The Evolving Burden, Disparities, Drivers, and Prevention Priorities of Heart Failure in the United States

BACKGROUND: Heart failure (HF) remains a leading cause of hospitalization and mortality in the United States. OBJECTIVES: We aim to quantify the burden of HF, characterize epidemiological trends, assess geographic disparities, and examine variation in underlying causes and risk factors using updated national estimates. METHODS: Data on the prevalence, years lived with disability (YLDs), and attributable causes of HF across the United States from 1990 to 2023 were obtained from the Global Burden of Disease Study 2023. Risk factors were evaluated using a complementary cause-pathway framework and a data-driven machine-learning approach. Bayesian age-period-cohort models were used to project HF burden through 2040. RESULTS: In 2023, the United States had 4.65 million prevalent HF cases and 432 thousand YLDs, an approximately 80% increase in absolute burden since 1990. Age-standardized rates remained largely stable, with an age-standardized prevalence rate of 864.29 (95% uncertainty intervals [UI]: 789.90-937.31) and age-standardized YLD rate of 80.41 (95% UI: 56.41-110.96) per 100,000 in 2023. The etiologic profile of HF was dominated by ischemic, hypertensive, valvular, and cardiomyopathic pathways. Marked geographic disparities persisted, with disproportionate burden concentrated in several Midwestern and Southern states. High systolic blood pressure had the highest population-attributable fraction of 40.7%, followed by dietary risks (27.3%), high BMI (22.5%), high low-density lipoprotein cholesterol (11.5%), and kidney dysfunction (10.9%). Projections suggested broadly stable trends in HF burden through 2040. CONCLUSIONS: HF remains a substantial and persistent public health burden in the United States. These findings support more targeted prevention, improved risk-factor control, and more equitable delivery of HF care.