Preventing Heart Failure One Risk Factor at a Time

Data have shown that in mid-life, having fewer risk factors for HF is associated with lower rates of cardiovascular disease and improved survival. Drs Ahmad and Wilkins, and colleagues sought to quantify the association between absence of HF risk factors in mid-life, survival free from HF, and overall survival in the Cardiovascular Disease Lifetime Risk Pooling study.2

A pooled analysis was performed on data from 4 cohort studies to evaluate the relationship between HF risk factors—hypertension, diabetes, and obesity—and the risk of developing HF. A total of 19,249 and 23,915 participants at the index ages 45 and 55 years, respectively, were included and follow-up data was obtained through 95 years of age or oldest age.2

Participants with no hypertension, obesity, or diabetes at age 45 years had a 73% to 86% lower risk of developing heart failure than participants with all 3 risk factors at the same index age. On average, participants without HF risk factors at age 45 years lived up to 38 years without incident HF, which was 3 to 15 years longer than participants with 1 or more risk factors. Similar trends were found for participants at index age 55 years.2

Preventing HF Risk Factors: Challenges and Possible Solutions

While the results of these studies are unlikely to change clinical practice recommendations, they provide information that supports efforts to prevent HF risk factors. “Our findings provide clinicians with a novel way to discuss the importance of adopting a healthy lifestyle in order to avoid the development of hypertension, diabetes, and obesity and to live longer without HF,” Dr Ahmad said.

According to Dr Wilkins, early screening for HF risk factors, such as identifying individuals with pre-hypertension or insulin resistance, may be warranted. “It’s really important to counsel those people to modify their lifestyles in order to normalize their blood sugar or blood pressure, so that they have a lower risk of developing hypertension or diabetes in the upcoming years,” he said.

Endocrinologist Eliot Brinton, MD of the Utah Lipid Center of Salt Lake City, agreed with Dr Wilkins. “Many endocrinologists are already actively involved with diagnosing prediabetes to prevent full-blown diabetes,” he said in an interview with Cardiology Advisor. “These study findings should add momentum to that movement.”

However, efforts to prevent obesity are not as robust as they are for preventing diabetes. “We need to get on that bandwagon of obesity prevention both in pediatric and younger adult patients, but we don’t have much by way of research into the mechanisms nor do we have many good and feasible treatments,” Dr Brinton said.

While endocrinologists are strong proponents of diabetes prevention, only half of family physicians follow national guidelines for prediabetes screening, even though prediabetes is estimated to affect 1 out of 3 adults in the United States.5 “Way too often, endocrinologists are diagnosing patients with prediabetes and diabetes when they are already in the hospital for cardiac disease,” Sara Lubitz, MD, an endocrinologist at Rutgers Robert Wood Johnson Medical School in New Jersey, told Cardiology Advisor.

According to Dr Lubitz, several factors may contribute to low rates of prediabetes screening. “Some critics say that widespread prediabetes screening leads to over-diagnosing, over-testing, and over-medicating,” she said. In addition, Dr Lubitz noted that the studies that showed weight loss prevented progression from prediabetes to diabetes also involved multidisciplinary teams that provided intensive training in diet, physical activity, and behavior modifications. “It is not enough to give someone a scary diagnosis and tell them to go lose weight,” she added.

“Multidisciplinary care seem to be the best model for managing patients with complicated chronic diseases like HF,” Dr Lubitz said. “At our institution, endocrinologists work closely with a team of cardiologists, pharmacists, nutritionists, mid-level practitioners, and physiatrists.”

Dr Brinton also recognizes that the multidisciplinary approach is important for prediabetes and obesity prevention and management. But there is a significant unmet need when it comes to putting this approach into action, especially among the HF population. “None of us refer patients to nutritionists or weight loss specialists as often as we should because managed care usually won’t pay for their services,” he said.

Dr Brinton also noted that even though the ideal scenario involves collaboration among cardiologists, endocrinologists, and primary care physicians, implementation of an integrated care model is often difficult to achieve on a large scale due to cost and logistical constraints.

According to Dr Brinton, more data is needed regarding effective models of collaboration between specialists, although we can try to implement such an approach even while we are gathering those data. “While multi-disciplinary collaboration is the ideal, however, at this point in many healthcare settings it may be more practical to spend limited resources to empower individual clinicians in each specialty, and their patients, by providing them with the tools and incentives they need to prevent and manage HF risk factors,” he said.

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  1. Mozaffarian D, Benjamin EJ, Go AS, et al; for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38-360. doi: 10.1161/CIR.0000000000000350.
  2. Ahmad FS, Ning H, Rich JD, et al. Hypertension, obesity, diabetes, and heart failure-free survival: the Cardiovascular Disease Lifetime Risk Pooling Project. JACC Heart Fail. 2016;4(12):911-919. doi: 10.1016/j.jchf.2016.08.001.
  3. Huffman MD, Berry JD, Ning H, et al. Lifetime risk for heart failure among white and black Americans: Cardiovascular Lifetime Risk Pooling Project. J Am Coll Cardiol. 2013;61(14):1510-7. doi: 10.1016/j.jacc.2013.01.022.
  4. Joyce E, Lala A, Stevens SR, et al; for the Heart Failure Apprentice Network. Prevalence, profile, and prognosis of severe obesity in contemporary hospitalized heart failure trial populations. JACC Heart Fail. 2016;4(12):923-931. doi: 10.1016/j.jchf.2016.09.013.
  5. Mainous AG, Tanner RJ, Scuderi CB, Porter M, Carek PJ. Prediabetes screening and treatment in diabetes prevention: the impact of physician attitudes. J Am Board Fam Med. 2016;29(6):663-671. doi:10.3122/jabfm.2016.06.160138.