Heart failure: preventing disease and death worldwide

Heart failure survival rates remain poor across the globe

Across the globe, 17–45% of patients admitted to a hospital with heart failure die within 1 year of admission and the majority die within 5 years of admission (Figure 2).3-24

In recent years, survival rates for patients with heart failure have improved in many parts of the world, in parallel with the introduction of modern evidence-based therapies and patient management systems.3, 25-31 Nevertheless, about 2–17% of individuals admitted to a hospital with heart failure die while in a hospital (Figure 2). Survival rates are better for those treated in outpatient clinics, who typically have less severe symptoms than those treated in a hospital.22, 32 However, even the latest therapies may only relieve symptoms in many patients, without slowing the progression of their disease or prolonging life.33, 34 This is because heart failure can arise from a number of different underlying problems with the structure or function of the heart, some of which are more difficult to treat than others (see Section on Preventing Heart Failure in High-risk Groups).

Despite improvements in care over the past 20 years, the outlook for patients with heart failure remains poor, and survival rates are worse than those for bowel, breast or prostate cancer.35-37

Heart failure is common, and patient numbers are increasing

About 26 million adults worldwide are living with heart failure,38 leading some to describe it as a global pandemic.39 In comparison, 32 million are living with cancer40 and 34 million with HIV/AIDS.41 In many countries, population-based studies have found that about 1–2% of people have heart failure, and similar or higher proportions have been reported in single-centre studies (Figure 3).4, 8, 9, 11, 42-46

Heart failure becomes more common with increasing age. In North America and Europe, few patients with heart failure are 50 years of age or younger50-52 and more than 80% are 65 years of age or older.38 The number of patients with heart failure is predicted to increase in countries with ageing populations.53 Japan, in particular, has the most rapidly ageing population of all economically developed nations.54 In the USA, there were 5.8 million patients living with heart failure in 2012, and this is expected to rise to 8.5 million by 2030.45 Another contributing factor to these increasing numbers is the improvement in treating heart attacks and other cardiovascular diseases that damage or place an extra burden on the heart. More patients with these conditions are surviving now than did in the past, but those who survive are at high risk of going on to develop heart failure.39

In economically developing areas, such as parts of Latin America and Asia, the numbers of patients with heart failure are also increasing.55-58 The increase is largely a result of the shift towards a Western-type lifestyle and its associated diseases, for example, conditions such as diabetes increase the risk of developing heart failure (see Section on Preventing Heart Failure in High-risk Groups). This is despite reductions in the number of cases caused by Chagas disease in urban areas of Latin America58 and reductions in the number of cases of Davies disease (a disorder in which the heart muscle becomes rigid) in tropical areas.59

Infections remain a common cause of heart failure in many parts of the world and can strike at any age. Heart failure is not a disease of the elderly in sub-Saharan Africa, where half of patients hospitalized with the disease are 55 years of age or younger.5 Patients in the Asia Pacific region also tend to be younger than those in Western regions.60 Rheumatic fever due to preventable bacterial infections is a prominent cause of heart failure in Africa, Asia, Australasia and Latin America.61 HIV infection is also a major contributor to heart-related disease across the world.62 In areas of Latin America where Chagas disease is common, nearly half of all heart failure cases are a direct result of this preventable parasitic infection.63

In tropical areas, Davies disease has historically been a common cause of heart failure. The underlying reasons for the development of Davies disease have not been fully established but candidates include childhood malnutrition, dietary toxins and inflammation, as well as infections. In the Kerala region in south India in recent years, the number of new cases of Davies disease has declined in parallel with improvements in socioeconomic and health status.59

Heart failure exacts severe economic, social and personal costs

Globally, the increasing burden of heart failure is taking its toll on society, in particular on patients, caregivers and healthcare systems.

As a primary diagnosis, heart failure accounts for about 1–4% of all hospital admissions in economically developed countries (Figure 4).14, 64-67 This is likely to be an underestimate because heart failure may be recorded as a secondary diagnosis, or may even go unrecorded, especially in the large number of patients who have other cardiovascular diseases.68 Country-wide information is sparse in other regions,55 highlighting the need to set up new national registries to quantify accurately the burden of heart failure.

Caring for patients with heart failure comes at a high economic cost and accounts for about 1–3% of total healthcare expenditure in North America,69 Western Europe70 and Latin America.58 In comparison, the total global expenditure on all healthcare goods and services in 2010 was in the region of $6.5tn.71, 72 In Germany, the total medical costs attributable to heart failure were estimated at €2.9bn in 2006. This figure includes costs for inpatient, outpatient and day care services, as well as drugs, devices and other medical products.70 In the USA, the total hospital, physician, prescription and home healthcare costs associated with heart failure were estimated at $20.9bn in 2012 and are projected to rise to $53.1bn by 2030.45 The 2012 figure is comparable with the annual capital spend required to ensure clean, safe drinking water for the entire nation.73

The lengthy and repeated hospital stays that are typically required by patients with heart failure account for the majority of this economic burden.45, 70 Across the globe, the average length of hospital stay is about 5–10 days.3, 5, 6, 11, 12, 14, 19, 20, 24, 43 Over the past two decades, the length of stay has become shorter in Europe, North America and Australasia.3, 5, 11, 43 Nevertheless, in Europe and North America, about a quarter of patients admitted to a hospital with heart failure are readmitted within a month and up to two-thirds within a year, usually for recurrence of heart failure.11 Individuals who are readmitted with worsening or recurrent symptoms of heart failure are at a high risk of terminal decline.74 Hospital readmission can improve survival rates amongst patients with worsening heart failure; however, identifying those for whom long-term monitoring is a suitable alternative may be a more efficient use of resources (Section on Future Directions in Care: Urgent Unmet Needs).4

Heart failure causes large numbers of deaths and widespread ill health and exacts huge economic and social costs—and the problem is becoming worse. Now is the time for coordinated public heart failure awareness programmes and strategic and political initiatives to improve care across the globe.

What causes heart failure?

The term ‘heart failure’ describes a situation in which a person's heart cannot pump enough blood around the body but does nothing to explain why this condition arises. The clinical picture is complex because there are many possible causes of heart failure, and some are illnesses in their own right (Figure 5). Many cases of heart failure can be regarded as the end stage of other underlying illnesses and could be prevented if patients with these illnesses were identified and treated appropriately at an earlier stage.80

The heart is a remarkably adaptable organ. To cope with problems that increase the demands placed on it, the heart muscle is able to remodel itself to maintain output in the short term. However, if this remodelling continues in the long term, it can lead to abnormalities and eventually to heart failure. For example, pumping activity may decrease and valves may malfunction as the heart enlarges, dilates and stiffens. Sooner or later, these changes will manifest as overt symptoms of heart failure, unless the process of deterioration can be halted or delayed.

For most patients with heart failure, quality of life can be dramatically improved by therapies that relieve symptoms. For many patients, modern evidence-based medications or devices are available that slow or halt the progress of heart disease and improve survival. However, no therapies have been shown to prolong life for nearly half of all patients—those who have heart failure with preserved ejection fraction (HFPEF) (Section on Future Directions in Care: Urgent Unmet Needs).

How can heart failure be prevented?

The fact that treatment is not always effective in prolonging life means that prevention of heart failure should be prioritized by policymakers. This is particularly important for groups at high risk of developing this condition. Many people have existing illnesses that place them at risk of heart failure. Healthcare professionals treating such patients should adopt a broad approach that includes encouraging positive lifestyle changes that reduce the risk of heart failure (see Section on Improving Public Awareness of Heart Failure) and prescribing preventive therapies as appropriate. Medications that control blood pressure, heart rhythm and cholesterol levels are effective in preventing heart failure in the large number of people who have conditions such as high blood pressure, coronary heart disease, kidney disease and diabetes.81 Pacemakers and heart valve replacement can also prevent heart failure in the small number of people who have particular heart rhythm or valve disorders.82 The range of illnesses that predispose patients to heart failure is extremely wide. Healthcare professionals across all clinical disciplines should be educated to identify patients with illnesses that increase the risk of heart failure and prescribe preventive medications. This will ensure that as many people as possible benefit from available therapies.

Patients receiving long-term preventive therapies need to be assessed regularly at the cost of healthcare providers.81 In addition, those with chronic conditions, such as coronary artery disease or Chagas disease, should be evaluated periodically and monitored for changes to the heart. Patients with breast cancer are another group who would benefit from such monitoring. Several existing and new cancer treatments are toxic to the heart,83, 84 and it is important for healthcare professionals to be aware of the need to assess and manage the associated risks.85

Bacterial infections that cause heart disease have been largely eliminated in economically developed countries, owing to the use of antibiotics. In other regions, bacteria and tropical parasites cause a substantial proportion of heart failure cases, many of which could be prevented if appropriate therapies were used.86-88 The potential benefits of policy initiatives aimed at eliminating infectious diseases therefore extend to preventing heart failure in many parts of the world. In particular, continuing global efforts are warranted to eradicate Chagas disease, building on the progress that has been made in Latin America over the past two decades.89

Identifying and treating patients at risk of developing heart failure

Preventive treatment could be started earlier by identifying people with early signs of abnormal heart muscle remodelling. Large-scale screening programmes, such as those that have enabled earlier treatment for bowel, cervical and breast cancer, are unfortunately not possible because there is no simple diagnostic test for heart failure (see Section on The Need to Apply Best Practice).90 Early changes in the structure or function of the heart can be detected using medical imaging technology; it is not practical, however, to perform these complex procedures in the enormous number of individuals with illnesses that lead to heart failure and certainly not in the general population.90 In the future, advanced genetic tests and statistical modelling of at-risk groups may be available that consider the multitude of potential causes of heart failure, and these may allow specific individuals to be identified for in-depth screening (see Section on Future Directions in Care: Urgent Unmet Needs).82

Targeting preventive medications towards individuals at greatest risk of heart failure could increase cost-effectiveness, allowing more people to benefit. Further research in these areas is ongoing and should continue to be supported by public and private funds. In addition, awareness programmes should be aimed towards everyone with medical conditions that predispose to heart failure. These should include education about the symptoms of heart failure and the benefits of positive lifestyle changes. The same messages are important for public awareness programmes (see Section on Improving Public Awareness of Heart Failure).

Preventing heart failure in the elderly and socioeconomically disadvantaged: unique challenges

Preventing heart failure in the elderly is becoming a more pressing healthcare priority as populations age.91 Heart failure is the most common reason for hospital admission in people over 65 years of age in economically developed regions (see Section on The Global Burden of Heart Failure).3, 11, 92, 93 Elderly patients hospitalized with heart failure are mainly women.94 Although a number of studies of heart failure patients have indicated that survival rates are better in women than in men, recent research has shown that the long-term prospects for women are not as good as previously thought.95 Initiatives aimed at improving heart failure prevention should therefore include strategies for reaching out to older people, particularly older women.

In economically developed countries, heart failure is both more common and more likely to be the cause of death in people with low socioeconomic status than in the rest of the population.29, 96 This is still the case after adjusting for differences in age, medication use and the proportion of people with other heart-related diseases.96 It has been suggested that housing stability, social support, substance abuse, language proficiency and distance to hospital may play a role.97 More elderly women than men live alone and in poverty in the USA and often lack the social support of their families or communities. Social support can help people to seek medical attention if symptoms emerge and to change their lifestyles to reduce the risk of heart failure (Section on Improving Public Awareness of Heart Failure).98

In rapidly developing countries, governments face the double challenge of prioritizing the elimination of infectious diseases in resource-poor or rural settings whilst not neglecting the diseases emerging in urban areas as a result of a shift towards a Western-type lifestyle.57 That elderly, isolated, female or poor people are amongst those most likely to have heart failure has done little to raise the profile of the disease. It is time to improve awareness of heart failure via mass campaigns funded by governments and industry.

Public awareness of heart failure symptoms is dangerously low

Delaying hospital treatment by as little as 4–6 h after symptoms of heart failure appear can increase the chances of death,99-101 yet patients typically do not seek treatment for hours or even days after developing symptoms.102 Public education about the symptoms of heart failure and the need to contact a healthcare provider as soon as symptoms appear is essential to ensure that patients benefit fully from the available therapies and care.

A healthy lifestyle reduces the risk of heart failure

Cost-effective awareness, education and support programmes to reduce the risk of heart failure should be at the forefront of public health directives.90 Lifestyle interventions could have substantial power to improve world health, because obesity, diabetes, cigarette smoking and high blood pressure all dramatically increase the likelihood of heart failure.90 In the USA alone, it has been estimated that a 30% reduction in the proportion of people classed as obese would prevent about 44 000 cases of heart failure every year, with an annual saving of nearly $500m in healthcare expenditure.106 Similarly, it has been estimated that a 5% reduction in the number of people with diabetes in the USA would prevent about 30 000 heart failure cases every year.107 Being severely overweight has been shown to double the risk of heart failure and smoking to increase it by about 50%.38

It is a sad fact that our improved understanding of these risk factors has not prevented an explosion in the numbers of people who are obese or who have diabetes or high blood pressure. Renewed commitment to public education about the importance of healthy diet and weight, regular exercise and avoiding smoking should be a priority for policymakers.

In low-income and middle-income countries, lifestyle-based interventions to prevent heart failure have been calculated to be more cost-effective than pharmaceutical interventions.108 The urgent need to address lifestyle risk factors globally is recognized by the United Nations,109 including in regions such as sub-Saharan Africa, where non-infectious diseases associated with a Western-type lifestyle are not yet the leading causes of death or illness.110 Given the already increasing numbers of patients with heart failure in economically developing regions, governments should be encouraged to combine lifestyle-based preventive measures with their programmes for tackling famine and pestilence.111 Regulating the aggressive marketing of high-calorie processed food by larger global corporate businesses, especially to school children and teenagers, could be considered.

Guidelines worldwide agree on the key stages in heart failure care

Clinical practice guidelines aim to help healthcare professionals make evidence-based decisions about the care of individual patients. Guidelines have been published by many governmental and professional bodies across the globe (Figure 6).58, 63, 80, 112-124 Each of these aims to summarize and evaluate the available evidence for using particular medical interventions for particular patients. Guidelines may differ, though, in what evidence is included, how it is assessed and whether an intervention is considered appropriate for care in the relevant country or region.

Smooth transitions between these stages are also crucial for ensuring that patients with heart failure are managed optimally throughout their healthcare journey. Depending on the severity of their symptoms and the services and facilities available in their communities, patients can follow many different and complex pathways through healthcare systems (Figure 7).11 Best practice involves a seamless system of care that embraces both hospital and community.

International consensus recommendations could help to identify the best ways to improve practice in diagnosis, treatment and long-term management. For example, although the published guidelines agree on which diagnostic tools are useful, they disagree on which should be used for all patients with suspected heart failure and in what order.125 A consensus recommendation leading to greater clarity about best practice should be encouraged, with endorsements from credible local bodies.

Best practice in heart failure care involves compliance with guidelines

Survival rates increase and readmission rates fall when patients with heart failure are cared for in hospitals that comply with clinical practice guidelines.126-128 Nevertheless, considerable variation in the quality of heart failure care and clinical outcomes between different hospitals has been demonstrated in several countries.46, 129-132 Before discussing ways of encouraging compliance with guidelines, this section presents evidence to show that there is room for improvement at all three stages of heart failure care.

Best practice in diagnosis requires appropriate facilities and knowledge

Diagnosing heart failure can be challenging, even for trained professionals. Not all patients with heart failure have the typical symptoms, and the same symptoms can be experienced by patients who do not have heart failure. Making an accurate diagnosis requires a range of diagnostic tools and information, in conjunction with clinical judgement and expert knowledge (Figure 8).

Not all hospitals and care centres have a full range of diagnostic tools available, especially in resource-poor settings.111 Furthermore, even when facilities are available, they are not always used. For example, all published guidelines agree that diagnosis should involve ultrasound imaging to assess heart function, but 10–25% of patients admitted to hospital with a primary diagnosis of heart failure in Europe and the USA do not undergo ultrasonography.133

Many patients are not initially seen by an expert in heart failure because of where they enter the healthcare system. Those with severe symptoms, such as breathlessness at rest, are most often assessed by paramedics or emergency doctors in hospital, whereas those with less obviously life-threatening symptoms are likely to go to their family doctor or an outpatient clinic (Figure 7). Education programmes are needed to raise awareness of clinical practice guidelines amongst healthcare professionals from a wide range of specialties who may be the first to encounter patients with undiagnosed heart failure.

Encouraging compliance: measuring and improving quality of care

Measuring performance and incentivizing improvement are key parts of bringing patient care into line with guidelines. Policymakers need to be aware, however, that not all performance measures currently in use necessarily reflect improved clinical outcomes for patients with heart failure.139 As well as recording survival and rehospitalization rates of patients with heart failure, an ideal measure would also capture how efficiently resources are used.11 Performance measures should be tailored to reflect local circumstances, particularly in low-income and middle-income countries where it would be unrealistic to offer every potentially beneficial therapy.140

Diagnosis: improved tools for medical decision-making in heart failure

Blood tests exist that are useful for ruling out a diagnosis of heart failure, but they cannot positively identify patients who do have heart failure.80 Diagnosis therefore remains complex and relies on the clinical judgement of an experienced healthcare professional (Section on The Need to Apply Best Practice). A new specific and sensitive blood test could make diagnosis of heart failure quicker, easier and more accurate. A suitable blood test could also enable large numbers of people to be screened for early signs of heart failure (Section on Preventing Heart Failure in High-risk Groups). Continued support is warranted for basic scientific research aimed at discovering the molecular signatures in the blood of different types of heart failure.

In the future, statistical methods known as risk stratification could be used to identify patients who need treatment most urgently.150 Patients have a high risk of dying from heart failure if they are admitted to hospital with very high or very low blood pressure, low blood oxygen levels, poor kidney function or a history of coronary heart disease. However, assessing any of these parameters in isolation is not accurate enough to drive decisions about a patient's care. Risk stratification involves entering several parameters into a statistical model to generate a profile of the treatment and follow-up most suitable for an individual patient. This has the potential to improve efficiency by enabling high-risk patients to be identified for intensive treatment in hospital, whilst others are safely discharged or treated as outpatients.150 Further development of risk stratification methods to make them suitable for widespread adoption should be supported.

Treatment: new options are needed for many patients with heart failure

Although symptoms can usually be relieved, modern heart failure therapies do not prolong life in about half of all patients. New therapies are needed for patients who have HFPEF (refer to the succeeding texts for a description), acute heart failure, advanced heart failure and certain heart muscle disorders. This highlights the need for policymakers to encourage international collaborative research to improve the understanding of how heart failure develops and how it can be prevented. Additionally, more affordable therapies are required for the huge market in the economically developing world.

Long-term management: innovation could save lives and money

In most patients, heart failure is a long-term disease that involves one or more episodes of hospitalization. New strategies for long-term monitoring and management of patients outside a hospital may improve quality of life and survival rates while reducing the number and frequency of readmissions.

The importance of encouraging patient self-care

Any programme aimed at improving long-term management should recognize that patients with heart failure have a key role to play in their own care. Self-care comprises maintenance, monitoring and management (Figure 10). Maintenance involves taking medication as prescribed, exercising regularly and eating a healthy diet. Monitoring involves keeping watch on symptoms and weight (which can provide a warning sign of increasing fluid accumulation). Management involves responding to changes in symptoms, by adjusting doses of certain medications if they have been prescribed for ‘use as needed’ (e.g. drugs that increase urine production to reduce fluid accumulation), or by seeking medical attention if symptoms worsen.165

A worldwide survey has revealed the need to improve patient self-care. Most patients reported taking their medication as prescribed but few reported monitoring their weight or taking exercise regularly.166 Education programmes are a priority but need to be designed carefully because patients with greater knowledge of heart failure have been reported to be more likely to delay seeking treatment.167 This may reflect false optimism and a lack of understanding that controlling the symptoms of heart failure does not slow the progression of the disease. The education medium also needs to be considered carefully. Short video clips, text messages and social media could be used to deliver simple but accurate messages. With 6 billion people now estimated to own a mobile phone,168 technology may provide an important way of reaching the remote and socioeconomically disadvantaged.

Educating people about how to support a partner, family member or friend with heart failure is also an important part of promoting self-care. Patients are more likely to engage in beneficial self-care behaviours if they have someone to help them than if they are socially isolated. This emphasizes the need to improve community support for socioeconomically disadvantaged patients and those who live alone.169 Policymakers should provide resources for the education and support of individuals with heart failure and their caregivers, empowering them to engage proactively in managing long-term care.