Prevalence of heart failure stages in elderly population: from a community-dwelling elderly people survey

Abstract

Background

Heart failure (HF) is a major public health concern in China, but there is a lack of epidemiological data on the prevalence of early-stage HF in the elderly.

Objectives

This study aimed to evaluate the prevalence of different stages of HF in individuals aged ≥ 60 years in a community-based survey.

Methods

This cross-sectional study enrolled 7,640 participants from a community. Basic demographic information, NT-proBNP, troponin T (TnT) levels, and echocardiographic data were collected. Participants were classified into four stages: Healthy, Stage A, Stage B, and Stage C. Prevalence and associated risk factors were analyzed.

Results

The mean age was 70.2 years, with 54.5% being female. The prevalence of Stage A and B was 44.0% and 27.8%, respectively. In Stage A, hypertension was the most common risk factor (80.89%), followed by diabetes (29.75%) and obesity (18.08%). In Stage B and C, 97.2% and 88.2% had an ejection fraction ≥ 50%. The prevalence of Stage B increased with age (P < 0.001), and women had higher prevalence of Stage B compared to men (29.69% vs. 25.65%, P < 0.001). Female gender (OR 1.352, P < 0.001), older age (OR 1.096, P < 0.001), atrial fibrillation/flutter (OR 2.853, P < 0.001), and coronary artery disease (OR 1.473, P < 0.001) were identified as significant risk factors for Stage B.

Conclusions

This survey revealed a high prevalence of Stage A and B HF in the elderly, with most Stage B individuals having an ejection fraction ≥ 50%, emphasizing the need for targeted prevention and management strategies for at-risk groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06631-z.

Background

Heart failure (HF) is a complex clinical syndrome characterized by structural or functional cardiac abnormalities, resulting in elevated intracardiac pressures or inadequate cardiac output[1]. With high morbidity, mortality, and substantial economic costs, HF represents a significant global public health challenge, particularly in aging populations [2–5]. Globally, an estimated 64.34 million individuals were affected by HF in 2017[6], with prevalence rates ranging from 1% to 3% in Europe and the United States. ¹ In China, the prevalence of Stage C/D HF among adults is approximately 1–2%, rising to 3.86% among those aged 65–79 years and 7.55% in individuals aged ≥ 80 years [7, 8]. HF imposes considerable economic burdens, with Chinese patients averaging 3.3 hospitalizations per year and annual costs of $4,406.8[8]. These statistics emphasize the urgent need for early detection and management of HF, especially during its early stages, to reduce its escalating impact on public health.

As a progressive condition, HF has been categorized by the American Heart Association (AHA) and the American College of Cardiology (ACC) into four stages based on disease development and progression: Stage A (at risk for HF), Stage B (pre-HF), Stage C (symptomatic HF), and Stage D (advanced HF).² Early identification of HF in Stage A and B, followed by timely intervention, can prevent progression to Stage C and D, significantly reducing HF-related mortality [9].

Previous studies conducted in Western countries have reported a high prevalence of Stage B heart failure [3, 10–13]. Amil M. Shah et al. analyzed data from 6,118 elderly community participants (aged 67–91 years) and found that 52% were classified as Stage A and 30% as Stage B[10]. Similarly, Reza Mohebi et al. enrolled 11,618 study participants, reporting that 37.4% were in Stage A, 43.2% in Stage B, and 2.7% in Stage C according to the 2022 ACC/AHA Heart Failure Stages Classification Criteria.⁶ Another study, evaluating 6,770 participants from the Framingham Study, revealed that the prevalence of Stage A and B HF was 36.5% and 24.2%, respectively[4].

In contrast, data on the prevalence of preclinical heart failure in China remains scarce. Cai et al. analyzed data from the China Hypertension Survey (CHS), which included 31,494 participants, and reported prevalence rates of 35.8% for Stage A, 42.8% for Stage B, and 1.1% for Stage C HF.[14] However, this study did not explicitly adhere to the updated diagnostic definitions outlined in the 2021 European Society of Cardiology (ESC) or 2022 AHA/ACC/Heart Failure Society of America (HFSA) guidelines. These updated definitions emphasize the use of biomarkers such as brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) in the diagnosis of Stage B HF. Additionally, the study population consisted of individuals aged ≥ 35 years, rather than specifically focusing on the elderly.

Given the high prevalence of hypertension, diabetes, obesity, and coronary artery disease in China, it is expected that the proportion of individuals in Stage A and B HF would be particularly high among the elderly. This cross-sectional study aims to comprehensively assess the prevalence of heart failure stages in a community-dwelling elderly population aged ≥ 60 years in China. It also aims to identify the key risk factors associated with Stage B heart failure, providing critical evidence to inform early clinical interventions and improve preventative strategies.

Methods

Study sample

A survey of community-dwelling elderly individuals was conducted between April 2024 and July 2024, in conjunction with free health examination services for residents aged ≥ 60 years in the Beicai community, Pudong New Area, Shanghai. Among the 14,124 elderly residents in the 22 neighborhood committees of Beicai community, 11,401 individuals initially planned to participate in the free health examinations. However, individuals who missed the examinations (n = 2,035), refused to provide written informed consent (n = 1,351), or did not complete the full survey (n = 381) were excluded from the analysis. Ultimately, 7,640 participants completed the survey (Fig. 1).

Fig. 1.

Flowchart of Study Population (Finally, 7640 participants were enrolled in this survey. NT-proBNP: N-terminal pro-B-type natriuretic peptide; TnT: troponin I.)

Inclusion criteria

Residents aged ≥ 60 years in the community completed the whole health examinations and signed informed consent were included.

Exclusion criteria

Residents didn’t finish the whole health examinations, refused to provide written informed consent and Stage D heart failure patients were excluded.

Written informed consent was obtained from all participants prior to data collection. The study was approved by the Ethics Committee of Shanghai East Hospital(2023.080).

Data collection

Data were collected using a standardized questionnaire developed by Shanghai East Hospital. (Table S1) Trained staffs administered the questionnaire to ensure consistency and accuracy in data collection. The questionnaire included information on demographic characteristics (age, sex), comorbidities, current medication use, and symptoms.

Comorbidities

Comorbid conditions assessed included hypertension, diabetes, coronary artery disease (CAD), atrial fibrillation/atrial flutter (AF/AFL), obesity, and malignancy. The definitions for these conditions were as follows:

Hypertension

A history of blood pressure levels ≥ 140/90 mmHg and/or the use of blood pressure-lowering drugs;

Diabetes

A history of fasting plasma glucose levels ≥ 7.0 mmol/L or oral glucose tolerance test (OGTT) 2-hour postprandial plasma glucose levels ≥ 11.0 mmol/L;

Coronary artery disease (CAD)

Documented by previous coronary computed tomography angiography (CTA) or coronary angiography demonstrating ≥ 50% coronary stenosis, or a history of myocardial infarction or coronary revascularization.

Atrial fibrillation/atrial flutter (AF/AFL)

Diagnosed based on previous or current electrocardiographic evidence of atrial fibrillation or atrial flutter. AF was defined as a disorganized, rapid atrial arrhythmia with ECG showing: absent P waves, replaced by irregular fibrillatory waves (f waves), and variable R-R intervals. AFL was defined as a regular, rapid atrial tachycardia characterized by sawtooth-shaped “F waves” on ECG, with ventricular response often at a fixed ratio (e.g., 2:1 or 4:1 conduction).

Malignancy

Any prior history of cancer.

Medications

Data on current medication use were collected, including but not limited to the following: Antithrombotic agents (antiplatelet and anticoagulant drugs), β-receptor blockers, Renin-angiotensin-aldosterone system inhibitors (RAASi), Sodium-glucose co-transporter 2 inhibitors (SGLT2i), Lipid-lowering drugs (statins, ezetimibe, or PCSK9 inhibitors), Antitumor drugs.

Symptoms

Key symptoms relevant to heart failure were recorded, including dyspnea and lower extremity edema. Dyspnea includes exertional dyspnea, nocturnal paroxysmal dyspnea, and orthopnoea (NYHA II-IV). Edema refers to concave edema in both lower limbs.

Anthropometric and blood pressure measurements

Body mass index (BMI) was calculated as weight (in kilograms) divided by the square of height (in meters). Obesity was defined as a BMI ≥ 28.0 kg/m², based on the recommended criteria [15]. Height was measured without shoes using a standard right-angle device and a fixed measuring tape, ensuring accuracy. Body weight was measured without heavy clothing using a calibrated weight measurement device.

Blood pressure (BP) was measured using a professional portable BP monitor. Measurements were taken on the right arm, positioned at heart level, after the participant had been seated and at rest for at least 5 min to ensure reliable readings.

Biomarker measurements

Blood samples were collected in the morning after participants had fasted overnight for at least 8 h. Levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and troponin T (TnT) were measured using standardized techniques with the AQT90 FLEX analyzer (Radiometer Medical APS, Denmark).

Echocardiographic measurements

Echocardiographic evaluations were conducted in accordance with the current guidelines of the American Society of Echocardiography for primary screening [16]. Given the large sample size and time constraints, echocardiographers focused exclusively on measuring left ventricular ejection fraction (LVEF) for each participant. LVEF was estimated using M-mode echocardiography instead of Simpson’s method. Although Simpson’s method is known for its higher accuracy, M-mode echocardiography was seemed more practical for large-scale screening due to its simplicity and efficiency [16].

Classification of heart failure stages

Stages of HF were classified according to the 2022 AHA/ACC/HFSA Heart Failure Guideline, with minor modifications[2].

Stage A was defined as individuals at risk for HF but without current or previous symptoms/signs of HF and without structural/functional heart disease or abnormal biomarkers (e.g. patients with hypertension, coronary artery disease, diabetes, obesity, atrial fibrillation/atrial flutter, or malignancy).

Stage B was defined as the absence of HF symptoms or signs but evidence of one of the following: ①LVEF < 52% in males and < 54% in females [16]. ②Elevated NT-proBNP levels (≥ 125 pg/ml) or TnT levels (>0.017 ng/ml).

Stage C was defined as a previous history of HF or structural heart disease with current or prior symptoms of HF (e.g. dyspnea, bilateral lower extremity swelling), as confirmed by two cardiac specialists.

Participants not meeting the criteria for Stage A, B, or C were categorized as healthy. HFrEF (Heart Failure with Reduced Ejection Fraction) was defined as LVEF < 50% and HFpEF (Heart Failure with Preserved Ejection Fraction) was defined as EF ≥ 50%. Detailed information on HF stage classification was provided in Table S2.

Statistical analysis

Continuous variables with normal distributions were expressed as mean ± standard deviation (SD), while those with non-normal distributions were expressed as median (interquartile range). Comparisons of continuous variables were conducted using Student’s t-test, the Mann–Whitney U test, or one-way analysis of variance (ANOVA), as appropriate. Categorical variables were reported as numbers (percentages) and compared using the chi-square test or Fisher’s exact test. Logistic regression analysis was performed to evaluate risk factors for Stage B HF. A P value < 0.05 was considered statistically significant, and all statistical tests were two-sided. Data analyses were conducted using SPSS software, version 23.0 (IBM Corp., Armonk, NY, USA).

Results

Cohort demographics

A total of 7,640 participants were enrolled in this survey. The mean age of the cohort was 70.2 years, with 4,166 (54.5%) participants being women. The age distribution showed that 48.9% of participants were aged 60–69 years, 43.8% were aged 70–79 years, and 7.3% were aged ≥ 80 years. Among the entire population, 55.7% had hypertension, and 20.8% had diabetes. The mean body mass index (BMI) of the cohort was 24.4 kg/m². The mean LVEF was 61.6%, and the mean NT-proBNP level was 90 pg/mL. Detailed demographic and clinical characteristics were presented in Table 1.

Table 1.

Baseline characteristics of study population by heart failure stages

	All population (n = 7640)	Stage A (n = 3479)	Stage B (n = 2128)	Stage C (n = 363)	P-value
Age	70.2 ± 6.1	69.4 ± 5.5	72.2 ± 6.7	75.1 ± 7.2	< 0.001
Age group, n(%)					< 0.001
60–69	3737(48.9)	1816(52.2)	780(36.7)	78(21.5)
70–79	3350(43.8)	1530(44.0)	1050(49.3)	196(54.0)
≥80	553(7.3)	133(3.8)	298(14.0)	89(24.5)
Sex, n(%)					< 0.001
Men	3474(45.5)	1708(49.1)	891(41.9)	139(38.3)
Women	4166(54.5)	1771(50.9)	1237(58.1)	224(61.7)
HF risk factor, n(%)
Hypertension	4254(55.7)	2814(83)	1189(55.9)	251(69.1)	< 0.001
Diabetes	1590(20.8)	1035(30.5)	436(20.5)	119(32.8)	< 0.001
Coronary artery disease	855(11.2)	435(12.8)	291(13.7)	129(35.5)	< 0.001
Obesity	912	629(18.1)	222(10.4)	61(16.8)	< 0.001
AF/AFL	284(3.7)	91(2.7)	120(5.6)	73(20.1)	< 0.001
Malignancy	427(5.6)	256(7.4)	128(6.0)	43(11.8)	< 0.001
Medication, n(%)
Antithrombosis drug	876(11.5)	422(12.1)	308(14.5)	99(27.3)	< 0.001
β-receptor blocker	595(7.8)	300(8.6)	193(9.1)	83(22.9)	< 0.001
RAASi	2176(28.5)	1443(41.5)	590(27.7)	135(37.2)	< 0.001
SGLT2i	403(5.3)	258(7.4)	109(5.1)	34(9.4)	< 0.001
Lipid-lowering drugs	1124(14.7)	566(16.3)	324(15.2)	99(27.3)	< 0.001
Antitumor drugs	155(2.0)	96(2.8)	44(2.1)	14(3.9)	< 0.001
Symptom, n(%)
Dyspnea	809(10.6)	361(10.4)	154(7.2)	167(46.0)	< 0.001
Edema of Lower Extremities	1036(13.6)	507(14.6)	205(9.6)	209(57.6)	< 0.001
BMI(kg/m2)	24.4 ± 3.4	25.3 ± 3.3	24.1 ± 3.5	24.5 ± 4.3	< 0.001
SBP(mmHg)	141.4 ± 19.2	142.9 ± 18.2	143.1 ± 20.3	145.7 ± 20.3	< 0.001
DBP(mmHg)	74.5 ± 11.0	75.7 ± 10.8	73.4 ± 11.4	72.4 ± 12.1	< 0.001
Heart rate(b.p.m.)	74.5 ± 7.2	74.8 ± 7.3	74.2 ± 7.1	75.3 ± 9.3	0.015
Fasting blood glucose (mmol/l)	5.66 ± 1.48	5.91 ± 1.63	5.62 ± 1.46	5.77 ± 1.66	< 0.001
NT-proBNP(pg/mL)	90(3–177)	68(22–114)	172(79–265)	305(49–561)	< 0.001
Elevated TnT, n(%)	46(0.6)	0	31(1.5)	15(4.1)	< 0.001
LVEF(%)	61.6 ± 4.0	62.0 ± 3.3	60.9 ± 4.6	58.3 ± 6.9	< 0.001
LVEF < 50%,n(%)	102(1.3)	0	59(2.8)	43(11.8)	< 0.001

AF/AFL atrial fibrillation/atrial flutter, RAASi renin-angiotensin-aldosterone system inhibitor, SGLT2i Sodium-Glucose co-Transporter 2 inhibitor, BMI body mass index, SBP systolic blood pressure, DBP diastolic blood pressure, NT-proBNP N-terminal pro-B-type natriuretic peptide, Elevated TnT troponin I>0.017ng/ml, LVEF left ventricular ejection fraction

Prevalence of heart failure stages

The prevalence of heart failure (HF) stages among the enrolled population were as follows: Stage A (44.0%), Stage B (27.8%), and Stage C (4.8%). (Fig. 2A) Within Stage B, the majority of participants (97.2%) had an LVEF ≥ 50%, while 2.4% had an LVEF between 40% and 50%, and only 0.4% had an LVEF ≤ 40%.(Fig. 2B) In Stage C, 88.2% of participants had an LVEF ≥ 50%, 8.5% had an LVEF between 40% and 50%, and 3.3% had an LVEF ≤ 40%.(Fig. 2C).

Fig. 2.

Prevalence of Heart Failure Stages in Community (2(A). The prevalence of Stage A and B was 44% and 27.8%. 2(B). The proportion of EF ≥ 50% in Stage B was 97.2%. 2(C). The proportion of EF ≥ 50% in Stage B was 88.2%.)

Age-related trends showed a significant decrease in the prevalence of Stage A with advancing age (P < 0.001), while the prevalence of Stage B (P < 0.001) and Stage C (P < 0.001) increased with age.(Fig. 3A).

Fig. 3.

Prevalence of Heart Failure Stages by age and sex (3 (A). The prevalence of Stage B and Stage C increased with age. 3(B). The prevalence of Stage B and Stage C was higher in women compared with men. P-values were determined via chi-square test or Fisher’s exact test; *** P < 0.001; ** P < 0.01)

Gender differences were also observed: the prevalence of Stage A was lower in women compared to men (42.51% vs. 49.16%, P < 0.001). However, women had higher prevalence rates of Stage B (29.69% vs. 25.65%, P < 0.001) and Stage C (5.38% vs. 4.00%, P = 0.005). (Fig. 3B) Additional data were summarized in Table S3.

Prevalence of stage A risk factors

In this study, Stage A risk factors included hypertension, diabetes, coronary artery disease, obesity, AF/AFL, and malignancy. Hypertension was the most prevalent risk factor, affecting 80.89% of participants, followed by diabetes (29.75%) and obesity (18.08%) (Fig. 4A).

Fig. 4.

Prevalence of Stage A risk factors by age and sex (4(A). Among all risk factors in Stage A, hypertension owns the highest proportion, followed by diabetes and obesity. 4(B). Prevalece of Stage A HF risk factors by age group. 4(C). Prevalence of Stage A HF risk factors by sex group. P-values were determined via chi-square test or Fisher’s exact test; *** P < 0.001; ** P < 0.01; * P < 0.05)

Gender differences were also observed. Women had a lower prevalence of coronary artery disease (11.69% vs. 13.35%, P < 0.001) and diabetes (28.85% vs. 30.68%, P = 0.03) compared to men, but a higher prevalence of malignancy (9.37% vs. 5.27%, P < 0.001). The prevalence of hypertension, AF/AFL, and obesity showed no significant differences between genders (Fig. 4B, Table S4).

Age-related trends revealed that the prevalence of hypertension, diabetes, coronary artery disease, and AF/AFL increased with age. However, no significant age-related trends were observed for obesity or malignancy (Fig. 4C, Table S4).

Risk factor assessment in stage B

To identify risk factors associated with progression to Stage B from Stage A or healthy status, logistic regression analysis was performed. Variables included sex, age, hypertension, diabetes, coronary artery disease, AF/AFL, and malignancy. The results indicated that female (odds ratio [OR] 1.352, 95% confidence interval [CI] 1.215–1.505, P < 0.001), older age (OR 1.096, 95% CI 1.086–1.106, P < 0.001), AF/AFL (OR 2.853, 95% CI 2.135–3.812, P < 0.001), and coronary artery disease (OR 1.473, 95% CI 1.246–1.742, P < 0.001) were significantly associated with an increased risk of Stage B (Fig. 5).

Fig. 5.

Logistic Regression Analysis of Stage B (Women, elderly, AF/AFL and coronary artery disease were risk factors of Stage B.)

Discussion

This study reported the prevalence of heart failure stages among a community-dwelling elderly population aged ≥ 60 years. The key findings were as follows:①The prevalence of Stage A and Stage B HF was 44.0% and 27.8%, respectively.②Among all Stage A risk factors, hypertension was the most common, followed by diabetes and obesity.③The prevalence of Stage B increased with age and was higher in women compared to men.④Among participants in Stage B and Stage C, 97.2% and 88.2% had a preserved ejection fraction (EF ≥ 50%).⑤Female sex, older age, AF/AFL, and coronary artery disease were identified as significant risk factors for Stage B HF.

Hypertension is the primary risk factor for stage A HF

In China, the prevalence of hypertension among individuals aged 60 years and older has been steadily increasing over the past few decades. According to the Chinese Guidelines for the Management of Hypertension in the Elderly 2023, the prevalence rates were reported as follows: 40.4% in 1991, 49.1% in 2002, and 53.2% between 2012 and 2015 [17]. These statistics highlight a rising trend in hypertension among China’s elderly population. Recent data from 2018 reveals that hypertension prevalence further increases with age: 54.4% in individuals aged 60–69 years, 65.2% in aged 70–79 years, and 66.7% in aged ≥ 80 years [17]. These data emphasize the significant burden of hypertension in the aging population of China and its critical role as a leading cause of Stage A HF. This underscores the importance of implementing targeted blood pressure control strategies as part of early HF prevention efforts.

Evolving diagnostic criteria and biomarker integration in stage B HF

The prevalence of Stage B HF has demonstrated significant variation with evolving diagnostic standards. The 2022 ACC/AHA/HFSA guidelines introduced critical updates by redefining Stage B (“pre-HF”) to include individuals with elevated cardiac biomarkers (e.g. NT-proBNP ≥ 125 ng/L, hs-Tn ≥ 99th percentile) in addition to structural heart abnormalities, such as left ventricular hypertrophy (LVH), left atrial enlargement (LAE), or reduced ejection fraction (LVEF < 50%)[2]. Under the 2013 ACC/AHA guidelines, which relied primarily on structural abnormalities detected through echocardiography, studies reported a Stage B prevalence of approximately 24.2% in middle-aged and elder populations, as shown in the Framingham Heart Study [4]. In contrast, applying the 2022 criteria to a pooled community cohort resulted in a significant reclassification of individuals from Stage A to Stage B, increasing prevalence from 15.9% (2013) to 43.2% (2022)[9].

Biomarkers, particularly NT-proBNP, have played a pivotal role in this shift, enhancing the detection of subclinical cardiac stress and dysfunction. NT-proBNP, which reflects myocardial wall stress, is elevated in asymptomatic individuals with latent cardiac dysfunction. Studies by Mohebi et al. and Gupta et al. demonstrated NT-proBNP’s efficacy in detecting left ventricular dysfunction and its superiority over traditional risk scores [11, 18]. Screening for Stage B HF using NT-proBNP has proven effective in preventing left ventricular dysfunction and reducing hospitalization or mortality caused by heart disease[19, 20].

Our study reported a Stage B prevalence of 27.8%, which was higher than the Framingham Heart Study findings [4], but significantly lower than the 42.8% observed by Cai et al. in the China Hypertension Survey [14]. Cai et al.[14] analyzed data from the China Hypertension Survey, which included 31,494 participants, and reported prevalence rates of 42.8% for Stage B HF. This study was the only one exploring the epidemiology of early stage heart failure in China till now. However, Stage B in this study was diagnosed only by echocardiogram, ignoring BNP or NT-proBNP, which did not explicitly adhere to the updated diagnostic definitions of Stage B outlined in the 2021 ESC or 2022 AHA/ACC/HFSA guidelines. And these updated definitions emphasize the importance of biomarkers such as BNP or NT-proBNP in the diagnosis of Stage B. Our study has effectively supplemented this section. Additionally, the study population consisted of individuals aged ≥ 35 years, rather than specifically focusing on the elderly in our study. Apart from differences in diagnostic criteria and population age, the discrepancy in stage B may be linked to Shanghai’s economic development as a southeastern coastal city, where better healthcare access and lifestyle contorls could influence results.

The integration of biomarkers into Stage B HF diagnosis allows for earlier identification of high-risk individuals and timely interventions (e.g. optimized hypertension control, SGLT2i, and RAASi), ultimately delaying or preventing progression to symptomatic HF (Stage C/D)[9]. This shift represents a critical advancement in heart failure prevention and management.

The prevalence of preserved ejection fraction (pEF) is high in stage B HF

In our study, 97.2% of participants in Stage B had a preserved ejection fraction (EF ≥ 50%), a proportion likely influenced by Shanghai’s rapidly aging population. Relatively, studies in Europe and the United States showed that the prevalence of EF ≥ 50% in Stage B was 89–95%[9, 10, 21]. However, the prevalence in our survey was similar to several Chinese elderly population studies. Chen et al.[22] revealed the prevalence of EF ≥ 50% in Stage B was 97.9% and Zheng et al.[23] was 97.3%. China officially became an aging society in 1999, and by the end of 2023, 37.4% of Shanghai’s registered residents were aged 60 or older [24]. Additionally, Shanghai’s average life expectancy reached 84.11 years in 2022, one of the highest in the nation [25]. Aging is associated with cardiac structural changes, such as left ventricular hypertrophy and diastolic dysfunction, which are characteristic of Stage B with preserved EF[26]. These changes, often driven by comorbidities like hypertension and diabetes, are more prevalent in elder populations. The demographic profile of Shanghai, therefore, likely contributes to the high prevalence of preserved EF observed in Stage B HF, underscoring the importance of targeted interventions in aging societies to prevent progression to symptomatic heart failure.

The prevalence of pEF in stage C HF

Our study revealed that 88.2% of participants in Stage C heart failure had preserved ejection fraction (EF ≥ 50%), a proportion significantly higher than previously reported. For instance, a Chinese study [16] reported a HFpEF prevalence of 30.6% in Stage C HF, while studies from Western populations [27–29] indicated that nearly 50% of Stage C/D HF patients were HFpEF. This discrepancy may be attributed to the demographic characteristics of our study population, which consisted of individuals aged 60 years and older, reflecting the epidemiological features of HF in the elderly. The rising proportion of HFpEF, particularly in Stage C HF, is well-documented and closely linked to older age, as aging is a significant risk factor for HFpEF [30]. Older adults are more prone to cardiac structural changes such as diastolic dysfunction and left ventricular stiffness, often driven by comorbidities like hypertension and diabetes [26, 31]. In our study, as shown in Fig. 3, participants in Stage B and C were of elder age, which explained the extremely high prevalence of preserved EF. Additionally, the complex diagnosis and insufficient recognition of HFpEF may contribute to its underestimation in elderly populations. These findings emphasize the importance of early identification and intervention for preclinical heart failure in aging populations to prevent progression to symptomatic HF, particularly given the increasing burden of HFpEF worldwide.

Otherwise, nowadays guidelines for the diagnosis and treatment of HFpEF at present were not perfectly suitable for clinical practice. But our study found a quite high incidence of HFpEF compared to HFrEF, suggesting the urgency of the unified and applicable diagnosis criteria and treatment of HFpEF.

Risk factors of stage B

We find a high consistency between prevalence of Stage B and age. Although the cross-sectional design precludes causal inferences, the association between prevalence of Stage B and age could be confounded by unmeasured factors (e.g. socioeconomic status), the high correlation still attract high attention. Previous research indicate that the prevalence of Stage C/D is much higher among the elderly, almost 3.86% in patients 65 to 79 years old and 7.55% in those ≥ 80 years old [7]. In addition, similar results were also observed in Stage B. A systematic review revealed that the prevalence of pre-HF was apparently higher in study conducted in elderly population than in the general population [32]. It is expected that by 2030, the elderly population ≥ 60 years old will account for nearly 30% of the total population, and China will enter into a stage of severe aging [33]. It will bring huge challenges to the prevention, control, and treatment of heart failure in China, so it’s extremely important to recognize potential HF patients, and move the checkpoint of prevention and control forward. Our study showed that elder age, women, AF/AFL and coronary artery disease were risk factors of Stage B. So early identification and treatment with AF/AFL and coronary artery disease is essential to prevent HF development.

Limitations of our study

Our study has several limitations. Due to the challenges of large-scale echocardiographic screening, we did not collect detailed structural and functional data, such as heart chamber size, valve regurgitation, and diastolic function, which may have led to underestimation or misclassification of Stage B, particularly in subclinical cases. Also, LVEF in our study was estimated using M-mode instead of Simpson’s method, which may affect the accuracy of EF. Additionally, the study was conducted in a single community in Shanghai, an economically developed and long-lifespan city in Southern China, limiting the generalizability of our findings to less developed or rural regions with differing socioeconomic conditions and healthcare access. Potential selection bias may also exist, as participants in affluent areas like Shanghai likely benefit from better healthcare services, enabling earlier diagnosis and intervention. Finally, clinical follow-up is ongoing to identify risk factors for progression to symptomatic heart failure (Stage C), and the absence of long-term prognostic data currently restricts our ability to fully evaluate the outcomes of subclinical abnormalities.

Conclusions

This study highlights the high prevalence of Stage A and Stage B heart failure among the elderly population in a community-dwelling cohort in Shanghai. Notably, 97.2% of Stage B and 88.2% of Stage C participants exhibited preserved ejection fraction (EF ≥ 50%). Risk factors such as elder age, female gender, AF/AFL, and coronary artery disease were significantly associated with Stage B HF. These findings emphasize the importance of early identification and targeted prevention strategies to reduce HF progression in aging populations.

Author’s contributions

Manyun Huang：Conceptualization, Methodology, Investigation, Formal analysis, Resources, Data Curation, Writing - Original Draft, VisualizationWei Han：Conceptualization, Methodology, Review & Editing, Supervision, Project administrationMin Wang：Investigation, Resources, Data CurationXin Gong：Formal analysis, ResourcesSibin Guan：Resources, Data CurationHao Hu：Resources, Data CurationXiaoling Xi：Data CurationChenying Zhu：Data CurationQingliu Zhang：Data CurationJianhong Cao：Data Curation All authors reviewed the manuscript.

Funding

This work was supported by the Research Program of Shanghai Health Commission (202440054), and by the Key Discipline Construction Project of Shanghai Pudong New Area Health Commission (Grant No. PWZxk2022-20).

Data availability

The datasets generated and/or analysed during the current study are not publicly available due [their containing information that could compromise the privacy of research participants] but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Shanghai East Hospital (2023.080). Written informed consent was obtained from all participants. All procedures were conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.