Age Influences the Effect of Risk Factors on Development of Heart Failure

Heart failure (HF) mostly affects adults 65 and older, but recent studies from Denmark and Sweden show an increase in the incidence of HF among younger adults. There is evidence the trend may be attributable to greater prevalence of HF risk factors, such as diabetes and particularly obesity, at younger ages.

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To investigate, Samantha Paniagua, MPH, biostatistician, and Jennifer Ho, MD, heart failure cardiologist and investigator at the Cardiovascular Research Center at Massachusetts General Hospital; Sanjiv J. Shah, MD, of Northwestern Medicine; and colleagues recently pooled data from three prospective, population-based studies. According to their report in The BMJ, diabetes and three other traditional risk factors confer a greater relative risk of HF in younger than in older adults.

Study Methods

The researchers analyzed data on 24,675 participants in the Framingham Heart Study in the U.S. (original and offspring cohorts), the Multi-Ethnic Study of Atherosclerosis in the U.S. and the Prevention of Renal and Vascular End-stage Disease study in the Netherlands, who did not have HF at baseline. They were stratified by age:

• 11,599 were young (≤55)
• 5,587 were middle-aged (55–64)
• 5,190 were old (65–74)
• 2,299 were elderly (≥75)

Incidence of HF

Over the median follow-up period of 12.7 years, 1,381 participants developed new-onset HF. The rate was 1% among young participants and 18% among elderly participants. Interestingly, 32% of participants who developed HF before age 65 had HF with preserved ejection fraction, often considered a disease of older people.

Predictors of HF

Hypertension, diabetes, current smoking and previous myocardial infarction (MI) conferred a greater relative risk of HF in younger participants than older participants (P for interaction <0.05 for all):

• Hypertension—HR, 3.02 for younger participants vs. 2.19 for old participants vs. 1.4 for elderly participants compared with those without hypertension
• Diabetes—3.86 vs. 1.98 vs. 1.66
• Current smoking—2.58 vs. 1.43 vs. 1.21
• Previous MI—3.30 vs. 2.92 vs. 1.35

Age did not modify the association of body mass index or obesity with HF.

The absolute risk of HF with each risk factor was lower in younger participants and increased with age. For example, among younger people, the incidence of HF was 6.0 events per 1,000 participant-years for those with diabetes and 0.8 for those without. Among elderly participants, the incidence of HF was greater, but the difference between those with and without diabetes was less pronounced (26.7 vs. 19.7 events per 1,000 participant-years).

Population-attributable Risk of HF

The total percentage of HF cases that could be attributed to traditional risk factors—male sex, hypertension, obesity, diabetes, smoking, previous MI or previous atrial fibrillation—was higher in younger participants (75%) than in elderly participants (53%).

Opportunities to Improve Care

Risk factor modification should be considered for younger adults who are at high risk of developing HF. Because of the lower absolute risk of HF in younger adults for each risk factor, the number needed to treat will be larger than in older people.

However, the higher population-attributable risk suggests a larger proportion of the risk of HF in younger adults will be sensitive to intervention. In addition, the potential number of disease-free life-years saved will be greater in younger people.

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