Background: Although risk factors for heart failure are increasingly common worldwide, the contribution of atherosclerosis to heart failure in sub-Saharan Africa is largely unknown.

Objective: This study assessed the association between atherosclerotic risk factors and heart failure in a developing country.

Methods: We performed a case-control study of heart failure in rural Kenya. We assessed the risk factors for heart failure by using international criteria based on electrocardiogram (ECG), echocardiogram, physical examination findings, and laboratory testing. Atherosclerotic risk factors were determined by ECG, echocardiogram, anklebrachial index (ABI), and lipid testing. We described the relationship of wall motion abnormalities on echocardiogram, ABI <0.9, and ischemic pattern on ECG with the presence of heart failure with multivariable logistic regression adjusting for age and sex and using adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

Results: There were 125 cases and 191 controls (n = 316); 49% were male. The mean age was 60 (SD = 13) years. Most patients had hypertension (53%), and 16% had human immunodeficiency virus infection. Lipids were in the normal range for all. Cases were older than controls (62 years vs. 58 years, respectively). The most common abnormality associated with heart failure was dilated cardiomyopathy. Ischemic heart failure was the second most common cause in men. Cases were more likely to have an ABI <0.9 (46% vs. 31%; AOR: 1.99; 95% CI: 1.19 to 3.32), ischemia or infarct on ECG (68% vs. 43%; AOR: 3.01; 95% CI: 1.43 to 6.34), and wall motion abnormalities on echocardiogram (54% vs. 15%; AOR: 7.00; 95% CI: 3.95 to 12.39).

Conclusions: Ischemic heart failure is more common in Kenya than previously recognized. Noninvasive markers of atherosclerosis are routinely found among patients with heart failure. Treatment and prevention of heart failure in sub-Saharan Africa must consider many causes including those related to atherosclerosis.

Highlights

• The most common cause of heart failure in western Kenya was dilated cardiomyopathy.
• Markers of atherosclerosis were more common in patients with heart failure than in patients without heart failure.
• Ischemic heart disease was the second most common cause of heart failure in men.
• Use of guideline-directed medical therapy was low.
• Inattention to atherosclerosis in Kenya may ignore a common cause of heart failure.