Key result
The 2022 AHA/ACC/HFSA guidelines reclassified 55% of stage A CKD patients to stage B; biomarker-based stage B had lower HF hospitalizations than echo-based (1.7 vs 2.9 per 100 person-years).
Why the study?
The applicability of the 2022 AHA/ACC/HFSA heart failure staging system with cardiac biomarkers in chronic kidney disease is not well established.
Does the 2022 AHA/ACC/HFSA HF staging system reclassify disease severity and predict outcomes differently than the 2013 guidelines in adults with chronic kidney disease?
Cohort (n=2,415)
Does the 2022 AHA/ACC/HFSA HF staging system reclassify disease severity and predict outcomes differently than the 2013 guidelines in adults with chronic kidney disease?
The 2022 AHA/ACC/HFSA HF staging guidelines reclassify a significant proportion of CKD patients to higher HF stages due to biomarker inclusion, though these reclassified patients have lower HF hospitalization rates than those staged by echocardiography.
Reclassifying CKD patients to stage B by biomarkers should not yet change practice; leaves open optimal staging criteria in this population.
BACKGROUND: In 2022 the American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines for Management of Heart Failure proposed an updated staging system with cardiac biomarkers to diagnose heart failure (HF) and its severity. The applicability of this staging system in chronic kidney disease is not well established. METHODS: This is a prospective cohort study of 2415 participants from CRIC (Chronic Renal Insufficiency Cohort). Individuals were classified into HF stages using 2013 and 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines using research echocardiograms, cardiac biomarkers (troponin T ≥10 ng/L [women], ≥15 ng/L [men], pro-B-type natriuretic peptide ≥125 pg/mL), laboratory measures, and history. Adjudicated outcomes of HF hospitalizations and all-cause mortality are reported. RESULTS: In individuals with chronic kidney disease, participants with lower estimated glomerular filtration rates were more likely to be reclassified to a more advanced HF stage using the current proposed thresholds of hsTNT (high-sensitivity troponin T) and NT-proBNP (N-terminal pro-B-type natriuretic peptide). The 2022 guidelines reclassified 55% of 2013 guideline stage A participants to stage B. HF hospitalization incidence rates differed when individuals were categorized into stage B HF based on elevated hsTNT or NT-proBNP (1.7 per 100 person-years) compared with echocardiographic abnormalities (2.9 per 100 person-years), whereas death rates were similar between these groups. CONCLUSIONS: Among individuals with CKD, the addition of elevated hsTNT or NT-proBNP to HF staging reclassified nearly 20% of total participants into a higher HF stage. These individuals had similar mortality rates to those previously in higher stages, but they had lower HF hospitalization rates. Those with more advanced chronic kidney disease were more likely to be reclassified.
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Zemke et al. (2025) conducted a cohort in Chronic Kidney Disease (n=2,415). 2022 AHA/ACC/HFSA Heart Failure Staging Guidelines vs. 2013 AHA/ACC/HFSA Heart Failure Staging Guidelines was evaluated on HF hospitalizations and all-cause mortality. The 2022 AHA/ACC/HFSA guidelines reclassified 55% of stage A CKD patients to stage B; biomarker-based stage B had lower HF hospitalizations than echo-based (1.7 vs 2.9 per 100 person-years).
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