Elsevier

American Heart Journal

Volume 170, Issue 2, August 2015, Pages 306-312.e6
American Heart Journal

Clinical Investigation
Heart Failure
Intermediate and long-term risk of new-onset heart failure after hospitalization for pneumonia in elderly adults

https://doi.org/10.1016/j.ahj.2015.04.028Get rights and content

Background

Pneumonia is associated with high risk of heart failure (HF) in the short term (30 days) postinfection. Whether this association persists beyond this period is unknown.

Methods

We studied 5,613 elderly (≥65 years) adults enrolled in the Cardiovascular Health Study between 1989 and 1994 at 4 US communities. Participants had no clinical diagnosis of HF at enrollment, and they were followed up through December 2010. Hospitalizations for pneumonia were identified using validated International Classification of Disease Ninth Revision codes. A centralized committee adjudicated new-onset HF events. Using Cox regression, we estimated adjusted hazard ratios (HRs) of new-onset HF at different time intervals after hospitalization for pneumonia.

Results

A total of 652 participants hospitalized for pneumonia during follow-up were still alive and free of clinical diagnosis of HF by day 30 posthospitalization. Relative to the time of their hospitalization, new-onset HF occurred in 22 cases between 31 and 90 days (HR 6.9, 95% CI 4.46-10.63, P < .001), 14 cases between 91 days and 6 months (HR 3.2, 95% CI 1.88-5.50, P < .001), 20 cases between 6 months and 1 year (HR 2.6, 95% CI 1.64-4.04, P < .001), 76 cases between 1 and 5 years (HR 1.7, 95% CI 1.30-2.12, P < .001), and 71 cases after 5 years (HR 2.0, 95% CI 1.56-2.58, P < .001). Results were robust to sensitivity analyses using stringent definitions of pneumonia and extreme assumptions for potential informative censoring.

Conclusion

Hospitalization for pneumonia is associated with increased risk of new-onset HF in the intermediate and long term. Studies should characterize the mechanisms of this association in order to prevent HF in elderly pneumonia survivors.

Section snippets

Study population and data collection

The Cardiovascular Health Study (CHS) enrolled 5,888 community-dwelling elderly adults (age ≥65 years) from 4 US communities in California, Philadelphia, North Carolina, and Maryland.10 The baseline evaluation (1989-1994) included a standardized physical examination, diagnostic and laboratory evaluation, and questionnaires on health status, medical history, lifestyle habits, and cardiovascular risk factors.10, 11, 12 Update of major examination components and surveillance of new cardiovascular

Results

Of 5,888 participants in CHS, 275 had clinical diagnosis HF at enrollment and were excluded. Our analysis included 5,613 participants. During follow-up, 1,315 (23.4%) participants were hospitalized with pneumonia at least once (median time to pneumonia 8.8 years, IQR 5.3-12.5 years), whereas 1,868 participants developed new-onset HF (median time to new-onset HF 9.0 years, IQR 4.8-13.6 years). Participants who were hospitalized with pneumonia were slightly younger than the rest of participants

Discussion

In a large community-based prospective sample of elderly adults without HF at baseline, hospitalization for pneumonia was independently associated with a pronounced increase in the risk of new-onset HF in the intermediate and long term. This association was evident for patients with both severe and nonsevere pneumonia. Our results did not substantially change even when stringent case definitions for pneumonia were used or under extreme assumptions for potential informative censoring. The

Conclusion

In this large community-based sample of elderly adults, hospitalization for pneumonia was associated with subsequent increase in the risk of new-onset HF in the intermediate and long term postinfection. Future studies are needed to clearly elucidate the mechanisms of this association in order to design targeted preventive strategies.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Role of investigators

V.F.C.-M., M.T., S.Y., R.K., G.D., M.S.V.E., and J.A.C. designed the study; the data were gathered by R.K., A.B.N., and M.F.L.; M.T. performed the statistical analyses; V.F.C.-M., M.T., and J.A.C. vouch for the data and analysis; all authors provided critical input to the interpretations of the results; V.F.C.-M. wrote the first manuscript draft; all authors approved the final version. The authors had full access to data and full control of the decision to publish.

Disclosures

CHS was supported by contracts HHSN268201200036C, HHSN268200800007C, N01 HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, and N01HC85086 and Grant HL080295 from the National Heart, Lung, and Blood Institute, with additional contribution from the National Institute of Neurological Disorders and Stroke. Additional support was provided by AG023629 from the National Institute on Aging. A full list of principal CHS investigators and institutions can be found at CHS-NHLB.org. Dr

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