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Original Investigation
March 27, 2019

Association of Influenza-like Illness Activity With Hospitalizations for Heart Failure: The Atherosclerosis Risk in Communities Study

Author Affiliations
  • 1Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Peter Munk Cardiac Centre, Toronto General Hospital and Cardiovascular Division, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
  • 3University of North Carolina at Chapel Hill, Chapel Hill
  • 4University of Wisconsin School of Medicine and Public Health, Madison
  • 5Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
  • 6University of Minnesota, Minneapolis
  • 7National Heart, Lung, and Blood Institute, Bethesda, Maryland
JAMA Cardiol. 2019;4(4):363-369. doi:10.1001/jamacardio.2019.0549
Key Points

Question  Is increased influenza activity associated with an increase in hospitalizations for heart failure and myocardial infarction?

Findings  In this community surveillance study of approximately 451 588 adults, a 5% absolute increase in influenza activity was associated with a 24% increase in heart failure hospitalizations rates within the same month but no significant increase in myocardial infarction hospitalizations.

Meaning  Increased levels of influenza activity are associated with increased hospitalizations for cardiovascular events, indicating that influenza activity should be addressed in efforts to prevent heart failure hospitalizations.


Importance  Influenza is associated with an increased risk of cardiovascular events, but to our knowledge, few studies have explored the temporal association between influenza activity and hospitalizations, especially those caused by heart failure (HF).

Objective  To explore the temporal association between influenza activity and hospitalizations due to HF and myocardial infarction (MI). We hypothesized that increased influenza activity would be associated with an increase in hospitalizations for HF and MI among adults in the community.

Design, Setting, and Participants  As part of the community surveillance component of the Atherosclerosis Risk in Communities (ARIC) study, a population-based study with hospitalizations sampled from 4 US communities, data were collected from 451 588 adults aged 35 to 84 years residing in the ARIC communities from annual cross-sectional stratified random samples of hospitalizations during October 2010 to September 2014.

Exposures  Monthly influenza activity, defined as the percentage of patient visits to sentinel clinicians for influenza-like illness by state, as reported by the Centers for Disease Control and Prevention Surveillance Network.

Main Outcomes and Measures  The monthly frequency of MI hospitalizations (n = 3541) and HF hospitalizations (n = 4321), collected through community surveillance and adjudicated as part of the ARIC Study.

Results  Between October 2010 and September 2014, 2042 (47.3%) and 1599 (45.1%) of the sampled patients who were hospitalized for HF and MI, respectively, were women and 2391 (53.3%) and 2013 (57.4%) were white, respectively. A 5% monthly absolute increase in influenza activity was associated with a 24% increase in HF hospitalization rates, standardized to the total population in each community, within the same month after adjusting for region, season, race/ethnicity, sex, age, and number of MI/HF hospitalizations from the month before (incidence rate ratio, 1.24; 95% CI, 1.11-1.38; P < .001), while overall influenza activity was not significantly associated with MI hospitalizations (incidence rate ratio, 1.02; 95% CI, 0.90-1.17; P = .72). Influenza activity in the months before hospitalization was not associated with either outcome. Our model suggests that in a month with high influenza activity, approximately 19% of HF hospitalizations (95% CI, 10%-28%) could be attributable to influenza.

Conclusions and Relevance  Influenza activity was temporally associated with an increase in HF hospitalizations across 4 influenza seasons. These data suggest that influenza may contribute to the risk of HF hospitalization in the general population.