Heart failure (HF) is on the rise in the US, but the reasons why might surprise you. While age-adjusted prevalence has remained steady, the underlying causes are shifting dramatically, suggesting a need to rethink how we approach prevention and treatment. But here's where it gets controversial: are we really managing heart failure any better, even with all our medical advancements? This question is at the heart of a recent analysis published in the Journal of the American College of Cardiology (JACC), which dives deep into the changing landscape of heart failure in the United States.
Over the past 35 years, data from registries indicates that the overall burden of heart failure has increased, even though the age-specific prevalence has remained relatively constant. In simpler terms, more people are living with heart failure, but this isn't necessarily because people are more likely to develop it at a given age. Instead, it seems to be related to other factors.
Researchers have observed a significant shift in the risk factors associated with heart failure. We're seeing more obesity, diabetes, and chronic kidney disease in HF patients. Conversely, we're seeing less elevated blood pressure, high cholesterol, and a history of prior heart attacks (myocardial infarction or MI). And this is the part most people miss: while cardiovascular mortality has decreased in the heart failure population, their self-reported health and physical function has improved.
Dr. Ahmed Sayed (Rochester General Hospital, NY), the lead author of the study, and his colleagues attribute these changes to "a complex interplay between 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." They believe these findings have significant implications for healthcare and health policy. In essence, we're getting better at managing some aspects of cardiovascular health, but struggling with others, particularly those related to metabolic health.
Dr. Marat Fudim (Duke University, Durham, NC), commenting on the findings, raises a crucial point. He notes that while the analysis offers insights into how heart failure prevalence has changed, it doesn't necessarily tell us how well we are managing the condition as a whole. He points to his own prior study which showed a recent rise in heart failure mortality. 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 other words, just because more people are living with heart failure doesn't mean they are living well with it.
In an accompanying editorial, Drs. John W. Ostrominski and Michael M. Givertz (both from Brigham and Women’s Hospital, Boston, MA) highlight the limitations of the analysis, particularly its reliance on self-reported data. But they also emphasize the key takeaway: "these findings underscore a rapidly evolving shift from ischemic to metabolic drivers of HF." Ischemic drivers refer to heart problems caused by reduced blood flow, like heart attacks. Metabolic drivers, on the other hand, relate to conditions like obesity and diabetes. This shift has far-reaching implications for how we design and conduct heart failure clinical trials. This global epidemiologic transition has far-reaching implications for HF clinical trials.
The analysis itself used data from the National Health and Nutrition Examination Survey (NHANES), a large, nationally representative survey. The sample included 83,552 participants, with a median age of 45 years and 52% women. Of these, 3,078 reported a history of heart failure.
Between 1988 and 2023, the crude prevalence of heart failure (the overall percentage of people with HF) increased from 2.1% to 3.0%, a relative jump of 43%. However, when the researchers looked at the prevalence within specific age groups, they found no significant change over time. This suggests that age itself is a more significant factor in determining heart failure prevalence than the passage of time.
A closer look at patients with heart failure revealed some striking trends. The prevalence of obesity rose dramatically, from 32.5% in 1988 to 60.4% in 2023. Similar increases 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%). On the other hand, the proportions of heart failure patients with elevated blood pressure (80.7% to 49.1%), hypercholesterolemia (71.5% to 22.6%), and a history of heart attack (59.3% to 42.1%) decreased.
Interestingly, the use of certain medications, such as ACE inhibitors/ARBs (9.2% to 54.7%), beta-blockers (6.2% to 71.7%), and statins (5.3% to 72.7%), increased significantly over time. Smoking also became less common (34.8% to 16.4%). These trends likely contribute to the observed decreases in cardiovascular mortality, which dropped in both people with heart failure (HR 0.30; 95% CI 0.22-0.41) and those without (HR 0.41; 95% CI 0.34-0.48). Self-reported health and physical function also improved in heart failure patients, although work-related impairments did not.
Dr. Fudim acknowledges the inherent limitations of the NHANES database, including missing medication data, compliance information, and incomplete lab results. He stresses that all databases have their strengths and weaknesses. He would like to see more research on how heart failure phenotypes have changed over time, noting that heart failure with preserved ejection fraction (HFpEF) is now much more common, and these comorbidities are driving a lot of that phenotype.
He also points out that the study only goes up to 2023, so the full impact of the COVID-19 pandemic on heart failure prevalence and outcomes may not be fully reflected in the findings. This is an important consideration, as the pandemic has likely exacerbated many of the underlying risk factors for heart failure.
The editorialists argue that these findings should influence the future of research in this field. They specifically call for trials targeting metabolism-, kidney-, and aging-related drivers of ventricular remodeling and disease progression. They also encourage trials targeting obesity in heart failure with reduced ejection fraction (HFrEF), especially given that obesity can contribute to adverse outcomes, functional impairment, and multimorbidity in this population. There is a need for research on how to modify the pathways of biological aging, including physical frailty, in the heart failure setting. And this is the part most people miss: Many prior heart failure trials have excluded patients with high BMI and advanced chronic kidney disease.
Finally, the editorialists highlight the growing importance of prevention in heart failure. They conclude that "the rapidly evolving needs of persons with or at-risk of HF demand parallel evolution in HF trial concepts, design, and execution." They emphasize that heart failure is not inevitable, and it is the responsibility of the cardiovascular community to demonstrate this.
So, what do you think? Given the shift towards metabolic risk factors, should we be focusing more on lifestyle interventions and preventative measures, even before someone develops heart failure? Or are we overlooking the importance of traditional cardiovascular risk factors like high blood pressure and cholesterol? And perhaps most importantly, are we truly making progress in improving the lives of people living with heart failure, or are we just managing to keep them alive longer despite underlying health problems? Share your thoughts in the comments below!
