Published Online
on September 24, 2009

A more recent version of this article appeared on November 1, 2009

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Original Article

Reverse Epidemiology in Systolic and Non-systolic Heart Failure: Cumulative Prognostic Benefit of Classical Cardiovascular Risk Factors

Gülmisal Güder¹; Stefan Frantz¹; Johann Bauersachs¹; Bruno Allolio¹; Christoph Wanner¹; Michael T. Koller²; Georg Ertl¹; Christiane E. Angermann¹ and Stefan Störk^1,3

¹ University Hospital Würzburg, Würzburg, Germany;
² University Hospital Basel, Basel, Switzerland

^* Corresponding author; email: stoerk_s{at}klinik.uni-wuerzburg.de

Background—Observational studies indicate that classical cardiovascular risk factors as body mass index (BMI), total cholesterol and systolic blood pressure are associated with improved rather than impaired survival in heart failure ("reverse epidemiology"). We estimated the prognostic role of these risk factors in unselected heart failure patients.

Methods and Results—Consecutive subjects with heart failure of any cause and severity were enrolled (n=867) and survivors were followed for a median period of 594 days (25th-75th percentile, 435-840). Mean age was 70±13 years, 41% were female, NYHA class distribution I through IV was 15/29/41/15%, and 49% had preserved left ventricular ejection function. At follow-up, 34% of the patients had died. Low levels of any risk factor (i.e., BMI, total cholesterol, systolic blood pressure in the low tertile) indicated the highest mortality risk. After adjustment for age, sex, NYHA class and ejection fraction, 2 two risk factors in the high tertile indicated a relative reduction in mortality risk of 51% (hazard ratio [HR] 0.49, 95% confidence interval [CI]: 0.35-0.68; P=0.001) compared to subjects with three risk factors in the low tertile. Further adjustment for cause of heart failure, relevant co-morbidities, medication and biomarkers attenuated this association only modestly (HR 0.63, 95% CI 0.45-0.89; P=0.009).

Conclusion—In heart failure patients, mortality risk counterintuitively increased on a cumulative scale with lower levels of BMI, total cholesterol and systolic blood pressure, irrespective of the type and severity of heart failure. Future studies need to identify whether risk factor control as presently recommended should be advocated in all heart failure patients.

Key Words: blood pressure • cholesterol • heart failure • body mass index • reverse epidemiology