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Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study

Dokainish H 1 , Teo K 2 , Zhu J 3 , Roy A 4 , AlHabib KF 5 , ElSayed A 6 Show all authors , Palileo-Villaneuva L 7 , Lopez-Jaramillo P 8 , Karaye K 9 , Yusoff K 10 , Orlandini A 11 , Sliwa K 12 , Mondo C 13 , Lanas F 14 , Prabhakaran D 15 , Badr A 16 , Elmaghawry M 17 , Damasceno A 18 , Tibazarwa K 19 , Belley-Cote E 2 , Balasubramanian K 2 , Islam S 2 , Yacoub MH 20 , Huffman MD 21 , Harkness K 2 , Grinvalds A 2 , McKelvie R 2 , Bangdiwala SI 2 , Yusuf S 2 , INTER-CHF Investigators

Affiliations 

  • 1 Population Health Research Institute, McMaster University, Hamilton, Canada. Electronic address: hisham.dokainish@phri.ca
  • 2 Population Health Research Institute, McMaster University, Hamilton, Canada
  • 3 Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
  • 4 All India Institute of Medical Science, New Delhi, India
  • 5 King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
  • 6 AlShaab Teaching Hospital, Khartoum, Sudan
  • 7 University of the Philippines, Manila, Philippines
  • 8 Fundación Oftalmológica de Santander, (FOSCAL) and Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
  • 9 Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
  • 10 UCSI University and UiTM Selayang, Selangor University, Cheras, Malaysia
  • 11 ECLA Foundation, Instituto Cardiovascular de Rosario, Argentina
  • 12 Hatter Institute for Cardiovascular Research in Africa, SAMRC, Faculty of Health Sciences, University of Cape Town, South Africa
  • 13 Mulago National Referral Hospital, Kampala, Uganda
  • 14 Universidad de La Frontera, Temuco, Chile
  • 15 Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India
  • 16 Hamad Medical Center, Doha, Qatar
  • 17 Aswan Heart Centre, Aswan, Egypt
  • 18 Eduardo Mondlane University, Maputo, Mozambique
  • 19 Department of Cardiovascular Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
  • 20 Hamad Medical Center, Doha, Qatar; Aswan Heart Centre, Aswan, Egypt
  • 21 Northwestern University Feinberg School of Medicine, Chicago, USA
Lancet Glob Health, 2017 07;5(7):e665-e672.
PMID: 28476564 DOI: 10.1016/S2214-109X(17)30196-1

Abstract

BACKGROUND: Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, we aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America; we also explored demographic, clinical, and socioeconomic variables associated with mortality.

METHODS: We enrolled consecutive patients with heart failure (3695 [66%] clinic outpatients, 2105 [34%] hospital in patients) from 108 centres in six geographical regions. We recorded baseline demographic and clinical characteristics and followed up patients at 6 months and 1 year from enrolment to record symptoms, medications, and outcomes. Time to death was studied with Cox proportional hazards models adjusted for demographic and clinical variables, medications, socioeconomic variables, and region. We used the explained risk statistic to calculate the relative contribution of each level of adjustment to the risk of death.

FINDINGS: We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables (New York Heart Association Functional Class III or IV, previous admission for heart failure, and valve disease) and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained.

INTERPRETATION: Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are needed.

FUNDING: The study was supported by Novartis.

Study site: Multination

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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