Institute of Health Informatics, University College London, London, UK.
University College London Hospitals NHS Trust, London, UK.
Eur J Heart Fail. 2022 Mar;24(3):466-480. doi: 10.1002/ejhf.2417. Epub 2022 Jan 26.
Primary prevention strategies for heart failure (HF) have had limited success, possibly due to a wide range of underlying risk factors (RFs). Systematic evaluations of the prognostic burden and preventive potential across this wide range of risk factors are lacking. We aimed at estimating evidence, prevalence and co-occurrence for primary prevention and impact on prognosis of RFs for incident HF.
We systematically reviewed trials and observational evidence of primary HF prevention across 92 putative aetiologic RFs for HF identified from US and European clinical practice guidelines. We identified 170 885 individuals aged ≥30 years with incident HF from 1997 to 2017, using linked primary and secondary care UK electronic health records (EHR) and rule-based phenotypes (ICD-10, Read Version 2, OPCS-4 procedure and medication codes) for each of 92 RFs. Only 10/92 factors had high quality observational evidence for association with incident HF; 7 had effective randomized controlled trial (RCT)-based interventions for HF prevention (RCT-HF), and 6 for cardiovascular disease prevention, but not HF (RCT-CVD), and the remainder had no RCT-based preventive interventions (RCT-0). We were able to map 91/92 risk factors to EHR using 5961 terms, and 88/91 factors were represented by at least one patient. In the 5 years prior to HF diagnosis, 44.3% had ≥4 RFs. By RCT evidence, the most common RCT-HF RFs were hypertension (48.5%), stable angina (34.9%), unstable angina (16.8%), myocardial infarction (15.8%), and diabetes (15.1%); RCT-CVD RFs were smoking (46.4%) and obesity (29.9%); and RCT-0 RFs were atrial arrhythmias (17.2%), cancer (16.5%), heavy alcohol intake (14.9%). Mortality at 1 year varied across all 91 factors (lowest: pregnancy-related hormonal disorder 4.2%; highest: phaeochromocytoma 73.7%). Among new HF cases, 28.5% had no RCT-HF RFs and 38.6% had no RCT-CVD RFs. 15.6% had either no RF or only RCT-0 RFs.
One in six individuals with HF have no recorded RFs or RFs without trials. We provide a systematic map of primary preventive opportunities across a wide range of RFs for HF, demonstrating a high burden of co-occurrence and the need for trials tackling multiple RFs.
心力衰竭（HF）的一级预防策略收效甚微，这可能是由于存在广泛的潜在风险因素（RFs）。缺乏对这一系列广泛风险因素的预后负担和预防潜力的系统评估。我们旨在评估用于 HF 一级预防的 RF 证据、患病率和共存情况，并评估其对 HF 发病的预后影响。
我们系统地回顾了 92 种潜在 HF 病因 RFs 的一级 HF 预防试验和观察性证据，这些 RFs 是从美国和欧洲临床实践指南中确定的。我们使用英国初级和二级保健电子健康记录（EHR）和基于规则的表型（ICD-10、Read 版本 2、OPCS-4 程序和药物代码），在 1997 年至 2017 年期间确定了 170885 名≥30 岁的 HF 发病患者。对于 92 个 RFs 中的每一个，都有 10/92 个因素具有与 HF 发病相关的高质量观察性证据；7 个具有有效的针对 HF 预防的随机对照试验（RCT-HF）干预措施，6 个具有针对心血管疾病预防而不是 HF（RCT-CVD）的干预措施，其余 6 个没有基于 RCT 的预防干预措施（RCT-0）。我们能够使用 5961 个术语将 91/92 个风险因素映射到 EHR，并且 88/91 个因素至少有一个患者。在 HF 诊断前的 5 年内，44.3%的患者有≥4 个 RFs。根据 RCT 证据，最常见的 RCT-HF RFs 是高血压（48.5%）、稳定性心绞痛（34.9%）、不稳定性心绞痛（16.8%）、心肌梗死（15.8%）和糖尿病（15.1%）；RCT-CVD RFs 是吸烟（46.4%）和肥胖（29.9%）；而 RCT-0 RFs 是房性心律失常（17.2%）、癌症（16.5%）和大量饮酒（14.9%）。所有 91 个因素的 1 年死亡率均不同（最低：妊娠相关激素紊乱 4.2%；最高：嗜铬细胞瘤 73.7%）。在新 HF 病例中，28.5%的患者没有 RCT-HF RFs，38.6%的患者没有 RCT-CVD RFs。15.6%的患者既没有 RF，也没有 RCT-0 RFs。
六分之一的 HF 患者没有记录 RFs 或没有经过试验的 RFs。我们提供了一个广泛的 HF 一级预防机会的系统图谱，展示了高度共存的负担和需要针对多个 RFs 进行试验的必要性。
