A bold truth about our health landscape: heart failure in the United States is rising, yet the drivers behind it are shifting in surprising ways. This transformation challenges how to prevent and treat HF, and it invites a deeper look at what really fuels the condition today.
A recent analysis, relying on self-reported data, suggests that ischemic causes are no longer as dominant in driving heart failure as they were 35 years ago. Over the past few decades, HF prevalence has climbed in the U.S., but age-specific prevalence has remained relatively stable according to registry data. In parallel, the profile of risk factors has evolved: obesity, diabetes, and chronic kidney disease have become more common among people with HF, while high blood pressure, high cholesterol, and prior myocardial infarction have appeared less frequently. Even as cardiovascular death declined within the HF group, self-reported health and physical functioning improved.
Lead author Ahmed Sayed, MD, notes that these shifts reflect a complex mix of medical advances, better application of risk-factor management, and the rising prevalence of other risk factors over the past four decades. The findings carry important implications for healthcare systems and policy.
Commentary from experts underscores that while the study sheds light on how HF prevalence has changed, it doesn’t fully reveal how well the nation is managing HF overall. For instance, an apparent rise in HF alongside more comorbidities may seem less alarming at first glance, but mortality among these sicker patients has actually worsened when looked at in age-adjusted terms, even as overall HF prevalence appears steady and applies to younger individuals as well.
An accompanying editorial acknowledges limitations, such as reliance on self-reported data, but emphasizes a notable global shift from ischemic to metabolic drivers of HF. This epidemiologic transition has far-reaching implications for the design and interpretation of HF clinical trials.
NHANES-based data analyzed 83,552 ambulatory adults (median age 45; 52% women), of whom 3,078 reported a history of HF. From 1988 to 2023, crude HF prevalence rose from 2.1% to 3.0% (a 43% relative increase), but age-stratified prevalence remained stable over time, indicating age as a stronger determinant of HF prevalence than calendar year.
Among those with HF, obesity surged from 32.5% in 1988 to 60.4% in 2023. Impaired glucose regulation climbed from 48.6% to 69.2%, diabetes from 21.2% to 36.2%, and chronic kidney disease from 38.6% to 52.3%. Conversely, the proportions with elevated blood pressure dropped from 80.7% to 49.1%, hypercholesterolemia from 71.5% to 22.6%, and a history of myocardial infarction from 59.3% to 42.1%.
Medication use also evolved, with greater adoption of ACE inhibitors/ARBs (9.2% to 54.7%), beta-blockers (6.2% to 71.7%), and statins (5.3% to 72.7%). Smoking declined (34.8% to 16.4%). The risk of cardiovascular mortality declined over the years for people with HF (hazard ratio 0.30; 95% CI 0.22–0.41) and for those without HF (hazard ratio 0.41; 95% CI 0.34–0.48). Self-reported health and physical function improved in HF patients, though work-related impairment did not.
Marat Fudim, MD, cautions about NHANES’ limitations, including missing data on medications and adherence, as well as incomplete laboratory information. He emphasizes the need to explore how HF phenotypes have evolved, noting that HF increasingly includes a higher proportion of heart failure with preserved ejection fraction (HFpEF) driven by comorbidities.
Additionally, the study’s time frame ends in 2023, so the potential effects of the COVID-19 pandemic on HF prevalence and outcomes may not be fully captured.
Implications for research are clear. Editorial authors Ostrominski and Givertz argue that the data provide a strong basis for trials focused on metabolism-, kidney-, and aging-related drivers of ventricular remodeling and disease progression. They advocate for increased attention to obesity in HF with reduced ejection fraction, as obesity contributes to adverse outcomes, functional impairment, and multimorbidity, and they call for research into aging pathways and physical frailty in HF.
They also urge greater inclusivity in future trials, noting that many past HF studies excluded patients with high BMI or advanced CKD. Finally, prevention in HF is highlighted as an increasingly important area of study. Taken together, these evolving needs demand parallel evolution in trial concepts, design, and execution, because HF is not inevitable, and the cardiovascular community bears responsibility to show it can be prevented.
