Action Points

Avoiding three key risk factors for heart failure between the ages of 45 and 55 lowered later-life heart failure risk by as much as 86%.

According to a study online in JACC: Heart Failure, men who reached the age of 45 without becoming obese or developing hypertension or diabetes lived an average of 10.6 years longer free of heart failure, while women who reached age 45 without any of the cardiovascular risk factors lived, on average, 14.9 years longer without heart failure.

The retrospective study is the first to quantify the impact of mid-life avoidance of heart failure risk factors with heart failure-free survival times later in life, and the researchers concluded that the new information may help clinicians better convey this to patients.

"Quantification of heart failure-free survival may be a novel, useful tool for risk communication to patients for the purpose of promoting cardiovascular health," wrote John Wilkins, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues.

The findings add to the understanding of how individual risk factors in middle age affect incident heart failure risk late in life, Wilkins told MedPage Today. "The effect size of primordial prevention is massive. Quantifying this risk really illustrates the importance of lifestyle interventions to prevent the onset of diabetes, hypertension, and obesity. Avoiding these risk factors can pay huge dividends in terms of reducing heart failure risk later in life."

When the researchers conducted a pooled, individual-level analysis sampling from communities across the United States, they found that at the ages of 45 and 55, respectively, 53.2% and 43.7% of participants had none of the three risk factors.

The sampling included data from four cohort trials: Framingham Heart, Framingham Offspring, Chicago Heart Association Detection Project in Industry, and the Atherosclerosis Risk in Communities studies.

Competing risk-adjusted Cox models, as well as a modified Kaplan-Meir estimator and Irwin's restricted mean were used to estimate the association between the absence of risk factors at mid-life and incident heart failure, heart failure-free survival, and overall survival.

For participants at age 45, with over 516,537 person-years of follow-up, 1,677 incident heart failure events occurred. At an index age of 55, during 502,252 person years of follow-up, 2,976 cases of incident heart failure were identified.

Diabetes was found to have a strong association with shorter heart failure-free survival: those without diabetes lived, on average, between 8.6 and 10.6 years longer without heart failure.

White and black participants without any of the three risk factors at age 45 lived, respectively, 12.4 and 12.9 years longer without heart failure, and similar trends were seen for the index age of 55.

"The benefits of risk factor avoidance and primordial prevention were consistent and substantial in black and white participants," the researchers wrote. "These data suggest that a public health strategy focused on primordial prevention of risk factors in blacks early on in the life course may reduce disparities in heart failure incidence and prevalence."

In an accompanying editorial, Thomas J. Wang, MD, director of the Division of Cardiovascular Medicine of Vanderbilt University and physician-in-chief of the Vanderbilt Heart and Vascular Institute in Nashville, Tenn., wrote that efforts to shift the focus in heart failure to prevention were bolstered by the introduction, more than a decade ago, of the American College of Cardiology and American Heart Association's two preclinical heart failure stages.

Stage A describes patients with major risk factors for heart failure such as diabetes and heart disease without myocardial infarction, and Stage B includes patients with structural heart disease but no overt symptoms of heart failure.

"The concept of heart failure-free survival adds another dimension to lifetime risk estimates by taking into account the timing of disease onset," Wang wrote. "Because healthy individuals live longer overall, they have more years exposed to the possibility of getting heart failure, which may increase lifetime risk estimates. However, when heart failure does occur in such individuals, it typically does so at a later age. The ability to enjoy more years free of disease is more important for many individuals than simply living longer."

Study limitations cited by the authors and Wang included the differing methods for ascertaining heart failure across the four studies and the inability to distinguish between heart failure with reduced ejection fraction, and heart failure with preserved ejection fraction.

But Wang noted that despite these limitations, the study findings highlight a new way to think about heart failure risk: "Such a perspective is particularly valuable when one considers another result embedded in the data: for almost all of the clinical subgroups, the interval between heart failure diagnosis and death was short (≤2 years)," he said. "Although advancing the care of patients with established heart failure remains an important objective, figuring out how to maximize the number of years free of disease is just as critical."

This research was funded in part by the National Heart, Lung, and Blood Institute and Northwestern University Feinberg School of Medicine.

The researchers reported having no relevant financial relationships with industry related to the study.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner