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PLoS Med. 2014 Aug 12;11(8):e1001699. doi: 10.1371/journal.pmed.1001699. eCollection 2014 Aug.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis.

Author information

1
The George Institute for Global Health, University of Oxford, Oxford, United Kingdom.
2
The George Institute for Global Health, University of Oxford, Oxford, United Kingdom; The George Institute for Global Health, University of Sydney, Sydney, Australia.
3
Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America.
4
Non-Communicable Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran; Endocrinology and Metabolism Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
5
Effi-Stat, Paris, France.
6
Department of Cardiology, Royal Brisbane and Women's Children Hospital and University of Queensland School of Medicine, Brisbane, Australia.
7
Non-Communicable Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
8
The George Institute for Global Health, University of Oxford, Oxford, United Kingdom; The George Institute for Global Health, Hyderabad, India.
9
Clinical Trials Service Unit, University of Oxford, Oxford, United Kingdom.
10
The George Institute for Global Health, University of Sydney, Sydney, Australia.
11
National University of Singapore, Singapore.
12
Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.
13
Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
14
National Cardiovascular Centre University Indonesia, Jakarta, Indonesia.
15
Universidad Nacional del Centro de la Provincia de Buenos Aires, Buenos Aires, Argentina.
16
Centre Hospitalier Universitaire de Poitiers, Poitiers Cedex, France.
17
Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Australia.
18
Bodleian Healthcare Libraries, University of Oxford, Oxford, United Kingdom.
19
The George Institute for Global Health, University of Sydney, Sydney, Australia; The George Institute for Global Health, Hyderabad, India.
20
The George Institute for Global Health, Peking University, Beijing, China.
21
University of Glasgow, Glasgow, United Kingdom.

Abstract

BACKGROUND:

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

METHODS AND FINDINGS:

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

CONCLUSIONS:

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

PMID:
25117081
PMCID:
PMC4130667
DOI:
10.1371/journal.pmed.1001699
[Indexed for MEDLINE]
Free PMC Article

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