The number of US adults living with heart failure has more than doubled over the past three decades, mostly due to the rising prevalence of obesity and diabetes, according to a new study published in the Journal of the American College of Cardiology.

Using data from the National Health and Nutrition Examination Survey, researchers found that the prevalence of heart failure rose from 2.1% in 1988 to 3.0% in 2023, a 43% increase (prevalence ratio [PR], 1.43; 95% CI, 1.08-1.91). However, when researchers adjusted for age, heart failure rates stayed at 3%, suggesting that the increase is largely due to the population getting older, not because people are more likely to get heart failure at younger ages.

The risk factor profile of patients with heart failure also changed. Among adults with heart failure, obesity increased from 32.5% in 1988 to 60.4% in 2023 (PR, 1.86; 95% CI, 1.36-2.55). Impaired glucose regulation — including diabetes and prediabetes — rose from 48.6% to 69.2% (PR, 1.42; 95% CI, 1.14-1.77), while diabetes alone increased from 21.2% to 36.2% (PR, 1.71; 95% CI, 1.28-2.29). Chronic kidney disease also became more common, increasing from 38.6% to 52.3% (PR, 1.35; 95% CI, 1.08-1.70).

That shift reflects what clinicians are seeing in practice, said Marwa A. Sabe, MD, associate director in the section of Advanced Heart Failure and Transplant Cardiology at Beth Israel Deaconess Medical Center, Boston, who was not involved in the study.

“There is certainly a higher prevalence of obesity, diabetes, and kidney disease in the overall population and thus in patients with heart failure,” she told Medscape Medical News. 

Decrease in Traditional Risk Factors

While patients with recent myocardial infarction remain at risk, Sabe added that “with a significant decrease in acute myocardial infarctions overall, advances in revascularization timing and techniques, and increased primary and secondary prevention, heart failure due to recent myocardial infarction is less prominent than in the past.”

Indeed, during the study period, researchers found that traditional cardiovascular risk factors for heart failure declined. The prevalence of elevated blood pressure fell from 80.7% to 49.0% (PR, 0.61; 95% CI, 0.51-0.73), hypercholesterolemia from 71.5% to 22.6% (PR, 0.32; 95% CI, 0.21-0.47), and a history of myocardial infarction from 59.3% to 42.1% (PR, 0.71; 95% CI, 0.57-0.88).

Lead study author Ahmed Sayed, MD, a first-year cardiology resident at Rochester Regional Health in Rochester, New York, said the findings point to opportunities both for prevention and earlier detection.

“When seeing a patient with one of these conditions in the clinic, we have to ask ourselves if there’s something we can do at that time to minimize the risk of them developing heart failure down the line,” Sayed said.

That can include both lifestyle and medical approaches, such as “intensive lifestyle modification, effective medications for some of these conditions, such as SGLT2 inhibitors or GLP-1 agonists, or bariatric surgery for morbid obesity,” Sayed said.

Considering Diagnosis

The findings also highlight the importance of diagnostic vigilance, Sayed said.

Clinicians should “have a higher clinical suspicion of underlying heart failure when patients with these conditions present with symptoms or signs that may be related to heart failure,” such as increasing shortness of breath or reduced activity, and to “consider early evaluation for otherwise unexplained symptoms,” he said.

Mortality trends add another layer of complexity. Although cardiovascular and all-cause mortality declined over time among patients with heart failure during the study, researchers found that noncardiovascular deaths now account for a growing share of mortality.

That pattern, however, varies by subtype, Sabe said.

“There is an increase in death due to noncardiovascular causes in patients with heart failure, but this is seen most often in patients with heart failure with preserved ejection fraction and in those with mildly reduced ejection fraction,” she said. “Cardiovascular causes of death remain the leading cause of death in patients with heart failure with reduced ejection fraction.”

Shared risk factors help explain this shift, Sayed said.

“A lot of potentially fatal conditions share a lot of risk factors in common,” Sayed said. “Many of the predisposing risk factors that we think of for heart failure are also associated with other potentially fatal diseases like cancer and kidney disease.”

As a result, he said, “It will be important to take a step back and think about the things we can do to tackle these risk factors so that all of the downstream conditions such as heart failure, kidney disease, and cancer are prevented or mitigated.”

Managing patients with multiple chronic conditions requires careful medication balancing, Sabe added.

“As patients have more comorbidities, the medications can start to pile up, and patients often become quite concerned about the number of medications they take every day,” Sabe said. 

Clinicians must balance those concerns with patient education and ensure that “guideline-directed medical therapy, especially in patients with heart failure with reduced ejection fraction, should not be compromised” unless limited by symptoms or organ dysfunction, Sabe said.

The study relied on self-reported heart failure diagnoses, which could affect prevalence estimates. Sayed said that misclassification could cut both ways. 

“There are definitely people with heart failure who may have never sought medical advice or never been told that they have it,” he said.

At the same time, “some people also get misdiagnosed with heart failure when their symptoms are more likely due to another cause,” such as chronic obstructive pulmonary disease, he said.

‘Untapped Potential’

In an accompanying editorial, cardiologists John W. Ostrominski, MD, and Michael M. Givertz, MD, both from Brigham and Women’s Hospital, Boston, shared their perspective on the data.

“[These findings] underscore a rapidly evolving shift from ischemic to metabolic drivers of heart failure,” with important implications for research and care, they wrote.

Sabe agreed, saying that clinicians are often forced to infer based on more limited data when treating patients with severe obesity or advanced kidney disease.

“We do often have to extrapolate beyond the guidelines in these cases, as there are evidence gaps in these types of patients,” she said. “There is a general lack of large datasets specifically addressing these patient populations.”

Sayed said recent trials have begun to reflect modern heart failure phenotypes, but prevention-focused research remains limited.

“We’ve focused quite a bit on cutting down the morbidity and mortality associated with heart failure in patients who already have it, but we have not yet focused as much as we could on what we can do to prevent heart failure from developing in the first place,” Sayed said. 

“There are some ongoing trials which will try to tackle this,” he added, “but I think heart failure prevention is a field with a lot of, as of yet, untapped potential.”

Sabe reports having consulted for Novo Nordisk. Sayed reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.