Global Variations in Heart Failure Etiology, Management, and Outcomes

Abstract

ImportanceMost epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries.ObjectiveTo examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development.Design, Setting, and ParticipantsMultinational 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 MeasuresHF cause, HF medication use, hospitalization, and death.ResultsMean (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 RelevanceThis 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.

Global Variations in Heart Failure—Reply

“…In Reply We thank Dr Entezari-Maleki for interest in our article . Two large trials of statins have demonstrated no benefit in people with heart failure .…”

Incorrect Results Detail and Author Names; Incomplete List of Study Investigators and Nonauthor Collaborators

“…In the Original Investigation titled “Global Variations in Heart Failure Etiology, Management, and Outcomes,” published in the May 16, 2023, issue of JAMA , errors in the article text and online supplements occurred. On page 1654, in the “Thirty-Day Case-Fatality Rate After the First Hospitalization Occurring in Follow-up” subsection of the Results, the first sentence should have read “Unadjusted 30-day case fatality after the first hospital admission date was lowest in high-income countries (6.7%), but case fatality increased as country income level decreased….” In the Conflict of Interest section, the surname should have been spelled as Yusuf for Salim Yusuf, DPhil.…”

Global Variations in Heart Failure

“…To the Editor The Global Congestive Heart Failure (G-CHF) Investigators recently published a landmark study on global variations in heart failure etiology, management, and outcomes among 23 341 participants from 40 countries across 4 income levels. They showed that patients with heart failure in low-income and lower-middle-income countries had a higher risk of death and were less likely to be prescribed heart failure therapies that improve survival compared with participants in high-income countries.…”

“…Similar recommendations come from the 2013 American College of Cardiology/American Heart Association guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults and the later 2018 update recommending a statin for adults (≥21 years of age) with atherosclerotic CVD and for individuals aged 40 to 75 years with diabetes. Therefore, considering that the G-CHF registry enrolled participants from 2016 to 2020, and a substantial proportion of these patients had CVD risk factors, including ischemic heart disease (38.1%), diabetes (30.9%), hypertension (65.7%), and smoking (8.4%), it is likely that many would have met criteria for statin use. SGLT2 inhibitors are another class of medication that improve survival in people with heart failure, type 2 diabetes, and/or chronic kidney disease .…”

“…SGLT2 inhibitors are another class of medication that improve survival in people with heart failure, type 2 diabetes, and/or chronic kidney disease . The G-CHF Investigators stated that they did not include SGLT2 inhibitor data in their study because at the time of the study’s inception in 2016, SGLT2 inhibitors were not part of the heart failure treatment regimen. However, on December 2, 2016, the US Food and Drug Administration approved the SGLT2 inhibitor empagliflozin as the first agent with improved survival for reducing cardiovascular death in individuals with type 2 diabetes.…”