Trends in the Prevalence of Self-reported Heart Failure by Race/Ethnicity and Age From 2001 to 2016 | Cardiology | JAMA Cardiology | JAMA Network
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Figure 1.  Overall Weighted Estimates of Prevalence of Heart Failure, 2001-2016
Overall Weighted Estimates of Prevalence of Heart Failure, 2001-2016

Trends in heart failure prevalence were not significant for crude (A) or age-standardized (B) prevalence of heart failure. Black solid and dashed lines represent the prevalence estimates and 95% CIs, respectively, for the overall sample. Solid lines and shaded areas represent heart failure prevalence estimates and 95% CIs, respectively, for racial/ethnic groups. Global P values for test for race interaction × time are as follows: logistic regression dummy P = .14, linear trend P = .26 (Wald test), and quadratic trend P = .51 (Wald test). NHANES indicates National Health and Nutrition Examination Survey.

Figure 2.  Weighted Estimates of Prevalence of Heart Failure Stratified by Age Group, 2001-2016
Weighted Estimates of Prevalence of Heart Failure Stratified by Age Group, 2001-2016

Trends in heart failure prevalence in younger (35-64 years of age) adults (A) and older (65 years or older) adults (B) were not significant overall and when stratified by race/ethnicity. Black solid and dashed lines represent prevalence estimates and 95% CIs, respectively, for the overall sample. Solid lines and shaded areas represent heart failure prevalence estimates and 95% CIs, respectively, for racial/ethnic groups. Global P values for test for age interaction × time are as follows: logistic regression (dummy) P = .75, linear trend P = .37 (Wald test), and quadratic trend P = .61 Wald test). Global P values for test for race and age interaction × time are as follows: logistic regression (dummy) P = .33, linear trend P = .29 (Wald test), and quadratic trend P = .68 (Wald test). NHANES indicates National Health and Nutrition Examination Survey.

Table.  National Health and Nutrition Examination Survey Sample Characteristics From Pooled Survey Cycles (2001-2004 and 2013-2016) by Race/Ethnicitya
National Health and Nutrition Examination Survey Sample Characteristics From Pooled Survey Cycles (2001-2004 and 2013-2016) by Race/Ethnicitya
1.
Virani  SS, Alonso  A, Benjamin  EJ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics-2020 update: a report from the American Heart Association.   Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757 PubMedGoogle ScholarCrossref
2.
Heidenreich  PA, Albert  NM, Allen  LA,  et al; American Heart Association Advocacy Coordinating Committee; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Stroke Council.  Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.   Circ Heart Fail. 2013;6(3):606-619. doi:10.1161/HHF.0b013e318291329a PubMedGoogle ScholarCrossref
3.
Chang  PP, Wruck  LM, Shahar  E,  et al.  Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005-2014): ARIC study community surveillance.   Circulation. 2018;138(1):12-24. doi:10.1161/CIRCULATIONAHA.117.027551 PubMedGoogle ScholarCrossref
4.
Gerber  Y, Weston  SA, Redfield  MM,  et al.  A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.   JAMA Intern Med. 2015;175(6):996-1004. doi:10.1001/jamainternmed.2015.0924 PubMedGoogle ScholarCrossref
5.
Glynn  P, Lloyd-Jones  DM, Feinstein  MJ, Carnethon  M, Khan  SS.  Disparities in cardiovascular mortality related to heart failure in the United States.   J Am Coll Cardiol. 2019;73(18):2354-2355. doi:10.1016/j.jacc.2019.02.042 PubMedGoogle ScholarCrossref
6.
Howard  G, Cushman  M, Moy  CS,  et al.  Association of clinical and social factors with excess hypertension risk in black compared with white US adults.   JAMA. 2018;320(13):1338-1348. doi:10.1001/jama.2018.13467 PubMedGoogle ScholarCrossref
7.
Gidding  SS, Lloyd-Jones  D, Lima  J,  et al.  Prevalence of American Heart Association heart failure stages in black and white young and middle-aged adults: the CARDIA study.   Circ Heart Fail. 2019;12(9):e005730. doi:10.1161/CIRCHEARTFAILURE.118.005730 PubMedGoogle Scholar
8.
McWilliams  JM, Meara  E, Zaslavsky  AM, Ayanian  JZ.  Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage.   Ann Intern Med. 2009;150(8):505-515. doi:10.7326/0003-4819-150-8-200904210-00005 PubMedGoogle ScholarCrossref
9.
Johnson  CL, Paulose-Ram  R, Ogden  CL,  et al.  National Health and Nutrition Examination Survey: analytic guidelines, 1999-2010.   Vital Health Stat. 2013;2(161):1-24.Google Scholar
10.
Korn  EL, Graubard  BI.  Analysis of Health Surveys. John Wiley; 1999. doi:10.1002/9781118032619
11.
Jackson  SL, Tong  X, King  RJ, Loustalot  F, Hong  Y, Ritchey  MD.  National burden of heart failure events in the United States, 2006 to 2014.   Circ Heart Fail. 2018;11(12):e004873. doi:10.1161/CIRCHEARTFAILURE.117.004873 PubMedGoogle Scholar
12.
Gure  TR, McCammon  RJ, Cigolle  CT, Koelling  TM, Blaum  CS, Langa  KM.  Predictors of self-report of heart failure in a population-based survey of older adults.   Circ Cardiovasc Qual Outcomes. 2012;5(3):396-402. doi:10.1161/CIRCOUTCOMES.111.963116 PubMedGoogle ScholarCrossref
13.
Jolly  S, Vittinghoff  E, Chattopadhyay  A, Bibbins-Domingo  K.  Higher cardiovascular disease prevalence and mortality among younger blacks compared to whites.   Am J Med. 2010;123(9):811-818. doi:10.1016/j.amjmed.2010.04.020 PubMedGoogle ScholarCrossref
14.
Bahrami  H, Kronmal  R, Bluemke  DA,  et al.  Differences in the incidence of congestive heart failure by ethnicity: the multi-ethnic study of atherosclerosis.   Arch Intern Med. 2008;168(19):2138-2145. doi:10.1001/archinte.168.19.2138 PubMedGoogle ScholarCrossref
15.
Bibbins-Domingo  K, Pletcher  MJ, Lin  F,  et al.  Racial differences in incident heart failure among young adults.   N Engl J Med. 2009;360(12):1179-1190. doi:10.1056/NEJMoa0807265 PubMedGoogle ScholarCrossref
Brief Report
September 2, 2020

Trends in the Prevalence of Self-reported Heart Failure by Race/Ethnicity and Age From 2001 to 2016

Author Affiliations
  • 1Division of Cardiology, Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 3Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 4Deputy Editor, JAMA Cardiology
JAMA Cardiol. 2020;5(12):1425-1429. doi:10.1001/jamacardio.2020.3654
Key Points

Question  Given changing cardiovascular risk factor profiles, were there differences in the prevalence of ambulatory heart failure by race/ethnicity and age in the US from 2001 through 2016?

Findings  In this cross-sectional study of 26 097 participants from the National Health and Nutrition Examination Survey, the prevalence of ambulatory heart failure was stable between 2001 and 2016. Heart failure prevalence was higher in Black participants compared with White participants, with the greatest disparities among adults aged 35 to 64 years.

Meaning  This study found that the prevalence of heart failure remained unchanged between 2001 and 2016, and large racial disparities persisted particularly by age group.

Abstract

Importance  Despite recent advances in therapies for heart failure (HF), deaths from HF are increasing, with persistent disparities between Black and White adults. Recent national trends in the prevalence of HF need to be clarified to appropriately allocate resources and develop effective preventive interventions.

Objectives  To examine the prevalence of ambulatory HF overall and by race/ethnicity and age and the temporal changes in HF prevalence between 2001 and 2016.

Design, Setting, and Participants  This cross-sectional study of nationally representative data collected biennially through the National Health and Nutrition Examination Survey (NHANES) from January 1, 2001, to December 31, 2016, assessed nonpregnant adults 35 years and older who self-identified as non-Hispanic Black, non-Hispanic White, or Mexican American. Data analysis was performed from November 16, 2019, to April 12, 2020.

Exposures  Survey period, race/ethnicity, and age group.

Main Outcomes and Measures  Age-standardized prevalence was calculated within 4-year survey periods (2001-2004, 2005-2008, 2009-2012, and 2013-2016) based on self-report of ambulatory HF overall and by race/ethnicity and age group (35-64 and ≥65 years). Weighted multivariable logistic regression was used to examine trends in ambulatory HF prevalence over time by race/ethnicity and age group.

Results  A total of 26 097 participants (mean [SD] age, 55.9 [10.7] years; 13 192 [52%] female; 6519 [12%] non-Hispanic Black; and 4906 [7%] Mexican American) were studied. Overall age-standardized prevalence (per 100 000 population) of ambulatory HF was 3184 (95% CI, 2641-3728) from 2001 to 2005 and 3045 (95% CI, 2651-3438) from 2013 to 2016. The prevalence of ambulatory HF was highest among non-Hispanic Black adults: from 2013 to 2016, HF prevalence (per 100 000 population) was 5017 (95% CI, 3755-6279) among non-Hispanic Black adults, 2746 (95% CI, 2313-3179) among non-Hispanic White adults, and 2508 (95% CI, 1154-3862) among Mexican American adults. Differences between White and Black adults in HF prevalence were also present in younger and middle-aged adults (eg, 35-64 years of age in 2013-2016: 3864 [95% CI, 2369-5359] for non-Hispanic Black adults vs 1297 [95% CI, 878-1716] for non-Hispanic White adults).

Conclusions and Relevance  This study found that a high burden of ambulatory HF persisted between 2001 and 2016 in the US. Disparities were most prominent by age group. Alongside prevention and aggressive management of risk factors, targeted efforts aimed at mitigating racial disparities are needed.

Introduction

In the US, more than 6 million adults have heart failure (HF), and this number has been projected to increase to more than 8 million by 2030.1,2 Previous analyses,3,4 however, have shown conflicting trends regarding changes in the incidence and mortality related to HF. An analysis4 from Olmsted County, Minnesota, found that incident HF decreased between 2000 and 2010, whereas data from the Atherosclerosis Risk in Communities study3 found an increase in the incidence of hospitalized HF during the same period. After years of persistent decreases in HF-related mortality, national death rates attributed to HF are now increasing, particularly among younger Black adults.5

It is well established that the incidence of HF varies by race/ethnicity, with the differences largely attributable to the disproportionate prevalence and earlier onset of HF risk factors, such as obesity, diabetes, and hypertension, among Black men and women.1,6,7 However, the increasing prevalence of particular risk factors (eg, obesity and diabetes) in recent decades in addition to persistently low rates of risk factor control may be associated with changes in HF prevalence in the US.8 Therefore, we sought to describe the contemporary burden of HF and examine temporal trends in HF by race/ethnicity and age group using a nationally representative sample.

Methods

This cross-sectional study was conducted across 8 cycles of the National Health and Nutrition Examination Survey (NHANES; 2001-2016). NHANES is a nationally representative, cross-sectional study administered biannually by the National Center for Health Statistics (eMethods in the Supplement).9 NHANES was approved by the National Center for Health Statistics Ethics Review Board. All participants provided written informed consent. All data were deidentified; therefore, the current analysis was deemed exempt from institutional review board approval by the National Center for Health Statistics Ethics Review Board.

Nonpregnant adults 35 years or older who identified as non-Hispanic White, non-Hispanic Black, or Mexican American were included in this analysis (eFigure and eTable 1 in the Supplement). Individuals younger than 35 years were excluded to minimize effects of congenital heart disease. Small sample sizes (Asian American adults) or changes in sampling (eg, Hispanic adults other than Mexican American adults) precluded analysis of other racial/ethnic groups.9 Heart failure status was derived from the interviewer-administered question, “Has a doctor or other health professional ever told you that you had congestive heart failure?”

Consecutive survey cycles were grouped into 4-year intervals (January 1 through December 31): 2001 to 2004 (period 1), 2005 to 2008 (period 2), 2009 to 2012 (period 3), and 2013 to 2016 (period 4). Crude and age-standardized estimates of ambulatory HF prevalence were calculated overall and by race/ethnicity. Analyses were stratified by age group based on a significant interaction with age. Further stratification by sex was considered, but no meaningful differences were found. The Korn and Graubard method10 was used to estimate the 95% CIs.

Logistic regression models were used to examine trends in HF prevalence. No linear or quadratic trends were noted using Wald tests. In supplementary analyses, trends in HF prevalence overall, by age group, and by race/ethnicity were examined, adjusting for risk factors as well as race/ethnicity and age group when appropriate. Multiple imputation (10 data sets) by fully conditional specification was used to impute missing covariate data. All analyses accounted for the complex sample design, including the use of 4- and 16-year NHANES sampling weights as appropriate.9 Data analysis was performed from November 16, 2019, to April 12, 2020. All statistical analyses were conducted using Stata software, version 15.1 (StataCorp LLC).

Results

A total of 26 097 participants (mean [SD] age, 55.9 [10.7] years; 13 192 [52%] female; 6519 [12%] non-Hispanic Black; and 4906 [7%] Mexican American) were studied (eTable 2 in the Supplement). Risk factors for HF were common, particularly among non-Hispanic Black adults. In the most recent period (2013-2016), prevalence of obesity (43%), diabetes (17%), and hypertension (36%) was higher compared with the prevalence in the first period (2001-2004: obesity, 34%; diabetes, 11%; and hypertension, 28%) for all racial/ethnic groups (Table and eTable 2 in the Supplement).

Crude and age-standardized prevalence of ambulatory HF did not change between 2001 and 2016. Overall age-standardized prevalence of ambulatory HF was 3184 per 100 000 population (95% CI, 2641-3728 per 100 000 population) from 2001 to 2005 and 3045 per 100 000 population (95% CI, 2651-3438 per 100 000 population) from 2013 to 2016 (Figure 1 and eTable 3 in the Supplement). In stratified analyses by race/ethnicity, HF prevalence (per 100 000 population) between 2013 and 2016 was 2746 (95% CI, 2313-3179) among non-Hispanic White adults, 5017 (95% CI, 3755-6279) among non-Hispanic Black adults, and 2508 (95% CI, 1154-3862) among Mexican American adults. For all periods between 2005 and 2016, a significant interaction was found between race/ethnicity and age-standardized HF prevalence. Age-standardized rates of HF were stable for non-Hispanic White adults and Mexican American adults, but rates of HF were higher in the last period compared with the first period for non-Hispanic Black adults (3733 [95% CI, 2556-4910] in 2001-2004 vs 5017 [95% CI, 3755-6279] in 2013-2016).

The prevalence of HF was higher among those older than 65 years compared with those 35 to 64 years of age for all racial/ethnic groups (Figure 2 and eTable 4 in the Supplement). For example, between 2013 and 2016, the prevalence (per 100 000 population) of HF among adults 35 to 64 years of age was 1297 (95% CI, 878-1716) among non-Hispanic White adults, 3864 (95% CI, 2369-5359) among non-Hispanic Black adults, and 2047 (95% CI, 518-3576) among Mexican American adults; the prevalence of HF among adults 65 years and older was 8006 (95% CI, 6572-9439) among non-Hispanic White adults, 11 038 (95% CI, 7491-14584) among non-Hispanic Black adults, and 6022 (95% CI, 3971-8072) among Mexican American adults. Across all periods, among those 35 to 64 years of age, HF prevalence was higher among non-Hispanic Black adults compared with non-Hispanic White adults (3864 [95% CI, 2369-5359] in non-Hispanic Black adults vs 1297 [95% CI, 878-1716] in non-Hispanic white adults in 2013-2016). The prevalence of HF in Mexican American adults and non-Hispanic White adults 35 to 64 years of age was similar. No significant trends were found in the prevalence of HF when stratified by age group (Figure 2). Furthermore, the prevalence of HF adjusted for educational level and HF risk factors in more recent survey periods was not significantly different than the prevalence in 2001 to 2004 overall, by age group, and by race/ethnicity (eTables 5 and 6 in the Supplement).

Discussion

In this nationally representative analysis of more than 25 000 individuals, both the crude and age-standardized prevalence of ambulatory HF remained largely stable between 2001 and 2016, indicating no improvements in the high burden of HF in the US. Although age-standardized HF prevalence was similar for Mexican American adults and non-Hispanic White adults over time, the age-standardized HF prevalence was generally higher among non-Hispanic Black adults. In the most recent period, HF prevalence was 3-fold higher among younger non-Hispanic Black adults compared with younger non-Hispanic White adults between 2013 and 2016.

The current analysis contrasts with prior projections anticipating increases in HF prevalence.2 Furthermore, the finding of a stable crude HF prevalence in the context of an aging US population is noteworthy.1,11 Of importance, these estimates are based on self-report rather than adjudicated HF, which likely underestimates true HF prevalence, particularly among non-Hispanic Black adults, as has been reported previously.12 Although this study was unable to determine the underlying factors associated with the stagnation of HF prevalence or the differing contributions from HF subtypes or origins, the findings are coincident with increasing HF mortality trends.5 The confluence of these trends underscores the importance of determining the underlying factors, from individual-level health behaviors to national policies (eg, Hospital Readmissions Reduction Program).

These results, in general, revealed a higher HF prevalence in younger Black adults and a similar prevalence in older Black adults compared with younger and older White adults, respectively, but there were changes in the prevalence estimates across periods that were likely attributable to sampling variability. These findings are consistent with and expand on prior studies.13-15 The higher rates of HF among younger non-Hispanic Black adults may be associated with a number of factors, including disparities in prevalence and control of risk factors as well as upstream socioeconomic factors.1,7 These factors are of particular concern given the morbidity associated with the diagnosis of HF and the unique financial and social consequences of an early diagnosis.

Strengths and Limitations

Strengths of this analysis include the use of a large, nationally representative data set with objective data collected during 16 years. Limitations include the lack of detailed phenotyping for different subtypes of HF (preserved or reduced ejection fraction), classification of HF symptoms (New York Heart Association), or degree of severity of HF (advanced HF that requires mechanical support).

Conclusions

This nationally representative analysis found that the prevalence of HF in the US remained stable between 2001 and 2016 and disparities persisted by race/ethnicity and age. Public policies and programs with substantial investments in HF prevention, such as the Million Hearts Initiative, appear to be needed to prevent the emerging trends of increasing disparities in HF.

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Article Information

Accepted for Publication: June 3, 2020.

Corresponding Author: Sadiya S. Khan, MD, MS, Division of Cardiology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 14-002, Chicago, IL 60611 (s-khan-1@northwestern.edu).

Published Online: September 2, 2020. doi:10.1001/jamacardio.2020.3654

Author Contributions: Dr Khan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition, analysis, or interpretation of data: Rethy, Petito, Vu, Kershaw, Mehta, Shah, Lloyd-Jones, Khan.

Drafting of the manuscript: Rethy, Petito.

Critical revision of the manuscript for important intellectual content: Petito, Vu, Kershaw, Mehta, Shah, Carnethon, Yancy, Lloyd-Jones, Khan.

Statistical analysis: Rethy, Petito, Vu.

Obtained funding: Lloyd-Jones.

Administrative, technical, or material support: Shah, Lloyd-Jones.

Supervision: Carnethon, Yancy, Lloyd-Jones, Khan.

Conflicts of Interest Disclosures: Ms Rethy reported receiving grants from the Sarnoff Cardiovascular Research Foundation during the conduct of the study. Dr Mehta reported receiving grants from the National Institutes of Health during the conduct of the study, personal fees from Akebia/Otsuka, and stock ownership from Teva Pharmaceuticals, Abbott Laboratories, and AbbVie outside the submitted work. Dr Lloyd-Jones reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Khan reported receiving grants from the American Heart Association and the National Institutes of Health, National Center for Advancing Translational Sciences during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by grant KL2TR001424 from the National Institutes of Health, National Heart, Lung, and Blood Institute and grant 19TPA34890060 from the American Heart Association (Dr Khan). The research reported in this publication was supported, in part, by grant KL2TR001424 from the National Institutes of Health's National Center for Advancing Translational Sciences (Dr Khan). Ms Rethy was supported from a fellowship from the Sarnoff Cardiovascular Research Foundation.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Yancy is Deputy Editor of JAMA Cardiology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

References
1.
Virani  SS, Alonso  A, Benjamin  EJ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics-2020 update: a report from the American Heart Association.   Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757 PubMedGoogle ScholarCrossref
2.
Heidenreich  PA, Albert  NM, Allen  LA,  et al; American Heart Association Advocacy Coordinating Committee; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Stroke Council.  Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.   Circ Heart Fail. 2013;6(3):606-619. doi:10.1161/HHF.0b013e318291329a PubMedGoogle ScholarCrossref
3.
Chang  PP, Wruck  LM, Shahar  E,  et al.  Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005-2014): ARIC study community surveillance.   Circulation. 2018;138(1):12-24. doi:10.1161/CIRCULATIONAHA.117.027551 PubMedGoogle ScholarCrossref
4.
Gerber  Y, Weston  SA, Redfield  MM,  et al.  A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.   JAMA Intern Med. 2015;175(6):996-1004. doi:10.1001/jamainternmed.2015.0924 PubMedGoogle ScholarCrossref
5.
Glynn  P, Lloyd-Jones  DM, Feinstein  MJ, Carnethon  M, Khan  SS.  Disparities in cardiovascular mortality related to heart failure in the United States.   J Am Coll Cardiol. 2019;73(18):2354-2355. doi:10.1016/j.jacc.2019.02.042 PubMedGoogle ScholarCrossref
6.
Howard  G, Cushman  M, Moy  CS,  et al.  Association of clinical and social factors with excess hypertension risk in black compared with white US adults.   JAMA. 2018;320(13):1338-1348. doi:10.1001/jama.2018.13467 PubMedGoogle ScholarCrossref
7.
Gidding  SS, Lloyd-Jones  D, Lima  J,  et al.  Prevalence of American Heart Association heart failure stages in black and white young and middle-aged adults: the CARDIA study.   Circ Heart Fail. 2019;12(9):e005730. doi:10.1161/CIRCHEARTFAILURE.118.005730 PubMedGoogle Scholar
8.
McWilliams  JM, Meara  E, Zaslavsky  AM, Ayanian  JZ.  Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage.   Ann Intern Med. 2009;150(8):505-515. doi:10.7326/0003-4819-150-8-200904210-00005 PubMedGoogle ScholarCrossref
9.
Johnson  CL, Paulose-Ram  R, Ogden  CL,  et al.  National Health and Nutrition Examination Survey: analytic guidelines, 1999-2010.   Vital Health Stat. 2013;2(161):1-24.Google Scholar
10.
Korn  EL, Graubard  BI.  Analysis of Health Surveys. John Wiley; 1999. doi:10.1002/9781118032619
11.
Jackson  SL, Tong  X, King  RJ, Loustalot  F, Hong  Y, Ritchey  MD.  National burden of heart failure events in the United States, 2006 to 2014.   Circ Heart Fail. 2018;11(12):e004873. doi:10.1161/CIRCHEARTFAILURE.117.004873 PubMedGoogle Scholar
12.
Gure  TR, McCammon  RJ, Cigolle  CT, Koelling  TM, Blaum  CS, Langa  KM.  Predictors of self-report of heart failure in a population-based survey of older adults.   Circ Cardiovasc Qual Outcomes. 2012;5(3):396-402. doi:10.1161/CIRCOUTCOMES.111.963116 PubMedGoogle ScholarCrossref
13.
Jolly  S, Vittinghoff  E, Chattopadhyay  A, Bibbins-Domingo  K.  Higher cardiovascular disease prevalence and mortality among younger blacks compared to whites.   Am J Med. 2010;123(9):811-818. doi:10.1016/j.amjmed.2010.04.020 PubMedGoogle ScholarCrossref
14.
Bahrami  H, Kronmal  R, Bluemke  DA,  et al.  Differences in the incidence of congestive heart failure by ethnicity: the multi-ethnic study of atherosclerosis.   Arch Intern Med. 2008;168(19):2138-2145. doi:10.1001/archinte.168.19.2138 PubMedGoogle ScholarCrossref
15.
Bibbins-Domingo  K, Pletcher  MJ, Lin  F,  et al.  Racial differences in incident heart failure among young adults.   N Engl J Med. 2009;360(12):1179-1190. doi:10.1056/NEJMoa0807265 PubMedGoogle ScholarCrossref
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