HF Care, Outcomes Disparities Persist by Country Income Level


Causes of heart failure (HF), medication usage, and HF-related hospitalization and death were investigated among patients from 40 countries and 4 economic levels.

Global efforts to improve heart failure (HF) prevention and treatment may benefit from new study data showing discrepancies in HF etiologies, management, and outcomes from an analysis conducted among patients from 40 countries and 4 economic levels.

Findings were published online today in JAMA.

Causes of HF, medication usage, and HF-related hospitalization and death were the main outcomes of this analysis of 23,341 patients from the Global Congestive Heart Failure registry followed for a median (IQR) 2 (2.0-3.2) years and enrolled between 2016 and 2020. They were from high-income (n = 17), upper–middle-income (n = 10), lower–middle-income (n = 9), and low-income (n = 4) countries, their mean (SD) age was 63.1 (14.9) years, and 60.9% were male patients. Baseline data were collected on demographics, clinical characteristics and health behaviors, New York Heart Association (NYHA) functional class, and use of HF therapies.

“Most epidemiological studies of HF have been conducted in high-income countries with limited comparable data from middle- or low-income countries,” the study investigators noted. “To better inform how HF management can be improved globally, additional data are needed to understand how the condition, its treatment, and its clinical course differ between countries at different levels of socioeconomic development.”

Ischemic heart disease was the most common cause of HF (38.1%), followed by hypertension (20.2%) and idiopathic dilated cardiomyopathy (15.4%). In addition, 4.9% of cases were due to rheumatic valve disease; 4.1%, nonrheumatic valve disease; and 17.2%, other etiologies.

There were 82.6% who had ejection fraction documented in the year before study enrollment, and among this group, 60.5% had a left ventricular ejection fraction (LVEF) below 40% (HF with reduced ejection fraction [HFrEF]); 15.5%, LVEF between 41% and 49%; and 24.4%, LVEF of 50% or higher. Sixty percent of all participants had NYHA functional class I/II disease at enrollment.

Compared with participants in high-income or upper–middle-income countries, the following results were seen in low-income countries:

  • Higher enrollment as inpatients
  • Shorter HF duration prior to enrollment
  • Enrolled with more advanced HF symptoms based on NYHA functional class
  • Lower rates of hypertension, diabetes, and chronic obstructive pulmonary disease
  • Hypertension as the most common cause of HF
  • Highest proportion of HF due to valve disease stemming from a higher proportion of rheumatic heart disease

Among the participants with HFrEF, the top 3 medications were β-blockers (84.5%), renin-angiotensin system (RAS) inhibitors (80.1%), and mineralocorticoid receptor antagonist (65.2%). RAS inhibitors were most common in low-income countries and β-blockers were most common in high-income, upper–middle-income, and lower–middle-income countries. Close to half of all study patients took all 3 (49.3%), but use in this manner was highest in upper–middle-income countries (61.9%) and lowest in lower–middle-income countries (39.5%) (P < .001). The highest proportion of implantable cardioverter-defibrillator use was in high-income countries and the lowest was in low-income countries: 30.3% vs 0.3% (P < .001).

The smallest proportion of deaths from any cardiovascular causes was in high-income (58.7%) vs lower–middle-income and low-income countries (84.3% each), and the age- and sex-standardized death rate was also lowest in high-income countries (7.8 per 100 person-years), increasing as income level decreased. Risk of death remained significantly different, at 48% and 110% higher, respectively, in lower–middle-income (HR, 1.48; 95% CI, 1.37-1.60) and low-income (HR, 2.10; 95% CI, 1.90-2.33) countries vs high-income countries.

High-income countries had the highest rate of first hospitalization during the study follow-up, and this decreased with decreasing country income level. Per 100 person-years, these rates were 29.9, 22.6, 17.3, and 11.7 in high-income, upper–middle-income, lower–middle-income, and low-income countries, respectively. Corresponding trends for first HF hospitalization were 8.0, 10.6, 10.0, and 6.0.

When hospitalization-to-death ratio was investigated, the rate for a first hospitalization was higher than that for death in high-income countries, at 3.8, and decreased with each lower income level: 2.4 in upper–middle-income countries and 1.1 in lower–middle-income countries. Only in low-income countries did the death rate exceed the hospitalization rate, at 0.6. Further, high-income countries also had the lowest unadjusted 30-day case fatality after first hospital admission, as 6.7%, and this increased with decreasing country income level: 9.7%, 21.1%, and 31.6% in upper–middle-income, lower–middle-income, and low-income countries, respectively.

After adjusting for patient characteristics and use of chronic HF treatments, 30-day risk of death after first hospitalization was highest in low-income countries (HR, 5.33; 95% CI, 4.20-6.77). By contrast, the rate was lowest in high-income countries (HR, 1.50; 95% CI, 1.24-1.82).

“Our observation that the etiology of HF varies between countries at different income levels has important implications for the prevention and management of HF,” the study authors wrote. “As the burden of HF is expected to rise in many middle-income and low-income countries, it is important to highlight that a large proportion of cases could potentially be avoided by greater use of relatively low-cost medications for the management of hypertension and ischemic heart disease.”

In addition, they highlight that their findings echo previous research showing lower–middle-income and low-income countries had higher rates of inpatient admissions linked to more advanced HF and less use of guideline-directed therapy.

“Since the clinical course of HF is characterized by acute episodes of decompensation where the risk of death abruptly increases, hospitalizations are an important opportunity to modify a patient’s risk through acute interventions that potentially prevent death,” the authors concluded. “

Overall, they believe their new data could help facilitate global improvement of HF prevention and treatment approaches.


Joseph P, Roy A, Lonn E, et al. Global variations in heart failure etiology, management, and outcomes. JAMA. 2023;329(19):1650-1661. doi:10.1001/jama.2023.5942

Related Videos
Dr Seun Ross: Achieving Equity is Necessary to Sustain the Health Care System
UPMC Health Plan Neighborhood Center
Susan Spratt, MD, senior medical director, Duke Population Health Management Office, associate professor of medicine, division of Endocrinology, Metabolism, and Nutrition,
Dr Monica Taylor-Desir on Taking Mental Health Care Awareness to Action
Dr Veronica Gillispie-Bell Explains the Impact of Implicit Bias on Maternity Care
Zachary Cox, PharmD
Dr Veronica Gillispie-Bell: We Cannot have Quality Without Equity
Dr Stephen Kingsmore Describes the Participants of the BeginNGS Consortium
Dr Margaret Ragni Sheds Light on the Necessity of Testing Hemophilia Carriers
Related Content
© 2023 MJH Life Sciences
All rights reserved.