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
Analyzed the data: TC KR MW. Wrote the first draft of the manuscript: TC KR. Contributed to the writing of the manuscript: TC KR MW GR JM FF.
In a systematic review and meta-analysis, Kazem Rahimi and colleagues examine the burden of heart failure in low- and middle-income countries.
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 We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.
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 Additional unpublished data were requested from investigators and international heart failure experts.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 (
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.
A healthy heart pumps about 23,000 liters of blood around the body every day. This blood delivers oxygen and nutrients to the rest of the body and carries carbon dioxide and waste products away from the tissues and organs. A healthy heart is therefore essential for life. Unfortunately, many people (particularly elderly people) develop heart failure, a life-threatening condition in which the heart no longer pumps enough blood to meet all the body's needs because it has become too weak or too stiff to work properly. Heart failure can affect the left, right, or both sides of the heart, and it can develop slowly (chronic heart failure) or quickly (acute heart failure). Its symptoms include swelling (edema) of the feet, ankles, and legs, tiredness, and shortness of breath. Heart failure, which is most commonly caused by coronary heart disease (blockage with fatty deposits of the blood vessels that supply the heart) or high blood pressure (hypertension), cannot be cured. However, lifestyle changes (for example, losing weight and avoiding salty food) and various medications can control heart failure and improve the quality of life of patients.
In high-income countries (HICs), heart failure is a common condition that typically consumes 1%–2% of healthcare resources. Experts believe that heart failure may soon become a major public health issue in low- and middle-income countries (LMICs) because fewer people are dying of infectious diseases in these countries than in the past. LMICs need to plan for this eventuality, but little is known about the current burden of heart failure in LMICs. Here, the researchers undertake a systematic review and meta-analysis of published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs. A systematic review uses predefined criteria to identify all the research on a given topic; a meta-analysis uses statistical approaches to combine the results of several studies.
The researchers identified 49 published studies and four unpublished databases that provided information on nearly 240,000 hospitalizations for acute and chronic heart failure in 31 LMICs. Across these LMICs, the average age of patients admitted to hospital for heart failure was 63 years, more than ten years younger than the average admission age in HICs. Differences in mean age at presentation, which ranged from 42 years in Cameroon and Ghana to 75 years in Argentina, largely correlated with the human development index (a measure of national well-being) of individual LMICs. Notably, acute heart failure accounted for 2.2% of all hospital admissions in the LMICs for which data were available. Hypertension was the main cause of heart failure in Africa and the Americas, whereas ischemic heart disease was the main cause in all other regions. More than two-thirds of patients were prescribed diuretics for heart failure, whereas only 57% of patients were treated with angiotensin-converting enzyme inhibitors, only 34% were treated with beta-blockers, and only 32% were treated with mineralocorticoid receptor antagonists, the three treatments currently recommended in guidelines for managing heart failure. Finally, on average, patients admitted to hospital for heart failure in LMICs spent ten days in hospital, and 8.3% of them died in hospital (compared to 6.7% and 4% of similar patients across Europe and the US, respectively).
These findings show that the presentation, causes, management, and outcomes of heart failure vary substantially across LMICs. Importantly, however, these findings reveal that heart failure is already a major burden in LMICs and that the use of recommended medications for heart failure is currently suboptimal in these countries. Because the studies included in this systematic review and meta-analysis set out to answer different research questions and used different methods to diagnose heart failure, the estimates of the burden of heart failure in LMICs provided here may not be completely accurate. Moreover, because the data were derived mainly from urban tertiary referral hospitals, these findings may not reflect the broader picture of heart failure in the community in LMICs. However, although additional studies are needed to completely assess the burden of heart failure in LMICs, the present findings nevertheless highlight the need to implement better strategies for the management of heart failure in LMICs.
Please access these websites via the online version of this summary at
This study is further discussed in a
The US National Heart, Lung, and Blood Institute provides information for patients about
The UK National Health Service Choices website provides information about all aspects of
The American Heart Association, a not-for-profit organization, also provides detailed information about
The British Heart Foundation, a not-for-profit organization, provides additional information about
MedlinePlus provides links to further resources about
In high-income countries (HICs), heart failure is a well-recognized public health problem representing a significant burden for patients and healthcare systems
With demographic changes and the epidemiological transition to non-communicable diseases
Therefore, we sought to conduct a systematic review of both published and unpublished data regarding the patterns of heart failure presentation, management, and outcomes in LMICs.
This systematic review was designed and undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines
In order to capture a comprehensive overview of heart failure in LMICs, a wide range of studies, each with differing objectives and designs, were included. Studies meeting the minimum quality requirement, as specified below, for inclusion were analysed for both methodological limitations and reporting quality, using items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
Algeria |
Prospective | 2008–2009 | All outpatients ≥21 y of age with either a previous or new diagnosis of heart failure.Exclusion: patients with acute decompensated heart failure, or those in another clinic trial. | Clinical diagnosis on the basis of the Framingham criteria. |
400 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. >90% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Cameroon |
Prospective and retrospective elements | 1998–2001 | Consecutive patients ≥15 y of age admitted to the cardiology clinic and/or the medical wards of Yaounde General Hospital. Those who had not had an echocardiogram were excluded.A prospective phase was carried out between September and November 2001, where all patients with suspected heart failure were included (39 patients).A retrospective phase involved the use of case notes of those with heart failure admitted to the hospital and undergoing echocardiography between 1998 and September 2001 (128 patients). | Clinical diagnosis on the basis of the Framingham criteria |
167 | Strengths: All patients had echocardiographic assessment.Limitations: This is a study of a single regional tertiary referral centre set in a rural area that may not be representative of the broader population. Patients who had not had an echocardiogram were excluded, but it is unclear how many patients with a clinical diagnosis of heart failure were thus excluded and to what extent this reduces the generalizability of the study findings. Missing data unreported. |
Cameroon |
Prospective | 2002–2008 | All consecutive patients diagnosed with congestive cardiac failure referred to the cardiac centre of St. Elizabeth Catholic General Hospital, Shisong, Cameroon. | Clinical diagnosis on the basis of the Framingham criteria.Echocardiography used, but no indication if all patients underwent this investigation. | 462 | Strengths: Comprehensive prospective study encompassing all patients diagnosed within the study period. Loss to follow-up documented.Limitations: This is a study of a single regional cardiology referral centre that may not be representative of the broader population. Missing data not transparently accounted for. |
Democratic Republic of the Congo |
Prospective | 2003–2004 | Every fourth patient admitted with heart failure as an inpatient having been seen at the cardiology clinic of the Lomo Medical Centre of the Heart of Africa Cardiovascular Centre in Kinshasa. | Echocardiography. | 100 | Strengths: All patients had echocardiographic assessment.Limitations: This is a study of a single urban outpatient cardiology referral centre that may not be representative of the broader population. Missing data not transparently accounted for. |
Ghana |
Prospective | 1992–1995 | Consecutive patients with heart failure referred to the National Cardiothoracic Centre, Accra, over 4 y. | Framingham criteria.All patients had an echocardiogram performed. | 572 | Strengths: This centre receives referrals from all hospitals across the country, increasing the generalizability of the results. All patients had echocardiography.Limitations: Acknowledged potential for referral bias as patients at this single urban tertiary specialist centre may not be representative of heart failure management elsewhere. Unclear if there were missing data, and how they were accounted for. |
Nigeria |
Retrospective | 1995–2005 | The case notes of 202 patients with heart failure were randomly selected from the outpatient and inpatient departments of University College Hospital, Ibadan. | New York Heart Association classification. | 202 | Limitations: Retrospective study with uncertain diagnostic accuracy. Inpatient and outpatient management were not separated. This is a study of a single urban tertiary referral centre that may not be representative of the broader population. Missing data not transparently accounted for. |
Nigeria |
Retrospective | 1996–2005 | All patients recorded as having a diagnosis of heart failure from the mortality records of the University of Ilorin Teaching Hospital | Not specified. | 228 | Strengths: Comprehensive review of all deaths and their respective case notes from the hospital, limiting selection bias.Limitations: Uncertain diagnostic accuracy. This is a single urban teaching hospital providing services to north-central Nigeria. Although the hospital covers a large catchment area, the patients may nonetheless not be representative of the broader population. |
Nigeria |
Prospective | 1997–2001 | Records of all patients admitted with cardiovascular disease to the Obafemi Awolowo University Teaching Hospitals Complex in Ife, Nigeria. | Not specified. | 386 | Strengths: Single tertiary referral centre providing services to 10 million individuals in the southwest of Nigeria, increasing the study's generalizability.Limitations: Single centre, though with a large catchment area, may not be representative of the broader population. No standardised diagnostic criteria used. |
Nigeria |
Retrospective | 1998–2001 | All patients admitted to the medical wards of the University of Uyo Teaching Hospital in southern Nigeria with heart failure during the dry seasons within the study period.Exclusion: Patients with renal disease or suspected coronary artery disease. | Clinical features with the aid of blood results, chest radiography, electrocardiography, and echocardiography. The proportion receiving additional investigations is unknown. | 245 | Strengths: Comprehensive assessment of patients with heart failure as coded for by this hospital.Limitations: Single tertiary referral centre may not be representative of the broader population. Study was a retrospective study of case notes; consequently, diagnostic accuracy is uncertain. Proportions receiving additional gold-standard investigations, such as echocardiography, not documented. |
Nigeria |
Retrospective | 2001–2005 | All adults ≥18 y with congestive cardiac failure admitted to the medical wards of the University of Port Harcourt Teaching Hospital.Exclusion: patients whose condition did not meet the Framingham criteria or who died within 24 h of admission. | Framingham criteria. | 423 | Strengths: Clear diagnostic criteria. Comprehensive assessment of patients with heart failure.Limitations: Single tertiary referral centre may not be representative of the broader population. Retrospective assessment with uncertain accuracy of the aetiology of heart failure. Unclear what proportion received additional investigations such as echocardiography. Unclear how missing data were accounted for. |
Nigeria |
Prospective | May–June 2004 | Consecutive patients ≥18 y with suspected heart failure presenting to outpatient department, wards, or the casualty unit of Jos University Teaching Hospital. | Framingham criteria. | 102 | Strengths: Consecutive patients included, limiting potential for selection bias. Clear documentation of rationale behind sample size. Standardised diagnosis criteria used. Acknowledged limitations.Limitations: Single tertiary referral centre may not be representative of the broader population. Inpatient and outpatient sample not separated. Aetiology of heart failure ascertained by case notes and clinical findings on examination rather than gold-standard investigation. Echocardiography not available to all patients. |
Nigeria |
Prospective | 2006–2008 | Consecutive patients ≥15 y with heart failure presenting to the University of Abuja Teaching Hospital. | European Society of Cardiology guidelines.Echocardiography available for all patients. | 340 | Strengths: Large catchment area for this referral centre, improving generalizability. All patients had echocardiographic assessment, improving overall diagnostic accuracy and that of assigned underlying aetiologies of heart failure.Limitations: Single tertiary referral centre may reflect more severe cases or those of uncertain diagnosis, therefore not reflecting practice in the broader health service. |
Nigeria |
Prospective | 2006–2010 | Clinical registry of consecutive individuals referred for the first time to the cardiology clinic of the University of Abuja Teaching Hospital.Exclusion: those with musculoskeletal chest pain or hepatic or renal failure. | European Society of Cardiology guidelines.Echocardiography available from >95% of patients. | 475 | Strengths: Consecutive patients, reducing the risk of selection bias. Clear, standardised, diagnostic criteria. Documented use of the STROBE guidelines |
Nigeria |
Prospective | Unknown (published 2009) | 177 consecutive individuals with heart failure presenting to the University College Hospital, Ibadan. | Framingham criteria.All patients underwent an echocardiogram. | 177 | Strengths: Clear, standardised, diagnostic criteria. All patients had an echocardiogram, improving the accuracy of heart failure diagnosis and that of underlying aetiology. Catchment area of greater than 3 million individuals, improving the generalizability of the results. Clear explanation of statistical methods used.Limitations: Single tertiary referral centre may reflect more severe cases or those of uncertain diagnosis, therefore not reflecting practice in the broader health service. |
Senegal |
Prospective | January–June 2001 | Selection criteria not specified. Urban hospital in Dakar. | Clinical diagnosis.All patients underwent echocardiography. | 170 | Strengths: All patients underwent echocardiography, improving the likely accuracy of the diagnosis of heart failure and of assigned aetiology.Limitations: Single urban hospital in the capital may not reflect broader population with heart failure. Unclear selection criteria. |
South Africa |
Prospective | 2006 | All patients with cardiovascular disease or presenting to the cardiology unit. Those with a de novo presentation with heart failure were included.Exclusion: those with acute ischaemic aetiology. | Based on European Society of Cardiology guidelines.All patients had an echocardiogram. | 844 | Strengths: Sole cardiovascular centre for a population of 1.1 million individuals, increasing the generalizability of findings. All patients underwent echocardiographic assessment, improving likely accuracy of diagnosis and of underlying aetiology of each patient's heart failure. Clear documentation of data availability and criteria applied.Limitations: Exclusion of those with an ischaemic aetiology may underestimate the proportion of those with heart failure due to IHD. Urban hospital setting may not reflect the broader population. |
Sub-Saharan Africa |
Prospective | 2007–2010 | Patients ≥12 y with acute heart failure confirmed by echocardiography were included.The study was conducted in the following countries: Sudan, Ethiopia, Kenya, Uganda, Mozambique, South Africa, Cameroon, Nigeria, Senegal.Exclusion: those with acute ST-elevation myocardial infarction, known severe renal failure, hepatic failure, or another cause of hypoalbuminemia. | Unspecified signs and symptoms of heart failure.All patients had an echocardiogram. | 1,006 | Strengths: All patients had echocardiographic assessment, improving diagnostic accuracy. Clear documentation of missing data and loss to follow-up as well as how this was accounted for in analyses. First published data on heart failure from a number of African countries.Limitations: Urban single hospital centres included. Individual study sites often had very few patients enrolled (range from 10 to 200). Exclusion criteria may lead to the underestimation of IHD as a cause of heart failure. |
Previously unpublished data.
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
Argentina |
Retrospective | 1992–1999 | All patients diagnosed with congestive heart failure, decompensated heart failure, or acute pulmonary oedema as recorded in the electronic vital statistics of a community hospital of Mar del Plata, Argentina. | Not specified. | 6,368 | Strengths: Comprehensive study with limited selection bias.Limitations: Single community hospital that may not be reflective of broader patterns of heart failure prevalence. No standardised method for diagnosing heart failure, relying on discharge reports. |
Argentina |
Prospective | 1996–1997 | Patients admitted to both the general medical and cardiology wards with decompensated chronic heart failure. Patients must have had heart failure, as diagnosed by the Framingham clinical criteria, for 30 d or more.Exclusion: acute heart failure due to an ischaemic event, those lost to follow-up, and those without an electrocardiogram and chest radiograph. | Framingham criteria.Unspecified proportion received echocardiography. | 751 | Strengths: 31 centres from across Argentina, 42% of which were in Buenos Aires. Standardised diagnostic criteria. Clear statistical methods documented.Limitations: Centres were invited to take part rather than randomised. Uncertain proportion received echocardiographic confirmation. Exclusion criteria may lead to underestimation of IHD as an aetiology of heart failure. |
Argentina |
Prospective | 2002–2003 | All patients >18 y hospitalised for decompensated chronic heart failure.Exclusion: heart failure secondary to a myocardial infarction or post-operatively. | Investigator's discretion. | 615 | Strengths: 36 centres predominantly based around Buenos Aires or neighbouring regions. Comprehensive assessment of all patients with likely low selection bias.Limitations: Centres were not randomised, rather invited. Consequently, results may not reflect the broader management of heart failure amongst physicians with less of an interest in heart failure. No standard diagnostic criteria. Exclusion criteria may lead to underestimation of IHD as an aetiology of heart failure. Uncertain adjustment for those with missing data. |
Argentina |
Prospective | 2007 | All patients >18 y of age were included if hospitalised for decompensated chronic heart failure.Exclusion: heart failure as a complication of a myocardial infarction or post-operatively. | Investigator's discretion. | 736 | Strengths: 36 centres from across Argentina.Limitations: Centres invited to take part rather than randomised, and those that did may reflect clinicians with an interest in heart failure, affecting the broader generalizability of results. Exclusion criteria may lead to underestimation of IHD as an aetiology of heart failure. No standard diagnostic criteria. Uncertain adjustment for those with missing data or lost to follow-up. No standard diagnostic criteria for heart failure. |
Brazil |
Retrospective | 1992 to 2010 | Patients admitted to public hospitals in São Paulo with heart failure. | Not specified. | 194,098 | Strengths: From the Datasus registry, providing hospital episode statistics for the entire public health system of São Paulo.Limitations: Uncertain diagnostic criteria based on individual physician's discretion. |
Brazil |
Prospective | 1998–2000 | Consecutive patients admitted to hospital with worsening symptoms of heart failure (NYHA functional classes III or IV).Exclusion: patients with heart failure due to valvular heart diseases, thyrotoxicosis, hypothyroidism, severe anaemia, amyloidosis, neoplasia, chronic non-cardiogenic pulmonary diseases, previous heart transplantation, chronic haemodialysis, or participation in drug protocols. | Clinical diagnosis based on the Framingham criteria. | 494 | Strengths: Standardised diagnostic criteria.Limitations: University Teaching Hospital in São Paulo dedicated to cardiology. Exclusion criteria may further hinder generalizability. Only patients with NYHA functional class III or IV, so may not be generalizable to those with milder symptoms. The exclusion of patients with valvular heart disease may impact on the assignment of aetiologies of heart failure. Unclear how loss to follow up and missing data were accounted for. |
Brazil |
Prospective | 2001 | 98 consecutive patients admitted to participating public hospitals and 105 consecutive patients admitted to participating private hospitals within the 3-mo study period in the city of Niteroi with a Boston criteria score of 8 or more. | Boston criteria score ≥8. | 203 | Strengths: Multiple hospitals within Niteroi, improving generalizability. Clear statistical methods reported. Just under half of patients were from the private sector, the remaining from the public sector, allowing direct comparison between these two groups and representation from a broader swathe of society.Limitations: The methods used to select the participating hospitals are unclear, as is the final number of sites included. |
Brazil |
Prospective | 2005–2006 | Consecutive patients admitted with heart failure and systolic dysfunction. | Clinical diagnosis with echocardiographic confirmation. | 263 | Limitations: Single urban centre that may not be representative of the patterns of care at the national level. Unclear how missing data and loss to follow-up were accounted for. Uncertain diagnostic criteria or proportion receiving echocardiography. Only patients with systolic dysfunction were included, possibly reducing the generalizability of results. |
Brazil |
Prospective | 2006–2008 | Consecutive patients ≥18 y referred to heart failure clinic with a Boston score of ≥7. Individuals were all classed as living in rural areas as per the Brazilian Institute of Geography and Statistics. | Boston criteria score ≥7.All patients underwent echocardiography. | 166 | Strengths: All patients had echocardiographic assessment. Standard diagnostic criteria.Limitations: Single centre study that may not be representative of the patterns of care at the national level. |
Brazil |
Prospective | Unknown (published 2008) | Patients consecutively admitted to the emergency department of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo over a period of 150 d with the diagnosis of decompensated heart failure. 100 out of the 212 patients initially assessed were retrospectively selected, for whom further details were collected. | Not specified. | 100 | Strengths: Although there were no standard diagnostic criteria for heart failure itself, there were standard criteria for assigning aetiologies of heart failure.Limitations: Single urban tertiary referral centre that may not be representative of the patterns of care at the national level. No standard diagnostic criteria used. Method of selection of the 100 patients for whom more detailed analysis was performed unclear. |
Brazil |
Prospective | 16 unspecified months (published 2012). | Tertiary centre in Salvador, Bahia, Brazil. Consecutive patients with a diagnosis of heart failure who had had echocardiography. | Echocardiography. | 383 | Strengths: All patients had echocardiographic assessment. Standard criteria for the assignment of aetiologies.Limitations: Single urban tertiary referral centre that may not be representative of the patterns of care at the national level. Only those patients who had already had echocardiography were included. Endemic zone for Chagas disease, which may hinder the generalizability of the study. |
Brazil |
Retrospective | 2008 | All patients with congestive heart failure treated at the outpatient clinic of Hospital das Clínicas of the Federal University of Goiás.Exclusion: those who died in 2008 (their medical records were incomplete) or who were not from the state of Goiás. | Not specified. | 144 | Strengths: Unbiased case selection.Limitations: Retrospective use of case notes without specified diagnostic criteria. Single urban centre that may not be representative of the patterns of care at the national level. Patients who died within the time frame of the study were excluded, limiting the study to patients with less severe forms of heart failure. |
Brazil |
Prospective | 1997 | 100 patients were randomly selected from the outpatient department of the Hospital das Clinicas, a tertiary referral centre in São Paulo. Patients were included if they were found on echocardiography to have a LVEF of <60%. | Echocardiography. | 100 | Strengths: All patients had echocardiography performed, aiding with the accuracy of diagnosis.Limitations: Single urban tertiary referral centre that may not be representative of the broader population. |
Brazil |
Retrospective | 1995 | Analysis of those patients admitted with heart failure to the Heart Institute of São Paulo using the PRODESP registry. | Not specified. | 903 | Strengths: Dataset of all patients admitted over the course of 1995 with heart failure to this hospital.Limitations: Specialist heart failure urban hospital, whose patients may not be generalizable. No formal standard for the diagnosis of heart failure is documented. |
Chile |
Prospective | 2002–2004 | 372 patients with NYHA class III or IV heart failure from 14 centres in Chile were included.Exclusion: principal reason for hospitalisation was not heart failure or new-onset heart failure or cardiogenic shock secondary to a myocardial infarction. | Clinical diagnosis using European Society of Cardiology diagnostic criteria. In cases of doubt response to treatment was used.52% underwent echocardiography. | 372 | Strengths: National Registry of Heart Failure of Chile, 14 centres. Clear diagnostic criteria.Limitations: Choice of participating centres not described. Exclusion of patients with heart failure after a myocardial infarction may lead to artificially low rates of IHD as the attributed cause of heart failure. |
Chile |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.78% had an echocardiogram. | 199 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. 78% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Colombia |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.72% had an echocardiogram. | 211 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. >70% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Mexico |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.75% had an echocardiogram. | 458 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. 75% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Previously unpublished data.
NYHA, New York Heart Association.
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
Egypt |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.73% had an echocardiogram. | 434 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. >90% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Iran |
Retrospective | 1998–2012 | All 277 patients with heart failure from a dataset of 83,895 hospitalised patients in Iran.Unpublished dataset. | Not specified. | 277 | Strengths: Multi-centre study.Limitations: Non-random selection of hospitals. Diagnostic criteria used unspecified. |
Iran |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.95% had an echocardiogram. | 105 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. >90% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Lebanon |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.83% had an echocardiogram. | 181 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. >80% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Pakistan |
Retrospective | 2002–2003 | First presentation to Agha Khan University Hospital in Karachi with the diagnosis of new-onset congestive heart failure that met the Boston criteria.Exclusion: LVEF≥40%, prior diagnosis of systolic heart failure dating back 3 mo, underlying disease with expected survival of less than 6 months, known primary valvular heart disease (rheumatic or nonrheumatic), patient died in-hospital, or no follow-up available after discharge. | Clinical diagnosis based on Boston criteria.All patients received echocardiography. | 196 | Strengths: All patients had echocardiographic assessment.Limitations: Single tertiary referral centre in Karachi may not be generalizable to the broader population. The exclusion of valvular heart disease may impact on the aetiologies ascribed to cases of heart failure. Similarly, the exclusion of those who died in hospital may affect the generalizability of the findings. |
Tunisia |
Prospective | 2008–2009 | All outpatients ≥21 y of age with new or previously diagnosed heart failure.Exclusion: patients with acute decompensated heart failure. | Framingham criteria.71% had an echocardiogram. | 257 | These data come from the I PREFER registry.Strengths: >10 centres. Sites were randomly selected, and all cardiologists within the country considered eligible. Missing data and loss to follow-up transparent. Prospective trial within a specified recruitment period. 71% had confirmation of heart failure through echocardiography.Limitations: Representative only of those attending outpatient cardiology services, excluding the acute sector or those patients in primary care with heart failure not under joint care of a cardiologist. |
Yemen |
Prospective | 2007–2008 | First 100 consecutive patients admitted to Ibn Seena Central Hospital, Mukalla, with heart failure. All patients were required to have blood tests, electrocardiogram, echocardiogram, and chest radiogram.Exclusion: all patients who for any reason dropped from follow-up before investigation was completed (died, transferred, discharged) | Framingham criteria.All patients underwent echocardiography. | 100 | Strengths: Clear diagnostic criteria for underlying aetiologies. All patients had echocardiographic assessment. Referral centre for a large catchment area.Limitations: Single urban tertiary referral centre may not be representative of the broader population of patients with heart failure. |
Previously unpublished data.
S. Rahimzadeh, F. Farzadfar F, and M. Ghaziani, unpublished data.
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
Romania |
Retrospective | 2006 | 459 consecutively admitted patients between January and December 2006 to the cardiology department with a discharge diagnosis of chronic heart failure. | Not specified. | 459 | Limitations: Single urban general hospital may not be representative of the broader population of patients with heart failure. Diagnostic criteria not clear. Data recorded from hospital files. Unclear how missing data were accounted for. |
Romania |
Prospective | 2008–2009 | All consecutive patients hospitalised with a primary diagnosis of acute heart failure syndromes.Exclusion: patients with high-output heart failure. | European Society of Cardiology guidelines.80% of patients had an echocardiogram. | 3,224 | Strengths: National registry involving 13 sites, increasing the generalizability of its results. A large majority of patients had echocardiographic assessment. Both tertiary academic centres and general hospitals were included, increasing generalizability.Limitations: Unclear how missing data were accounted for, although this issue is acknowledged in their limitations section. |
Serbia |
Cross-sectional | Unknown | Patients with chronic heart failure were recruited from an outpatient cardiology clinic at the Clinic for Cardiovascular Diseases, Clinical Center Niš.Exclusion: those who had had a worsening of symptoms or changes in treatment in the preceding 2 wk. | European Society of Cardiology and echocardiography. | 127 | Strengths: All patients underwent echocardiography. Standardised diagnostic criteria.Limitations: Single urban centre may not be representative of the broader population. Unclear method of case ascertainment. |
Turkey |
Retrospective | 1997–1998 | Medical records of consecutive patients admitted for congestive heart failure at 16 academic hospitals were selected for review: “The most recent, in average, 50 patients from each centre with sufficient data for CHF [congestive heart failure] in their files were included”. | American Heart Association guidelines.81% had an echocardiogram. | 661 | Strengths: 16 centres from across the country. A large majority of individuals had echocardiographic assessment.Limitations: Results from academic hospitals may not be generalizable to the broader health system. Method of case ascertainment may lead to selection bias. Unclear how missing data were accounted for. |
Turkey |
Prospective | 1999–2000 | A survey was conducted of a random sample of 117 primary care physicians from across Turkey who logged all patients they saw with heart failure. | Not specified. | 876 | Strengths: Real-world practice taken from a random sample of 117 primary care physicians from across Turkey.Limitations: Diagnosis of heart failure left to the clinicians. |
Turkey |
Prospective | 2005 | A sample of 4,650 randomly selected individuals had their height, weight, blood pressure measured as well as an ECG and blood taken for NT-proBNP level. Any of the sample with a cardiac history, abnormal ECG, or NT-proBNP ≥120 pg/ml was further investigated with echocardiography. | Echocardiography. | 320 | Strengths: Population-based random sample of individuals may provide generalizable information on prevalence of heart failure. |
ECG, electrocardiogram.
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
India |
Retrospective | 2008–2012 | Billing codes from hospital used to identify patients with heart failure in Andhra Pradesh. | Not specified. | 5,758 | Strengths: This study of billing data is from a large sample of over 1.5 million hospitalisations.Limitations: Billing data rely on clinical coding, and consequently there are no standardised diagnostic criteria available. |
Indonesia |
Prospective | 2006 | Consecutively hospitalised patients ≥18 y in five hospitals. Patients with heart failure primarily being treated as a co-morbid rather than primary condition.Exclusion: those without an accessible medical record, those without acute decompensated heart failure. | Not specified. | 1,687 | Indonesian arm of ADHERE-International.Strengths: Five hospitals, improving the potential generalizability of results. Missing data transparently accounted for. Echocardiographic assessment in 37.9% of patients.Limitations: Discharge data with lack of standardisation in the diagnosis of heart failure, which may lead to selection bias. |
Thailand |
Retrospective | 2006–2007 | Consecutively hospitalised patients age more than 18 y at 18 cardiovascular centres. Patients with heart failure primarily being treated as a co-morbid rather than primary condition.Exclusion: those without an accessible medical record, patients with cardiogenic shock, and perioperative heart failure. | Not specified. | 1,612 | Thai arm of ADHERE-International.Strengths: 18 cardiovascular centres from across the country, consequently greater generalizability of the results. 60.4% had echocardiographic assessment.Limitations: Discharge data with lack of standardisation in the diagnosis of heart failure, which may lead to selection bias. |
Previously unpublished data.
Country of Origin | Study Design | Recruitment Period | Selection Criteria | Heart Failure Definition | Cases of Heart Failure | Strengths and Limitations |
China |
Retrospective | 1980–2000 | Patients admitted with heart failure to participating hospitals. | Not specified. | 1,756 | Strengths: Multi-centre study may increase generalizability of results. Long study time period enabling analysis of trends across time.Limitations: Retrospective use of case notes, with consequent lack of standardised diagnostic criteria, may increase selection and reporting bias. |
China |
Retrospective | 1980–2008 | Patients admitted to the medical wards during the study period. | Not specified. | 2,458 | Strengths: Long time period of study allowed the analysis of medication prescription changes over time.Limitations: Urban single-centre study may not be generalizable to broader health service. Retrospective use of case notes without standardised diagnostic criteria for heart failure may increase reporting and selection bias. |
China |
Retrospective | 1995–2004 | Patients admitted with heart failure. | Not specified. | 259 | Limitations: Diagnostic criteria not standardised, leading to potential for reporting and selection bias. |
China |
Retrospective | 1995–2009 | Patients admitted with heart failure to three university hospitals. | American Heart Association 2005 guidelines. | 1,119 | Strengths: Multi-centre cohort study.Limitations: Academic centres may not reflect the broader health service. |
China |
Retrospective | 2007 | Patients admitted with heart failure. | Framingham criteria. | 478 | Limitations: Rural single-centre study that may not be generalizable to the broader health service. Retrospective analysis of case notes open to reporting bias. |
China |
Retrospective | 2008–2009 | Patients admitted with heart failure. | European Society of Cardiology 2005 guidelines | 206 | Limitations: Urban single-centre study that may not be generalizable to the broader health service. |
China |
Prospective | Unknown (published 2012) | Individuals admitted to the People's Liberation Army General Hospital, Beijing, over the age of 60 y with a diagnosis of chronic heart failure.Exclusion: those with severe aortic stenosis, anticipated cardiac transplantation, or a left ventricular assist device. | European Society of Cardiology 2008 guidelines. | 327 | Limitations: Single-centre army general hospital in the capital with a high proportion of male patients (78% of this cohort) may not be broadly generalizable. |
China |
Prospective | Unknown (published 2009) | Cluster randomised sample of adults in primary care facilities with congestive heart failure in six counties of Liaoning Province. | Framingham criteria. | 529 | Strengths: Cluster randomisation of primary care facilities, reducing potential for bias. Representation from six counties of Liaoning Province may improve regional generalizability of the results.Limitations: Uncertain diagnostic criteria and patient pool. |
Malaysia |
Retrospective | 2007–2008 | Consecutive individuals with a principal discharge diagnosis of heart failure, using the relevant International Classification of Disease-9 codes. Patients with heart failure primarily being treated as a co-morbid rather than primary condition.Exclusion: patients <18 y, those without an accessible medical record, those without acute decompensated heart failure. | Not specified. | 907 | Malaysian arm of ADHERE-International.Strengths: Multi-centre trial, improving the potential generalizability of results. All questions on the electronic case report were required to be completed, eliminating reporting bias due to missing data.Limitations: Discharge data with lack of standardisation in the diagnosis of heart failure, which may lead to selection bias. |
Philippines |
Retrospective | 2006–2007 | All consecutive individuals admitted with an International Classification of Disease-9 code for heart failure. Patients with heart failure primarily being treated as a co-morbid rather than primary condition.Exclusion: Patients <18 y, those without an accessible medical record, and those without acute decompensated heart failure. | Not specified. | 261 | Philippines arm of ADHERE-International.Strengths: Multi-centre trial, improving the potential generalizability of results. All questions on the electronic case report were required to be completed, eliminating reporting bias due to missing data.Limitations: Discharge data with lack of standardisation in the diagnosis of heart failure, which may lead to selection bias. |
Previously unpublished data.
Study-specific data on percentages are presented as forest plots with exact binomial 95% confidence intervals (CIs). These percentages were pooled, by World Health Organization region (
Africa | Americas | Eastern Mediterranean | Europe | South East Asia | Western Pacific |
Algeria | Argentina | Egypt | Romania | India | China |
Cameroon | Brazil | Iran | Turkey | Indonesia | Malaysia |
DRC | Chile | Lebanon | Serbia | Thailand | Philippines |
Ethiopia | Colombia | Pakistan | |||
Ghana | Mexico | Tunisia | |||
Kenya | Yemen | ||||
Mozambique | |||||
Nigeria | |||||
Senegal | |||||
South Africa | |||||
Uganda |
DRC, Democratic Republic of the Congo.
Patients presenting acutely to hospitals may differ in many respects from those that are seen in clinics for chronic management. When pooling the data we therefore indicate the setting of each study in all forest plots. Studies from community primary care or outpatient clinics were designated as non-acute, and studies from inpatient populations, acute. Studies reporting both inpatient and outpatient data were included in the non-acute category. Additional subgroup analyses were performed by level of country income and by study time period. For income level analyses, studies were divided into low-income, low-middle-income, and upper-middle-income groups according to World Bank
Statistical analyses were done using R version 3.0.2 and Stata version 11.2.
Overall, 49 published studies
Most studies were based in a single hospital, although 21 datasets documented multi-centre studies in Algeria
The studies together included 237,908 episodes of heart failure hospitalisation. The median number of cases across all studies was 386 (range: 100–194,098). Diagnosis of heart failure was established according to the Framingham criteria
Characteristic | Region | ||||||
Africa | Americas | Eastern Mediterranean | Europe | South East Asia | Western Pacific | All | |
Mean age (range), in years |
52 (42–64) | 70 (53–77) | 63 (57–69) | 67 (61–73) | 54 (50–64) | 67 (53–74) | 63 (42–77) |
Number of studies | 14 | 14 | 4 | 5 | 3 | 7 | 45 |
Percent male (95% CI) | 51% (43%–59%) | 58% (54%–63%) | 65% (61%–70%) | 61% (48%–73%) | 60% (51%–70%) | 58% (50%–65%) | 58% (54%–62%) |
99% (98%–99%), |
98% (98%–99%), |
61% (6%–84%), |
99% (98%–99%), |
99% (98%–99%), |
98% (97%–99%), |
100% (100%–100%), |
|
Number of studies | 13 | 16 | 3 | 6 | 3 | 9 | 48 |
Mean (range) LVEF, in percent |
42% (29%–49%) | 41% (27%–43%) | 50% (34%–55%) | 38% (38%–40%) | 33% (—) | 42% (38%–57%) | 40% (27%–57%) |
Number of studies | 6 | 7 | 1 | 3 | 1 | 2 | 17 |
Mean (range) number of days |
11 (9–13) | 10 (5–25) | 5 (—) | — | 3 (—) | 23 (13–35) | 10 (5–35) |
Number of studies | 3 | 6 | 1 | — | 1 | 3 | 14 |
*Weighted by study size.
The demographic characteristics of patients and outcomes by region are shown in
Region and Country | Recruitment Period | Heart Failure Cases | Mean Age (Years) | Male (Percent) | Mean Length of Stay (Days) | Mean LVEF (Percent) |
Algeria |
2008–2009 | 400 | 64 | 60% | — | 49% |
Cameroon |
1998–2001 | 167 | 57 | 59% | — | 23% |
Cameroon |
2002–2008 | 462 | 43 | 57% | 13 | |
Democratic Republic of the Congo |
2003–2004 | 100 | 57 | 48% | — | |
Ghana |
1992–1995 | 572 | 42 | 55% | — | |
Nigeria |
2006–2008 | 340 | 51 | 51% | — | 42% |
Nigeria |
2006–2010 | 475 | 49 | 50% | — | |
Nigeria |
2004 | 102 | 45 | 31% | — | |
Nigeria |
Unspecified | 177 | 52 | 51% | — | 45% |
Nigeria |
2001–2005 | 423 | 54 | 57% | — | |
Nigeria |
1995–2005 | 202 | 56 | 54% | — | |
Senegal |
2001 | 170 | 50 | — | 11 | |
South Africa |
2006 | 844 | 55 | 43% | — | 45% |
Sub-Saharan Africa |
2007–2010 | 1,006 | 52 | 49% | 9 | 40% |
Argentina |
1996–1997 | 751 | 66 | 41% | — | |
Argentina |
2002–2003 | 615 | 70 | 55% | — | |
Argentina |
2007 | 736 | — | 59% | — | |
Argentina |
1992–1999 | 6,368 | 77 | 65% |
5 | |
Brazil |
2006–2008 | 166 | 61 | 51% | — | 49% |
Brazil |
2001 | 203 | 67 | 50% | 8 |
|
Brazil |
1998–2000 | 494 | 58 | 70% | — | 34% |
Brazil |
1992–2010 | 194,098 | — | 51% | 10 | |
Brazil |
Unspecified | 100 | 59 | 56% | 9 | 46% |
Brazil |
2005–2006 | 263 | 60 | 63% | 25 | 27% |
Brazil |
Unspecified | 383 | 54 | 53% | — | |
Brazil |
1997 | 100 | 57 | 76% | — | 43% |
Brazil |
2008 | 144 | 61 | 54% | — | |
Brazil |
1995 | 903 | 53 | 60% | — | |
Chile |
2002–2004 | 372 | 69 | 59% | 11 | 35% |
Chile |
2008–2009 | 199 | 65 | 55% | — | 42% |
Colombia |
2008–2009 | 211 | 70 | 86% | — | 46% |
Mexico |
2008–2009 | 458 | 68 | 43% | — | 54% |
Egypt |
2008–2009 | 434 | 58 | 66% | — | 55% |
Iran |
1998–2012 | 277 | 67 | — | 5 | |
Iran |
2008–2009 | 105 | 57 | 77% | — | 34% |
Lebanon |
2008–2009 | 181 | 69 | 61% | — | 43% |
Pakistan |
2002–2003 | 196 | 61 | 65% | — | |
Tunisia |
2008–2009 | 257 | 67 | 51% | — | 53% |
Yemen |
2007–2008 | 100 | 58 | 65% | — | |
Romania |
2008–2009 | 3,224 | 69 | 56% | — | 38% |
Romania |
2006 | 459 | 61 | 86% | — | |
Serbia |
Unspecified | 127 | 71 | 73% | — | 40% |
Turkey |
1997–1998 | 661 | 61 | 64% | — | 38% |
Turkey |
2005 | 320 | — | 40% | — | |
Turkey |
1998–2000 | 876 | 64 | 48% | — | |
India |
2008–2012 | 5,758 | 50 | 66% | 3 | |
Indonesia |
2006 | 1,687 | 60 | 65% | — | 33% |
Thailand |
2006–2007 | 1,612 | 64 | 50% | — | |
China |
1995–2009 | 1,119 | 65 | 71% | — | 38% |
China |
2008–2009 | 206 | 74 | 56% | — | |
China |
2007 | 478 | 69 | 47% | — | |
China |
1995–2004 | 259 | 70 | 63% | 29 | |
China |
1980–2000 | 1,756 | 68 | 56% | 35 | |
China |
1980–2008 | 2,458 | 71 | 52% | 13 | |
China |
Unspecified | 327 | — | 78% | — | 57% |
China |
2008 | 529 | — | 30% | — | |
Malaysia |
2007–2008 | 907 | 61 | 69% | — | |
Philippines |
2006–2007 | 725 | 53 | 55% | — |
Previously unpublished dataset.
*Contributed by author.
S. Rahimzadeh, F. Farzadfar F, and M. Ghaziani, unpublished data.
Although most studies made a clear distinction between aetiologies and co-morbidities, the categories reported were highly variable, and multiple causes were often attributed to individual cases of heart failure. Across all LMICs, non-communicable diseases, and in particular ischaemic heart disease (IHD) and hypertension, are the leading causes of heart failure (
Percentage of heart failure cases with a documented cause of IHD.
Percentage of heart failure cases with a documented cause of hypertension.
Percentage of heart failure cases with a documented cause of cardiomyopathy.
Percentage of heart failure cases with a documented cause of valvular heart disease.
Cause | Region | ||||||
Africa | Americas | Eastern Mediterranean | Europe | South East Asia | Western Pacific | All | |
Percent (95% CI) | 46% (36%–55%) | 31% (19%–43%) | 52% (35%–69%) | 30% (12%–48%) | 12% (10%–14%) | 21% (11%–30%) | 37% (30%–43%) |
98% (98%–99%), |
99% (99%–99%), |
97% (95%–98%), |
99% (98%–99%), |
— | 98% (97%–99%), |
99% (99%–99%), |
|
Number of studies | 13 | 12 | 2 | 3 | 1 | 4 | 33 |
Percent (95% CI) | 8% (5%–11%) | 33% (27%–38%) | 59% (46%–71%) | 61% (58%–64%) | 45% (43%–48%) | 54% (37%–71%) | 35% (28%–42%) |
98% (97%–98%), |
96% (94%–97%), |
94% (89%–97%), |
59% (0%–86%), |
— | 99% (99%–100%), |
100% (100%–100%), |
|
Number of studies | 11 | 14 | 2 | 4 | 1 | 5 | 35 |
Percent (95% CI) | 18% (13%–23%) | 15% (11%–20%) | 22% (14%–30%) | 25% (4%–46%) | 19% (17%–21%) | 21% (8%–34%) | 18% (15%–22%) |
96% (95%–97%), |
95% (92%–96%), |
89% (78%–95%), |
99% (—), |
— | 99% (98%–99%), |
98% (97%–98%), |
|
Number of studies | 13 | 9 | 2 | 2 | 1 | 4 | 29 |
Percent (95% CI) | 24% (19%–29%) | 30% (21%–39%) | 27% (12%–42%) | 7% (3%–12%) | 14% (12%–16%) | 14% (4%–24%) | 24% (20%–29%) |
94% (91%–96%), |
98% (97%–99%), |
97% (95%–98%), |
— | — | 99% (99%–100%), |
99% (98%–99%), |
|
Number of studies | 12 | 7 | 2 | 1 | 1 | 4 | 26 |
Amongst all studies, the management of heart failure varies considerably between regions and within regions, as well as between studies from the same country (
Loop and/or thiazide diuretics. ∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Management | Region | ||||||
Africa | Americas | Eastern Mediterranean | Europe | South East Asia | Western Pacific | All | |
Percent (95% CI) | 70% (62%–79%) | 60% (51%–69%) | 48% (27%–69%) | 64% (53%–76%) | 31% (21%–40%) | 47% (19%–74%) | 57% (49%–64%) |
96% (94%–98%), |
98% (98%–99%), |
99% (99%–99%), |
99% (99%–99%), |
97% (—), |
100% (100%–100%), |
100% (100%–100%), |
|
Number of studies | 6 | 9 | 3 | 5 | 1 | 7 | 29 |
Percent (95% CI) | 25% (13%–37%) | 38% (26%–51%) | 49% (27%–71%) | 29% (9%–49%) | 26% (24%–27%) | 27% (9%–44%) | 34% (28%–41%) |
99% (98%–99%), |
99% (99%–99%), |
99% (99%–99%), |
100% (100%–100%), |
0% (—), |
100% (100%–100%), |
100% (99%–100%), |
|
Number of studies | 7 | 8 | 3 | 4 | 1 | 5 | 26 |
Percent (95% CI) | 73% (48%–99%) | 71% (62%–80%) | 71% (49%–94%) | 71% (58%–85%) | 65% (50%–80%) | 57% (30%–85%) | 69% (60%–78%) |
100% (100%–100%), |
99% (99%–99%), |
99% (99%–100%), |
100% (99%–100%), |
99% (—), |
100% (100%–100%), |
100% (100%–100%), |
|
Number of studies | 6 | 9 | 2 | 5 | 1 | 6 | 27 |
Percent (95% CI) | 46% (30%–63%) | 32% (24%–40%) | 26% (13%–39%) | 41% (25%–58%) | 15% (10%–19%) | 17% (7%–26%) | 32% (25%–39%) |
98% (97%–99%), |
96% (94%–97%), |
97% (95%–98%), |
100% (100%–100%), |
92% (—), |
99% (99%–99%), |
100% (100%–100%), |
|
Number of studies | 5 | 5 | 2 | 5 | 1 | 4 | 20 |
Across LMICs, patients admitted with heart failure remained in hospital for a mean of 10 d (
In-hospital mortality was 8% (95% CI: 6%–10%,
∧Rahimzadeh S, Farzadfar F, Ghaziani M (2013) Iranian hospital data project (unpublished data).
Data relating to heart failure as a proportion of total hospital admissions were available for five countries. Across these countries, heart failure accounted for 2.2% (range: 0.3%–7.7%) of total admissions. Brazil was the only LMIC with nationwide registry data compiled for all patients with heart failure treated by its public health system
In sub-Saharan Africa, the total number of cardiovascular admissions was reported, rather than total hospital admissions. In Nigeria, heart failure accounted for 31% of cardiovascular cases presenting to hospital
Population-level data regarding the prevalence of heart failure were available in only one study, from Turkey
Meta-regression was performed to investigate the potential effect of the time period in which each study was undertaken on between-study heterogeneity in the causes, management, and outcomes of heart failure.
A statistically significant effect was observed between the study time period and hypertension as a cause of heart failure, which rose by 2.5% per year (95% CI: 1.4%–3.6%,
The reported utilization rates for medical treatments of heart failure did not differ significantly over time, with the exception of beta-blockers, which showed an increase of 2.8% per year (95% CI: 1.5%–4.1%,
There was also some evidence to suggest in-hospital mortality rate declined by 0.28% per year between 1990 and 2010 (95% CI: −0.54% to −0.012%,
Our study presents, to our knowledge, the most comprehensive review to date and the first pooled analysis of the burden of heart failure in LMICs worldwide, collating data on over 230,000 episodes from 31 countries, with representation from all world regions. We found that heart failure is already a major burden to populations and health services in LMICs, where it makes up an average of 2.2% of hospital admissions, affecting more men than women. Reflecting the broad range of countries included and their differing levels of socio-economic development, there are wide variations in patient characteristics and the causes of heart failure and its management. Nonetheless, noticeable similarities can be discerned both between the included LMICs themselves and between these LMICs and HICs.
Across all LMICs from which data were available, the mean age of patients was 63 y, which is over a decade younger than in studies from HICs
Substantial inter-regional variation is present in the causes ascribed to individual cases of heart failure. Heart failure is a syndrome made up of a constellation of signs and symptoms, with additional features present on further investigation. Given that a number of its aetiological underpinnings are often potential co-morbidities, disentangling one from the other is fraught with challenges, particularly in low-resource environments without recourse to a broad range of investigative tools
Current guidelines worldwide stress the importance of ACEIs, beta-blockers, and mineralocorticoid receptor antagonists in the management of heart failure with reduced LVEF, with loop/thiazide diuretics given for symptom relief. Across the 29 studies from which management data were available, few studies reported the LVEF of patients, and fewer still separated data by LVEF. Overall mean LVEF was 40%: 38% amongst inpatients and 48% amongst those in non-acute settings. Consequently, it is not possible to make strong conclusions about the adherence of practice to evidence-based practices worldwide, but it is evident that management diverges considerably between regions and remains suboptimal on average. Data from the EuroHeart Failure Survey II of 30 high-income European countries also demonstrated poor medical management
Across represented LMICs, patients admitted with heart failure had a poorer immediate prognosis than those in many HICs. However, as is the case for HICs, the estimates from LMICs varied substantially, although we found the difference between the two outlying regions in terms of prognosis, the Americas and South East Asia, was not statistically significant (
Remarkable regional variation exists in the incidence of heart failure admissions to hospital. Of particular note is the low rate of reported admissions for heart failure in India and Iran. Unpublished data from India, based on the hospital billing codes assigned to patients from a sample of just under 1,551,410 admissions, showed an incidence of 0.37%
This review collates data over a time period of almost 20 y, which may be one explanation for the degree of heterogeneity in results between studies. However, when study period was analysed using meta-regression against the causes, management, and outcomes of heart failure, only three statistically significant effects were found. These included a rising percentage of patients in whom hypertension was reported as a contributing cause of heart failure, an increasing trend in the reported prescription of beta-blockers over time, and a substantial decline in in-hospital death rates (see
The data included are derived from a heterogeneous group of studies that set out with differing research goals. Variation in the methodologies used, particularly in methods of standardising the diagnosis and assessment of heart failure, may impact on some of the findings. These factors likely explain the high estimates of between-study variation that we found. Such variation may lead to underestimation of the true prevalence of heart failure, as well as inaccuracies in the causes ascribed to cases of heart failure. Our study includes individuals from three groups: those with their first presentation with acute heart failure, those with acute decompensation of chronic heart failure, and those with stable chronic heart failure seen in the outpatient clinic setting. Differences between healthcare systems may mean that the characteristics of patients seen in various settings may differ between countries, whilst adherence to gold-standard management may be more common amongst those with stable chronic heart failure seen in outpatient settings staffed by cardiologists than amongst those with acute heart failure treated in hospitals staffed by general internal physicians. In analysing these patients we have focussed on the evidence-based medical management methods common to all three groups. Combining data from 1995 to 2014, this study summarises management techniques over an almost 20-y period, an approach that may underestimate adherence to current management standards. However, when evaluated with meta-regression, the heterogeneity in a management variable was rarely found to be explained by changes over time. Another limitation of our study is that our data are derived from studies conducted for the most part in urban tertiary referral centres, which may not reflect the broader picture of heart failure in other hospitals and the community. Finally, despite the large number of studies included, information from some regions and for some outcomes was limited. In countries where few data are available, these results may not be truly reflective of the population and should therefore be interpreted as only a guide to the true prevalence, causes, and management of heart failure.
This review shows that heart failure places a considerable burden on health systems in LMICs, and affects a wide demographic profile of patients in these countries. Non-communicable diseases dominate the causes of heart failure across LMICs, although infectious valvular diseases and cardiomyopathies continue to impose a significant burden. Together, this suggests a double burden of communicable and non-communicable diseases for countries in the midst of epidemiological transition. In addition, we have identified high in-hospital mortality and wide variation and significant suboptimal use of pharmacological therapies. Further population-level studies, with clear case and outcome definitions, are needed for a more accurate assessment of heart failure in LMICs.
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(DOC)
angiotensin-converting enzyme inhibitor
Acute Decompensated Heart Failure Registry
confidence interval
human development index
high-income countries
ischaemic heart disease
Identification of Patients with Heart Failure and Preserved Systolic Function
low- and middle-income countries
left ventricular ejection fraction