Healthy lifestyle and decreasing risk of heart failure in women: the Women's Health Initiative observational study

Abstract

Background: The impact of a healthy lifestyle on risk of heart failure (HF) is not well known.

Objectives: The objectives of this study were to evaluate the effect of a combination of lifestyle factors on incident HF and to further investigate whether weighting each lifestyle factor has additional impact.

Methods: Participants were 84,537 post-menopausal women from the WHI (Women's Health Initiative) observational study, free of self-reported HF at baseline. A healthy lifestyle score (HL score) was created wherein women received 1 point for each healthy criterion met: high-scoring Alternative Healthy Eating Index, physically active, healthy body mass index, and currently not smoking. A weighted score (wHL score) was also created in which each lifestyle factor was weighted according to its independent magnitude of effect on HF. The incidence of hospitalized HF was determined by trained adjudicators using standardized methodology.

Results: There were 1,826 HF cases over a mean follow-up of 11 years. HL score was strongly associated with risk of HF (multivariable-adjusted hazard ratio [HR] [95% confidence interval (CI)] 0.49 [95% CI: 0.38 to 0.62], 0.36 [95% CI: 0.28 to 0.46], 0.24 [95% CI: 0.19 to 0.31], and 0.23 [95% CI: 0.17 to 0.30] for HL score of 1, 2, 3, and 4 vs. 0, respectively). The HL score and wHL score were similarly associated with HF risk (HR: 0.46 [95% CI: 0.41 to 0.52] for HL score; HR: 0.48 [95% CI: 0.42 to 0.55] for wHL score, comparing the highest tertile to the lowest). The HL score was also strongly associated with HF risk among women without antecedent coronary heart disease, diabetes, or hypertension.

Conclusions: An increasingly healthy lifestyle was associated with decreasing HF risk among post-menopausal women, even in the absence of antecedent coronary heart disease, hypertension, and diabetes. Weighting the lifestyle factors had minimal impact.

Keywords: cardiovascular diseases; heart failure; lifestyle; primary prevention; risk factors.

Figure 1. Comparison of Non-weighted and Weighted Healthy Lifestyle Score in relation to Heart Failure Risk

Risk of heart failure in relation to tertiles of the healthy lifestyle score and weighted healthy lifestyle score, Women's Health Initiative Observational Study. HRs adjusted for age, race, marital status, US region, education, and antecedent: CHD, hypertension and diabetes.

Figure 2. Healthy Lifestyle and Heart Failure Risk in Women Without vs. With Antecedent CHD

Risk of heart failure in relation to the healthy lifestyle score among women without versus with antecedent CHD, Women's Health Initiative Observational Study. Abbreviations: CHD, coronary heart disease; HL-score, healthy lifestyle score. HRs adjusted for age, race, marital status, US region, education, and antecedent hypertension or diabetes.

Figure 3. Healthy Lifestyle and Heart Failure Risk in Women Without Antecedent CHD, Hypertension, or Diabetes

Risk of heart failure in relation to the healthy lifestyle score among women without antecedent CHD, hypertension, and diabetes, Women's Health Initiative Observational Study. Abbreviations: HL-score, healthy lifestyle score. HRs adjusted for age, race, marital status, US region, and education.

Figure 4. Healthy Lifestyle and Heart Failure Risk in African-Americans vs. Non-Hispanic Whites

Risk of heart failure in relation to the healthy lifestyle score among african americans versus non-hispanic whites, Women's Health Initiative Observational Study. Abbreviations: HL-score, healthy lifestyle score. HRs adjusted for age, race, marital status, US region, education, and antecedent hypertension and diabetes. *HR could not be calculated due to 0 heart failure cases in this category.

Central Illustration. Healthy Lifestyle and Risk of Heart Failure in the Women's Health Initiative

An overall healthy lifestyle is strongly associated with lower risk of heart failure among post-menopausal, even in the absence of coronary heart disease (CHD), hypertension, or diabetes.