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. 2023 Jun 13;81(23):2231-2242.
doi: 10.1016/j.jacc.2023.04.007.

Effect of 2022 ACC/AHA/HFSA Criteria on Stages of Heart Failure in a Pooled Community Cohort

Reza Mohebi  1 , Dongyu Wang  2 , Emily S Lau  3 , Juhi K Parekh  4 , Norrina Allen  5 , Bruce M Psaty  6 , Emelia J Benjamin  7 , Daniel Levy  8 , Thomas J Wang  9 , Sanjiv J Shah  10 , John S Gottdiener  11 , James L Januzzi Jr  12 , Jennifer E Ho  13
Affiliations

Effect of 2022 ACC/AHA/HFSA Criteria on Stages of Heart Failure in a Pooled Community Cohort

Reza Mohebi et al. J Am Coll Cardiol. .

Erratum in

  • Correction.
    [No authors listed] [No authors listed] J Am Coll Cardiol. 2023 Sep 5;82(10):1051. doi: 10.1016/j.jacc.2023.07.009. J Am Coll Cardiol. 2023. PMID: 37648354 No abstract available.

Abstract

Background: The 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) clinical practice guideline proposed an updated definition for heart failure (HF) stages.

Objectives: This study aimed to compare prevalence and prognosis of HF stages according to classification/definition originally described in 2013 and 2022 ACC/AHA/HFSA definitions.

Methods: Study participants from 3 longitudinal cohorts (the MESA [Multi-Ethnic Study of Atherosclerosis], CHS [Cardiovascular Health Study], and the FHS [Framingham Heart Study]), were categorized into 4 HF stages according to the 2013 and 2022 criteria. Cox proportional hazards regression was used to assess predictors of progression to symptomatic HF and adverse clinical outcomes associated with each HF stage.

Results: Among 11,618 study participants, according to the 2022 staging, 1,943 (16.7%) were healthy, 4,348 (37.4%) were in stage A (at risk), 5,019 (43.2%) were in stage B (pre-HF), and 308 (2.7%) were in stage C/D (symptomatic HF). Compared to the classification/definition originally described in 2013, the 2022 ACC/AHA/HFSA approach resulted in a higher proportion of individuals with stage B HF (increase from 15.9% to 43.2%); this shift disproportionately involved women as well as Hispanic and Black individuals. Despite the 2022 criteria designating a greater proportion of individuals as stage B, the relative risk of progression to symptomatic HF remained similar (HR: 10.61; 95% CI: 9.00-12.51; P < 0.001).

Conclusions: New standards for HF staging resulted in a substantial shift of community-based individuals from stage A to stage B. Those with stage B HF in the new system were at high risk for progression to symptomatic HF.

Keywords: biomarker; heart failure; mortality; outcome; prevalence.

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Conflict of interest statement

Funding Support and Author Disclosures This work was partially supported by the National Heart, Lung, and Blood Institute (NHLBI) (Framingham Heart Study: contract N01-HC25195 and HHSN268201500001I; Cardiovascular Health Study: contracts HHSN268201200036C, HHSN268200800007C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, 75N92021D00006, and U01HL130114 and grant U01HL080295, Multi-Ethnic Study of Atherosclerosis: contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168, N01-HC-95169, UL1-TR-000040, UL1-TR-001079, UL1-TR-001420, UL1-TR-001881, and DK063491). Funding support for the Multi-Ethnic Study of Atherosclerosis Renal Function data set was provided by grant DK083538-01. The Cardiovascular Health Study received additional contributions from the National Institute of Neurological Disorders and Stroke and grant R01AG023629 from the National Institute on Aging. A full list of principal Cardiovascular Health Study investigators and institutions can be found at https://chs-nhlbi.org/. A full list of participating Multi-Ethnic Study of Atherosclerosis investigators and institutions can be found at https://www.mesa-nhlbi.org. Dr Mohebi has received grants from the Barry Fellowship. Dr Lau has received grants from the NIH (K23-HL159243) and the American Heart Association 18SFRN34110082. Dr Psaty has served on the Steering Committee of the Yale Open Data Access Project funded by Johnson & Johnson. Dr Benjamin has received grants from R01HL092577, 2U54HL120163, and the Sheila Balson Endowed Cardiac Scholarship. Dr Januzzi has received grants from the Hutter Family Professorship, Abbott Diagnostics, Applied Therapeutics, HeartFlow, Innolife, and Roche Diagnostics; has been a Trustee of the American College of Cardiology; has been a board member of Imbria Pharmaceuticals; has been a Director at Jana Care; has received consulting income from Abbott Diagnostics, Boehringer Ingelheim, Janssen, Novartis, Prevencio, Roche Diagnostics; and has participated in clinical endpoint committees/data safety monitoring boards for AbbVie, Siemens, Takeda, and Vifor. Dr Ho has received grants from the NIH (R01 HL134893, R01 HL140224, R01 HL160003, and K24 HL153669) and Bayer, AG. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

FIGURE 1
FIGURE 1. Distribution of Cardiac Stress Biomarkers Across Heart Failure Stages
Higher concentrations of natriuretic peptides and high-sensitivity cardiac troponin were observed among patients with stage B according to 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America compared to 2013 AHA/ACC definition. Overall, concentrations of natriuretic peptides and high-sensitivity cardiac troponin were higher among patients with stage B compared to healthy and stage A individuals according to both definitions. Median and error bars representing 25th and 75th percentile, minimum, and maximum biomarker values on a log-scale. BNP = B-type natriuretic peptide; CHS = Cardiovascular Health Study; FHS = Framingham Heart Study; hsTn = high-sensitivity cardiac troponin; MESA = Multi-Ethnic Study of Atherosclerosis; NT-proBNP = N-terminal pro-B-type natriuretic peptide.
FIGURE 2
FIGURE 2. Prevalence of Heart Failure Stages Stratified by Sex
Implementation of 2022 ACC/AHA/Heart Failure Society of America resulted in a more prominent shift from stage A to stage B among females. In both sexes, the shift was mainly from study participants in stage A heart failure. Abbreviations as in Figure 1.
FIGURE 3
FIGURE 3. HRs and Incidence Rates of All-Cause Mortality Across Heart Failure Stages
The 2013 ACC/AHA stages are shown in red, and 2022 ACC/AHA/Heart Failure Society of America shown in blue. Referent group for each was healthy individuals. HRs of incident all-cause mortality for heart failure (HF) stages were comparable according to both definitions. p-y = person-year; other abbreviations as in Figure 1.
FIGURE 4
FIGURE 4. Kaplan-Meier Curves Showing Incidence of Clinical Outcomes Across HF Stages
(A) Heart failure. (B) Cardiovascular (CV) mortality. (C) AU-cause mortality for each HF stage during follow-up period. The 2022 ACC/AHA/Heart Failure Society of America and 2013 ACC/AHA guideline stages are shown side by side. Lower survival rate, in a stepwise fashion, was observed among patients from stage C/D, B, A to healthy people, respectively, according to both definitions. Abbreviations as in Figure 1.
CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Prevalence and Prognosis of Heart Failure Stages in the Community
Implementation of 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) stages of heart failure significantly increased the prevalence of stage B heart failure in the community particularly among female population compared to 2013 ACC/AHA guideline definition. Despite significant increase in prevalence of stage B, risk of adverse outcome remains elevated.
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References

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