The number of adult heart failure (HF) patients in the U.S. increased from 3.3 million to 7.4 million people over the past 40 years, a new analysis reveals. This rise was accompanied by increasing rates of obesity, diabetes and chronic kidney disease, and decreasing rates of high blood pressure, elevated cholesterol levels and previous heart attacks. Ahmed Sayed, MD, from Rochester General Hospital, New York, and colleagues, reported these results in a manuscript published online in the Journal of the American College of Cardiology. Treatments for HF have changed rapidly in the past 20 years, with emerging technologies and updated guidelines for the disease improving patient outcomes and lifespans. Risk factors for HF have also changed. Investigators in this present study evaluated the changing dynamics of the HF landscape, including risk factors and clinical outcomes. A total of 83,552 ambulatory patients, representative of the U.S. population, over or at 20 years of age, were assessed for self-reported HF and corresponding risk factors (n=3,078 patients with HF). Risk factors that were assessed included obesity (body mass index [BMI]≥30 kg/m), elevated blood pressure (≥130 mmHg systolic and ≥80 mmHg diastolic), impaired glucose homeostasis (HbA1C≥5.7%), hypercholesterolemia (total cholesterol≥200 mg/dL), a history of myocardial infarction (MI) and chronic kidney disease. Disease prevalence differences from 2023 to 1988 were reported using prevalence ratios. The investigators also examined cause-specific trends. The exact prevalence of HF jumped from 2.1% in 1988 to 3.0% in 2023 (3.3 million people to 7.4 million people), demonstrating a 43% increase (95% confidence interval [CI]=8%-91%). Age-standardization showed no change in prevalence. In patients who had HF, rates of obesity went up (32.5% to 60.4%) from 1988 to 2023. Similarly, rates also increased for impaired blood sugar regulation (48.6% to 69.2%), diabetes (21.2% to 36.2%) and chronic kidney disease (38.6% to 52.3%). Decreases between 1988 and 2023 were observed in elevated blood pressure (80.7% to 49.1%), hypercholesterolemia (71.5% to 22.6%) and history of MI (59.3% to 42.1%). Participants self-reported that their health and physical functioning improved over time, but work-related problems continued to be an issue over time. Overall reductions in cardiovascular mortality and all-cause death were also observed. These trends demonstrate that HF has become more common throughout the past four decades, but risk factors have shifted, with current risk factors leaning toward increased rates of BMI and diabetes and decreasing rates of hypertension and MI. In an accompanying editorial, John W. Ostrominski, MD, and Michael M. Givertz, MD, both from the Brigham and Women’s Hospital and Harvard Medical School, Boston, commented on the evolution of HF management and the current state of HF prevention. Notably, the editorialists commented on the need for a shift in focus of HF in clinical trials. “These may include trials evaluating new modes of preclinical HF detection (eg, biomarkers, advanced imaging, and artificial intelligence–based electrocardiography and echocardiography analysis) and smaller-scale simple trials evaluating surrogate endpoints, such as transitions between early HF stages,” Drs. Ostrominski and Givertz wrote. They concluded with optimism, “HF is not inevitable, and it is our responsibility as a cardiovascular community to demonstrate this.” Sources: Sayed A, Vasan RS, Harrell FE, et al. Trends in the prevalence, associated risk factors, and health burden of heart failure in the United States, 1988 to 2023. J Am Coll Cardiol. 2025 November 26 (Article in Press). Ostrominski JW, Givertz MM. Designing trials in an era of shifting heart failure: A focus on prevention to achieve success. J Am Coll Cardiol. 2025 November 26 (Article in Press). Image Credit: jarun001 – stock.adobe.com