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Meta-Analysis
. 2014 Aug 12;11(8):e1001699.
doi: 10.1371/journal.pmed.1001699. eCollection 2014 Aug.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis

Thomas Callender  1 , Mark Woodward  2 , Gregory Roth  3 , Farshad Farzadfar  4 , Jean-Christophe Lemarie  5 , Stéphanie Gicquel  5 , John Atherton  6 , Shadi Rahimzadeh  7 , Mehdi Ghaziani  4 , Maaz Shaikh  8 , Derrick Bennett  9 , Anushka Patel  10 , Carolyn S P Lam  11 , Karen Sliwa  12 , Antonio Barretto  13 , Bambang Budi Siswanto  14 , Alejandro Diaz  15 , Daniel Herpin  16 , Henry Krum  17 , Thomas Eliasz  1 , Anna Forbes  1 , Alastair Kiszely  1 , Rajit Khosla  1 , Tatjana Petrinic  18 , Devarsetty Praveen  19 , Roohi Shrivastava  1 , Du Xin  20 , Stephen MacMahon  2 , John McMurray  21 , Kazem Rahimi  1
Affiliations
Meta-Analysis

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis

Thomas Callender et al. PLoS Med. .

Abstract

Background: Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

Methods and findings: Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

Conclusions: The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

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Conflict of interest statement

CL is funded by a Clinician Scientist Award from the National Medical Research Council of Singapore; receives research grants from Boston scientific, Medtronic, and Vifor Pharma; and serves as a consultant for Bayer and Novartis. JML is employed by the contract research organization Effi-Stat, which receives funding from pharmaceutical and biotechnology companies. In 2009 and 2010 Effi-Stat received financial support from Sanofi-Aventis for providing statistical analysis and programming for the I-Prefer study included in this review (reference [70]). SG is employed by the contract research organization Effi-Stat, which receives research funding from pharmaceutical and biotechnology companies. AP is a member of the Editorial Board of PLOS Medicine.

Figures

Figure 1
Figure 1. Data acquisition flowchart.
Figure 2
Figure 2. Geographic distribution of studies on heart failure in lowand middle-income countries.
Figure 3
Figure 3. Male patients by region.
Figure 4
Figure 4. Correlation of age and human development index, by country.
r = 0.71, p<0.001. The HDI is a measure produced by the United Nations Development Programme that incorporates gross national income per capita, life expectancy, and time spent in education. It serves as a single statistic that provides a comparable measure of development across nations. HF, heart failure.
Figure 5
Figure 5. Aetiology of heart failure: ischaemic heart disease by region.
Percentage of heart failure cases with a documented cause of IHD.
Figure 6
Figure 6. Aetiology of heart failure: hypertension by region.
Percentage of heart failure cases with a documented cause of hypertension.
Figure 7
Figure 7. Aetiology of heart failure: cardiomyopathies by region.
Percentage of heart failure cases with a documented cause of cardiomyopathy.
Figure 8
Figure 8. Aetiology of heart failure: valvular heart disease by region.
Percentage of heart failure cases with a documented cause of valvular heart disease.
Figure 9
Figure 9. Diuretic use by region.
Loop and/or thiazide diuretics. ∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Figure 10
Figure 10. Angiotensin-converting enzyme inhibitor use by region.
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Figure 11
Figure 11. Beta-blocker use by region.
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Figure 12
Figure 12. Mineralocorticoid receptor antagonist use by region.
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Figure 13
Figure 13. In-hospital mortality rates by region.
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Figure 14
Figure 14. Meta-regression of hypertension against study period.
Figure 15
Figure 15. Meta-regression of ischaemic heart disease against study period.
Figure 16
Figure 16. Meta-regression of cardiomyopathies against study period.
Figure 17
Figure 17. Meta-regression of valvular heart disease against study period.
Figure 18
Figure 18. Meta-regression of beta-blocker use against study period.
Figure 19
Figure 19. Meta-regression of angiotensin-converting enzyme inhibitor use against study period.
Figure 20
Figure 20. Meta-regression of mineralocorticoid receptor antagonist use against study period.
Figure 21
Figure 21. Meta-regression of diuretic use against study period.
Figure 22
Figure 22. Meta-regression of in-hospital mortality rates against study period.
See this image and copyright information in PMC

Comment in

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