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

Xiaoming Jia, Mahmoud Al Rifai, Chiadi E. Ndumele, Salim S. Virani, James A. de Lemos, Emmanuel Lee, Amil M. Shah, Justin B. Echouffo-Tcheugui, Biykem Bozkurt, Ron Hoogeveen, Elizabeth Selvin, Christie M. Ballantyne, Vijay Nambi

Research output: Contribution to journalArticlepeer-review


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 Anew and Stage Bnew HF, respectively. Stage Bnew 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 Bnew with 1,123 (21.1%) meeting criteria for elevated biomarkers only. Compared with Stage Anew, Stage Bnew 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 Bbiomarkers only and Stage Becho only were associated with increased HF risk, whereas Stage Bbiomarkers only was also associated with increased death. Stage Becho+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.

Original languageEnglish (US)
Pages (from-to)440-450
Number of pages11
JournalJACC: Heart Failure
Issue number4
StatePublished - Apr 2023


  • Stage B heart failure
  • cardiovascular risk
  • heart failure prevention
  • heart failure stages
  • pre-heart failure

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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