Global Disparities in Heart Failure: Incidence and Mortality Across Income Levels and Regions
Highlights
The PURE study provides the first comprehensive comparison of heart failure (HF) incidence and mortality across 25 countries, revealing stark disparities by income level and geographic region. Key findings include:
- Highest HF incidence in upper middle-income countries (UMICs) and sub-Saharan Africa.
- 30-day case fatality rates were 59% in low-income countries (LICs) vs. 11% in high-income countries (HICs).
- Hypertension accounted for 25% of the population attributable fraction (PAF) for HF globally.
Background
Heart failure is a leading cause of morbidity and mortality worldwide, yet most epidemiological data originate from HICs. The Prospective Urban Rural Epidemiology (PURE) study addresses this gap by examining HF incidence and outcomes across diverse economic and geographic settings.
Study Design
The PURE study enrolled 172,653 community-dwelling participants from 25 countries across 8 global regions, categorized by income level (HICs, UMICs, lower middle-income countries [LMICs], and LICs). Participants were followed for a median of 15 years. Primary outcomes included age- and sex-standardized HF incidence rates and 30-day, 1-year, and 5-year case fatality. The study also estimated PAFs for 13 modifiable risk factors.
Key Findings
Incidence Rates
HF incidence varied significantly by income level:
- UMICs: 0.58 per 1,000 person-years (95% CI: 0.52-0.64)
- HICs: 0.36 (95% CI: 0.30-0.43)
- LMICs: 0.34 (95% CI: 0.30-0.38)
- LICs: 0.26 (95% CI: 0.22-0.30)
Regionally, sub-Saharan Africa (1.18) and Europe/Central Asia (0.86) had the highest rates, while South Asia (0.19) had the lowest.
Case Fatality
Mortality disparities were profound:
- 30-day fatality: 59% in LICs vs. 11% in HICs
- 5-year fatality: 77% in LICs vs. 28% in HICs
South Asia and sub-Saharan Africa had the highest fatality rates, while North America had the lowest.
Risk Factors
Modifiable risk factors accounted for 71% of HF PAF, led by hypertension (25%), followed by household air pollution (12%), and low education (9%).
Expert Commentary
The study underscores the critical role of socioeconomic and environmental factors in HF disparities. Dr. Salim Yusuf, senior author, notes: “These findings call for equitable access to guideline-directed therapies and targeted prevention strategies, particularly in resource-limited settings.” Limitations include potential underdiagnosis in LICs and variability in HF definitions across regions.
Conclusion
The PURE study reveals alarming global inequities in HF burden, with preventable risk factors like hypertension driving most cases. Prioritizing early detection, affordable treatments, and risk factor control could mitigate these disparities.
Funding and Registration
The PURE study was funded by the Population Health Research Institute and other public and philanthropic organizations. ClinicalTrials.gov Identifier: NCT03225586.
References
- Johansson Bartolini I, et al. J Am Coll Cardiol. 2026;77(14):1789-1804.
- Yusuf S, et al. Lancet. 2020;396(10244):75-88.
- McMurray JJV, et al. Eur Heart J. 2021;42(36):3599-3726.
