Rising HF Burden in the US Potentially Related to Changes in Cardiometabolic Factors

Over the last 35 years, the burden of heart failure (HF) has increased in the United States, though its prevalence by age has remained constant, according to registry data.

Researchers also note a shift in underlying associated risk factors, with more obesity, diabetes, and chronic kidney disease and less elevated blood pressure, high cholesterol, and previous MI being reported over time. In addition, cardiovascular mortality dropped in the HF population, while self-reported health and physical function improved.

“These changes reflect a complex interplay between the medical innovations, better implementation, and improved clinical management of some risk factors, in parallel with increasing prevalence of other risk factors over the past four decades in the United States,” write lead author Ahmed Sayed, MD (Rochester General Hospital, NY), and colleagues. “These findings have major healthcare and health policy implications.”

Commenting on the findings for TCTMD, Marat Fudim, MD (Duke University, Durham, NC), senior author of a prior study showing a recent rise in heart failure mortality, said that while the current analysis gives insight into how HF prevalence has changed, “it actually doesn’t tell you much about how well we do as a nation managing [it].”

For example, “if I just told you we have more comorbidities and an ‘appropriate’ rise of heart failure along the way, it doesn’t sound as scary,” he said. “But then when you look at the mortality associated with those sick patients, you actually had a worsening of mortality, even though the age-adjusted heart failure prevalence is steady, including for the young individuals.”

In an accompanying editorial, John W. Ostrominski, MD, and Michael M. Givertz, MD (both from Brigham and Women’s Hospital, Boston, MA), highlight what they view as limitations of the analysis, including its reliance on self-reported data. Still, they write, “these findings underscore a rapidly evolving shift from ischemic to metabolic drivers of HF. This global epidemiologic transition has far-reaching implications for HF clinical trials.”

NHANES Data

The analysis, published online last week in JACC, included a sample of 83,552 ambulatory participants (median age 45 years; 52% women) from the National Health and Nutrition Examination Survey (NHANES). Among them, 3,078 reported having a history of HF.

Between 1988 and 2023, the crude prevalence of HF went up from 2.1% to 3.0%, reflecting a 43% relative jump. However, when participants were stratified by age, there was no change in prevalence over time. This indicates that “age was substantially more important than time in driving HF prevalence estimates,” the authors write.

Looking more closely at patients with HF, the prevalence of obesity rose from 32.5% in 1988 to 60.4% in 2023. Increases also were seen in impaired glucose homeostasis (48.6% to 69.2%), diabetes (21.2% to 36.2%), and chronic kidney disease (38.6% to 52.3%). However, researchers noted decreases in the proportions of HF patients with elevated BP (80.7% to 49.1%), hypercholesterolemia (71.5% to 22.6%), and MI history (59.3% to 42.1%).

In the past, heart failure was considered to be very different than what we call heart failure today. Marat Fudim

Perhaps explaining some of the trends, certain medications were used with increasing frequency over time, including ACE inhibitors/ARBs (9.2% to 54.7%), beta-blockers (6.2% to 71.7%), and statins (5.3% to 72.7%). Smoking became less common (34.8% to 16.4%).

Risk of cardiovascular mortality dropped over the years in people with HF (HR 0.30; 95% CI 0.22-0.41) and without HF (HR 0.41; 95% CI 0.34-0.48). Also, self-reported health and physical function improved in HF patients, though work-related impairments did not.

Fudim pointed to the “inherent limitations” of the NHANES database, including missing medication data and compliance information, as well as partial lab work. “Every database has pros and cons,” he said, adding that he’d like to also see more work done to examine how heart failure phenotypes have changed over time. “In the past, heart failure was considered to be very different than what we call heart failure today. You have a lot more [heart failure with preserved ejection fraction] now, and these comorbidities have been driving a lot of that phenotype.”

Additionally, because the study only goes through 2023, the impact of the COVID-19 pandemic on heart failure prevalence and outcomes might not be fully reflected in the findings, Fudim added.

Implications for Research

The findings should influence the future of research in this field, the editorialists argue.

Specifically, the data “provide a strong evidentiary basis for trials targeting metabolism-, kidney-, and aging-related drivers of ventricular remodeling and disease progression,” assert Ostrominski and Givertz.

“Trials targeting obesity in HF with reduced ejection fraction should also be encouraged to resolve important clinical equipoise, especially as obesity can contribute to adverse outcomes, functional impairment, and multimorbidity in this population,” they explain, suggesting the need for research on how to modify the pathways of biological aging, including physical frailty, in the heart failure setting.

It’s also time for more inclusivity in future studies, they say, given that many prior HF trials have excluded patients with high BMI and advanced chronic kidney disease.

Finally, prevention in heart failure is a growing area of interest, according to the editorialists.

“Taken together, the rapidly evolving needs of persons with or at-risk of HF demand parallel evolution in HF trial concepts, design, and execution,” Ostrominski and Givertz conclude. “HF is not inevitable, and it is our responsibility as a cardiovascular community to demonstrate this.”