Heart failure (HF) risk increases with worsening cardiovascular-kidney-metabolic health in older adults. Published in Circulation, this prospective cohort analysis from the Atherosclerosis Risk in Communities (ARIC) study included participants at visit 5 (2011 to 2013) who underwent echocardiography and evaluated the association between cardiovascular–kidney–metabolic (CKM) staging and cardiac remodeling and incident HF.

A total of 5646 participants aged 66 to 90 years, including 57.9% women, had sufficient data for CKM staging. Distribution across stages included 0.4% in stage 0, 1.8% in stage 1, 8.1% in stage 2, 56.0% in stage 3, 32.3% in stage 4a, and 0.3% in stage 4b, indicating a predominance of advanced CKM stages.

Participants were categorized using the American Heart Association CKM syndrome staging framework, which incorporates adiposity, metabolic risk factors, kidney disease, subclinical cardiovascular disease, and clinical cardiovascular disease.

Higher CKM stage was associated with adverse left ventricular remodeling, along with worsening systolic and diastolic function. Longitudinal evaluation through visit 7 (2018 to 2019) showed greater progression of adverse remodeling with increasing CKM stage.

Among participants without prevalent heart failure at baseline (n=4827), 656 incident heart failure events occurred over a median follow-up of 9.0 years. Event rates increased with higher CKM stage, with no events observed in stages 0 and 1, 2.9 events per 1000 person-years in stage 2, 15.1 in stage 3, and 37.4 in stage 4. Stage 2 served as the referent group due to no events in stages 0 and 1. Adjusted hazard ratios increased with advancing stage, with 3.6 (95% CI, 2.1-6.0) for stage 3 and 8.3 (95% CI, 4.9-14.2) for stage 4 (Ptrend<0.001).

Higher CKM stage was associated with adverse myocardial remodeling and increased incidence of heart failure in this cohort.