The Association of Hemoglobin A1c With Incident Heart Failure Among People Without Diabetes: The Atherosclerosis Risk in Communities Study

  1. Elizabeth Selvin1
  1. 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
  2. 2Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland;
  3. 3Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil;
  4. 4Department of Epidemiology and Prevention, Wake Forest University Health Sciences, Winston-Salem, North Carolina;
  5. 5Department of Medicine, Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina.
  1. Corresponding author: Kunihiro Matsushita, kmatsush{at}


OBJECTIVE This study sought to investigate an association of HbA1c (A1C) with incident heart failure among individuals without diabetes and compare it to fasting glucose.

RESEARCH DESIGN AND METHODS We studied 11,057 participants of the Atherosclerosis Risk in Communities (ARIC) Study without heart failure or diabetes at baseline and estimated hazard ratios of incident heart failure by categories of A1C (<5.0, 5.0–5.4 [reference], 5.5–5.9, and 6.0–6.4%) and fasting glucose (<90, 90–99 [reference], 100–109, and 110–125 mg/dl) using Cox proportional hazards models.

RESULTS A total of 841 cases of incident heart failure hospitalization or deaths (International Classification of Disease, 9th/10th Revision, 428/I50) occurred during a median follow-up of 14.1 years (incidence rate 5.7 per 1,000 person-years). After the adjustment for covariates including fasting glucose, the hazard ratio of incident heart failure was higher in individuals with A1C 6.0–6.4% (1.40 [95% CI, 1.09–1.79]) and 5.5–6.0% (1.16 [0.98–1.37]) as compared with the reference group. Similar results were observed when adjusting for insulin level or limiting to heart failure cases without preceding coronary events or developed diabetes during follow-up. In contrast, elevated fasting glucose was not associated with heart failure after adjustment for covariates and A1C. Similar findings were observed when the top quartile (A1C, 5.7–6.4%, and fasting glucose, 108–125 mg/dl) was compared with the lowest quartile (<5.2% and <95 mg/dl, respectively).

CONCLUSIONS Elevated A1C (≥5.5–6.0%) was associated with incident heart failure in a middle-aged population without diabetes, suggesting that chronic hyperglycemia prior to the development of diabetes contributes to development of heart failure.


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  • See accompanying commentary, p. 1868.

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  1. Diabetes vol. 59 no. 8 2020-2026
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