The primary drivers of heart failure (HF) have shifted significantly over the past 35 years, with metabolic conditions such as obesity and diabetes now playing a more prominent role than traditional risk factors like myocardial infarction (MI).¹˒² This finding comes from a large US-based study analysing national health trends.

Methodology

Researchers conducted a retrospective analysis of data from the National Health and Nutrition Examination Survey (NHANES) between 1988 and 2023. The study included a nationally representative sample of 83,552 adults aged 20 years or older, of whom 3,078 had a self-reported diagnosis of HF. The objective was to assess temporal changes in the prevalence of HF, its associated risk factors, and related health outcomes.¹

Results

The crude prevalence of HF in the US adult population increased from 2.1% in 1988 to 3.0% in 2023, representing a rise from 3.3 million to 7.4 million individuals. However, the age-standardised prevalence remained stable (2.9% to 3.0%), indicating that the increase is largely attributable to an ageing population rather than a higher incidence at younger ages.¹

A substantial shift was observed in the risk factor profile of patients with HF. The prevalence of obesity rose from 32.5% to 60.4%, while diabetes increased from 21.2% to 36.2%. Chronic kidney disease (CKD) also became more common, increasing from 38.6% to 52.3%. In contrast, the prevalence of traditional risk factors declined significantly. A history of MI decreased from 59.3% to 42.1%, elevated blood pressure fell from 80.8% to 49.0%, and hypercholesterolaemia dropped from 71.5% to 22.6%.¹

Over the study period, cardiovascular and all-cause mortality among patients with HF declined. However, this was partially offset by an increase in noncardiovascular deaths.¹

In Practice/Interpretation

These findings underscore a major transition from ischaemic to metabolic drivers of HF. The study authors concluded that the rising number of adults with HF “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.”¹

This evolving landscape presents new opportunities for prevention. Lead author Dr Ahmed Sayed commented, “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.”² This highlights the need for increased diagnostic vigilance and early intervention for patients with metabolic comorbidities.

Next Steps

While the management of established HF has advanced, the authors suggest that future research should place a greater emphasis on primary prevention strategies that target the rising burden of metabolic risk factors to curb the growing prevalence of HF.

References

1. Sayed A, Vasan RS, Harrell FE Jr, Butler J. 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;86(25):2542-2564. https://doi.org/10.1016/j.jacc.2025.09.1503

2. Salahi L. Chronic Diseases Replace Heart Attack as Lead Drivers of Heart Failure. Medscape. December 19, 2025. https://www.medscape.com/viewarticle/chronic-diseases-replace-heart-attack-lead-drivers-heart-2025a1000zt8

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