Global Variations in Heart Failure Etiology, Management, and Outcomes

Abstract

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries.

Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development.

Design, setting, and participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years.

Main outcomes and measures: HF cause, HF medication use, hospitalization, and death.

Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies.

Conclusions and relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Figure 1.. Countries Included in the Registry

The countries are sorted by income level then listed by continent from west to east, north to south. Türkiye is the new spelling, approved by the United Nations in June 2022 and also by the US Board on Geographic Names, for the country formerly known as Turkey. The basis for this figure was created with MapChart.

Figure 2.. Variation in the Causes of Heart Failure and the Use of Treatments for Heart Failure With Reduced Ejection Fraction by Country Income Level in a Registry Study of 40 Countries

A, See eTable 3 in Supplement 1 for an expanded list of heart failure causes by income level. B, See eTable 4 in Supplement 1 for an expanded list of heart failure treatments by country income level. Data report on the proportion of participants with an left ventricular ejection fraction of less than or equal to 40% taking a specific class of medication or combination of medications. Implantable cardioverter-defibrillator use is reported in participants with a left ventricular ejection fraction of less than or equal to 35%. RAS inhibitor refers to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or an angiotensin receptor–neprilysin inhibitor. MRA indicates mineralocorticoid receptor antagonist; RAS, renin-angiotensin system.

Figure 3.. Rate of Hospitalization, Rate of Death, and Proportional Risk of Death From Any Cause by Country Income Level

Events were captured at a median follow-up period of 2.0 years. HR indicates hazard ratio. ^aData reflect the first hospitalization after enrollment. Observation hospitalizations are common in the US but uncommon in many of the other countries participating in the registry; therefore, observation vs inpatient hospitalizations were not specifically delineated in the registry. ^bModel was adjusted for age and sex. ^cModel was adjusted for variables in model 1 plus clinical characteristics (body mass index, systolic blood pressure, diabetes, chronic obstructive pulmonary disease, current tobacco use, stage 4-5 kidney dysfunction, left ventricular ejection fraction [>50%, 41%-49%, ≤40%], having no echocardiography performed within the previous year, New York Heart Association functional class, heart failure duration >12 months), heart failure etiology (ischemic, hypertension, dilated, rheumatic valvular, nonrheumatic valvular, other), inpatient recruitment, patient education level, chronic heart failure treatments (β-blocker, renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist, implantable cardioverter-defibrillator).

Figure 4.. Risk of Death Within 30 Days of the First Hospital Admission by Country Income Level

HR indicates hazard ratio. ^aData reflect the first hospitalization after enrollment. Observation hospitalizations are common in the US but uncommon in many of the other countries participating in the registry; therefore, observation vs inpatient hospitalizations were not specifically delineated in the registry. ^bModel was adjusted for age and sex. ^cModel was adjusted for variables in model 1 plus clinical characteristics (body mass index, systolic blood pressure, diabetes, chronic obstructive pulmonary disease, current tobacco use, stage 4-5 kidney dysfunction, left ventricular ejection fraction [>50%, 41%-49%, ≤40%], having no echocardiography performed within the previous year, New York Heart Association functional class, heart failure duration >12 months), heart failure etiology (ischemic, hypertension, dilated, rheumatic valvular, nonrheumatic valvular, other), inpatient recruitment, patient education level, chronic heart failure treatments (β-blocker, renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist, implantable cardioverter-defibrillator).