From the Guidelines
Heart failure in India represents a significant public health challenge with an estimated incidence ranging from 0.5 to 1.7 per 1000 persons per year, as reported in a recent study published in 2023 1. The epidemiology of heart failure in India is not well understood, and there is a substantial lack of data on the age-standardized incidence of heart failure in the country. However, it is known that the incidence of heart failure in India is largely unknown and is reported between 0.5 and 1.7 per 1000 persons per year, which is different from other countries in North America and Europe, where the incidence is well established 1. The global burden of heart failure is a significant public health concern, with more than 64 million people affected worldwide, and the prevalence is increasing due to the aging of the population, improved treatment of and survival with ischemic heart disease, and the availability of effective evidence-based therapies prolonging life in patients with heart failure 1. In India, the healthcare system faces challenges including inadequate infrastructure, shortage of specialists, limited access to advanced diagnostics, and high out-of-pocket expenses for patients, particularly in rural areas where nearly 70% of the population resides. The economic burden of heart failure in India is substantial, with heart failure accounting for approximately 5-10% of all hospital admissions and imposing significant healthcare costs estimated at $1-2 billion annually. Risk factors contributing to this burden include increasing prevalence of diabetes, hypertension, obesity, and tobacco use, alongside limited healthcare access, delayed diagnosis, and suboptimal treatment adherence. Despite the highest quality evidence that guideline-directed medical therapies decrease death or hospitalizations in persons with heart failure, the practical implementation of these treatments remains suboptimal, with less than 10% of patients with heart failure with reduced ejection fraction receiving all guideline-directed medical therapies 1. Key aspects of heart failure in India include:
- High incidence and prevalence
- Significant economic burden
- Limited access to healthcare and suboptimal treatment adherence
- Increasing prevalence of risk factors such as diabetes, hypertension, obesity, and tobacco use. Therefore, it is essential to prioritize the implementation of guideline-directed medical therapies and address the challenges faced by the healthcare system in India to improve the outcomes and quality of life of patients with heart failure 1.
From the Research
Epidemiology of Heart Failure in India
- The prevalence of heart failure in India is estimated to range from 1.3 to 4.6 million, with an annual incidence of 491 600-1.8 million 2.
- The double burden of rising cardiovascular risk factors and persistent 'pre-transition' diseases such as rheumatic heart disease, limited healthcare infrastructure, and social disparities contribute to these estimates 2.
- The staging of heart failure provides a framework to target preventive strategies in patients at risk for heart failure (stage A), with structural disease alone (B), with heart failure symptoms (C), and with end-stage disease (D) 2.
Burden of Heart Failure
- Heart failure remains a high prevalence disease among older adults with a high risk of death at 1 year, with one-year heart failure case fatality ranging from 4% to 45% 3.
- The prevalence, incidence, and survival of heart failure vary widely across countries and studies, reflecting a range of study design 3.
- Policy-level interventions, such as regulations to limit salt and tobacco consumption, are effective for primordial prevention and would have a wider impact on prevention of heart failure 2.
Treatment and Management
- Angiotensin-converting enzyme (ACE) inhibitors are recommended as first-choice therapy for patients with cardiovascular disease, while angiotensin receptor blockers (ARBs) are considered an alternative for ACE inhibitor-intolerant patients 4.
- ACE inhibitors and ARBs have similar efficacy in terms of blood pressure and outcomes, but ACE inhibitors are associated with cough and a very low risk of angioedema and fatalities 4.
- Overall withdrawal rates due to adverse events are lower with ARBs than with ACE inhibitors, suggesting that ARBs may be a better option for some patients 4.