Predictors of Heart Failure Among Women With Coronary Disease

Bibbins-Domingo K, Lin F, Vittinghoff E, Barrett-Connor E, Hulley SB, Grady D, Shlipak MG. Circulation. 2004;110:1424-1430.

Risk factors for the progression of coronary disease to heart failure are not well understood in women. In this prospective cohort study, investigators looked at the risk factors for heart failure in postmenopausal women with established coronary heart disease.

Data from the Heart and Estrogen/progestin Replacement Study (HERS), a randomized, placebo-controlled trial, were used. The HERS study involved 2763 postmenopausal women with established coronary disease and was carried out between 1993 and 2000 at 20 clinical centers in the US. At the outset of the study, information on demographics, medical history, medications, and behavioral risk factors was obtained from all participants by self-report. Diabetes was defined as use of an oral hypoglycemic agent or insulin. For this analysis, data from 2391 participants were used, and the primary outcome measure was hospitalization or death due to heart failure.

In total, 9 risk factors for heart failure were identified: diabetes, atrial fibrillation, myocardial infarction, renal insufficiency (creatinine clearance <40 mL/min), hypertension (systolic blood pressure >120 mm Hg), obesity, smoking (current), body mass index [BMI] >35 kg/m², left bundle-branch block, and left ventricular hypertrophy. At the end of the follow-up period (mean 6.3 years), approximately 10% of participants (n=237) had developed heart failure.

Diabetes was found to be the strongest risk factor for heart failure, particularly when accompanied by concomitant renal insufficiency or morbid obesity. Of women with diabetes, those with concomitant renal insufficiency (creatinine clearance <42.8 mL/min) were at highest risk of heart failure, with an annual incidence of 13%, followed by women with diabetes and concomitant morbid obesity (BMI >36 kg/m²), with an annual incidence of 7%. Those women with diabetes who did not have concomitant renal insufficiency or morbid obesity had just over twice the annual incidence of heart failure (2.8%) compared with women without diabetes (1.2%).

In summary, of the 9 risk factors for heart failure among postmenopausal women with coronary heart disease identified in the study, diabetes was the strongest predictor, particularly when accompanied by concomitant renal insufficiency or obesity. The results of this study emphasize the importance of heart failure prevention, particularly in patients with diabetes. There are a number of modifiable risk factors, including hypertension, renal insufficiency, obesity, and smoking, that can be targeted in prevention efforts.