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Modifiable Risk Factors for Incident Heart Failure in the Coronary Artery Surgery Study

Richard M. Hoffman, MD, MPH; Bruce M. Psaty, MD, MPH; Richard A. Kronmal, PhD
Arch Intern Med. 1994;154(4):417-423. doi:10.1001/archinte.1994.00420040081012.
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Background:  Even with aggressive treatment, heart failure is associated with a substantial morbidity and mortality. This poor prognosis has led to increasing interest in primary prevention, and the identification of modifiable risk factors. Our objective was to determine whether modifiable cardiovascular risk factors, including systolic and diastolic blood pressure, fasting glucose level, cholesterol level, weight, and smoking, were independent risk factors for heart failure in patients with anatomically confirmed coronary artery disease.

Methods:  We studied all patients with documented coronary artery disease eligible for the multicenter, randomized-controlled Coronary Artery Surgery Study. After excluding 79 prevalent cases, we identified incident cases of heart failure using hospital discharge abstracts, mortality records, or self-reported follow-up questionnaires. Criteria for self-reported cases were treatment with digitalis and/or furosemide plus two or more heart failure symptoms, including dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. Cox regression analysis was used to estimate adjusted relative risks.

Results:  At 12-year follow-up, the cumulative incidence of heart failure was 20.6%. Smoking (relative risk, 1.47) and weight (relative risk, 1.15/10 kg) were independently associated with incident heart failure. Myocardial infarction during follow-up, age, female sex, and baseline left ventricular dysfunction were also risk factors for heart failure.

Conclusions:  Patients with stable coronary artery disease are at high risk for developing heart failure, especially following myocardial infarction. However, interventions aimed at smoking cessation and weight reduction may prevent clinical heart failure in these patients.(Arch Intern Med. 1994;154:417-423)


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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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