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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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“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]
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“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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2013 ACCF/AHA Guideline for the Management of Heart Failure
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“The presence of clinical diabetes mellitus markedly increases the likelihood of developing HF in patients without structural heart disease (100) and adversely affects the outcomes of patients with established HF (101,102).”
BackgroundHeart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., Das, S. R., de Ferranti, S., Després, J.-P., Fullerton, H. J., et al. (2016) · Circulation · doi:10.1161/cir.0000000000000350 · Cited by 6,596
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2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
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WRITING COMMITTEE MEMBERS, Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M., Konstam, M. A., Mancini, D. M., et al. (2005) · Circulation · doi:10.1161/circulationaha.105.167586 · Cited by 2,251
2013 ACCF/AHA Guideline for the Management of Heart Failure
Yancy, C. W., Jessup, M. L., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T. B., Januzzi, J. L., et al. (2013) · Circulation · doi:10.1161/cir.0b013e31829e8776 · Cited by 2,234
“The presence of clinical diabetes mellitus markedly increases the likelihood of developing HF in patients without structural heart disease (100) and adversely affects the outcomes of patients with established HF (101,102).”
Epidemiology and risk profile of heart failure
Bui, A. L., Horwich, T. B., & Fonarow, G. C. (2011) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2010.165 · Cited by 2,077
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“In the first National Health and Nutrition Examination Survey (NHANES I), coronary disease had the largest population attributable risk for HF at 62% compared with the other risk factors analyzed (hypertension, obesity, diabetes mellitus, and smoking).(129) The attributable risk of hypertension was 10% and that of dia…”
BackgroundGuidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary
Rydén, L., Standl, E., Bartnik, M., den Berghe, G. V., Betteridge, J. D., de Boer, M., Cosentino, F., Jönsson, B., Laakso, M., Malmberg, K., et al. (2007) · European Heart Journal · doi:10.1093/eurheartj/ehl260 · Cited by 1,644
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HFSA 2010 Comprehensive Heart Failure Practice Guideline
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“2% of the PAR.(32) Conversely, data from African populations attribute”
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“However, these PAR estimates are comparable with or higher than PAR estimates in the 10–35% range reported for cardiovascular disease based on commonly recognized risk factors such as hypertension,((26,27)) high cholesterol levels,((28)) and lipid profiles.”
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“It is likely that disparities in obesity and smoking in early life influence disparities in CVD in later life among lesbians and bisexual women.(57,58)”
BackgroundEvidence-Based Guidelines for Cardiovascular Disease Prevention in Women
Mosca, L. J., Appel, L. J., Benjamin, E. J., Berra, K. A., Chandra‐Strobos, N., Fabunmi, R. P., Grady, D. G., Haan, C. K., Hayes, S. N., Judelson, D. R., et al. (2004) · Circulation · doi:10.1161/01.cir.0000114834.85476.81 · Cited by 918
A Contemporary Appraisal of the Heart Failure Epidemic in Olmsted County, Minnesota, 2000 to 2010
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Thiazolidinedione Use, Fluid Retention, and Congestive Heart Failure
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“Risk factors for CHF, such as coronary artery disease and hypertension, frequently occur in patients with diabetes (1,9).”
BackgroundSex differences in heart failure
Lam, C. S. P., Arnott, C. G., Beale, A. L., Chandramouli, C., Hilfiker‐Kleiner, D., Kaye, D. M., Ky, B., Santema, B. T., Sliwa, K. S., & Voors, A. A. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz835 · Cited by 873
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“However, in human studies, we mainly have to rely on crosssectional 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).”
BackgroundObesity and Cardiovascular Disease
Poirier, P., Giles, T. D., Bray, G. A., Hong, Y., Stern, J. S., Pi-Sunyer, X., & Eckel, R. H. (2006) · Arteriosclerosis Thrombosis and Vascular Biology · doi:10.1161/01.atv.0000216787.85457.f3 · Cited by 748
Heart Failure Incidence and Survival (from the Atherosclerosis Risk in Communities Study)
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“63 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.”
InfluentialEzekowitz, J. A., O'Meara, E., McDonald, M. A., Abrams, H., Chan, M., Ducharme, A., Giannetti, N., Grzeslo, A., Hamilton, P. G., Heckman, G. A., et al. (2017) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2017.08.022 · Cited by 676
Executive Summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline
Heart Failure Society of America (2006) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2005.12.001 · Cited by 676
Dunlay, S. M., Givertz, M. M., Aguilar, D., Allen, L. A., Chan, M., Desai, A. S., Deswal, A., Dickson, V. V., Kosiborod, M. N., Lekavich, C. L., et al. (2019) · Circulation · doi:10.1161/cir.0000000000000691 · Cited by 639
Depression and anxiety in heart failure: a review.
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Thiazolidinedione Use, Fluid Retention, and Congestive Heart Failure
Nesto, R. W., Bell, D. S. H., Bonow, R. O., Fonseca, V. A., Grundy, S. M., Horton, E. S., Winter, M. L., Porte, D., Semenkovich, C. F., Smith, S. E., et al. (2004) · Diabetes Care · doi:10.2337/diacare.27.1.256 · Cited by 585
Insulin Resistance and Risk of Congestive Heart Failure
Ingelsson, E., Sundström, J., Ärnlöv, J., Zethelius, B., & Lind, L. (2005) · JAMA · doi:10.1001/jama.294.3.334 · Cited by 569
“Obesity is a more recently described risk factor for CHF3,6,7 and is also associated with changes in left ventricular geometry and function.14 Abdominal obesity is closely associated with insulin resistance and manifest diabetes.15 We hence hypothesized that insulin resistance may predict CHF and may provide the link…”
BackgroundInfluentialHeart Failure and Chronic Obstructive Pulmonary Disease: Diagnostic Pitfalls and Epidemiology
Hawkins, N. M., Petrie, M. C., Jhund, P. S., Chalmers, G. W., Dunn, F. G., & McMurray, J. J. V. (2009) · European Journal of Heart Failure · doi:10.1093/eurjhf/hfn013 · Cited by 587
“Inflammation is itself implicated in the pathogenesis of HF. Incidence of HF was greater in Framingham subjects with elevated Creactive protein and cytokine levels, independent of established risk factors [hazard ratio (HR) 4.07; 95% CI 1.34–12.37; P ¼ 0.01].100 However, two population studies found no evidence of a r…”
BackgroundInfluentialDifferences in the Incidence of Congestive Heart Failure by Ethnicity
Bahrami, H., Kronmal, R. A., Bluemke, D. A., Olson, J., Shea, S., Liu, K., Burke, G. L., & Lima, J. A. C. (2008) · Archives of Internal Medicine · doi:10.1001/archinte.168.19.2138 · Cited by 570
“These studies suggest that the relative importance of different genetic and environmental risk factors for CHF as well as the mechanisms or pathways of circulatory impairment leading to symptomatic CHF vary among different racial/ethnic groups.(8,9) Given the high incidence of heart failure over the human lifetime(10,…”
BackgroundSchocken, D. D., Benjamin, E. J., Fonarow, G. C., Krumholz, H. M., Levy, D. A., Mensah, G. A., Narula, J., Stuart‐Shor, E., Young, J. B., & Hong, Y. (2008) · Circulation · doi:10.1161/circulationaha.107.188965 · Cited by 562
Fonarow, G. C., Srikanthan, P., Costanzo, M. R., Cintron, G. B., & Lopatin, M. (2007) · American Heart Journal · doi:10.1016/j.ahj.2006.09.007 · Cited by 512
Bozkurt, B., Aguilar, D. A., Deswal, A. M., Dunbar, S. B., Francis, G. S., Horwich, T. B., Jessup, M. L., Kosiborod, M., Pritchett, A. M., Ramasubbu, K., et al. (2016) · Circulation · doi:10.1161/cir.0000000000000450 · Cited by 556
The risk of congestive heart failure in rheumatoid arthritis: A population‐based study over 46 years
Nicola, P., Kremers, H. M., Roger, V. L., Jacobsen, S. J., Crowson, C. S., Ballman, K. V., & Gabriel, S. E. (2005) · Arthritis & Rheumatism · doi:10.1002/art.20855 · Cited by 484
“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
“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 469
“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 467
“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 450
10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2024
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Pathophysiology of heart failure
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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
“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 439
“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 441
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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 414
“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
“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 442
“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
Relationship between physical activity, body mass index, and risk of heart failure
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Metadata
- 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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