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Published on: June 10, 2025
Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure
Hisham Dokainish1, Koon Teo1, Jun Zhu2
1Population Health Research Institute, McMaster University, Hamilton, Canada.
Insights
Heart failure mortality varies significantly by region, with Africa and India showing the highest rates. Factors like cardiac and non-cardiac conditions influence survival, but regional disparities persist, suggesting other influences on patient outcomes.
Area of Science:
- Cardiology
- Global Health
- Epidemiology
Background:
- Limited data exists on heart failure mortality and prognostic factors outside North America and Europe.
- The International Congestive Heart Failure (INTER-CHF) study addresses this gap by examining patients across Africa, Asia, the Middle East, and South America.
Purpose of the Study:
- To measure 1-year mortality in heart failure patients across diverse global regions.
- To identify demographic, clinical, and socioeconomic variables associated with heart failure mortality.
Main Methods:
- Enrolled 5823 heart failure patients from 108 centers in six geographical regions.
- Collected baseline data and conducted 6-month and 1-year follow-ups to record outcomes.
- Utilized Cox proportional hazards models to analyze time-to-death, adjusting for multiple variables.
Main Results:
- Overall 1-year mortality was 16.5%, with significantly higher rates in Africa (34%) and India (23%).
- Regional mortality differences remained significant even after multivariable adjustment.
- Key predictors of mortality included advanced New York Heart Association Functional Class, prior heart failure admissions, valve disease, low body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease.
Conclusions:
- Substantial regional variations in heart failure mortality persist globally, even after accounting for known cardiac and non-cardiac factors.
- These disparities may be attributed to differences in healthcare infrastructure, quality, access, or environmental and genetic factors.
- Further research in large, international cohorts is essential to understand and address these global health inequities.
Background:
Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, we aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America; we also explored demographic, clinical, and socioeconomic variables associated with mortality.
Methods:
We enrolled consecutive patients with heart failure (3695 [66%] clinic outpatients, 2105 [34%] hospital in patients) from 108 centres in six geographical regions. We recorded baseline demographic and clinical characteristics and followed up patients at 6 months and 1 year from enrolment to record symptoms, medications, and outcomes. Time to death was studied with Cox proportional hazards models adjusted for demographic and clinical variables, medications, socioeconomic variables, and region. We used the explained risk statistic to calculate the relative contribution of each level of adjustment to the risk of death.
Findings:
We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables (New York Heart Association Functional Class III or IV, previous admission for heart failure, and valve disease) and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained.
Interpretation:
Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are needed.
Funding:
The study was supported by Novartis.
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