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Global Variations in Heart Failure Etiology, Management, and Outcomes

In a study of heart failure (HF) in 40 countries with varying income levels, hospitalization rates were higher and mortality rates lower in patients from more prosperous countries, researchers report. “Mortality rates were more than 2-fold higher in lower–middle-income and low-income countries compared with high-income countries,” the authors write. “In low-income countries, deaths were more frequent than hospitalizations, and the short-term risk of death associated with a hospitalization was 3- to 5-fold higher in lower–middle-income and low-income countries compared with high-income countries.”

A total of 23,341 participants in 40 high-income, upper–middle-income, lower–middle-income, and low-income countries were identified in the Global Congestive Heart Failure (G-CHF) registry and followed up for a median of 2.0 years. Based on the main outcome measures of HF cause, HF medication use, hospitalization, and death, the investigators found: “Mean (SD) age of participants was 63.1 (14.9) years, and 9,119 (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.”

Audio interview of an author available.

Source: JAMA