Heart Failure Prevalence and Mortality: A Global White Paper
Prevention of heart failure and related deaths must become a global health priority. Despite the increasing number of people suffering and dying from heart failure, awareness of these issues remains low in society, politics, and even among healthcare professionals. While heart failure is not curable, it can often be prevented, and most patients can be effectively treated to improve their quality of life and extend their life expectancy. Health policymakers are responsible for making existing preventive measures, diagnostics, and long-term heart failure treatments more accessible to as many people as possible. At the same time, untapped opportunities for research in this area should be supported.
The Heart Failure Association of the European Society of Cardiology has launched a global heart failure awareness program. The document prepared by working groups dedicated to addressing the issue of heart failure is an essential part of the program’s inception. It examines the global burden of heart failure, highlights the challenges faced in managing this disease, and provides evidence-based recommendations to transform healthcare strategies. Initiating a unified strategy at the local, national, and international levels should reduce mortality from heart failure and improve patients’ quality of life.
1. Global Burden of Heart Failure
Heart failure is a serious condition in which the heart is unable to pump an adequate amount of blood to meet the body’s needs. Although life-threatening, typical heart failure symptoms (such as shortness of breath, swollen limbs, and weakness) are not as dramatic as those of a heart attack. In economically developed countries, one in five individuals is expected to develop heart failure at some point in their lifetime, affecting many others, including family members, friends, and healthcare professionals.
Patient Perspective
"When you have heart problems, you always fear that your next breath will be your last. You never know."
Survival Rates of Heart Failure Patients Remain Poor Worldwide
Worldwide, 17–45% of patients hospitalized for heart failure die within 1 year of hospitalization, with the majority of patients dying within 5 years. In recent years, survival rates for heart failure patients have improved in many countries due to the implementation of advanced, evidence-based therapies and better organization of patient care. However, about 2–17% of patients hospitalized for heart failure die during hospitalization. Survival rates are better for patients treated on an outpatient basis with milder symptoms than for those requiring inpatient treatment.
Nevertheless, even the latest treatment methods primarily alleviate symptoms for most patients without halting disease progression or significantly extending life expectancy. This is because heart failure develops due to various structural or functional impairments of the heart, some of which are more challenging to treat than others (see section 2). Despite improvements in patient care over the past 20 years, the prognosis for heart failure patients remains poor, and survival rates are worse than those for patients with colorectal, breast, or prostate cancer.
Increasing Number of Patients with Heart Failure
Approximately 26 million adults suffer from heart failure, which is increasingly being described as a global pandemic. For comparison, 32 million people have cancer and 34 million have HIV/AIDS. In many countries, population-based studies have found that about 1–2% of people suffer from HF, with similar or even higher percentages reported in studies conducted in medical centers. Heart failure is more common in older age. In North America and Europe, there are few patients under 50 years old, and over 80% of patients are 65 years old or older.
It is estimated that the number of patients with heart failure will increase in countries with aging populations. Japan’s population is aging the fastest among economically developed countries. In 2012, there were 5.8 million HF patients in the United States, and it is projected that by 2030 this number will increase to 8.5 million. Another factor contributing to these increasing numbers is the improved treatment of myocardial infarction and other cardiovascular diseases (CVD) that affect the heart and impair its function. More patients with these conditions are surviving now than in the past, but survivors have a higher risk of developing heart failure.
In economically developing countries in Latin America and Asia, the number of patients with HF is also increasing. This rise is associated with the transition to a Western lifestyle and related diseases; for example, conditions such as diabetes increase the risk of HF (see Chapter 2). This trend is occurring despite a decrease in cases of Chagas disease in urbanized areas of Latin America, as well as a reduction in cases of Davies’ disease (a condition in which the heart muscle becomes rigid) in tropical regions. Infections remain a common cause of HF worldwide, affecting people of all ages. Heart failure in sub-Saharan Africa is not a disease of the elderly; here, half of the patients are hospitalized at 55 years of age or younger.
Patients in the Asia-Pacific region are also younger than those in Western regions. Rheumatic disease, caused by preventable bacterial infections, is a common cause of HF in Africa, Asia, Australasia, and Latin America. HIV infection is also one of the main factors contributing to heart disease worldwide. In regions of Latin America where Chagas disease is prevalent, almost half of heart failure cases are a consequence of this preventable parasitic infection. Historically, Davies’ disease has also been a common cause of HF in tropical regions.
The main cause of this disease is not fully understood, but it is believed that contributing factors may include childhood malnutrition, food toxins, and infections. In recent years, there has been a decrease in new cases of Davies’ disease in the South Indian state of Kerala due to improvements in healthcare and socio-economic conditions.
High Economic, Social, and Personal Costs
Heart failure (HF) imposes significant burdens on society worldwide, particularly on patients, caregivers, and healthcare systems. In economically developed countries, HF accounts for 1–4% of all hospitalizations as a primary diagnosis. In reality, the numbers are likely higher because HF is often recorded as a secondary diagnosis or may not be recorded at all, especially among patients with other cardiovascular diseases.
In other regions, limited data are available, highlighting the need to implement national registries to accurately assess the burden of HF. The care of patients with HF results in substantial economic costs, estimated to account for about 1–3% of healthcare expenditures in North America, Western Europe, and Latin America.
For comparison, total healthcare expenditures on goods and services in the United States in 2010 amounted to 6.5 trillion U.S. dollars. In Germany, medical expenses related to HF were estimated at 2.9 billion euros in 2006. This figure included inpatient, outpatient, and day-care treatment services, as well as medications, equipment, and other medical supplies. HF-related costs in the United States—including hospital care, physician services, prescriptions, and home care—amounted to 20.9 billion dollars in 2012, with projections reaching 53.1 billion dollars by 2030. The amount spent in 2012 is equivalent to the annual funding required to provide clean and safe drinking water for the entire country. Long and recurrent hospitalizations for patients with HF account for a significant portion of this economic burden. The average duration of hospitalization worldwide is 5–10 days. Over the past two decades, hospital stays have shortened in Europe, North America, and Australasia.
However, in Europe and North America, one-fourth of patients hospitalized for HF are readmitted within one month, and two-thirds within a year, usually due to recurrent HF. Individuals rehospitalized due to worsening HF have a high risk of mortality.
Repeat hospitalizations may improve survival in some patients with heart failure; however, identifying those who would benefit most from long-term monitoring as an alternative could help use healthcare resources more effectively. Heart failure significantly affects patients’ quality of life. They often experience fear, anxiety, and depression, while work, travel, social interactions, and leisure activities become challenging due to shortness of breath and general weakness. The emotional, physical, and financial burden on caregivers of patients with HF is also substantial.
Patients’ Perspective
"I don't have depression… not real depression… I feel oppressed, unhappy; sometimes it seems like my life no longer has any meaning."
2. Prevention of CVD in High-Risk Patient Groups
Prevention of heart failure is of primary importance. When deterioration of heart function is detected, it can usually be treated, but it cannot be completely reversed. Health policymakers should aim to ensure that all healthcare specialists are able to identify patients with diseases that increase the risk of CVD and provide preventive treatment.
Preventive therapies should be equally accessible to patients at the highest risk of developing CVD, regardless of age, gender, or income. It is also crucial to eliminate relevant infectious diseases in countries where they still contribute to CVD.
What Causes Heart Failure?
The term “heart failure” describes a situation in which a person’s heart can no longer pump a sufficient amount of blood to meet the body’s needs, but it does not explain how this condition develops. The clinical picture is complex because there are many possible causes of CVD, with some diseases directly leading to it.
Most cases of CVD can be considered the final stage of underlying diseases and could be avoided if patients were identified and properly treated in earlier stages.
The heart is an extraordinarily adaptable organ. The heart muscle, when coping with conditions that increase its workload, undergoes remodeling to temporarily maintain the amount of blood pumped. If this remodeling persists over time, pathological changes can develop and ultimately lead to heart failure. For example, the force of ejection decreases and valve insufficiency occurs as the heart enlarges and stiffens. Sooner or later, these changes manifest as clear symptoms of CVD unless the deteriorating condition is halted or delayed. The quality of life of most patients with CVD can be significantly improved by adjusting treatment to alleviate symptoms.
Modern, evidence-based medical therapies are available for many patients and can slow or halt the progression of heart disease and extend survival. Unfortunately, almost half of all patients do not receive life-prolonging treatment, particularly those whose ejection fraction remains preserved.
How Can Heart Failure Be Prevented?
The fact that treatment is not always effective in prolonging life underscores the importance of preventing heart failure. This is especially relevant for the large group of patients at high risk of developing this condition.
Many people suffer from diseases that increase the risk of CVD. Healthcare specialists treating such patients should apply a wide range of measures: promoting healthy lifestyle habits that reduce the risk of CVD (see Chapter 3) and using preventive therapies when necessary. Medications that control blood pressure, heart rate, and cholesterol levels are effective for most patients with hypertension, ischemic heart disease, kidney disease, or diabetes. Pacemakers or heart valve replacement can also help prevent CVD in a small percentage of people with heart rhythm or valve disorders.
Diseases predisposing individuals to CVD are highly diverse. Healthcare specialists across all disciplines must be trained to recognize conditions that increase the risk of CVD and to provide appropriate preventive treatment.
This would help ensure that as many people as possible receive currently available therapies. The condition of patients receiving long-term preventive treatment must be regularly assessed by healthcare providers. Patients with chronic diseases such as ischemic heart disease or Chagas disease should be periodically monitored for changes in heart function.
Such monitoring may also be beneficial for breast cancer patients. Some existing and emerging cancer treatments are toxic to the heart, so healthcare specialists should be aware of the importance of assessing and managing related risks.
In economically developed countries, infections that cause heart disease have largely been eliminated.
In other regions, bacteria and tropical parasites remain major causes of heart failure, many of which could be prevented with appropriate treatment. Initiatives aimed at preventing the spread of infectious diseases could also help reduce the global burden of CVD.
Selection and Treatment of Patients at Risk of CVD
For patients with early signs of pathological cardiac muscle remodeling, preventive treatment is necessary. Large-scale screening programs, similar to those implemented for the early detection of colon, cervical, or breast cancer, are unfortunately not possible because there is no simple test to detect heart failure (see Chapter 4).
Early changes in heart structure or function can be detected through imaging studies, but applying such complex procedures to a large number of individuals with conditions that may lead to heart failure is not practical, especially at the population level. In the future, advanced genetic tests and statistical modeling of risk groups may become available, incorporating many potential causes of heart failure and helping to selectively identify patients for further evaluation.
For patients at the highest risk of heart failure, allocating preventive treatment would make better use of resources and benefit more people. Further research in these areas is ongoing and should be supported by both public and private funding. Furthermore, educational programs should be directed at individuals with diseases predisposing them to heart failure, teaching them to recognize heart failure symptoms and emphasizing the benefits of a healthy lifestyle (see Chapter 3).
Prevention of Heart Failure in Older and Socially Disadvantaged Individuals: Unique Challenges
As populations age, the prevention of heart failure among older individuals becomes an urgent healthcare priority. In economically developed countries, heart failure is the most common reason for hospitalization among people over 65 years of age (see Chapter 1).
Among hospitalized elderly patients with heart failure, women predominate. Although some studies suggest better survival rates for women than men, more recent research indicates that the long-term prognosis for women may not be as favorable as previously thought. Initiatives aimed at improving heart failure prevention should include strategies targeting older individuals, especially elderly women. In economically developed countries, heart failure is more prevalent and more likely to be fatal among socially disadvantaged individuals compared to the general population.
This pattern persists even after adjusting for age, medication use, and comorbidities. Factors such as access to stable housing, social support, substance use, language proficiency, and distance to healthcare facilities all play a significant role. Rapidly developing countries face a dual challenge: addressing infectious diseases with limited resources or in rural environments while also managing conditions associated with a Western lifestyle.
Heart failure profiles are least understood among elderly, socially isolated women and economically disadvantaged individuals, who are also at the highest risk of developing heart failure.
Improving Public Education on Heart Failure
Many people die prematurely due to heart failure or by ignoring its symptoms. Public education programs that describe heart failure in simple, easily understandable language, explain how to recognize symptoms, and emphasize the importance of seeking emergency medical help should not be delayed. It is important to recognize that a healthy lifestyle can help prevent many types of heart failure.
3. Public Knowledge of Heart Failure Is Dangerously Low
Delaying hospital treatment by even 4–6 hours from the onset of heart failure symptoms can increase the likelihood of death, yet patients often delay seeking help for hours or even days after symptoms begin. Educating the public about heart failure symptoms and the importance of contacting healthcare providers as soon as symptoms appear is essential to ensure that patients benefit from available treatments and care.
When asked why they delayed seeking treatment, many patients who sought help later than average reported that they “did not think the symptoms were related to the heart” and that “initially the symptoms were not severe.” According to a large European study, only 3% of respondents could identify heart failure from a list of typical symptoms, compared with 28% who could identify a heart attack and 48% who could identify a stroke.
Most patients mistakenly consider heart failure a minor or normal consequence of aging. In low- and middle-income countries such as Indonesia, patients may also face barriers to accessing medical care, including long distances to hospitals or lack of health insurance, which further contributes to delays.
Another factor contributing to delayed medical care is depression, which affects 20–40% of patients with heart failure. Delays of more than 72 hours in seeking hospitalization after symptom onset were twice as common among patients with symptoms of depression compared to those without. This highlights the need for targeted public education programs combined with social support initiatives for high-risk groups.
Patients’ Attitudes
"Sometimes I would feel a mild tingling or pain on one side; it happened once or twice while I was driving. I stopped the car but didn’t do anything more about it. Then I started experiencing sleep apnea or difficulty breathing, until I could no longer breathe normally for several days. I didn’t pay attention to the initial symptoms.
On the last day, I woke up unable to breathe normally and asked my child to take me to the hospital. When I arrived, I was unconscious."
Healthy Lifestyle Reduces NCD Risk
Public health directives should prioritize the effective use of funds for education, training, and support programs that reduce NCD risk. Lifestyle changes could significantly improve global health, as obesity, diabetes, smoking, and high blood pressure greatly increase the likelihood of NCDs.
It has been estimated that in the U.S. alone, reducing the proportion of obese individuals by 30% could prevent 44,000 cases of NCDs, saving $500 million in healthcare costs. Similarly, reducing the prevalence of diabetes by 5% could prevent 30,000 NCD cases annually in the U.S. Severe obesity doubles the risk of NCDs, while smoking increases it by 50%.
Unfortunately, improved understanding of these risk factors has not prevented the rapid increase in the number of obese, diabetic, or hypertensive individuals. A renewed commitment to educating the public about the importance of healthy eating, regular physical activity, and smoking cessation should be a priority for policymakers.
It has been estimated that lifestyle-based measures to prevent NCDs are more cost-effective than pharmacological interventions in low- and middle-income countries. The importance of addressing lifestyle risk factors worldwide has been recognized by the United Nations, including in regions such as sub-Saharan Africa, where non-communicable diseases related to a Western lifestyle are not yet the leading cause of death or disease.
Given the increasing prevalence of NCDs in economically developing regions, efforts should be made to combine lifestyle-based preventive measures with programs addressing hunger and malaria. Regulation of the marketing and distribution of calorie-dense foods by large global corporations, especially targeting school-age children and adolescents, should also be considered.
4. Why Best Practices Should Be Applied
Clinical practice aligned with guidelines is often associated with improved outcomes for NCD patients. In many countries, hospitals vary widely in their adherence to national guideline recommendations. In response, health policymakers must advocate for equal access to treatment for all patients.
It is crucial to promote training programs that expand healthcare professionals’ knowledge of NCD guidelines. Further improvements in care using locally available, incentivized measures should be pursued. Funding is needed for studies evaluating evidence-based medical practices that demonstrate improved outcomes for NCD patients. By actively implementing health improvement plans, policymakers can create healthcare systems in which NCDs are diagnosed in a timely manner and managed effectively over the long term.
Global Recommendations Agree on Key NCD Care Stages
Clinical practice guidelines help healthcare professionals make evidence-based decisions tailored to individual patients. Although guidelines may differ in the evidence presented, evaluation methods, and applicability to specific countries or regions, they consistently emphasize three essential stages of care for NCD patients:
- Diagnosis – it must be accurate and timely;
- Treatment – it should be appropriate for each patient and accessible without delay;
- Long-term care – it should include regular visits, monitoring of clinical indicators, and ongoing support.
A smooth transition between these stages is essential for optimal patient care throughout the course of illness. Depending on symptom severity and the availability of healthcare services, patients are managed within complex healthcare systems.
Best practice involves a continuous healthcare system that integrates hospital and community care. International consensus recommendations can help identify the most effective approaches to improving diagnosis, treatment, and long-term care.
For example, although guidelines indicate which diagnostic tools are useful, there is no universal consensus on which should be used for all patients suspected of HF or in what order. Encouraging the development of clearer, consensus-based recommendations endorsed by local organizations should be prioritized.
Adherence to Best HF Practices Is Determined by Recommendations
Survival rates increase and readmission rates decrease when HF patients are treated in accordance with clinical practice guidelines. However, in some countries, significant differences in care quality and clinical outcomes have been observed between hospitals. Before discussing ways to improve adherence, it is important to note that there remains substantial room for improvement across all three stages of HF care.
Good Diagnostic Practice Requires Appropriate Equipment and Knowledge
Diagnosing heart failure can be challenging, even for experienced specialists. Not all HF patients present with typical symptoms, and similar symptoms may occur in individuals without HF. Accurate diagnosis requires appropriate diagnostic tools, clinical evaluation, and specialized knowledge. Not all hospitals and care centers have access to all currently available diagnostic tools, particularly in resource-limited settings.
Furthermore, even when equipment is available, it is not always used. For example, all major guidelines recommend echocardiography to confirm diagnosis, yet 10–25% of HF patients admitted to hospitals in Europe and the U.S. do not undergo this test. Many patients do not see an HF specialist, often depending on where they first enter the healthcare system.
Patients with severe symptoms, such as dyspnea at rest, are usually assessed by paramedics or emergency physicians, while those with milder symptoms are more likely to consult primary care physicians first. Training programs are needed to improve awareness and understanding of clinical guidelines among all healthcare professionals who may encounter patients with undiagnosed HF.
All Eligible Patients Should Receive Evidence-Based Treatment
All published guidelines recommend modern, evidence-based therapies that improve outcomes for HF patients.
For example, certain medications have been shown to improve survival in patients with left ventricular systolic dysfunction (LVSD), a condition characterized by reduced pumping ability of the heart, affecting approximately half of HF patients.
For patients with arrhythmias and some individuals with LVSD who require implantable devices, continuous monitoring of heart activity and automated delivery of appropriate electrical stimulation significantly improve survival. Despite clear recommendations, many HF patients do not receive beneficial treatments because guidelines are not consistently followed.
In a study conducted in the U.S., more than a quarter of eligible HF patients discharged from hospital did not receive necessary medications. Prescription rates for recommended drugs in Europe are also suboptimal, and even when prescribed, doses are often lower than recommended.
In Africa, available data suggest that preventive medications are prescribed to less than half of hospitalized HF patients, and effective drug combinations are rarely used among African American populations.
Health policies should therefore encourage greater adherence to evidence-based prescribing practices. It is important to note that most clinical trials supporting HF treatments have been conducted in Europe and the U.S. Because the causes of HF vary globally, further research is needed to determine the effectiveness of treatments across different populations.
Long-Term Patient Care Is as Important as Diagnosis and Treatment
Guidelines recommend a seamless transition to long-term care programs that include regular consultations, monitoring, and support. However, research shows that many healthcare systems fall short: in the U.S., fewer than half of hospitals implemented even half of the recommended practices, and less than 3% implemented all of them. In Europe, only 7 out of 26 countries had HF care programs in more than 30% of hospitals.
Even where programs exist, they are not always fully utilized. Community clinics and specialized nursing services play a crucial role in long-term care. Alongside improvements in diagnosis and treatment, the implementation of structured care programs should be encouraged.
Promoting Guideline Adherence: Assessing and Improving Care Quality
Evaluating clinical practice and promoting improvements are essential steps toward aligning patient care with established guidelines. Policymakers should recognize that not all current performance indicators directly reflect improved patient outcomes. In addition to tracking survival and readmission rates, it is important to assess whether healthcare resources are used effectively.
Audits, Registries, and Professional Initiatives
Audits allow comparison between care quality and patient outcomes, enabling targeted improvements. For example, the National Heart Failure Audit in the UK collects data on hospitalized HF patients across England and Wales. One hospital improved in-hospital survival rates from 77% (below average) to 94% (above average) after establishing a specialized HF team.
Another hospital improved survival rates (from 87% to 92%) and reduced 30-day readmissions (from 24% to 15%) by improving adherence to guideline-based care.
Registries provide important global data on HF severity, causes, treatment, and outcomes, although they are less comprehensive than audits. Some registries also provide feedback that helps improve clinical practice. For example, prescription rates of HF medications at hospital discharge increased by 30% over three years following participation in the ADHERE registry (USA).
Most registry data currently come from North America and Western Europe, although HF causes vary worldwide. Expanding regional registries is essential for improving global understanding of HF. National registries such as HEARTS (Saudi Arabia) and CHART-2 (Japan), as well as multinational initiatives like GULF CARE and ASIAN-HF, contribute valuable insights, each including data on approximately 5,000 patients.
Professional initiatives also support guideline adherence. For example, hospitals in the U.S. can participate in the “Get With The Guidelines – Heart Failure” program run by the American Heart Association. Participation helps improve clinical decision-making and patient care, with successful institutions receiving public recognition.
A study of participating hospitals showed that improved discharge planning and transitional care reduced 30-day readmission rates for HF patients, while other strategies had less impact on patient outcomes.
Financial Incentives and Penalties
Improving hospital practices can be incentivized by introducing financial penalties or rewards (known as “pay-for-performance”). For example, since 2001, U.S. hospitals have been required to report on the quality of HF care, and if they do not meet established standards, their healthcare funding may be reduced. In many countries, hospitals face penalties for readmissions within 30 days of discharge.
These penalties are aimed at reducing avoidable readmissions, but there is concern that hospitals with high survival rates may be unfairly penalized, reflecting variations in post-discharge care rather than in-hospital care standards. Incentives for good performance can also be extended beyond hospital settings. For example, in the UK, primary care physicians can participate in the “Quality and Outcomes Framework” program, which includes HF indicators, targets, and associated payments.
Care Directions
Adherence to guidelines can be encouraged through the use of care algorithms, i.e., guideline-based systematic plans for managing specific patients over a defined period. Care algorithms have improved survival rates among patients with cardiovascular diseases in hospital settings, but there is no single “one-size-fits-all” algorithm that can be applied across all healthcare facilities. Guidelines for the management of acute heart failure patients have been adopted in Scotland.
Source: "Lietuvos gydytojo žurnalas"
