A new Scientific Statement from the American Heart Association (AHA) proposed a comprehensive framework for the risk-based primary prevention of heart failure, addressing what has become a growing epidemic with substantial health care expenditures and disproportionate impact on underrepresented populations.

The statement outlined how clinicians can identify patients at high risk for developing heart failure (HF) and implement targeted interventions prior to symptom manifestation.

“The burden of [HF] is increasing in the United States,” the statement authors wrote. “An estimated 6.7 million adults in the [United States] have HF, with projections exceeding 11 million by 2050. HF accounted for over 1 million hospital discharges in 2020 and 421,938 deaths in 2021, with projected annual costs rising to $142 billion over this time period.” They emphasized the urgency of primary prevention, as pathophysiologic changes associated with symptomatic HF are often irreversible.

A Risk-Based Prevention Paradigm

To operationalize HF prevention in clinical care, the statement proposed adapting the Calculate–Personalize–Reclassify (CPR) framework previously used for atherosclerotic cardiovascular disease (ASCVD) prevention. Central to this paradigm is the recently developed AHA PREVENT (Predicting Risk of Cardiovascular Disease Events) risk prediction tool, which estimates both 10-year and 30-year HF risk using routinely collected clinical data.

“A highly accurate and precise risk prediction model, such as PREVENT, is central to the success of a risk-based prevention paradigm for HF,” the statement authors noted.

PREVENT was developed from a population of more than 3.2 million adults and includes sex-specific models that integrate traditional cardiovascular risk factors (eg, blood pressure, and body mass index [BMI]) as well as kidney/metabolic health markers (eg, estimated glomerular filtration rate, hemoglobin A1C, and the urine albumin-to-creatinine ratio). A zip code–based social deprivation index was also included. Race was intentionally excluded from the model, given its status as a social construct.

While the base PREVENT model doesn't include imaging or biomarkers such as brain natriuretic peptide (BNP), the investigators recommended a sequential testing approach in which these tools are reserved for patients at higher pretest risk.

Personalization: Recognizing Risk-Enhancing Factors

The investigators stressed the importance of accounting for risk-enhancing factors—clinical characteristics that may not be captured by traditional risk models but substantially elevate HF risk. These include:

• Chronic inflammatory diseases (eg, human immunodeficiency virus and COVID-19 infections)

• Exposure to cardiotoxins (eg, anthracyclines, HER2 inhibitors, and radiotherapy)

• Adverse pregnancy outcomes

• Metabolic dysfunction–associated steatotic liver disease

• Pathogenic or likely pathogenic inherited cardiomyopathy variants.

Incorporating these factors into clinical judgment could allow clinicians to personalize a patient's estimated risk and make more tailored prevention decisions.

Reclassification and Detection of Preclinical HF

The third step of the CPR framework involves risk reclassification using diagnostic tools to detect pre-HF (stage B HF), including:

• Biomarkers: BNP, NT-proBNP, and high-sensitivity troponin

• Cardiac imaging: Echocardiography to assess structural or functional abnormalities.

While universal screening isn't currently cost-effective, these tests may be appropriate in patients with elevated predicted HF risk, prevalent ASCVD, diabetes, or other comorbidities.

A Four-Pillar Approach to Prevention

The Scientific Statement outlined four key therapeutic domains for evidence-based prevention of HF:

• Metabolic Health: Weight management and use of cardioprotective antihyperglycemic agents in eligible patients (eg, sodium-glucose cotransporter 2 [SGLT2] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists)

• Blood Pressure (BP) Control: Target BP < 130/80 mmHg in those at increased risk

• Kidney Protection: Use of SGLT2 inhibitors, GLP-1 receptor agonists, or nonsteroidal mineralocorticoid receptor antagonists in appropriate patients

• Secondary ASCVD Prevention: Guideline-directed therapy in patients with post–myocardial infarction asymptomatic left ventricular dysfunction.

“The emergence of SGLT2 [inhibitors] offers a potential promising strategy for HF prevention,” the statement authors detailed, noting consistent reductions in incident HF across a broad range of clinical trials.

Addressing Disparities Through the CKM Lens

A central component of the framework is the cardiovascular–kidney–metabolic (CKM) syndrome, which the AHA defined as the predominant phenotype of HF risk. CKM syndrome recognizes the overlapping contribution of cardiovascular, kidney, and metabolic dysfunction to HF development.

In parallel, the AHA integrates Life’s Essential 8—a construct encompassing diet, physical activity, nicotine exposure, sleep, BMI, BP, glycemia, and lipids—into HF staging and prevention strategies.

HF disproportionately affects non-Hispanic Black adults, who have a higher incidence and earlier onset compared with non-Hispanic White adults. The statement attributed up to 50% of health outcomes to social determinants of health and urged a multilevel approach:

• Assess SDoH at the individual and clinic level

• Implement interventions (eg, transportation, housing, and care coordination)

• Advocate for policy changes to improve equity in access and delivery.

Research Gaps and Priorities

The statement identified ten key unanswered questions critical to advancing the implementation of risk-based HF prevention:

• What is the predicted HF risk threshold for initiating therapy?

• Are preventive therapies cost-effective in high-risk groups?

• Can therapies be guided by predicted risk alone?

• How can artificial intelligence enhance prediction and detection?

• What mechanisms govern progression to symptomatic HF?

• Can integrating SDoH improve prediction accuracy?

• How can antiracist care delivery mitigate disparities?

• What system-level interventions and policies are most effective?

• Can clinician-directed nudges improve therapy adoption?

• How can digital technologies (eg, wearables and applications) support prevention?

“In aggregate, the available evidence supports the fact that HF is eminently preventable in clinical practice today,” the statement authors indicated, “[b]ut moving from this theoretical concept to routine clinical practice and implementing effective risk-based prevention of HF will require additional work and a multidisciplinary care model,” they concluded.

Disclosure information and scientific references can be found in the original publication.

Source: Circulation