Reclassification of Pre-Heart Failure Stages Using Cardiac Biomarkers: The ARIC Study

Background: The recent heart failure (HF) guideline recommends the inclusion of cardiac biomarkers in defining Stage B HF. Objectives: The authors evaluated the impact of incorporating cardiac biomarkers to reclassify HF in 5,324 participants (mean age: 75.8 years) without prevalent HF enrolled in the ARIC (Atherosclerosis Risk In Communities) study and assessed prognosis of Stage B using cardiac biomarkers. Methods: Using N-terminal pro–B-type natriuretic peptide (<125 pg/mL or ≥125 pg/mL), high-sensitivity troponin T (<14 ng/L or ≥14 ng/L), and abnormal cardiac structure/function by echocardiography, individuals were classified as Stage A_new and Stage B_new HF, respectively. Stage B_new was further evaluated as elevated biomarker only, abnormal echocardiogram only, and abnormalities in both (echo + biomarker). The authors assessed risk for incident HF and all-cause death using Cox regression. Results: Overall, 4,326 (81.3%) individuals were classified as Stage B_new with 1,123 (21.1%) meeting criteria for elevated biomarkers only. Compared with Stage A_new, Stage B_new was associated with increased risk for incident HF (HR: 3.70 [95% CI: 2.58-5.30]) and death (HR: 1.94 [95% CI: 1.53-2.46]). Stage B_{biomarkers only} and Stage B_{echo only} were associated with increased HF risk, whereas Stage B_{biomarkers only} was also associated with increased death. Stage B_{echo+biomarker} had the highest risk for HF (HR: 6.34 [95% CI: 4.37-9.19]) and death (HR: 2.53 [95% CI: 1.98-3.23]). Conclusions: Incorporating biomarkers based on the new HF guideline reclassified approximately 1 in 5 older adults without prevalent HF to Stage B. The routine measurement of biomarkers can help to identify individuals at higher HF risk who may benefit most from HF prevention efforts.