CLINICAL RESEARCH: VIEWPOINT
Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure
Kamyar Kalantar-Zadeh, MD, MPH* ,
Gladys Block, PhD,
Tamara Horwich, MD and
Gregg C. Fonarow, MD, FACC,*
* Harbor-UCLA Medical Center, Torrance, USA
University of California, Berkley, School of Public Health, Berkeley, USA
Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California, USA
Manuscript received September 7, 2003;
revised manuscript received October 30, 2003,
accepted November 4, 2003.
* Reprint requests and correspondence: Dr. Gregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, University of California at Los Angeles, 47-123 CHS, 10833 LaConte Avenue, Los Angeles, California 90095-1679, USA.
gfonarow{at}mednet.ucla.edu
Traditional risk factors of a poor clinical outcome and mortality in the general population, including body mass index (BMI), serum cholesterol, and blood pressure (BP), are also found to relate to outcome in patients with chronic heart failure (CHF), but in an opposite direction. Obesity, hypercholesterolemia, and high values of BP have been demonstrated to be associated with greater survival among CHF patients. These findings are in contrast to the well-known associations of over-nutrition, hypercholesterolemia, and hypertension with a poor outcome in the general population. The association between traditional cardiovascular risk factors and an adverse clinical outcome in CHF patients is referred to as "reverse epidemiology." The mechanisms for this inverse association in CHF is not clear. There are other populations with a similar risk factor reversal phenomenon, including patients with end-stage renal disease receiving dialysis, those with advanced malignancies, and individuals with advanced age. Several possible causes are hypothesized: the time discrepancy of the competing risk factors may play a role; the presence of the "malnutrition-inflammation complex syndrome" in CHF patients may explain the existence of reverse epidemiology; and a decreased level of lipoprotein molecules may distort their endotoxin-scavenging role, predisposing CHF patients with a low serum cholesterol level to inflammatory consequences of endotoxemia. It is possible that new goals for such traditional risk factors as BMI, serum cholesterol, and BP should be developed for CHF. Reverse epidemiology of conventional cardiovascular risk factors is observed in CHF and may have a bearing on the management of these patients; thus, it deserves further investigation.
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Abbreviations and Acronyms
| | BMI | = body mass index | | BP | = blood pressure | | CHF | = chronic heart failure | | ESRD | = end-stage renal disease | | MICS | = malnutrition–inflammation complex syndrome | | NYHA | = New York Heart Association | | PEM | = protein-energy malnutrition | | TNF | = tumor necrosis factor |
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