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Heart Failure Stages Among Older Adults in the Community: The Atherosclerosis Risk in Communities Study
Amil M Shah1, Brian Claggett2, Laura R Loehr2
1From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., S.D.S.); Gillings School of Global Public Health (L.L., A.K.N., G.H.) and School of Medicine (P.C., C.S.), University of North Carolina, Chapel Hill; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (K.M., J.C.); Wake Forest School of Medicine, Winston-Salem, NC (D.K.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (S.K., A.R.F.); Divisions of Geriatrics and Neurology, University of Mississippi Medical Center, Jackson (T.H.M.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Washington, DC (J.W.) ashah11@partners.org.
Insights
Most older adults have heart failure (HF) risk factors or structural heart disease, with advanced measures improving risk prediction. These findings emphasize the burden of HF with preserved ejection fraction in the elderly.
Area of Science:
- Cardiology
- Geriatrics
- Public Health
Background:
- Heart failure (HF) disproportionately impacts older adults, yet data on HF stage prevalence in this demographic are limited.
- The role of advanced measures like longitudinal strain and diastolic dysfunction in defining HF stages in older adults remains unclear.
Purpose of the Study:
- To determine the prevalence of American College of Cardiology/American Heart Association (ACC/AHA) HF stages in community-dwelling older adults.
- To assess the utility of longitudinal strain and diastolic dysfunction in refining HF staging and risk stratification.
Main Methods:
- Classified HF stages (A, B, C1, C2) in 6118 Atherosclerosis Risk in Communities study participants (aged 67-91).
- Utilized traditional definitions and incorporated measures of left ventricular (LV) structure, systolic function (LV ejection fraction, longitudinal strain), and diastolic function (e', E/e', left atrial volume index).
Main Results:
- 52% of participants were Stage A, 30% Stage B, 7% Stage C1, and 6% Stage C2; only 5% were Stage 0.
- Incorporating longitudinal strain and diastolic dysfunction reclassified 14% from Stage A to B, significantly improving risk prediction.
- Abnormal LV structure, systolic, and diastolic function were independently associated with increased risk of HF hospitalization or death.
Conclusions:
- The majority of older adults in the community are at risk for HF (Stages A or B), exceeding prevalence in younger populations.
- A significant proportion of older adults with prevalent HF (Stage C) have preserved left ventricular ejection fraction (HFpEF).
- LV diastolic function and longitudinal strain offer incremental prognostic value beyond conventional measures for identifying individuals at risk for HF hospitalization or death.
Background:
Although heart failure (HF) disproportionately affects older adults, little data exist regarding the prevalence of American College of Cardiology/American Heart Association HF stages among older individuals in the community. Additionally, the role of contemporary measures of longitudinal strain and diastolic dysfunction in defining HF stages is unclear.
Methods:
HF stages were classified in 6118 participants in the Atherosclerosis Risk in Communities study (67-91 years of age) at the fifth study visit as follows: 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 earlier 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. Left ventricular (LV) ejection fraction was preserved in 77% and 65% in Stages C1 and C2, respectively. Incorporation of longitudinal strain 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 LV ejection fraction and longitudinal strain), 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 with previous reports in younger community-based samples. LV ejection fraction is robustly preserved in at least two-thirds of older adults with prevalent HF (Stage C), highlighting the burden of HF with preserved LV ejection fraction in the elderly. LV diastolic function and longitudinal strain provide incremental prognostic value beyond conventional measures of LV structure and LV ejection fraction in identifying persons at risk for HF hospitalization or death.
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