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Circ Heart Fail. 2018 May;11(5):e004642. doi: 10.1161/CIRCHEARTFAILURE.117.004642.

Risk Factor Burden, Heart Failure, and Survival in Women of Different Ethnic Groups: Insights From the Women's Health Initiative.

Author information

Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson (K.B.).
Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC (I.L.).
Institute for Informatics, Washington University in St Louis School of Medicine, MO (R.E.F.).
Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (W.T.A.).
Division of Public Health Sciences, Wake Forest School of Medicine, Social Sciences and Health Policy, Winston-Salem, NC (L.C., S.S.).
Wayne State University, Detroit, MI (K.E.W.).
Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (J.E.M.).
Department of Family Medicine, Alpert Medical School of Brown University and Department of Epidemiology, School of Public Health of Brown University, Center for Primary Care and Prevention, Pawtucket, RI (C.B.E.).
MedStar Health Research Institute and Georgetown/Howard Universities Center for Clinical and Translational Science, Washington, DC (B.V.H.).
Division of Cardiology, Altru Health System, Grand Forks, ND (N.I.).
Division of General Internal Medicine, University of North Carolina-Chapel Hill (C.W.C.).
Division of Cardiology, George Washington University, Washington, DC (L.W.M.).
Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis (K.C.J.).
Division of Cardiology, University of California San Francisco (L.K.).



The higher risk of heart failure (HF) in African-American and Hispanic women compared with white women is related to the higher burden of risk factors (RFs) in minorities. However, it is unclear if there are differences in the association between the number of RFs for HF and the risk of development of HF and death within racial/ethnic groups.


In the WHI (Women's Health Initiative; 1993-2010), African-American (n=11 996), white (n=18 479), and Hispanic (n=5096) women with 1, 2, or 3+ baseline RFs were compared with women with 0 RF within their respective racial/ethnic groups to assess risk of developing HF or all-cause mortality before and after HF, using survival analyses. After adjusting for age, socioeconomic status, and hormone therapy, the subdistribution hazard ratio (95% confidence interval) of developing HF increased as number of RFs increased (P<0.0001, interaction of race/ethnicity and RF number P=0.18)-African-Americans 1 RF: 1.80 (1.01-3.20), 2 RFs: 3.19 (1.84-5.54), 3+ RFs: 7.31 (4.26-12.56); Whites 1 RF: 1.27 (1.04-1.54), 2 RFs: 1.95 (1.60-2.36), 3+ RFs: 4.07 (3.36-4.93); Hispanics 1 RF: 1.72 (0.68-4.34), 2 RFs: 3.87 (1.60-9.37), 3+ RFs: 8.80 (3.62-21.42). Risk of death before developing HF increased with subsequent RFs (P<0.0001) but differed by racial/ethnic group (interaction P=0.001). The number of RFs was not associated with the risk of death after developing HF in any group (P=0.25; interaction P=0.48).


Among diverse racial/ethnic groups, an increase in the number of baseline RFs was associated with higher risk of HF and death before HF but was not associated with death after HF. Early RF prevention may reduce the burden of HF across multiple racial/ethnic groups.


ethnic groups; heart failure; risk factors; survival; women

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