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A pivotal publication of the Global Heart Failure Awareness Programme in 20141 calls for an integrated international effort to make heart failure a health priority in every country across the globe. Ensuring equity of care for all patients by delivering timely access to diagnostic services and treatment of heart failure is one of the key aspects highlighted by this initiative. Several recent reports clearly demonstrate, however, that there is still significant regional variability in several facets of the diagnosis and management of heart failure across different parts of the world.2 Moreover, healthcare system organisation and resource use also vary greatly, producing major constrains to patients’ care, particularly in low-income to middle-income countries.
There is a growing body of international data evaluating patients with heart failure outside North America and Europe, mostly in the acute setting or in tertiary care referral facilities. The Sub-Saharan Africa Survey of Heart Failure (THESUS-HF) was pioneer to prospectively evaluate clinical characteristics, patterns of treatment and short-term outcomes of patients with acute decompensated heart failure admitted to university hospitals in nine African countries.3 THESUS-HF investigators demonstrated that heart failure affected African patients at an early age, was caused mostly by hypertension and had low rates of beta-blockers prescription at discharge. Rates of readmissions and death in 60 days was approximately 16%. Similar results have been reported in other African countries,4 5 Asia2 and South America.6 The INTERnational Congestive Heart Failure (INTER-CHF) initiative was a prospective longitudinal study, designed to assess contemporary sociodemographics, clinical variables, heart failure aetiologies and treatments in 108 centres in 16 countries from Africa, Asia, the Middle East and South America. The protocol enrolled 5813 participants both as outpatients (64%) and inpatients (36%). Again, participants from Africa were younger, had lower literacy levels and were less likely to have health or medication insurance or be on beta-blockers compared with participants from other regions. Disease severity at presentation was apparently greater in African patients. Aetiology was also inconsistent across continents: approximately 50% of patients with heart failure were ischaemic in Asia and the Middle East, while hypertension accounted for 20%–35% of the cases in South America and Africa. Importantly, valvular heart disease and Chagas disease, once leading causes of heart failure in several parts of the world, were less relevant in the pathogenesis of the syndrome in the INTER-CHF. The Breathe Registry evaluated acute decompensated patients with heart failure from 52 centres in Brazil and identified low rates of prescription of disease-modifying medical therapies and one of the world’s highest intrahospital mortality rates (12.6%).6 Figure 1 describes contemporary rates of use of beta-blockers, ACE inhibitors and aldosterone antagonists in cohorts with heart failure in underprivileged regions of the world, based on available data typically derived from specialised and reference centres. Overall, it seems clear that heart failure is diverse in presentation, management and course across the world. Efforts to reduce these disparities will require a broader understanding of the reality in every region.
The healthcare journey for patients with heart failure might be greatly heterogeneous. The ‘first encounter’ of the undiagnosed patient with heart failure to a healthcare professional most probably will not be with an expert in the heart failure clinic, but with a general physician in the primary care setting. There is limited representative data looking at how good (or bad) are primary care facilities in offering a full range of diagnostic and therapeutic tools, even in the developed world. For instance, there is a general agreement from international guidelines that ultrasound imaging is essential to assess heart function for the appropriate diagnosis of heart failure. But is that at all feasible in a rural community-based outpatient clinic or hospital in a resource-poor environment? In their Heart paper, Carlson and coworkers7 addressed this important issue. They reported on the availability of cardiac diagnostic technologies and medications for heart failure by analysing a nationally representative survey of 340 health facilities in Kenya and Uganda. Results are ‘heart-breaking’, but not surprising. Less than 10% of the ambulatory facilities and less than 50% of the hospitals were functional in ultrasound capability. Medication availability was also limited, especially in the outpatient care, with less than a quarter of the facilities offering furosemide, an ACE inhibitor and a beta-blocker. Moreover, stock outs were relatively common in both hospital and ambulatory care. Is there a different scenario for a great part of the population in Brazil, Colombia, India, China or Saudi Arabia? The answer for that question is mostly unknown, but one could predict that the overall picture might not be substantially diverse. The revolutionary results from several clinical trials changed the natural history of heart failure, but the present findings underscore a reality that is uncomfortably far from ideal.
Following the journey, patients with advanced heart failure might require complex, costly and multifaceted care. However, some of the fundamental and basic principles of heart failure management are applicable throughout the different stages of the disease and represent incontestable clinical practices worldwide. The use of ultrasound for diagnosis and disease-modifying drugs for treatment of heart failure are crystal-clear examples of such practices. Cost-effectiveness of the mainstream pharmacological treatment of heart failure is also indisputable, as several of such strategies might even be cost-saving.8 There is an urgent need to develop a global health policy that establishes simple, cross-cultural and cost-effective measures for the adequate diagnosis and treatment of heart failure in different parts of the world. This set of minimum requirements could be periodically monitored and publicised worldwide to shed more light in the inequities of healthcare. Carlson and coworkers should be commended to unravel the real world in the diagnosis and treatment of heart failure and to demonstrate that even these simple principles of care remain as an enormous challenge in several parts of the world. Unfortunately, the pathway to excellence of care in heart failure is full of such obstacles. The ‘iceberg’ is huge, and is not melting in the sub-Saharan Africa.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.