Heart Failure Stages Among Older Adults in the Community

Abstract

Background Although HF disproportionately affects older adults, little data exist regarding the prevalence of American College of Cardiology/American Heart Association heart failure (HF) stages among older individuals in the community. Additionally, the role of contemporary measures of longitudinal strain (LS) and diastolic dysfunction in defining HF stages is unclear. Methods HF stages were classified in 6,118 participants in the Atherosclerosis Risk in Communities study (age 67 – 91 years) at the fifth study visit as follows: stage A (asymptomatic with HF risk factors but no cardiac structural or functional abnormalities), B (asymptomatic with structural abnormalities, defined as left ventricular hypertrophy, dilation or dysfunction, or significant valvular disease), C1 (clinical HF without prior hospitalization), and C2 (clinical HF with prior hospitalization). Results Using the traditional definitions of HF stages, only 5% of examined participants were free of HF risk factors or structural heart disease (Stage 0), 52% were categorized as Stage A, 30% Stage B, 7% Stage C1, and 6% Stage C2. Worse HF stage was associated with a greater risk of incident HF hospitalization or death at a median follow-up of 608 days. LVEF was preserved in 77% and 65% in Stages C1 and C2 respectively. Incorporation of LS and diastolic dysfunction into the Stage B definition reclassified 14% of the sample from Stage A to B and improved the net reclassification index (p=0.028) and integrated discrimination index (p=0.016). Abnormal LV structure, systolic function (based on LVEF and LS), and diastolic function (based on e′, E/e′, and left atrial volume index) were each independently and additively associated with risk of incident HF hospitalization or death in Stage A and B participants. Conclusions The majority of older adults in the community are at risk for HF (Stages A or B), appreciably more compared to previous reports in younger community-based samples. LVEF is robustly preserved in at least two-thirds of older adults with prevalent HF (Stage C), highlighting the burden of HFpEF in the elderly. LV diastolic function and LS provide incremental prognostic value beyond conventional measures of LV structure and LVEF in identifying persons at risk for HF hospitalization or death.

“Malignant” Left Ventricular Hypertrophy Identifies Subjects at High Risk for Progression to Asymptomatic Left Ventricular Dysfunction, Heart Failure, and Death: MESA (Multi‐Ethnic Study of Atherosclerosis)

“…Stage B HF is defined as the presence of structural heart disease in the absence of symptoms of HF and represents the tip of the iceberg compared with the morbidity, mortality, and cost associated with stage C disease 15, 16. Currently, routine cardiac imaging to screen for LVH is not recommended, attributed, in part, to the observation that the progression of LVH to symptomatic HF is heterogeneous 17.…”

Age‐specific diastolic dysfunction improves prediction of symptomatic heart failure by Stage B heart failure

“…1 The American College of Cardiology Foundation and American Heart Association guideline describes four stages of HF, Stages A and B that are asymptomatic and Stages C and D that are symptomatic. 3,4 SBHF predicts symptomatic HF, 3,4 and its recognition offers an opportunity to use cardioprotective medication and/or lifestyle modification to prevent or retard its progression to symptomatic HF. 3,4 SBHF predicts symptomatic HF, 3,4 and its recognition offers an opportunity to use cardioprotective medication and/or lifestyle modification to prevent or retard its progression to symptomatic HF.…”

“…There has been discussion about how best to define SBHF with respect to cut-offs for LV dimensions, LVH, and LVEF, and whether inclusion of diastolic dysfunction (DD) and longitudinal strain (LS) as part of SBHF criteria improves the prediction of symptomatic HF. 3,7,9,10 In the present study, we compared the prevalence of SBHF in a community-based cohort of individuals aged ≥60 years with CVD risk factors using ASE/EACVI and ARIC criteria and investigated whether addition of DD and LS to SBHF criteria improved the prediction of symptomatic HF. 7,8 The American Society of Echocardiography and European Association of Cardiovascular Imaging (ASE/EACVI) guideline describes normal ranges based on populations with mean ages ranging from 37 to 50 years, 7 whereas the Atherosclerosis Risk in Communities (ARIC) study defined 95th percentile limits derived from the ARIC study healthy subgroup aged 67-91 years.…”

A History of Asthma From Childhood and Left Ventricular Mass in Asymptomatic Young Adults

“…LV mass indexed to height 2.7 (LVMI) predicts incident events, progression, and severity stages of heart failure (3). Increased LVMI, a cardiac subclinical measure indicating the extent of LV hypertrophy, is an independent risk factor of death and major cardiovascular (CV) outcomes (4,5).…”