The India component of the study was led by Dorairaj Prabhakaran, vice-president (Research & Policy), Public Health Foundation of India, New Delhi; and Ambuj Roy, professor of Cardiology, All India Institute of Medical Science, New Delhi. Of the 5,823 heart failure patients observed in India, Africa, Southeast Asia, China, South America, and West Asia, two-thirds were clinic outpatients. The study was funded by pharmaceutical company Novartis.

According to Dr. Prabhakaran, one of the major reasons for the high mortality rate among Indians was that patients reached hospitals at a later stage of the disease, along with an associated high prevalence of risk factors such as diabetes and hypertension.

“In other countries, patients may present to hospitals earlier. Access to healthcare and compliance to long-term treatment is also a problem in India, as heart failure patients need to take lifelong medications,” said Dr. Prabhakaran. Of the 858 patients observed in India, an equal number were from urban and rural centres. “We wanted a non-metro representation so patients were taken from all parts of the country,” said Dr. Roy, and added that this was one of the first studies comparing global mortality rates for heart failure patients.

Need for better health coverage

He pointed out that while the predisposition of Indians to lifestyle diseases at a younger age is known, the study highlights the need for better health coverage, particularly in rural settings. “Rural health setups in India are not equipped to handle non-communicable diseases such as diabetes, hypertension and heart failure, which need regular follow-up; they are more geared towards containing communicable diseases,” said Dr. Roy.

Another area of note was the low permeance of medical insurance. According to the AIIMS professor, only 19% of patients from India who were part of the study were insured, the lowest across countries. This meant that even after diagnosis, many patients dropped out of treatment.

Hisham Dokainish, principal investigator, Population Health Research Institute, Hamilton, Canada; who is the corresponding author of the study, said that after accounting for 20 demographic, clinical, treatment and socio-economic variables, Indian patients were at approximately three times the risk of death within one year compared with heart failure patients in relatively higher income regions observed in the study, including West Asia, China and South America.

“We can only speculate the reasons for this, which include healthcare access, quality, infrastructure, genomic and genetic factors, environmental factors, and adherence to and availability of evidence-based medicines for heart failure,” said Dr. Dokainish.

Heart failure is a condition in which the heart is unable to pump enough blood to meet the body’s needs. The heart doesn’t stop beating, as happens in a cardiac arrest, but rather weakens so that it is unable to pump out all the blood that enters in chambers, either due to weakness or stiffness of heart muscle.

Other institutes involved in the study include the Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China; King Fahad Cardiac Center, Riyadh, Saudi Arabia; and other institutes in Sudan, Philippines, Colombia, Malaysia, Argentina, South Africa, Chile, Qatar, Tanzania, Mozambique, and Chicago.

(Originally published in The Hindu.)