Heart Failure Epidemiology and Outcomes Statistics: A Report of the Heart Failure Society of America

Summary of Top 10 Key Points1.Approximately 6.7 million Americans over 20 years of age have heart failure (HF), and the prevalence is expected to rise to 8.5 million Americans by 2030.2.The lifetime risk of HF has increased to 24%; approximately 1 in 4 persons will develop HF in their lifetime.3.Approximately 33% of the United States (US) adult population is at-risk for HF (Stage A HF) and 24-34% of the US population have pre-HF (Stage B HF). The risk of developing HF in individuals with obesity and hypertension has increased.4.The incidence and prevalence of HF is higher among Black individuals compared with other racial and ethnic groups. The prevalence of HF has increased among Black and Hispanic individuals over time.5.HF mortality rates have been increasing since 2012.6.Black, American Indian, and Alaska Native individuals have the highest all-cause age-adjusted HF mortality rates compared with other racial and ethnic groups. From 2010 to 2020, HF mortality rates have increased for Black women and men at a rate higher than any other racial or ethnic groups, particularly for individuals below the age of 65.7.A greater relative annual increase in HF-related mortality rates has been noted for younger (35–64 years) compared with older (65–84 years) adults.8.Highest HF death rates have been reported in the Midwest, Southeast, and Southern states. Rural areas demonstrate higher HF mortality rates for both younger and older age groups compared with urban areas.9.Rates of HF hospitalizations have increased from 2014 to 2017. This increase was consistent between age groups and sexes, with the highest rates being among Black patients.10.Disparities in social determinants of health and health inequities are important HF risk factors and result in increased mortality and other adverse outcomes in individuals at risk for HF or with HF. 1.Approximately 6.7 million Americans over 20 years of age have heart failure (HF), and the prevalence is expected to rise to 8.5 million Americans by 2030.2.The lifetime risk of HF has increased to 24%; approximately 1 in 4 persons will develop HF in their lifetime.3.Approximately 33% of the United States (US) adult population is at-risk for HF (Stage A HF) and 24-34% of the US population have pre-HF (Stage B HF). The risk of developing HF in individuals with obesity and hypertension has increased.4.The incidence and prevalence of HF is higher among Black individuals compared with other racial and ethnic groups. The prevalence of HF has increased among Black and Hispanic individuals over time.5.HF mortality rates have been increasing since 2012.6.Black, American Indian, and Alaska Native individuals have the highest all-cause age-adjusted HF mortality rates compared with other racial and ethnic groups. From 2010 to 2020, HF mortality rates have increased for Black women and men at a rate higher than any other racial or ethnic groups, particularly for individuals below the age of 65.7.A greater relative annual increase in HF-related mortality rates has been noted for younger (35–64 years) compared with older (65–84 years) adults.8.Highest HF death rates have been reported in the Midwest, Southeast, and Southern states. Rural areas demonstrate higher HF mortality rates for both younger and older age groups compared with urban areas.9.Rates of HF hospitalizations have increased from 2014 to 2017. This increase was consistent between age groups and sexes, with the highest rates being among Black patients.10.Disparities in social determinants of health and health inequities are important HF risk factors and result in increased mortality and other adverse outcomes in individuals at risk for HF or with HF. Trends in the epidemiology and outcomes for heart failure (HF) are critically important and have not been explicated and compiled in a comprehensive contemporary document. There have been concerning trends in the incidence, prevalence, mortality, and HF hospitalization rates over the past decade. Therefore, the specific goals of this document are:1.To establish a clear and comprehensive synthesis of trends in HF epidemiology and outcomes as a foundation for clinical care, resource allocation, and research.2.To address differences in HF epidemiology and outcomes according to sex, race, ethnicity, and age.3.To identify current knowledge gaps and limitations in HF epidemiologic data and to forecast the future impact and burden of HF. The emphasis of the document is epidemiological trends in the United States (US), but when applicable, global trends are also included. The Heart Failure Society of America (HFSA) commissioned this document and selected the members of the Data in Heart Failure Committee. The Data in Heart Failure Committee (Biykem Bozkurt, MD, PhD [Chair], Kelly Bosak, PhD, APRN, ANP-BC, Gregg C. Fonarow, MD, Jennifer E. Ho, MD, Paul Heidenreich, MD, Alanna A. Morris, MD, MSc, Robert Page III, PharmD, Josef Stehlik, MD, MPH, Lynne Stevenson, MD), identified the additional 18 writing group members of the document. The writing committee consisted of individuals with domain expertise in HF, both the epidemiology of and outcomes in HF. Each member completed writing assignments as primary or secondary authors, and HFSA Data Committee members served as senior advisors for primary or secondary authors for assigned sections and provided guidance and edits. The writing group members focused on contemporary data and recent publications, when available, and validated data sources. The writing group members reviewed and synthesized available published data regarding HF epidemiology, incidence, prevalence, rates of HF and all-cause mortality and hospitalizations, and differences according to sex, race/ethnicity, and age. A succinct and high-level summary is included for each section. The writing group convened virtual consensus conferences to review and build consensus on the available data. The work of the writing committee was accomplished via teleconference and Web conference meetings, along with email correspondence. The review work was distributed among subgroups of the writing committee based on interest and expertise. The proceedings of the workgroups were then assembled, resulting in the final document. Terminologies for sex, gender, race, and ethnicity were used in reference to the terminologies used in the original publication. All members reviewed and approved the final document. •Approximately 6.7 million Americans over 20 years of age have HF, and the prevalence is expected to rise to 8.5 million Americans by 2030.•The lifetime risk of HF has increased to 24%; approximately 1 in 4 persons will develop HF in their lifetime.•The prevalence rate of HF among US adults is approximately 1.9% to 2.6% for the overall population and is higher among older patients. The prevalence rate is expected to increase to 8.5% among 65- to 70-year-olds.•The prevalence of HF with preserved ejection fraction (HFpEF) across populations is increasing, with significant differences by race and ethnicity, and men experience a higher lifetime risk HFpEF.•Approximately 33% of the US adult population without known symptomatic HF is at-risk for HF (Stage A HF) and 24%–34% have pre-HF (Stage B HF). The risk of developing HF in individuals with obesity and hypertension has increased. In the Framingham Heart Study (FHS) cohort, the lifetime risk of HF increased to 23.7% during the second 25-year epoch (1990–2014) from 19.0% in the first 25-year epoch (1965–1989) (Fig. 1, Table 1).Table 1Estimation of Lifetime Risk of HF Open table in a new tab During the second 25-year epoch (1990–2014), the lifetime risk of HFpEF (19.3%) was higher than HF with reduced ejection fraction (HFrEF) (11.4%).1Vasan RS Enserro DM Beiser AS Xanthakis V. Lifetime risk of heart failure among participants in the Framingham Study.J Am Coll Cardiol. 2022; 79: 250-263Crossref PubMed Scopus (10) Google Scholar In the FHS Cohort, the lifetime risk of HF has risen across participants of both sexes (from 18.9% to 22.6% in women and from 19.1% to 25.3% in men).1Vasan RS Enserro DM Beiser AS Xanthakis V. Lifetime risk of heart failure among participants in the Framingham Study.J Am Coll Cardiol. 2022; 79: 250-263Crossref PubMed Scopus (10) Google Scholar Similarly, the lifetime risk of HF in the Multi-Ethnic Study of Atherosclerosis (MESA) and Cardiovascular Health Study (CHS) cohort ranged from 23.8% in women to 27.4% in men and varied by race and ethnicity (Table 1; Fig. 2). Among HF subtypes, the lifetime risk of HFpEF was greater than the lifetime risk of HFrEF in women (10.7% vs 5.8%, respectively), whereas lifetime risk of HFpEF was similar to HFrEF in men (Fig. 2),2Pandey A Omar W Ayers C LaMonte M Klein L Allen NB et al.Sex and race differences in lifetime risk of heart failure with preserved ejection fraction and heart failure with reduced ejection fraction.Circulation. 2018; 137: 1814-1823Crossref PubMed Scopus (102) Google Scholar but these vary by race and ethnicity.3Chang PP Wruck LM Shahar E Rossi JS Loehr LR Russell SD et al.Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005-2014).ARIC Study Community Surveillance. Circulation. 2018; 138: 12-24Crossref PubMed Scopus (0) Google Scholar The risk of developing HF in overweight or obese body mass index categories and participants with intermediate blood pressure (systolic blood pressure ≥130 but <140 mm Hg or diastolic blood pressure ≥80 but <90 mm Hg); and/or hypertension was 24%–62% higher during the second epoch (1990–2014) relative to corresponding risk factor strata in the first epoch (1965–1989).1Vasan RS Enserro DM Beiser AS Xanthakis V. Lifetime risk of heart failure among participants in the Framingham Study.J Am Coll Cardiol. 2022; 79: 250-263Crossref PubMed Scopus (10) Google Scholar The 10-year risk of HF, assessed via the Pooled Cohort Equations to Prevent Heart Failure among a representative sample of Americans from the National Health and Nutrition Examination Survey (NHANES), increased from 1.0% in 1999 to 3.0% in 2015.4Glynn PA Ning H Bavishi A Freaney PM Shah S Yancy CW et al.Heart failure risk distribution and trends in the United States population, NHANES 1999-2016.Am J Med. 2021; 134: e153-e164Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The incidence of HF varies according to different populations and different time frames (Table 2). Differences in data sources, population demographics and composition (including age, comorbidities, sex, race, and ethnicity), HF ascertainment methodology, and periodic differences likely play a role in this variation. A decline in overall HF incidence has been reported in Medicare beneficiaries over the age of 65 from 35.7/1000 person-years (PY) to 6.5/1000 PY from 2011 to 2016 (Table 2).5Khera R Kondamudi N Zhong L Vaduganathan M Parker J Das SR et al.Temporal trends in heart failure incidence among Medicare beneficiaries across risk factor strata, 2011 to 2016.JAMA Netw Open. 2020; 3e2022190Crossref Scopus (28) Google Scholar Olmsted County in Minnesota, with relatively homogeneous demographics, also demonstrated a declining incidence from 2000 to 2010 (Table 2).6Gerber Y Weston SA Redfield MM Chamberlain AM Manemann SM Jiang R et al.A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.JAMA Intern Med. 2015; 175: 996-1004Crossref PubMed Scopus (493) Google Scholar The 3-generational FHS population, which is predominantly composed of participants of White race, did not have a changing incidence from 1990 to 2009.7Tsao CW Lyass A Enserro D Larson MG Ho JE Kizer JR et al.Temporal trends in the incidence and mortality associated with heart failure with preserved and reduced ejection fraction.JACC Heart Fail. 2018; 6: 678-685Crossref PubMed Scopus (0) Google Scholar On the other hand, a modest increased incidence of HF has been reported in the Atherosclerosis Risk in Communities (ARIC) cohort with populations intentionally selected from 4 different cohorts with more diverse demographic and geographic characteristics (Table 2). In the ARIC study, there was an initial focus on atherosclerosis and complications, and HF adjudication was slightly different from other studies. Some of the variations in the overall incidence and prevalence of HF across different studies can be explained by the variation of representation of HFpEF in different populations as it becomes the dominant phenotype.8Rosamond WD Chang PP Baggett C Johnson A Bertoni AG Shahar E et al.Classification of heart failure in The Atherosclerosis Risk in Communities (ARIC) study: a comparison of diagnostic criteria.Circ Heart Fail. 2012; 5: 152-159Crossref PubMed Scopus (237) Google Scholar A trend for increasing prevalence of HFpEF was recognized across different populations. The rise in HFpEF prevalence can be attributed to increasing risk factors for HF, such as obesity and diabetes, but also to the difficulty of discrimination of HF from other causes of dyspnea and leg swelling in patients with obesity or large body habitus.Table 2Incidence Estimates of Heart Failure in the United States Open table in a new tab After age 45, HF incidence ranges from 6.0/1000 PY among the ARIC participants (between 1987 and 2005) to 7.9/1000 PY among the Chicago Heart Association Detection Project in Industry participants (between 1967 and 2003). After the index age of 65 years, the incidence is significantly higher, at 21.1/1000 PY as reported in the CHS participants (between 1989 and 2004).9Huffman MD Berry JD Ning H Dyer AR Garside DB Cai X et al.Lifetime risk for heart failure among White and Black Americans: cardiovascular lifetime risk pooling project.J Am Coll Cardiol. 2013; 61: 1510-1517Crossref PubMed Scopus (154) Google Scholar According to data from NHANES 2017–2020, approximately 6.7 million Americans over 20 years of age have HF, which has increased from former reports of 6.0 million (Fig. 3). HF prevalence progressively rises across each decade of life, with an up to 4-fold higher prevalence (8.0%–9.1%) among US adults older than 65 years compared with age less than 65. The overall prevalence of HF among US adults has ranged from 1.9% to 2.6% for the overall population based on self-reported data from NHANES (Table 3).10Siontis GC Bhatt DL Patel CJ. Secular trends in prevalence of heart failure diagnosis over 20 years (from the US NHANES).Am J Cardiol. 2022; 172: 161-164Abstract Full Text Full Text PDF PubMed Google ScholarTable 3Prevalence of HF in the United States Open table in a new tab Based on self-report among participants of NHANES, the prevalence of HF for the overall population remained similar over time, from 31.8/1000 persons in 2001–2005 to 30.4/1000 persons in 2013–2016.11Rethy L Petito LC Vu THT Kershaw K Mehta R Shah NS et al.Trends in the prevalence of self-reported heart failure by race/ethnicity and age from 2001 to 2016.JAMA Cardiol. 2020; 5: 1425-1429Crossref PubMed Scopus (21) Google Scholar However, among participants over the age of 65, the prevalence of HF has increased from 55/1000 persons in 1999 to 98/1000 persons in 2004 and declined to 64/1000 persons in 2017.10Siontis GC Bhatt DL Patel CJ. Secular trends in prevalence of heart failure diagnosis over 20 years (from the US NHANES).Am J Cardiol. 2022; 172: 161-164Abstract Full Text Full Text PDF PubMed Google Scholar By another report, among Medicare beneficiaries over the age of 65, the prevalence of HF assessed by claims-based diagnosis in the inpatient or outpatient setting increased from 162/1000 in 2004 to 172/1000 in 2013 (Table 3).12Khera R Pandey A Ayers CR Agusala V Pruitt SL Halm EA et al.Contemporary epidemiology of heart failure in fee-for-service Medicare beneficiaries across healthcare settings.Circ Heart Fail. 2017; 10e004402Crossref PubMed Scopus (44) Google Scholar Among participants of the ARIC study above the age of 55, the age-adjusted prevalence of HF was higher among Black men (38.1/1000 PY) and Black women (30.5/1000 PY) vs White men (20.7/1000 PY) and White women (15.2/1000 PY) from 2005 to 2014.3Chang PP Wruck LM Shahar E Rossi JS Loehr LR Russell SD et al.Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005-2014).ARIC Study Community Surveillance. Circulation. 2018; 138: 12-24Crossref PubMed Scopus (0) Google Scholar Prevalence of HF rose significantly (between 2% to 5% increase per year) across the study period. Prevalence of HF remains understudied in American Indian and Alaska Native populations (Table 3).13Breathett K Sims M Gross M Jackson EA Jones EJ Navas-Acien A et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: e948-e959Crossref PubMed Scopus (81) Google Scholar The prevalence of HF is expected to rise to 8.5 million Americans in 2030, based on NHANES data and US Census Bureau projected population counts (Fig. 3).14Van Nuys KE Xie Z Tysinger B Hlatky MA Goldman DP. Innovation in heart failure treatment: life expectancy, disability, and health disparities.JACC Heart Fail. 2018; 6: 401-409Crossref PubMed Scopus (33) Google Scholar The impact of coronavirus disease 2019 (COVID-19) on future risk of HF is still being assessed and may further increase the burden of HF. If HF prevalence remains constant by age, the percentage of the US population with HF is projected to rise from 2.4% in 2012 to 3.0% in 2030 (Fig. 3).15Heidenreich PA Albert NM Allen LA Bluemke DA Butler J Fonarow GC et al.Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.Circ Heart Fail. 2013; 6: 606-619Crossref PubMed Scopus (1970) Google Scholar By another estimate, based on 2010–2012 Health and Retirement Study historical data, the prevalence of HF is expected to increase from 4.3% in 2010 to 8.5% in 2030 among 65- to 70-year-olds.14Van Nuys KE Xie Z Tysinger B Hlatky MA Goldman DP. Innovation in heart failure treatment: life expectancy, disability, and health disparities.JACC Heart Fail. 2018; 6: 401-409Crossref PubMed Scopus (33) Google Scholar Data are substantially limited regarding the prevalence of HF stratified by HF stages: Stage A (at-risk) HF, Stage B (pre-HF), Stage C (clinical HF), and Stage D (advanced HF). Additionally, the criteria and definitions of HF stages are evolving, adding further complexity to prevalence estimates by HF stages.16Bozkurt B Coats AJ Tsutsui H Abdelhamid M Adamopoulos S Albert N et al.Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure.J Card Fail. 2021 Mar 1; S1071-9164: 00050-00056Google Scholar,17Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA guideline for the management of heart failure.J Card Fail. 2022; 28 (e1–e167)Google Scholar In an analysis of the Coronary Artery Risk Development in Young Adults cohort, the prevalence of Stage A and B HF increased with age, from the year-5 follow-up cohort (mean age 30 years) to the year-30 follow-up cohort (mean age 55 years), from 24% to 76% in Black men, 13% to 64% in White men, 34% to 81% in Black women, and 13% to 56% in White women.18Gidding SS Lloyd-Jones D Lima J Ambale-Venkatesh B Shah SJ Shah R et al.Prevalence of American Heart Association Heart Failure stages in Black and White young and middle-aged adults: the CARDIA study.Circ Heart Fail. 2019; 12e005730Crossref PubMed Scopus (16) Google Scholar In the FHS (mean age: 51 ± 16 years), the prevalence of Stage A HF was 36.5%, Stage B was 24.2%, Stages C/D were 1.2%, and healthy without HF or HF risk was 38% (Fig. 4).19Xanthakis V Enserro DM Larson MG Wollert KC Januzzi JL Levy D et al.Prevalence, neurohormonal correlates, and prognosis of heart failure stages in the community.JACC Heart Fail. 2016; 4: 808-815Crossref PubMed Scopus (68) Google Scholar In a study from Olmsted County, Minnesota, among participants aged 45 years and older, the prevalence of Stage A HF was 22%, Stage B was 34%, Stage C was 12%, and Stage D was 0.2%. Healthy without HF or HF risk (Stage 0) was 32% (Fig. 4).20Ammar KA Jacobsen SJ Mahoney DW Kors JA Redfield MM Burnett JC et al.prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association Heart Failure Staging Criteria in The Community.Circulation. 2007; 115: 1563-1570Crossref PubMed Scopus (374) Google Scholar Among older patients aged 67–91 years from the ARIC study, 52% had Stage A HF, 30% had Stage B HF, and 13% had Stage C HF, with only 5% of participants being without HF risk factors of structural heart disease (Fig. 4).21Shah AM Claggett B Loehr LR Chang PP Matsushita K Kitzman D et al.Heart failure stages among older adults in the community: the Atherosclerosis Risk in Communities study.Circulation. 2017; 135: 224-240Crossref PubMed Scopus (117) Google Scholar Among ARIC study participants (mean age: 75.8 years) without prevalent HF, but with HF risk factors (Stage A), a strategy using abnormal N-terminal pro-B-type natriuretic peptide or high-sensitivity troponin levels and abnormal cardiac structure/function by echocardiography for the new definition of Stage B HF17Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA guideline for the management of heart failure.J Card Fail. 2022; 28 (e1–e167)Google Scholar reclassified 81.3% of the individuals from Stage A to Stage B, with 21.1% meeting criteria for elevated biomarkers only. Incorporating biomarkers based on the new HF guideline reclassified approximately 1 in 5 older adults with Stage A to Stage B (Fig. 4).22Jia X Al Rifai M Ndumele CE Virani SS de Lemos JA Lee E et al.Reclassification of pre-heart failure stages using cardiac biomarkers: the ARIC study.JACC Heart Fail. 2023; 11: 440-450Crossref PubMed Scopus (1) Google Scholar Among middle-aged Black participants in the ARIC cohort, 20% had Stage A HF, 67% had Stage B HF, and 8.6% had Stage C/D HF. Approximately 98% of the participants classified as Stage B HF had evidence of left ventricular hypertrophy at baseline.23Vasan RS Musani SK Matsushita K Beard W Obafemi OB Butler KR et al.Epidemiology of heart failure stages in middle-aged Black people in the community: prevalence and prognosis in the Atherosclerosis Risk in Communities Study.J Am Heart Assoc. 2021; 10e016524Crossref Scopus (7) Google Scholar A pooled analysis from the MESA, CHS, and ARIC cohorts, the 2023 updated AHA/ACC/HFSA definitions of HF stages, which incorporates elevation in cardiac biomarkers to classify pre-HF or Stage B HF, identified 37.4% of participants with Stage A, 43.2% with Stage B, and 2.7% with Stage C/D HF. Compared with 2013, the 2022 updated definition identified a greater proportion of individuals with Stage B HF with a disproportionate increase in prevalence noted among women as well as Hispanic and Black individuals (Fig. 4).24Mohebi R Wang D Lau ES Parekh JK Allen N Psaty BM et al.Effect of 2022 ACC/AHA/HFSA criteria on stages of heart failure in a pooled community cohort.J Am Coll Cardiol. 2023; 81: 2231-2242Crossref PubMed Scopus (1) Google Scholar With the exception of the FHS population, most of these cohorts represented homogenous populations. The incidence and burden of risk factors for HF is increasing over time. The proportion of individuals with HF exhibiting 3 or more comorbidities increased from 68% in 2002–2004 to 87% in 2012–2014. The risk factors with the greatest increases in prevalence are hypertension, obesity, and smoking.25Conrad N Judge A Tran J Mohseni H Hedgecott D Crespillo AP et al.Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals.Lancet. 2018; 391: 572-580Abstract Full Text Full Text PDF PubMed Scopus (669) Google Scholar At least one-third of US adults can be defined as Stage A HF or at-risk for HF and have at least 1 HF risk factor.19Xanthakis V Enserro DM Larson MG Wollert KC Januzzi JL Levy D et al.Prevalence, neurohormonal correlates, and prognosis of heart failure stages in the community.JACC Heart Fail. 2016; 4: 808-815Crossref PubMed Scopus (68) Google Scholar, 20Ammar KA Jacobsen SJ Mahoney DW Kors JA Redfield MM Burnett JC et al.prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association Heart Failure Staging Criteria in The Community.Circulation. 2007; 115: 1563-1570Crossref PubMed Scopus (374) Google Scholar, 21Shah AM Claggett B Loehr LR Chang PP Matsushita K Kitzman D et al.Heart failure stages among older adults in the community: the Atherosclerosis Risk in Communities study.Circulation. 2017; 135: 224-240Crossref PubMed Scopus (117) Google Scholar,26Kovell LC Juraschek SP Russell SD. Stage A heart failure is not adequately recognized in US Adults: analysis of the National Health and Nutrition Examination Surveys, 2007-2010.PLoS One. 2015; 10e0132228Crossref PubMed Scopus (15) Google Scholar An increasing number of risk factors is associated with increased risk of HF, particularly for minoritized racial and ethnic groups.27Breathett K Leng I Foraker RE Abraham WT Coker L Whitfield KE et al.Risk factor burden, heart failure, and survival in women of different ethnic groups: insights from the Women's Health Initiative.Circ Heart Fail. 2018; 11e004642Crossref Scopus (13) Google Scholar According to data from Olmsted County, Minnesota, between 1979 and 2002, the prevalence of hypertension, obesity, and smoking increased over time. Population attributable risk (PAR) for developing HF was highest for coronary heart disease (CHD) and hypertension; each accounted for 20% of HF cases in the population, although CHD accounted for the greatest proportion of cases in men (PAR 23%) and hypertension was of greatest importance in women (PAR 28% in women vs 13% in men). PAR for tobacco smoking was 14%, obesity was 12%, and diabetes was 12%.28Dunlay SM Weston SA Jacobsen SJ Roger VL. Risk factors for heart failure: a population-based case-control study.Am J Med. 2009; 122: 1023-1028Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar Despite the decline in myocardial infarction incidence and severity,28Dunlay SM Weston SA Jacobsen SJ Roger VL. Risk factors for heart failure: a population-based case-control study.Am J Med. 2009; 122: 1023-1028Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar,29Yeh RW Sidney S Chandra M Sorel M Selby JV Go AS. Population trends in the incidence and outcomes of acute myocardial infarction.N Engl J Med. 2010; 362: 2155-2165Crossref PubMed Scopus (1299) Google Scholar incidence of HF following infarction remains unchanged.30Gerber Y Weston SA Enriquez-Sarano M Manemann SM Chamberlain AM Jiang R et al.Atherosclerotic burden and heart failure after myocardial infarction.JAMA Cardiol. 2016; 1: 156-162Crossref PubMed Scopus (39) Google Scholar The PAR% for hypertension, obesity, diabetes mellitus, and CHD vary according to race and ethnicity (Fig. 5). For HFpEF, approximately two-thirds of the PAR is associated with hypertension and obesity, whereas diabetes mellitus and CHD make up approximately one-fourth of the PAR%. For Black women, hypertension and obesity were associated with more than 90% of the PAR%, and for Hispanic women, the same risk factors were associated with approximately 72% of the PAR%. For HFrEF, hypertension showed the strongest PAR% in all 3 race/ethnicity groups.31Eaton CB Pettinger M Rossouw J Martin LW Foraker R Quddus A et al.Risk factors for incident hospitalized heart failure with preserved versus reduced ejection fraction in a multiracial cohort of postmenopausal women.Circ Heart Fail. 2016; 9e002883Crossref Scopus (58) Google Scholar Not only is the contribution of risk factors of hypertension, diabetes, obesity, hypercholesterolemia, and smoking to incident HF greater in Black patients than White patients, but this difference seems to be increasing over time.32Cheng S Claggett B Correia AW Shah AM Gupta DK Skali H et al.Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study.Circulation. 2014; 130: 820-828Crossref PubMed Scopus (114) Google Scholar •Overall HF prevalence is increasing globally, but HF incidence, prevalence, etiology, and outcomes vary across different regions around the globe.•HF prevalence estimates around the world range from 1% to 3% of the overall population.•The prevalence of risk factors for HF including hypertension, obesity, and smoking are increasing globally over time. The proportion of individuals with HF exhibiting 3 or more comorbidities increased from 68% in 2002–2004 to 87% in 2012–2014.•Disparities in social determinants of health (SDoH) and health inequities are important HF risk factors and result in increased mortality and other adverse outcomes in individuals at risk for HF or with HF. Worldwide, it is estimated that 56.2 million (95% confidence interval [CI] 46.4 to 67.8 million) people are living with HF.33GBD 2019 Diseases and Injuries CollaboratorsGlobal burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Abstract Full Text Full Text PDF PubMed Scopus (5553) Google Scholar Prevalence estimates around the world range from 1% to 3% of the overall population (Fig. 6).34Savarese G Becher PM Lund LH Seferovic P Rosano GMC Coats AJS. Glo