Key result
Updated Stage B HF definition linked to ~3-fold higher incident HF risk vs. Stage A.
Why the study?
Heart failure guidelines redefined Stage B HF to include elevated cardiac biomarkers alongside echocardiographic abnormalities, but whether this improves identification and prognostication beyond the former echo-only definition is unknown.
Does the updated Stage B HF definition incorporating cardiac biomarkers improve the identification and prognostication of incident heart failure compared to the former echo-only definition in patients without prior HF or CVD?
Cohort (n=11,426)
Yes
Does the updated Stage B HF definition incorporating cardiac biomarkers improve the identification and prognostication of incident heart failure compared to the former echo-only definition in patients without prior HF or CVD?
Hazard Ratio: 3.02 (95% CI 2.12–4.31)
Incorporating cardiac biomarkers into Stage B heart failure criteria identifies a substantial at-risk subgroup missed by echocardiography alone, validating the updated guideline definitions and improving long-term risk prediction.
Supports updated HF staging for risk stratification; extends consensus definitions observationally but leaves open prospective validation.
Background Heart failure (HF) guidelines redefined Stage B HF to include elevated cardiac biomarkers alongside echocardiographic abnormalities. Whether this improves identification and prognostication beyond the former echo-only definition is unknown. Methods Participants without HF or CVD were pooled from four community-based cohorts (ARIC, CRIC, FHS Offspring, FHS Third Generation). Stage B Former was defined as echo abnormalities alone, Stage B Updated as echo and/or biomarker abnormalities, and Stage B Updated further subclassified as Biomarker Only, Echo Only, or Biomarker+Echo. Cox models assessed HF risk for Stage B vs Stage A under each definition and across Stage B updated subtypes. Incremental value over PREVENT-HF was assessed by NRI/IDI. Optimal NT-proBNP thresholds for predicting HF risk were stratified by echo abnormality status. Results Among 11,426 participants (56% women, mean 60y), 8,413 (73.6%) were Stage B Updated vs 6,659 (58.3%) Stage B Former , with 15.4% newly classified by biomarkers alone. Risk of incident HF associated with Stage B versus Stage A HF was higher using the updated (aHR[95%CI], 3.02[2.12–4.31]) versus former definition (1.67[1.36–2.06]). Among Stage B updated subtypes, Stage B Biomarker Only (3.11[2.07–4.66]) and Stage B Biomarker+Echo (5.12 [3.54–7.41]) carried elevated risk of incident HF, but Stage B Echo Only did not (1.31 [0.86–1.99]). When added to PREVENT-HF, the updated definition improved reclassification (NRI, 0.099[0.040–0.152]) and discrimination slope (IDI, 0.009[0.006–0.012]); the former provided a smaller gain in discrimination slope (IDI, 0.003[0.000–0.007]) without improving reclassification (NRI, 0.020[−0.050 to 0.088]). Optimal NT-proBNP thresholds were lower without than with echo abnormalities (80.3 vs 166.3 pg/mL), and risk above each threshold was elevated in both strata (5.70[3.00–10.83] and 4.84[3.75–6.24]). Conclusions Incorporating biomarkers into HF staging identifies a substantial at-risk subgroup missed by echo alone, supporting biomarker inclusion in Stage B HF criteria.
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Keshvani et al. (2026) conducted a cohort in Stage B Heart Failure (n=11,426). Stage B HF Updated Definition (echo and/or biomarker abnormalities) vs. Stage A HF was evaluated on Incident heart failure (aHR 3.02, 95% CI 2.12-4.31). The updated Stage B HF definition incorporating biomarker and echocardiographic abnormalities identified elevated incident HF risk compared to Stage A (aHR 3.02; 95% CI 2.12–4.31).
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