Risk Factors


 Risk Factors


An understanding of the risk factors linked to the development of heart failure is important for the  advancement of interventions aimed at prevention. Epidemiologic and clinical research have identified a number of preexistent medical conditions that increase an individual’s risk of developing heart failure. See Figure 1 (adapted from Dunlay et al.1). A study conducted at the Mayo Clinic in Rochester, Minnesota, in the U.S.A. by Dunlay et al.1 between 1979 and 2002 indicates that coronary artery disease and hypertension are responsible for the largest proportion of new HF cases. Risk factors include:

·         Advancing age is a significant risk factor in the development of heart failure. Aging is associated with extensive physiologic changes that contribute substantially to reducing cardiac reserve and predisposing elderly people to heart failure.2

1.      Structural changes

2.      Functional changes

3.      Cardioprotection and repair processes

4.      Increased cardiovascular disease incidence and prevalence

5.      Systemic disease/other organ systems

·         Coronary artery disease may be responsible for more than 60% of the newly diagnosed cases of HF in the United States. It occurs when cholesterol deposits buildup in the heart’s arteries, a process known as atherosclerosis.  Coronary artery disease is characterized by a thickening and hardening of the small and medium-sized arteries that supply blood to the heart. This results in a progressive narrowing of these blood vessels with reduced blood flow and oxygen delivery to the heart muscle that they supply. When the obstruction to blood flow is significant, acute clinical manifestations such as unstable angina, myocardial infarction, and sudden death can occur. Myocardial infarction compromises cardiac function by reducing muscle contractility. The muscle tissue in the infarcted area dies and is replaced by scar tissue which is no longer able to contribute to the pumping activity of the heart. As a result, overall cardiac performance is reduced. Furthermore, the remaining healthy heart muscle must compensate for the loss of function and this additional workload can initiate changes that eventually lead to heart failure. Additionally, almost any type of heart disease can eventually lead to heart failure.3

·         Hypertension is a chronic elevation of systemic blood pressure. High blood pressure forces the heart to work harder to pump blood to the rest of the body. Over time, the heart muscle will weaken and will not be able to pump blood efficiently. In the coronary vessels, hypertension can exacerbate other conditions such as atherosclerosis that diminish vessel size and restrict blood flow. This increases the risk of coronary occlusion and the likelihood of a myocardial infarction.3 Hypertension is associated with a smaller relative risk of development of heart failure than that associated with coronary heart disease but is a greater contributing cause to the overall population burden of heart failure due to its greater prevalence.4;5

·         Arrhythmia, or dysrhythmia, is any variation from the normal rhythm of the heartbeat. Arrhythmias range in severity from periodic “missed” or rapid beats to serious rhythm abnormalities that impair the pumping ability of the heart, contributing to the development of heart failure and death.8

·         Diabetes increases the risk of both coronary artery disease and hypertension. The drugs rosiglitazone (Avandia) and pioglitazone (Actos), both prescribed for the treatment of diabetes, have been reported to increase the risk of developing heart failure.3;6 It is not recommended that you stop taking these medications without first consulting your doctor.

·         Sleep apnea is a potentially serious sleeping disorder characterized by recurrent episodes of partial and/or total upper airway collapse and obstruction during sleeping. Clinical evidence supports an association between sleep apnea with an increased risk of hypertension, coronary artery disease, cardiac rhythm abnormalities (arrhythmias), myocardial infarction, and heart failure.7

·         Heart valve disease. The heart has four chambers (right atrium, right ventricle, left atrium and left ventricle) and four valves (tricuspid valve, pulmonary valve, mitral valve and aortic valve).  The valves open to allow blood to move through or out of the heart, and then close to prevent the blood from flowing backward through the valve. As the valvular disease worsens, the heart has to work harder than normal to pump blood  to the rest of the body, potentially leading to heart failure.

·         Congenital heart defects where structural malformations of the heart’s arteries, chambers or valves place an extra burden on the healthy parts of the heart to pump blood through the heart, which in turn may lead to heart failure.8

·         Alcohol abuse. The relationship between alcoholism and cardiovascular disease has long been recognized. Malnutrition is common in chronic alcoholics where alcohol can replace the intake of adequate calories and nutrients in the diet.9

·         Chemotherapy related cardiac dysfunction is a well-recognized complication of many anti-cancer drugs. The clinical manifestations arising from the use of anti-tumor drugs can range from asymptomatic subclinical abnormalites to life-threatening events such as myocardial infarction and heart failure.10 The early identification of cardiac damage is critical.11 Cardiac complications may appear during or shortly after the cessation of treatment (within days or weeks), or they may not become evident for months, and sometimes years following the completion of chemotherapy.10 The restoration of cardiac function in no uncertain terms depends on the amount of time elapsed from the end of chemotherapy to the initiation of standard heart failure therapy.11

Prevalence of Risk Factors HF


  • Obesity substantially increases the risk for hypertension, coronary artery disease and diabetes: medical conditions that place people at risk for developing heart failure.12;13
  • Non-steroidal anti-inflammatory drugs (NSAIDs) are extensively used in the United States and throughout the rest of the world. They are primarily used to alleviate pain, but their long-term use is associated with a number of serious side effects. A new study recently published in the Lancet,14 investigated the cardiovascular and gastrointestinal side effects associated with the daily treatment of cyclo-oxygenase 2 (COX2) inhibitors, such as celecoxib and entricoxib, or high dose daily regimens of ibuprofen (2,400 mg), diclofenac (150 mg), naproxen (1,000 mg). All NSAIDs except naproxen increased the risk of myocardial infarction, including ibuprofen, COX2 inhibitors, and diclofenac. The authors of the study also revealed that the risk of hospitalization due to heart failure was approximately doubled by all NSAIDs. All NSAID regimens, especially naproxen, increased upper gastrointestinal complications, including bleeds, perforation and obstruction.

  • Viral infections of the heart have been known to be associated with acute myocarditis, inflammatory dilated cardiomyopathy and heart failure for over 100 years. The viruses most commonly involved are the enteroviruses, coxsackie A and B viruses and echoviruses. Other viruses commonly implicated in the infection of healthy individuals include influenza virus types A and B, hepatitis A virus and varicella-zoster virus. In addition, other types of viruses, most notably, cytomegalovirus and herpes simplex virus, can lead to heart failure in immunocompromised individuals.15
  • Tobacco use is the most important preventable cause of disease and premature death in the United States. Current smokers have a significantly higher risk for the development of heart failure compared with ex-smokers and non-smokers.3 Smoking increases your risk of developing coronary artery disease and having a heart attack, which permanently damages the heart muscle and often leads to heart failure. Smoking exerts its detrimental effects on the cardiovascular system via several mechanism, including endothelial dysfunction (increasing blood pressure), alterations in lipoprotein metabolism (decreasing high-density cholesterol levels), and the induction of a prothrombotic state (increasing the tendency for the blood to clot).16

Reference List

1.   Dunlay SM, Weston SA, Jacobsen SJ, Roger VrL. Risk Factors for Heart Failure: A Population-Based Case-Control Study. The American Journal of Medicine 2009;122:1023-1028.

2.   Strait JB, Lakatta EG. Aging-Associated Cardiovascular Changes and Their Relationship to Heart Failure. Heart Failure Clinics 2012;8:143-164.

3.   Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nature Reviews Cardiology 2011;8:30-41.

4.   Heidenreich PA, Albert NM, Allen LA et al. Forecasting the Impact of Heart Failure in the United States: A Policy Statement From the American Heart Association. Circulation: Heart Failure 2013;6:606-619.

5.   Georgiopoulou V, Kalogeropoulos A, Butler J. Heart Failure in Hypertension. Drugs 2012;72:1373-1398.

6.   Khalaf KI, Taegtmeyer H. After avandia – The use of antidiabetic drugs in patients with heart failure. Texas Heart Institute Journal 2012;39:174-178.

7.   Silver MA. Depression and heart failure: An overview of what we know and donGÇÖt know. Cleveland Clinic Journal of Medicine 2010;77:S7-S11.

8.   Clark JB, Pauliks LB, Myers JL, Undar A. Mechanical circulatory support for end-stage heart failure in repaired and palliated congenital heart disease. Current Cardiology Reviews 20131;7:102-109.

9.   Riegel B, Moser DK, Anker SD et al. State of the Science. Circulation 2009;120:1141-1163.

10.   Berardi R, Caramanti M, Savini A et al. State of the art for cardiotoxicity due to chemotherapy and to targeted therapies: A literature review [abstract]. Crit Rev Oncol Hematol 2013;

11.   Colombo A, Meroni C, Cipolla C, Cardinale D. Managing Cardiotoxicity of Chemotherapy. Curr Treat Options Cardio Med 20131-15.

12.   Zamora E, Lup+¦n J, de Antonio M et al. The obesity paradox in heart failure: Is etiology a key factor? International Journal of Cardiology 2011

13.   Bittner V, Johnson BD, Zineh I et al. The triglyceride/high-density lipoprotein cholesterol ratio predicts all-cause mortality in women with suspected myocardial ischemia: A Report From the Women’s Ischemia Syndrome Evaluation (WISE). American Heart Journal 2009;157:548-555.

14.    Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. The Lancet 2013

15.   Calabrese F, Thiene G. Myocarditis and inflammatory cardiomyopathy: microbiological and molecular biological aspects. Cardiovasc Res 2003;60:11-25.

16.   Frey P, Waters DD. Tobacco smoke and cardiovascular risk: a call for continued efforts to reduce exposure. Current Opinion in Cardiology 2011;26:424-428.