Result card

  • CUR8: What are the known risk factors for the disease or health condition?

What are the known risk factors for the disease or health condition?

Authors: Ingrid Wilbacher, Nadine Berndt, Francesca Gillespie

Internal reviewers: Alessandra Lo Scalzo, Christian Vladescu, Christina Mototolea, Kristina Lampe, Maria Camerlingo

  • The basic search for the CUR domain was used to answer this question article selected to be relevant for this assessment element.



  • Moreover, a manual search was done to find relevant information about risk factors and determinants of the HF syndrome as published in evidence-based guidelines and in additional scientific studies on HF. European and American guidelines for the diagnosis and treatment of acute and chronic HF were consulted by doing a manual search on the website of the ESC and the AHA, and the references of the ESC guidelines published in 2008 and 2012 and the AHA practice guideline published in 2013 were reviewed and these led occasionally to an additional article that was relevant for this assessment element. Moreover, the 2015 Update of Heart Disease and Stroke Statistics of the AHA and the report “Heart failure: preventing disease and death worldwide” published by the World Heart Failure Alliance was also consulted for this AE were reviewed. Finally, an additional search on the website of the ESC was done with the key words “risk factors” AND “heart failure” resulting in the studies listed below, which occasionally led to an additional reference in order to refer to the original study. The additional searches were conducted the 06th of January 2015 by one of the investigators.

Risk factors for HF vary from lifestyle factors (e.g. smoking, alcohol intake, sedentary lifestyle and a unhealthy diet) to consequences of a unhealthy lifestyle (diabetes, obesity, arteriosclerosis) to socio-demographic factors (e.g. higher age, socio-economic status) and hereditary factors (e.g. race, hypercholesteria, atherosclerosis) and disease history (e.g. history of atrial fibrillation, presence of hypertension, diagnosis of CHD, chemotherapy, viral infection) and more specific biological factors (e.g. higher levels of hematocrit, increased circulating concentrations of resistin, cystatin C).

Many developing countries are now facing the similar risk factors due to a shift towards a Western-type lifestyle. Risk factors for hospital (re-) admission are highly comparable to the risk factors for developing a HF.

A greater survival has been noted for patients with established CHF (“reverse epidemiology”,) who have obesity, hypercholesterolaemia and hypertension.

Coronary artery disease notably increases the likelihood of developing HF. According to Hellermann et al. (2003) {40}, at least one third of patients will experience HF in less than 10 years after having experienced a myocardial infarction, especially those who have left ventricular systolic dysfunction during admission {40}. Although people who have hypertension have a smaller likelihood of developing HF than those who have had a myocardial infarction, hypertension contributes considerably to the population burden of HF as it is much more prevalent than myocardial infarction {69}. Hypertension leads to a myocardial overload and thus to left ventricular systolic and diastolic dysfunction that in turn can lead to congestive HF. Especially an elevated level of systolic blood pressure is a major risk factor for HF. Data suggest that patients with hypertension have a particularly high incidence of left ventricular diastolic dysfunction {115}. Obesity, caused by a sedentary behavior and an unhealthy diet and increasingly present in Western societies, doubles the likelihood of developing HF after adjustment for associated risk factors {56}. Another risk factor associated with obesity is the metabolic syndrome signifying abdominal adiposity, hypertriglyceridemia, a high level of low high-density lipoprotein in the blood, and fasting hyperglycemia {115}. Diabetes also increases the risk for developing HF. Valvular abnormalities, factors indicative of heart disease (left ventricular hypertrophy, left ventricular dilatation, cardiomyopathy), atrial fibrillation, myocarditis, ischemic heart disease, angina pectoris, a parental history of HF, congenital heart disease, as well extracardiac conditions (renal insufficiency, obstructive pulmonary disease, rheumatic fever, sleep apnea) all increase the risk of HF {57},{82},{58}. There is no doubt on the relation of obesity, increased cholesterol values and hypertension to cardiovascular morbidity and mortality {82}. According to the AHA, seventy-five percent of HF cases have antecedent hypertension {83}.


As regards socio-demographic and clinical factors, the Heart Disease and Stroke Statistics of the AHA reveal various risk factors for HF that have been identified by a range of studies. As such, an increasing age, a male gender, an African American race, hypertension, obesity, a low socio-economic status, a history of atrial fibrillation, and a diagnosis of CHD are socio-demographic risk factors that increase the likelihood for developing HF. Lifestyle risk factors that increase the risk of HF are smoking, an unhealthy diet, high alcohol consumption, a sedentary behavior, and high salt intake {83}. Atherosclerosis is another very important clinical risk factor for the development of HF {115}. Other clinical risk factors associated with incident HF relate, amongst others, to a low level of adiponectin and a high level of pro-B-type natriuretic peptide (BNP) in the bloodstream, a high sodium level in the blood, an increased urinary albumin excretion, an elevated serum γ-glutamyl transferase, higher levels of hematocrit, increased circulating concentrations of resistin, cystatin C, inflammatory markers (interleukin-6 and tumor necrosis factor-α) and low serum albumin levels. Moreover, cardiomyopathy, ventricular premature complexes, left ventricular mass index, cardiac (high-sensitivity) troponin, and changes in high-sensitivity troponin levels have been significantly associated with incident HF {117},{83}. Several of these risk factors do slightly differ between HFPEF and HFREF underscoring differential pathophysiological mechanisms for both subtypes of HF. As such, a higher age, a female gender, cystatin C, increased urinary albumin excretion, and a history of atrial fibrillation have been strongly associated with the new onset of HFPEF. Conversely, a male gender, current smoking, an increased highly sensitive troponin T or an increased pro-B-type natriuretic peptide, and previous myocardial infarction have revealed to significantly increase the likelihood for HFREF {5}.


According to the ESC 2012 {77}, HF with reduced ejection fraction or systolic HF is the best understood type of HF in terms of pathophysiology and treatment. Coronary artery disease is the cause of approximately two-thirds of cases of systolic HF, although hypertension and diabetes are probable contributing factors in many cases. There are many other causes of systolic HF, which include previous recognized or unrecognized viral infection, an increased alcohol intake, chemotherapy, and ‘idiopathic’ dilated cardiomyopathy {77}.


HF with a preserved ejection fraction or diastolic HF seems to have a different epidemiological and etiological profile from HF with a reduced ejection fraction. Patients with diastolic HF are more often older, female have a history of hypertension and are obese compared with those with systolic HF. They are less likely to have coronary heart disease but more likely to have hypertension and atrial fibrillation {77}. Coronary artery disease, diabetes mellitus, and hyperlipidemia are also highly prevalent in HFPEF patients {115}. Patients with diastolic HF have a better prognosis than those with systolic HF {77}.


Many developing countries are facing similar risk factors as developed countries due to a shift towards a Western-type lifestyle. Other risk factors related to infections caused by bacteria and tropical parasites contribute to the development of HF in these countries as well. Infections remain an important cause HF in many developing countries such as rheumatic fever due to preventable bacterial infections. HIV is also an important risk factor for heart-related disease since it leads to increased risk for infections due to a weakened immune system. Although rheumatic HF is the most common cause for HF in certain countries of South Asia, trends towards an ischemic cause for HF have also been observed in Asia, China and Japan {98}. In areas of South America, Chagas, a parasitic infection, is the cause for HF in almost 50 % of all HF cases {73}. In tropical areas, Davies has been a major risk factor for HF {111}. According to the systematic review and pooled analysis by Khatibzadeh et al. 2013 {58}, risk factors of HF vary considerably among six world regions. In their review, crude proportion of HF patients with an ischemic heart disease was highest in Europe and North America, followed by East Asia, Latin American and the Caribbean, and lowest in Sub-Saharan Africa. Hypertension was an important risk factor in all regions, whereas cardiomyopathy was the most common risk factor in Latin America, the Caribbean, Sub-Saharan Africa, and Asia Pacific High Income. Cardio-pulmonary disease was most prevalent in HF patients in East Asia, likely due to the high smoking prevalence. Rheumatic heart disease appeared to be most prevalent in East Asia and Sub-Saharan Africa {58}. These findings are similar to two reviews that revealed a high proportion of HF attributed to ischemic heart disease in developed countries, and a higher proportion of HF attributed to rheumatic heart disease and non-ischemic cardiomyopathies in developing countries {61},{78}.


As regards risk factors for hospitalization in HF, these concern a higher age, a nonwhite race, a low socio-economic status, lack of employment, living alone, smoking, ischemic heart disease, a low systolic blood pressure, a higher NYHA class (III or IV), prior HF hospitalization, the presence of hypertension, diabetes mellitus, anemia, hyponatremia, a history of renal insufficiency, worsening renal function, chronic obstructive pulmonary disease, obstructive sleep apnea, depression, a low quality of life and absence of emotional support or social network, and a low adherence to therapies, to name a few {30}. Risk factors for hospital readmission among older persons with a new onset of HF have also been identified. These concern diabetes mellitus, NYHA class III or IV, chronic kidney disease, a reduced ejection fraction (< 45 %), muscle weakness, slow gait, and having a depression {8}.


Healthy lifestyle factors such as a normal weight, nonsmoking, regular exercise, moderate alcohol intake, a healthy diet (consumption of fruit and vegetables and consumption breakfast cereals) are related to a lower risk of HF. Moreover, high circulating individual and total omega-3 fatty acid concentrations decrease the likelihood for developing HF {83}.


Evidence exists that obesity, an elevated blood cholesterol level and hypertension are associated with a greater survival in HF patients. This phenomenon has been termed “reverse epidemiology” {54}. Although the phenomenon is not yet clearly understood, proposed explanations are the syndrome of cardiac cachexia, reverse causation and time discrepancies among competitive risk factors. The reverse epidemiology does not hold for all conventional risk factors, as smoking cessation improves prognosis in HF patients {105}.

Wilbacher I et al. Result Card CUR8 In: Wilbacher I et al. Health Problem and Current Use of the Technology In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 21 June 2021]. Available from: