In 1988, the typical American with heart failure (HF) was likely recovering from a myocardial infarction (MI) and struggling to manage hypertension and hypercholesterolemia. By 2023, that profile dramatically shifted: today's HF patients are more likely battling obesity, diabetes and kidney disease.

This remarkable transformation, documented in a sweeping new study published in JACC, reveals both progress and a warning. While cardiology advances have tamed traditional risk factors, a new set of metabolic issues have emerged. This reshaping of HF has important implications for patient care today and the design of clinical trials that will shape care tomorrow.

HF Trends in the U.S. (1988-2023)

Ahmed Sayed, MD, Javed Butler, MD, MPH, MBA, FACC, and colleagues examined 35-year trends in HF prevalence and associated risk factors among U.S. adults using data from the National Health and Nutrition Examination Survey (NHANES). The research analyzed 83,552 participants, including 3,078 with self-reported HF.

The crude prevalence of HF increased by 43% from 2.1% in 1988 (3.3 million adults) to 3.0% in 2023 (7.4 million adults), with a prevalence ratio (PR) of 1.43 (p<0.05). However, age-standardized prevalence remained essentially constant at around 3%, indicating that population aging, rather than age-independent secular trends, drove the increase in absolute HF cases.

Notably, what has changed dramatically is why people develop HF and what they look like when they do.

Dramatic Shifts in Risk Factor Profiles

The investigators documented striking changes in cardiovascular risk factors among HF patients, including a near doubling in the rate of obesity (See Table). Even more concerning, severe obesity – defined as a BMI>40 – surged by 249%. Central adiposity, measured by waist-to-height ratio, proved nearly universal, affecting >90% of patients with HF throughout the entire study period, with marked central obesity increasing from 44% to 73%.

Diabetes followed a similar trajectory, jumping 71%. When researchers broadened their definition to include pre-diabetes, they found that dysglycemia affected 69.2% of patients with HF by 2023, up from 48.6% in 1988. Chronic kidney disease prevalence rose 35%.

Table: Summary of (Selected) Changes in Risk Factor Prevalence Among Patients With HF in the U.S., 1988-2023 (all p<0.05)

Conversely, traditional cardiovascular risk factors showed marked improvements. Hypertension decreased 39%, hypercholesterolemia 68% and MI history 29%. These changes paralleled substantial increases in guideline-directed medical therapy utilization, including ACE inhibitors/ARBs (9.2% to 54.7%) and beta-blockers (6.2% to 71.7%).

Mortality and Functional Outcomes

The evolution in risk factors has translated into measurably better, albeit complex, outcomes for patients with HF. Age-adjusted cardiovascular mortality significantly decreased (hazard ratio [HR], 0.30 comparing 2016 to 1988), though this benefit was partially offset by an increase in noncardiovascular mortality (HR, 1.81), which increased from 24% to 62% of all-cause mortality.

When researchers combined both types of death, the overall mortality improvement was more modest (a 27% reduction), which was still meaningful but tempered by the rise in deaths from other causes.

Self-reported health and physical functioning improved substantially over time with patients reporting less difficulty walking or climbing stairs.

Shifting Phenotypes Necessitate Fundamental Rethink

In an accompanying editorial comment, John Ostrominski, MD, and Michael M. Givertz, MD, FACC, argue that these findings demand a fundamental rethinking of HF research and treatment. "These findings underscore a rapidly evolving shift from ischemic to metabolic drivers of HF," they write, noting that the obesity epidemic and its downstream consequences now represent the primary battleground.

The implications for clinical trials are significant. Traditional HF trials have often excluded patients with severe obesity or advanced kidney disease, creating knowledge gaps for the fastest-growing patient populations. Future trials, the editorialists argue, should embrace more inclusive eligibility criteria and consider new types of interventions targeting metabolism, kidney function and biological aging.

The increase in noncardiovascular deaths also challenges the conventional wisdom about trial endpoints. Since HF trials have historically focused on cardiovascular death as a primary outcome, the shift toward noncardiovascular mortality may require researchers to reconsider their measures of success. Should trials targeting obesity-related HF also track dementia, infection, respiratory disease and cancer, all conditions linked to excess body weight?

These trends amplify recent calls for an enhanced focus on prevention. With obesity, diabetes and chronic kidney disease now dominating the risk landscape, preventing HF may require addressing these interconnected metabolic problems years earlier.

For researchers, clinicians, and public health officials, the message is clear: yesterday's victories should be celebrated (and secured into the future), but tomorrow's battles will be fought on different ground.

Limitations and Caveats

The study's reliance on self-reported HF diagnosis represents an important limitation, as does the lack of information about specific HF subtypes. The analysis excluded nonambulatory persons, potentially underestimating HF prevalence among the severely ill. Still, the consistency of these findings with other datasets lends confidence to the overall conclusions.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Cardiology Magazine, ACC Publications, CM-Jan-Feb-2026, United States, Heart Failure