Heart Failure Staging and Prevention: Perspectives From Clinical Forums

Heart failure classification is entering a period of active revision. Data continue to challenge how clinicians define phenotype, stage disease, and time treatment, particularly as heart failure with preserved ejection fraction closes in on heart failure with reduced ejection fraction in US prevalence.

Two clinical forums, one moderated by Ali Valika, MD, in Chicago and another by Orly Vardeny, PharmD, MS, FHFSA, FAHA, FCCP, in Minneapolis, brought clinicians together around a shared question: how can earlier recognition and phenotype-guided treatment reduce cardiovascular risk and heart failure burden?

Heart Failure Prevalence and Evolving Staging Frameworks

Both sessions opened with epidemiology that framed the stakes. An estimated 56 million people worldwide and roughly 7 million adults in the US live with heart failure, with a lifetime risk near one in four and an annual cost approaching $108 billion driven largely by hospitalization.¹ Participants in both cities noted that heart failure with reduced ejection fraction remains the more common global diagnosis, but in the US, preserved ejection fraction has caught up, or in some practices overtaken it, a shift linked to rising rates of obesity and metabolic syndrome.

Valika walked Chicago participants through standard heart failure staging, noting that stage C captures most symptomatic patients while stage A and stage B remain poorly defined in everyday practice. In Minneapolis, Vardeny introduced the cardiovascular-kidney-metabolic staging framework recently released by the American Heart Association, which layers onto traditional heart failure stages and asks clinicians to account for overlapping obesity, diabetes, and chronic kidney disease rather than treating heart failure in isolation. Vardeny also noted that an updated framework for classifying heart failure phenotype is expected within months, a signal that current ejection fraction cutoffs may soon be reframed.

Biomarkers and Trial Data on SGLT2 Inhibitors, Finerenone, and GLP-1s

Participants in both forums discussed the H2FPEF score for identifying heart failure with preserved ejection fraction, with Valika citing data showing that body mass index above 30, hypertension, and paroxysmal atrial fibrillation alone confer a 90% probability of the diagnosis. Urine albumin-to-creatinine ratio came up in both sessions as an underused marker. Valika noted that even a normal estimated glomerular filtration rate does not rule out elevated cardiovascular risk once microalbuminuria is present, with every 0.4 mg/mmol increase in the ratio raising heart failure risk by nearly 11%, while Minneapolis participants said the test is rarely ordered outside established diabetes or chronic kidney disease indications.

Discussion in both cities converged on recent trial data reshaping the four pillars of guideline-directed therapy. Finerenone reduced the composite of cardiovascular death and total heart failure events by 16% in the 6,000-patient FINEARTS-HF trial among patients with mildly reduced or preserved ejection fraction, a contrast to the neutral TOPCAT and SPIRIT-HF spironolactone data, with a second spironolactone trial expected to read out later this year.² Participants in both cities noted that dapagliflozin's DELIVER trial included patients with improved ejection fraction while empagliflozin's EMPEROR-Preserved trial did not, a distinction some said factors into prescribing once ejection fraction has recovered.³

Semaglutide's SELECT trial, which enrolled 17,000 patients with established cardiovascular disease, showed consistent benefit across ejection fraction categories for its composite endpoint.⁴ Chicago participants noted a possible signal toward worsening heart failure events with GLP-1 therapy in patients with reduced ejection fraction, a contrast with more favorable heart failure hospitalization data reported in the SUMMIT trial among patients with preserved ejection fraction. In Minneapolis, participants said GLP-1 prescribing in heart failure is outpacing the evidence base and is often initiated by primary care rather than cardiology.

Barriers to Timely Heart Failure Diagnosis and Treatment

Access and education barriers echoed across both forums. Participants described cost and prior authorization as continuing hurdles for finerenone and GLP-1 therapy, alongside a persistent knowledge gap among general cardiologists and primary care clinicians unfamiliar with nonsteroidal mineralocorticoid receptor antagonists. Minneapolis participants added that caregivers are frequently left out of heart failure education despite carrying much of the medication and symptom-monitoring burden, and that hospitalist teams restart or continue guideline-directed therapy inconsistently after discharge.

Both forums closed on a similar note: earlier identification, not just better late-stage treatment, is where the field needs to move next. Participants in Minneapolis pointed to the incoming cardiovascular-kidney-metabolic staging framework and cautioned against discontinuing SGLT2 inhibitors once started, while participants in Chicago emphasized that closing the gap between guideline publication and everyday practice, historically estimated at about a decade, will require primary care, nephrology, and pharmacy to share more of the diagnostic and titration burden long treated as cardiology's alone.

References

1. Fonarow GC, Ahmad FS, Ahmad T, et al. HF STATS 2025: heart failure epidemiology and outcomes statistics. An updated 2025 report from the Heart Failure Society of America. J Card Fail. Published online 2025. doi:10.1016/j.cardfail.2025.07.007

2. Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-1485.

3. Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2022;387(12):1089-1098.

4. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221-2232.