Atherosclerosis 210 (2010) 237–242 Contents lists available at ScienceDirect Atherosclerosis journal homepage: www.elsevier.com/locate/atherosclerosis The metabolic syndrome predicts incident congestive heart failure: A 20-year follow-up study of elderly finns Jianjun Wang, Katriina Sarnola, Sanna Ruotsalainen, Leena Moilanen, Päivi Lepistö, Markku Laakso, Johanna Kuusisto ∗ Department of Medicine, University of Kuopio and Kuopio University Hospital, Kuopio, Finland article info Article history: Received 26 May 2009 Received in revised form 28 October 2009 Accepted 29 October 2009 Available online 10 November 2009 Keywords: Metabolic syndrome Definition Congestive heart failure Components Predictor abstract Objective: We investigated whether the metabolic syndrome (MetS) and its components defined by four different criteria including subjects with prevalent diabetes in their definitions were associated with congestive heart failure (CHF) independent of interim myocardial infarction (MI) and prevalent diabetes during a 20-year follow-up in an elderly population-based study. Methods and results: The MetS was defined according to the World Health Organization (WHO), the National Cholesterol Education Program (NCEP), the International Diabetes Federation (IDF), and the American Heart Association and the National Heart, Lung, and Blood Institute (AHA) criteria. The asso- ciation of the MetS with incident CHF (303 cases) was investigated with Cox regression analyses in a 20-year follow-up study of 1032 Finns, aged 65–74 years at baseline. Among all subjects the MetS by all four criteria was significantly associated with a 1.45–1.74-fold risk for incident CHF after the adjustment for confounding factors. When subjects with interim MI during the follow-up and with prevalent dia- betes were excluded, the MetS was significantly associated with a 1.37–1.87-fold risk for incident CHF after the adjustment for confounding factors. Of the single components of the MetS, the following were associated with incident CHF: impaired fasting glucose (IFG) [fasting plasma glucose (FPG) ≥ 6.1 mmol/l, Hazards ratio (HR) 1.46 or FPG ≥ 5.6 mmol/l, HR 1.62)]; raised blood pressure (BP) [(BP ≥ 140/90 mmHg or antihypertensive medications, HR 1.89); central obesity (waist circumference ≥ 94 cm in men or ≥80 cm in women, HR 1.49); (waist circumference ≥102 cm in men or ≥88 cm in women, HR 1.48); obesity (body mass index ≥ 30 kg/m 2 , HR 1.79); and low high-density lipoprotein cholesterol (<1.03 mmol/l in men or <1.29 mmol/l in women, HR 1.55). Conclusions: The MetS defined by four different criteria predicted CHF independent of interim MI and prevalent diabetes in elderly Finns, but not above and beyond the risk associated with one component of the MetS, hypertension. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Congestive heart failure (CHF) is responsible for a large and still growing proportion of cardiovascular morbidity and mortal- Abbreviations: ACE, American College of Endocrinology; ACR, the ratio of urinary albumin to urinary creatinine; AHA, American Heart Association; BMI, body mass index; CHD, coronary heart disease; CVD, cardiovascular disease; CHF, congestive heart failure; EGIR, European Group for the Study of Insulin Resistance; FPG, fasting plasma glucose; HDL, high-density lipoprotein; HR, hazard ratio; IDF, International Diabetes Federation; MetS, metabolic syndrome; MI, myocardial infarction; NCEP, National Cholesterol Education Program; OGTT, oral glucose tolerance test; 2-h PG, 2-h post glucose load; WHO, World Health Organization; WHR, waist-to-hip ratio. ∗ Corresponding author at: Department of Medicine, Cardiology Unit, University of Kuopio and Kuopio University Hospital, P.O. Box 1777, 70211 Kuopio, Finland. Tel.: +358 17 173949; fax: +358 17 173959. E-mail address: johanna.kuusisto@kuh.fi (J. Kuusisto). ity. Hypertension and coronary heart disease (CHD) are considered to be the main causes of CHF. Other established risk factors for CHF are left ventricular hypertrophy (LVH), valvular heart dis- ease, diabetes, cigarette smoking, obesity and dyslipidemia [1–4]. The metabolic syndrome (MetS), a clustering of cardiovascular risk factors conferring an increased risk of cardiovascular disease (CVD), has been defined by a variety of organizations, including the World Health Organization (WHO) in 1999 [5], the European Group for the Study of Insulin Resistance (EGIR) in 1999 [6], the National Cholesterol Education Program (NCEP) Expert Panel in 2001 [7], American College of Endocrinology (ACE) in 2003 [8], the International Diabetes Federation (IDF) in 2005 [9], and the American Heart Association and the National Heart, Lung, and Blood Institute (AHA criteria) in 2005 [10]. Since these differ- ent definitions were published, a few prospective studies have reported that the MetS defined by the NCEP criteria predicts CHF [11–15]. However, none of them investigated the effect of the 0021-9150/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.atherosclerosis.2009.10.042