Global Burden of Heart Failure: Prevalence, Incidence, and Risk Factors Unveiled

In a review article published in the journal Nature Reviews Cardiology, the authors provide a detailed overview of the global burden of heart failure, including the incidence and prevalence of heart failure, disease etiology, risk factors, and disease outcomes across geographical regions and populations.

Review Article: Global epidemiology of heart failure. Image Credit: Vector_Leart / Shutterstock

Background

Heart failure is a multifactorial clinical syndrome caused by structural and functional cardiac abnormalities. The key symptoms include shortness of breath, ankle swelling, fatigue, and clinical symptoms, such as increased jugular venous pressure, pulmonary crackles, and peripheral edema.  

Heart failure can be of three types depending on the left ventricular ejection fraction, i.e., heart failure with preserved ejection fraction, heart failure with mildly reduced ejection fraction, and heart failure with reduced ejection fraction.  

Non-modifiable risk factors of heart failure include age, gender, and genetic variants. Medically modifiable risk factors include hypertension, diabetes, obesity, hyperlipidemia, atrial fibrillation, sleep apnea, poor renal function, pregnancy-related hypertension, chronic kidney disease, and chronic obstructive pulmonary disease.

Lifestyle-related risk factors of heart failure include smoking and alcohol drinking habits, unhealthy diet, lack of physical activity, stress, and socioeconomic deprivation.   

Prevalence of heart failure in North America and Europe

The prevalence of heart failure is gradually increasing worldwide, which can be attributed to aging populations, an increase in risk factors, better treatment outcomes, and improved survival. A 29% increase in the global prevalence of heart failure occurred between 2010 and 2019.

An estimated global prevalence of heart failure was 56.2 million individuals in 2019, with the highest prevalence observed in East Asia, North America, and Western Europe.   

In the USA, the prevalence of heart failure was estimated to be 2.5% among adults, whereas in Canada, it was 3.5% in 2022. In Europe, the estimated prevalence was 1.7% across 13 countries in 2019. The highest prevalence was observed in Germany and Lithuania, and the lowest was observed in Greece, the Netherlands, Spain, and the UK. However, in Spain, estimates of heart failure prevalence have ranged from 2.6% to 6.8%, depending on the population studied and the care setting.

In the USA, heart failure with preserved ejection fraction has been noticed in approximately 50% of all heart failure patients in the past decade. In contrast, a comparatively lower prevalence of heart failure with preserved ejection fraction has been observed in European countries, where heart failure with reduced ejection fraction remains the predominant subtype.

In the USA, a reduction and an induction in heart failure prevalence have been observed among older adults and young adults, respectively, in the past decade. Regarding gender-related variations, a higher global prevalence of heart failure has been observed in women (35 million) than in men (29 million).

Regarding race- and ethnicity-related variations, the highest prevalence of heart failure between 2013 and 2016 has been observed among non-Hispanic Black adults, followed by non-Hispanic White adults and Mexican American adults.

Prevalence of heart failure in Asia and Australia

The estimated prevalence of heart failure in Asia and Oceania is 722 per 100,000 population, with East Asia having the highest prevalence and South Asia having the lowest prevalence in 2019. Notably, Japan, South Korea, and Thailand have the lowest prevalence in Asia (<1%).

Considering left ventricular ejection fraction, heart failure with reduced ejection fraction has been observed in 81% of all heart failure patients in Asia. 

Prevalence of heart failure in Africa and South America 

The estimated prevalence of heart failure in South America was 1% between 1994 and 2014. Although no population-level estimates are currently available for African countries, data obtained from five African countries shows that 53.7% of patients have heart failure with reduced ejection fraction, 30.1% have heart failure with mildly reduced ejection fraction, and 16.2% have heart failure with preserved ejection fraction.

Global incidence of heart failure

Over the past decade, the global incidence of heart failure has decreased. However, this reduction varies significantly by region and demographic. In the USA, heart failure patients aged 65 years and above have experienced a reduction from 36 cases per 1,000 individuals in 2011 to 26 cases per 1,000 individuals in 2016. A similar reduction has been noticed in Cabada.

In Europe, the incidence of heart failure ranges from 1.99 in Italy to 6.55 in Germany per 1000 person-years. In the UK, a 7% reduction in the incidence of heart failure was observed between 2002 and 2014.

A higher incidence of heart failure has been noticed in women compared to men in the USA and Europe. However, the incidence of heart failure with preserved ejection fraction is significantly higher in women than men in Europe.

In the USA, the highest incidence has been observed in non-Hispanic Black adults, followed by Hispanic adults, White adults, and Chinese American adults. In the UK, a 61% higher risk of incident heart failure has been observed among individuals with the lowest socioeconomic status.

In Australia, the annual incidence of heart failure was 0.348% between 2013 and 2018. In China, the age-standardized incidence was 275 per 100,000 person-years in 2017.

In South America, an incidence of 1.99 cases per 1000 person-years and 5.57 cases per 1000 person-years have been reported in Brazil and Argentina, respectively.

Mortality rate

A variation in heart failure-related mortality has been observed across geographical regions and populations, which could be due to the differences in healthcare access, economic resources, population health profiles, and clinical management practices.

A systematic review involving 1.5 million heart failure patients has shown that the 1-year, 2-year, 5-year, and 10-year survival rates of heart failure are 87%, 73%, 57%, and 35%, respectively. A systematic review involving 1.5 million heart failure patients has shown that the 1-year, 2-year, 5-year, and 10-year survival rates of heart failure are 87%, 73%, 57%, and 35%, respectively.

Comparatively higher mortality has been observed in Black adults compared to that in other races and ethnicities. In the USA, age-adjusted mortality in young adults has increased from 2.36 in 1999 to 3.16 in 2019, which is a more significant rise than that in older adults.