Trends in the Prevalence, Associated Risk Factors, and Health Burden of Heart Failure in the United States, 1988 to 2023.

Abstract

The management heart failure (HF) and its risk factors has changed substantially in recent decades. The authors sought to determine changes in the prevalence of HF, its underlying risk factors, and associated health outcomes from 1988 to 2023. Using a nationally representative sample of 83,552 ambulatory participants (3,078 with HF) aged ≥20 years, we assessed the prevalence of self-reported HF and associated major risk factors, including obesity (body mass index [BMI] of 30 kg/m² or higher), elevated blood pressure (systolic blood pressure of 130 mm Hg or higher and/or diastolic blood pressure of 80 mm Hg or higher), impaired glucose homeostasis (HbA_1c of 5.7% or higher), hypercholesterolemia (total cholesterol of 200 mg/dL or higher), history of myocardial infarction (MI), and chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m² or albumin/creatinine ratio of 30 mg/g or higher). Prevalence ratios (PRs) comparing disease prevalence in 2023 to 1988 were reported. Cause-specific trends in mortality rates were also analyzed, as were trends in self-reported health, physical function, and work-related impairments. The crude prevalence of HF increased from 2.1% in 1988 (3.3 million adults) to 3.0% in 2023 (7.4 million adults); a 43% increase (95% CI: 8%-91%). There was no change in age-standardized prevalence (2.9% to 3.0%). Among respondents with HF, prevalence of obesity increased from 32.5% in 1988 to 60.4% in 2023 (PR: 1.86; 95% CI: 1.36-2.55), impaired glucose homeostasis from 48.6% to 69.2% (PR: 1.42 [95% CI: 1.14-1.77), diabetes from 21.2% to 36.2% (PR: 1.71 [95% CI: 1.28-2.29]), and chronic kidney disease from 38.6% to 52.3% (PR: 1.35 [95% CI: 1.08-1.70]). Elevated blood pressure decreased from 80.7% to 49.1% (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 MI history from 59.3% to 42.1% (PR: 0.71 [95% CI: 0.57-0.88]). Trends that were more pronounced in respondents with HF compared with respondents without HF included reductions in elevated blood pressure, hypercholesterolemia, MI, and increases in the prevalence of obesity. Significant reductions in cardiovascular and all-cause mortality were observed, albeit the latter was partially offset by increases in noncardiovascular mortality. Self-reported health and physical function also improved over time, though work-related impairments persisted. From 1988 to 2023, the number of U.S. adults with HF increased from 3.3 to 7.4 million. Age-standardized prevalence was constant. This was accompanied by a major shift in underlying risk factor profiles, with a rising prevalence of obesity, diabetes. and chronic kidney disease paralleled by a decline in elevated blood pressure, elevated cholesterol, and previous MIs. Accompanying this has been a reduction in all-cause and cardiovascular deaths paralleled by an increase in noncardiovascular deaths. Finally, impairments in self-reported health and physical functioning among patients with HF have significantly decreased over time.