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Risk variables of heart failure among patients in China: grey relational approach based multi-dimensional assessment study

Diabetology & Metabolic Syndrome volume 16, Article number: 205 (2024) Cite this article

Abstract

Background

Understanding the potential risk factors of heart diseases is key to effectively managing cardiac diseases. The present study quantifies the association of identified risk factors. In addition, the study has compared the association of mortality with hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia using Grey Relational Approach (GRA) for stroke, lung diseases, smoking, stress, obesity, and lack of exercise.

Method

Data on risk factors of heart failure were collected from the Global Burden of Disease (GBD) study (2001–2017). From the GBD database, variables have selected the top leading risk factors responsible for mortality from cardiac diseases. Data on risk factors was analyzed using the GRA procedure (utilizing Grey [8.0] software). In the GRA method, the correlation was categorized into three components: GRA – Deng (assesses the effect of one variable specified by data on the other variables), GRA- absolute (assesses the association between variables measured), and GRA-SS (assessed the overall association between the variables measured). Stroke, lung diseases, smoking, stress, obesity, and lack of exercise were taken as dependent variables and their impact was assessed. Hypertension (high grade) uncontrolled diabetes, and uncontrolled hyperlipidemia were considered as independent variables. The relationship between dependent and independent variables was assessed.

Results

Overall correlational analysis showed that type 2 diabetes (T2DM) is the risk factor that has a strong relationship with causing heart failure and thereby increases morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was severe dyslipidemia which is responsible for causing heart failure. High-grade hypertension is one-third most common risk factor in causing heart failure. GRA – Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by high-grade hypertension and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by high-grade hypertension and T2DM (uncontrolled). GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled).

Conclusions

The study reported that T2DM, severe dyslipidemia, and high-grade hypertension as strongly correlated with the development of heart failure after considering other several key risk factors (stroke, lung diseases, smoking, stress, obesity, and lack of exercise).

Level of evidence

IV.

Technical efficacy

Stage 5.

Introduction

Heart failure is characterized by significantly decreased ejection fraction, which leads to decreased cardiac output and increased pressure in the ventricles [1,2,3]. So far, there is no promising treatment option available that effectively improves myocardial function by acting directly on the myocardium [4,5,6,7,8]. Recently, it was reported that the cardiac myosin activators act directly on the cardiac sarcomere to increase the function of the myocardium. Cardiac myosin activators significantly improve the contractility of cardiac muscle by targeting particularly myosin, which thereby increases the generation of several myosin heads that bind to the actin monofilament. Cardiac myosin activators were found effective in reducing ejection fraction by increasing systolic ejection time and also by improving stroke volume. Moreover, it decreased left ventricular systolic and diastolic volumes. Further, it reduces natriuretic peptide levels and heart rate which helps in reversing cardiac remodeling [4,5,6,7,8].

Heart failure is one of the most common causes of mortality in China, accounting for approximately 15% of deaths in urban cities in China [2,3,4,5, 7]. China is becoming the world’s rich country, however, at the same time, these changes in the lifestyle of the Chinese population, increase lifestyle-related diseases, such as diabetes, heart disease, and increased blood pressure. The prevalence of diseases and diabetes-induced coronary heart diseases is increasing at a high pace [8,9,10,11,12]. Heart failure is responsible for 2 out of 5 deaths reported in China, the death cases are higher among rural cities of China than urban. This is possibly due to undertreatment and could be a failure to manage risk factors associated with heart failure. Thus, understanding the potential risk factors of heart diseases is key to effectively managing cardiac diseases in Chinese population [13,14,15,16]. There are several top risk factors for heart diseases already identified that cause cardiac diseases. Hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia are the top risk factors. In addition, stroke and lung diseases are the leading causes of congenital heart defects-related mortality. Other risk factors reported are smoking, stress, obesity, and lack of exercise [16, 17]. Understanding the risk factor and its impact is the key strategy to combat the risk factors and is the key for successful management of heart failure.

Logistic regression is unable to illustrate the association among the measured variables in the biomedical area due to its reliance limitations [18]. The Grey Relational Approach (GRA) models may overcome this limitation as it is lacking of reliance restrictions theory. The main strength of the GRA model method is to forecast and make resolutions with low sample sizes, poor records, and omitted data. It is also used to comprehend the unclear associations between the features. Also, the GRA model method provides weighted data with ranks, which is suitable when there are several variables to assess. In addition, it provides analysis according to significance of the variables under study [19].

The present study quantifies the association of identified risk factors. In addition, the study has compared the mortality associated with hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia with the mortality due to stroke, lung diseases, smoking, stress, obesity, and lack of exercise. This was performed by the GRA models technique.

Methods

Study population

Data on risk factors of heart failure were collected from the Global Burden of Disease (GBD) study (2001–2017). From the GBD database, we have selected the top leading risk factors responsible for mortality from cardiac diseases. These are namely hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, stroke, lung diseases, smoking, stress, obesity, and lack of exercise. Data on risk factors was analyzed using the GRA procedure (utilizing Grey [8.0] software). The present study quantifies the association of identified risk factors. We have compared the mortality associated with hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia with the mortality due to stroke, lung diseases, smoking, stress, obesity, and lack of exercise. This was performed by the GRA models technique. The data from patients who were clinically unstable and had severe hepatic and kidney diseases which may jeopardize the results. Also, the patients with any other conditions that most possibly affect the study outcomes, and data from any patients undergoing any type of major surgical intervention were excluded.

Selection criteria for the global burden of Disease (GBD)

Patients aged 25 years or more from Brazil, China, India, and the USA with of heart failure [20].

GRA method

The GRA method utilizes the correlation method to check the degree of correlation for each variable assessed to compare the risk factors of heart failure. In the GRA method, the correlation was categorized into three components: GRA - Deng, GRA- absolute, and GRA-SS. GRA – Deng assesses the effect of one variable specified by data on the other variables. GRA- absolute assesses the association between variables measured. GRA-SS model also assessed the overall association between the variables measured. Further detailed information can be found in published articles [21, 22]. The data obtained from the GBD data base on a different risk factor on patients with heart failure were received ranking according to different categorization in GRA model.

Using GRA software, the impact of identified risk factors was quantified using GRA-Deng, GRA-absolute, and GRA-SS. GRA-absolute, and GRA-SS have values from 0 to 1, while GRA–Deng has values from 0.5 to 1. Variables were considered highly correlated if the values were close to 1. If the values are departing from 1 it indicates that there are weak associations. The absolute GRG and SSGRG models have values ranging from zero to one, whereas, Deng GRG has values ranging from 0.5 to 1. It’s also considered highly associated if it’s near to 1 and weak if it departs from 1.

Statistical analyses

Since this was a pilot study and hence no formal sample size calculation was performed as the present analysis quantifies the association of identified risk factors. In the present analysis, we compared the mortality associated with hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia with the mortality due to stroke, lung diseases, smoking, stress, obesity, and lack of exercise. This was performed by the GRA models technique. Stroke, lung diseases, smoking, stress, obesity, and lack of exercise are taken as dependent variables and their impact was assessed. Hypertension (high grade) uncontrolled diabetes, and uncontrolled hyperlipidemia were considered as independent variables. The relationship between dependent and independent variables was assessed. Appropriate statistical tests were used to analyze data. Relationships between both variables were assessed using the Pearson method or correlation analysis. Also, ranking was done for each analysis assessing the association between dependent and independent variables. Statistical analysis was performed using Graph Pad (version 9.4.1) software. R values were used to assess the association between dependent and independent variables. The r values near to 1 indicate the association was strong and vice versa.

Results

GRA evaluation was performed by all the top most identified risk factors associated with heart failure that causes the mortality among majority of the Chinese population. The summary of data for GRA evaluation for smoking is described in Table 1. The association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that type 2 diabetes (T2DM) is the top risk factor associated with heart failure, followed by high-grade hypertension and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by high-grade hypertension and T2DM (uncontrolled). GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). Overall correlational analysis showed that T2DM is the risk factor that has a strong relationship in causing heart failure and thereby increases morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was severe dyslipidemia which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 1 GRA evaluation for smoking
Full size table

The summary of data for GRA evaluation for stroke is described in Table 2. The association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by high-grade hypertension and T2DM (uncontrolled). GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). Overall correlational analysis showed that T2DM is the risk factor that has a strong relationship in causing heart failure and thereby increases morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was severe dyslipidemia which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 2 GRA evaluation for stroke
Full size table

The summary of data for GRA evaluation for lung diseases is described in Table 3. The association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia (uncontrolled) and high-grade hypertension. GRA-absolute analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia and high-grade hypertension. GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). Overall correlational analysis showed that severe dyslipidemia is the risk factor that has strong relationship in causing heart failure and thereby increases the morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing the heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 3 GRA evaluation for lung diseases
Full size table

The summary of data for GRA evaluation for stress is described in Table 4. The association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia (uncontrolled). GRA–absolute analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia. GRA-SS analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by T2DM (uncontrolled) and high-grade hypertension. Overall correlational analysis showed that severe dyslipidemia is the risk factor that has strong relationship in causing heart failure and thereby increases the morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing the heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 4 GRA evaluation for stress
Full size table

The summary of data for GRA evaluation for obesity is described in Table 5. The association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that severe dyslipidemia (uncontrolled) is the top risk factor associated with heart failure, followed by T2DM and high-grade hypertension. GRA- absolute analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia. GRA-SS analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by T2DM (uncontrolled) and high-grade hypertension. Overall correlational analysis showed that severe dyslipidemia is the risk factor that has a strong relationship in causing heart failure and thereby increases morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 5 GRA evaluation for obesity
Full size table

The summary of data for GRA evaluation for lack of exercise is described in Table 6. The association of risk factors was analyzed by smoking as a relational variable. GRA–Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia (uncontrolled) and high-grade hypertension. GRA-absolute analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia and high-grade hypertension. GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). Overall correlational analysis showed that severe dyslipidemia is the risk factor that has a strong relationship in causing heart failure and thereby increases morbidity and mortality among Chinese patients. After severe dyslipidemia, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure.

Table 6 GRA evaluation for lack to exercise
Full size table

Discussion

Understanding the risk factors and their impact is the key strategy for successful management of heart failure. The present study quantifies the association of identified risk factors. We have compared the association with hypertension, uncontrolled diabetes, and uncontrolled hyperlipidemia using GRA for stroke, lung diseases, smoking, stress, obesity, and lack of exercise. Our study results were almost consistent with previous reports showing that controlling high blood cholesterol and blood pressure is essential to prevent the risk of heart failure [22]. Our study reported that T2DM, severe dyslipidemia, and high-grade hypertension as strongly correlated with the development of heart failure after considering other several key risk factors (stroke, lung diseases, smoking, stress, obesity, and lack of exercise). For smoking, the overall correlational analysis showed that T2DM is the risk factor that has a strong relationship with causing heart failure and thereby increased morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was severe dyslipidemia which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. Also, for stroke, the overall correlational analysis showed that T2DM is the risk factor that has a strong relationship with causing heart failure and thereby increased morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was severe dyslipidemia which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. For lung diseases, severe dyslipidemia is the risk factor that has a strong relationship with causing heart failure and thereby increases morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. For lung diseases. For stress, the overall correlational analysis showed that severe dyslipidemia is the risk factor that has a strong relationship with causing heart failure and thereby increased morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. For obesity, the overall correlational analysis showed that severe dyslipidemia is the risk factor that has a strong relationship with causing heart failure and thereby increased morbidity and mortality among Chinese patients. After T2DM, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. For lack of exercise, the overall correlational analysis showed that severe dyslipidemia is the risk factor that has a strong relationship with causing heart failure and thereby increased morbidity and mortality among Chinese patients. After severe dyslipidemia, the second highest risk factor associated was T2DM which is responsible for causing heart failure. High-grade hypertension is one of 3rd most common risk factors in causing heart failure. T2DM, severe dyslipidemia, and high-grade hypertension have a more grounded relationship with mortality from heart failure.

For smoking, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by high-grade hypertension and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by high-grade hypertension and T2DM (uncontrolled). GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). For stroke, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by high-grade hypertension and T2DM (uncontrolled). GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). For lung diseases, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia (uncontrolled) and high-grade hypertension. GRA-absolute analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia and high-grade hypertension. GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled). For stress, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia (uncontrolled). GRA-absolute analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia. GRA-SS analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by T2DM (uncontrolled) and high-grade hypertension. For obesity, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that severe dyslipidemia (uncontrolled) is the top risk factor associated with heart failure, followed by T2DM and high-grade hypertension. GRA-absolute analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by T2DM and severe dyslipidemia. GRA-SS analysis showed that severe dyslipidemia is the top risk factor associated with heart failure, followed by T2DM (uncontrolled) and high-grade hypertension. For lack of exercise, the association of risk factors was analyzed by smoking as a relational variable. GRA – Deng analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia (uncontrolled) and high-grade hypertension. GRA-absolute analysis showed that T2DM is the top risk factor associated with heart failure, followed by severe dyslipidemia and high-grade hypertension. GRA-SS analysis showed that high-grade hypertension is the top risk factor associated with heart failure, followed by severe dyslipidemia and T2DM (uncontrolled).

In the limitations of the study, for example, data collected from GBD and lack of dynamic study. In other limitations of the study, for example, only T2DM, dyslipidemia, and hypertension are evaluated for mortality in heart failure. However, remaining other variables are silent to be evaluated.

Conclusions

Multi-dimensional assessment study reported that type 2 diabetes, severe dyslipidemia, and high-grade hypertension as strongly correlated with the development of heart failure after considering other several key risk factors (stroke, lung diseases, smoking, stress, obesity, and lack of exercise) in Chinese patients. The study might be helpful for risk prediction and further treatment strategy for heart failure patients. Study finding provides bases for clinical practice and future research for heart failure management. The present study encourages to conduct of a larger randomized multicentric study to confirm the findings of the present study. Further research would be necessary in which effects of combination of two or more variables would be evaluated on mortality of patients with heart failure.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

GRA:

Grey Relational Approach

GBD:

The Global Burden of Disease

T2DM:

Type 2 diabetes

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Acknowledgements

The authors would like to thank patients and study staff for their support in conducting this study.

Funding

This study was supported by Key research and development project of Shaanxi Province (No: S2021-YF-YBSF-0536).

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, First Affiliated Hospital of Xi’an Jiaotong University, No. 277 Yanta West Road, Xi’an, 710061, P.R. China

    Xue Wang, Chao Deng & Xiantong Cao

  2. Department of Emergency Internal Medicine, Shaanxi Provincial People’s Hospital, 256 Youyi West Road, Xi’an, 710068, P.R. China

    Heng Gao

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Contributions

All authors read and approved the manuscript for publication. XW was project administrator and contributed to the literature review, funding acquisition, validation, methodology, formal analysis, software, resources, and data curation of the study. CD contributed to the conceptualization, supervision, funding acquisition, resources, methodology, software, and literature review of the study. XC contributed to the literature review, funding acquisition, investigation, supervision, methodology, software, and resources of the study. HG contributed to formal analyses, funding acquisition, literature review, methodology, software, and data curation of the study and drafted and edited the manuscript for intellectual content. All authors agree to be accountable for all aspects of this work, ensuring integrity and accuracy.

Corresponding author

Correspondence to Heng Gao.

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Ethics approval and consent to participate

The study received approval from the institutional ethics committee of Shaanxi Provincial People’s Hospital vide ICE approval no. S2021-YF-YBSF-0536. Informed consent from all subjects was waived by the institutional ethics committee of Shaanxi Provincial People’s Hospital.

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The authors declare no competing interests.

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Wang, X., Deng, C., Cao, X. et al. Risk variables of heart failure among patients in China: grey relational approach based multi-dimensional assessment study. Diabetol Metab Syndr 16, 205 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13098-024-01445-2

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Keywords

Diabetology & Metabolic Syndrome

ISSN: 1758-5996

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