Journal of the Practice of Cardiovascular Sciences

: 2016  |  Volume : 2  |  Issue : 1  |  Page : 2--3

Heart failure in India – iceberg tsunami?

S Harikrishnan 
 Department of Cardiology, SCTIMST, Trivandrum, Kerala, India

Correspondence Address:
S Harikrishnan
Additional Professor, SCTIMST, Trivandrum, Kerala

How to cite this article:
Harikrishnan S. Heart failure in India – iceberg tsunami?.J Pract Cardiovasc Sci 2016;2:2-3

How to cite this URL:
Harikrishnan S. Heart failure in India – iceberg tsunami?. J Pract Cardiovasc Sci [serial online] 2016 [cited 2023 Feb 2 ];2:2-3
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Cardiovascular diseases (CVDs) have emerged as the leading cause of mortality and morbidity in both developed and developing countries toward the end of the last millennium itself. While the developing nations could successfully bring down the incidence of CVD,[1] the disease is showing a rising trend in the developing world.[2]

Heart failure (HF) which is the “end-stage” of most of the heart diseases has emerged as a major global public health problem. HF has become the leading cause of hospitalization in the United States and Europe, representing 1–2% of the total hospital admissions.[3] Increasing life expectancy and better availability of chronic care have contributed to the rising prevalence of HF in the developed world.

HF is a disease associated with significant mortality and morbidity; 1-year mortality rate of > 30% is higher than many cancers. Therapy of HF is resource intensive and consumes a major share and healthcare expenditures in the developed world.[4]

The epidemiological data on HF from the developing world are very limited.[5] There are few registry data, but data on incidence and prevalence are almost nonexistent. There are certain estimates and projections based on data from the Western world.[6],[7]

HF is likely to be an important contributor to death and disability in developing countries as well because of the reasons we discuss below.

HF is predominantly a disease of the elderly as the lifetime risk for HF increases with age.[3] As we projected before, the number of people above 60 years of age in South Asian region is likely to increase from 133 million in 2011 to 494 million in 2051.[6] Hence, the burden of HF is likely to rise with the growing age of the population. The second reason is the increasing prevalence of vascular diseases and its risk factors. There are data to show that prevalence of vascular diseases is rising in the developing world. The prevalence is likely to rise in the future also as per our projections.[2] The third reason is the continuing prevalence of old diseases such as rheumatic heart disease (RHD) and untreated congenital heart diseases. The high prevalence of chronic obstructive pulmonary disease due to biomass fuel use in India also contributes to the HF burden.

The Trivandrum HF registry (THFR) was the first registry of HF from India, which was funded by the ICMR. The registry enrolled 1205 consecutive admissions (834 men, 69%) using the ESC 2012 criteria for enrollment. “Guideline-based” medical treatment was defined as the combination of beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aldosterone receptor blockers in patients with left ventricular systolic dysfunction.

Mean age was 61.2 (13.7) years. The most common etiology of HF was ischemic heart disease (72%). HF with preserved ejection fraction (HFpEF [EF ≥ 45%]) constituted 26% of the population. Prevalence of diabetes and tobacco use was much higher compared to the western data.

Patients hospitalized with HF in the Trivandrum HF registry were younger by 10 years, more likely to be men and had a higher prevalence of coronary artery disease (CAD). The patients reported longer length of hospital stay and higher in-hospital mortality compared with published data from other registries from the West. Guideline-based therapy was found to improve outcomes, but dismally suboptimal (25%).

In this issue of the journal, Chaturvedi et al. have attempted to estimate the burden of HF in India.[8] Since we do not have any data on the incidence and prevalence of HF from India or from most of the developing world, such data becomes very important.

Adults of six villages in Northern India were screened, and cases of dyspnea were identified by trained health workers. Of 10,163 cases screened, chronic breathlessness was present in 128 (1.3%). Echocardiography was performed in all and HF was diagnosed in 12 of them. Thus, the prevalence of HF in this rural community was estimated to be 1.2/1000. Case selection using dyspnea on exertion as the only criterion might have resulted in many cases being missed in the community.

The authors did a small survey of in-hospital patients (n = 500) and found that the mean age of the patients was low (39 ± 16 years). The mean age of patients from another large in-hospital data of 1985 patients was 49.2 years and the mean age in THFR was 61.2 years, meaning that this population from North India is much younger, compared to South Indian patients and still younger than Western patients.

Regarding etiology of HF, there was disconnect between hospital data and community data in the current study. In the community study, two-thirds of the patients had HFpEF and all of them had uncontrolled hypertension (HTN). In the in-hospital group, RHD (52%) was the most common cause followed by ischemic heart disease (17%). We also noticed that RHD (37.1%) was the most common etiology followed by CAD (33.4%) in a tertiary hospital cohort.[9] One reason for the higher rates of RHD is due to the referral bias of patients from the low socioeconomic sector to public sector hospitals where the study was conducted. The low rates of CAD need to be further probed with larger studies.

The finding that two-thirds of the rural population had HFpEF in the current study is quite surprising as only 4% was the prevalence of HTN-induced HF in Trivandrum HF registry.

The authors did an estimation of the prevalence of HF in India based on whatever minimal data were available and also did projections based on data from the West. They estimated that prevalence of HF to be about 1% (8–10 million) individuals and the mortality attributable to HF is about 0.1–0.16 million individuals per year.

This study should be seen as an initial attempt to capture the real data regarding HF from India. The need of the hour is to generate data from our population. Professional societies and research institutions such as ICMR should come forward to fund such initiatives. The Kerala HF registry which is starting to recruit patients from May 2016 is such an initiative.

There are many implications of the data which have recently emerged from India on HF including the current study. The younger population with more risk factors will demand longer duration and more intensive treatment regimen. We know that treatment of HF is resource intensive and majority of the people cannot afford such costly treatment.[10] The projected burden of 1% is most likely an underestimate of the problem. The iceberg of HF is going to hit the Indian health systems in a bad way.

Hence, the way forward is to prevent HF. This can be achieved through control of risk factors such as HTN, diabetes, tobacco use, and early and timely initiation of evidence-based therapy. This only can reduce the enormous burden of HF in India.

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Conflicts of interest

There are no conflicts of interest.


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