood Institute (R03 HL-61954, R01HL60300)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- congestive heart failure, risk factors, attributable risk, incidence, sex differences, educational attainment, physical inactivity, cigarette smoking, overweight, hypertension, diabetes mellitus, valvular heart disease, coronary artery disease, coronary revascularization, coronary angioplasty, coronary artery bypass grafting, coronary angiography
- MeSH terms
- Aged, Aged, 80 and over, Coronary Disease, Death Certificates, Educational Status, Female, Follow-Up Studies, Heart Failure, Heart Valve Diseases, Humans, Hypertension, Male, Middle Aged, Nutrition Surveys, Obesity, Risk Factors, Smoking, United States, Exercise, Incidence, Proportional Hazards Models, Sex Distribution, Diabetes Complications
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