Addressing Modifiable Risk Factors in Heart Failure Management

Addressing Modifiable Risk Factors in Heart Failure Management
Regan Truttschel, PharmD
Hennepin Healthcare

BackgroundHeart failure (HF) and the risk of developing HF are common, estimated to affect roughly 6.2 million US adults. Despite preventative efforts, prevalence continues to increase globally. Specific modifiable risk factors include prediabetes or diabetes, uncontrolled hypertension, hyperlipidemia, atherosclerotic cardiovascular disease (ASCVD), tobacco and other substance use, as well as obesity, among other renal and cardiovascular complications. According to the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, patients who receive care from a multidisciplinary team benefit from improved guideline-directed medication therapy, reduced hospitalizations for HF, and improved survival. Though the guidelines specifically call out pharmacist intervention in Stages C and D due to the complexity of care for these patients, this also underscores the importance of pharmacist involvement in identifying and addressing modifiable risk factors in patients with heart failure beginning as early as Stage A.

EvidenceThe management of modifiable risk factors including hyperlipidemia, poor glycemic control, obesity, and uncontrolled hypertension is imperative due to their role in the development of structural heart disease. The 2022 ADA Heart Failure Consensus Report describes one study that demonstrated how appropriate treatment with statins in patients with diabetes may decrease the incidence of HF. Optimal blood pressure targets for HF remain unknown, but the 2022 AHA/ACC/HFSA HF Guidelines recommend optimizing antihypertensive therapy according to ACC/AHA Hypertension Guidelines to decrease incident risk of HF in the general public. Additionally, HF is a common complication of diabetes with an estimated prevalence of up to 22% in those diagnosed with diabetes. Along with appropriate medication therapy, the implementation of lifestyle modifications such as optimal nutrition, regular physical exercise, and tobacco cessation are known to reduce the impact of these HF risk factors to treat and prevent HF. 

Sodium restriction has historically been a common nonpharmacologic strategy to manage symptoms of congestive HF and reduce hospitalizations. However, more recently, concerns have been raised regarding diminished quality of nutrition with strict limitations on sodium intake. Of note, the recommendations regarding sodium intake are supported by low-quality evidence of clinical benefit. A recent study by Li and colleagues found an association with worse outcomes including survival and HF hospitalization for patients with heart failure with preserved ejection fraction who follow an overstrict sodium restriction (defined as no salt added to homemade foods). Both the 2022 ADA Heart Failure Consensus Report and AHA/ACC/HFSA Guidelines for the Management of Heart Failure support the DASH diet for HF in combination with dietary counseling to achieve a diet low in sodium and fat, but rich in antioxidants, vegetables, and whole grains.

Physical activity, specifically aerobic exercise, has demonstrated benefit for the prevention and treatment of HF. Per the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, incorporation of regular, structured exercise can improve functional capacity and prevent progression. Thus, consistent exercise can ultimately lead to reduced hospitalizations and improve patients’ quality of life. Of note, cardiopulmonary exercise testing should be completed before recommending specific exercise in individuals with HF to ensure safety.

Smoking is considered a major modifiable risk factor, increasing the risk of HF in both current and former smokers. A 2022 study by Ding et al. demonstrated a decreasing risk of incident HF with tobacco cessation and further declining risk with longer duration of tobacco cessation. HF risk was significantly reduced after ≥20-30 years of tobacco cessation (HR 1.34; 95% CI 1.07-1.67). Incorporation of counseling, motivational interviewing, approved pharmacologic treatment, and/or appropriate referrals is encouraged at each contact.

Clinical ImpactThe specialized training and accessibility of pharmacists offers an opportunity for significant impact in the care of patients with HF. By intervening and educating on risk factors, pharmacists can play an important role in reducing the impact that HF has on patients’ lives. In fact, the ADA specifically encourages pharmacist involvement as part of the care team for the treatment of individuals with HF. In addition to performing a comprehensive review of patients’ regimens for use of appropriate guideline-directed medication therapies, pharmacists can contribute to management of these risk factors by assessing adherence and helping to address barriers such as noncompliance, affordability, tolerability, pill burden, and knowledge gaps. In fact, these are contributions that pharmacists already make on a daily basis in the ambulatory care setting. Modifiable risk factors and lifestyle changes should be assessed at every visit with resources, counseling, and motivational interviewing employed to encourage positive changes and lifestyle modifications such as medication adherence, tobacco cessation, regular physical activity, and reducing sodium intake through the DASH diet.


  1. Ding N, Shah AM, Blaha MJ, Chang PP, Rosamond WD, Matsushita K. Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction. J Am Coll Cardiol. 2022;79(23):2298-2305. doi:10.1016/j.jacc.2022.03.377