INTRODUCTION
Cardiovascular disease (CVD) is the leading cause of death and disability in India.1 Age-adjusted death rate attributable to CVD in India is 283 per 100,000 population.1,2
Heart failure is a major cause of CVD morbidity and mortality in India.3,4 India is supposed to have the dual burden of heart failure due to the emergence of new age diseases such as diabetes, hypertension, and coronary artery disease along with the persistence of old age diseases such as rheumatic heart disease and untreated congenital heart disease.
There are no real estimates of incidence and prevalence of heart failure from India. Based on assumptions and projections based on data from western world, heart failure prevalence in India is estimated to be around 4,278,000 cases (4.3 million cases).54
EPIDEMIOLOGIC PROFILE OF INDIAN PATIENTS WITH HEART FAILURE—COMPARISON
Table 1 shows the comparison of epidemiologic profile of Indian and Western patients with heart failure.
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The PARADIGM-H (Prospective Comparison of ARNI with ACE inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial showed clear mortality and morbidity benefits with angiotensin receptor-neprilysin inhibitor (ARNI) in heart failure patients. It is, however, used in place of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) and in conjunction with other standard heart-failure treatments.5
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A 16% relative-risk reduction of mortality at 2-year is attributed to ARNI treatment over and above ACE inhibitor/ARB (Table 2).
Further, in patients with and without diabetes and in patients with renal disease adversely impacting heart failure outcomes, sodium-glucose cotransporter-2 (SGLT-2) inhibitors are associated with up to 17% relative-risk reduction in mortality. Recently Vericiguat, a novel oral soluble guanylate cyclase stimulator reduced cardiovascular death and heart failure hospitalisation by 10%.8
HEART FAILURE IN INDIA—PROBLEMS AND SOLUTIONS
As we have seen earlier that Indian patients are younger and the disease burden is mostly in the population below 65 years.6–8 We also know that heart-failure therapy is resource intensive and patients require life-long treatment. The intake of pharmacologic therapy is low as we have seen earlier, also the referral for and intake of device [cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD)] therapy is much lower.
Accessibility, availability, and affordability issues plague the heart failure management issue in the country. So, the most feasible way to control heart-failure in India is prevention of heart failure. This can be achieved by primordial prevention which prevents development of risk factors and through primary prevention by early detection and control of risk factors such as hypertension and diabetes. Early and timely initiation of treatment of coronary artery disease is very important as 70% of heart-failure in India is contributed by ischemic heart disease (IHD). Timely detection and referral for treatment of congenital heart 6disease and penicillin prophylaxis for rheumatic heart disease will also all help control the burden of heart-failure in India.9
REFERENCES
- India State-Level Disease Burden Initiative CVD Collaborators. The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990-2016. Lancet Glob Health. 2018;6(12):e1339–51.
- GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Lond Engl. 2018;392(10159):1736–88.
- Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol. 2017;70(1):1–25.
- Prabhakaran D, Jeemon P, Roy A. Cardiovascular Diseases in India: Current Epidemiology and Future Directions. Circulation. 2016;133(16):1605–20.
- Huffman MD, Prabhakaran D. Heart failure: epidemiology and prevention in India. Natl Med J India. 2010;23(5):283–8.
- Harikrishnan S, Sanjay G, Anees T, Viswanathan S, Vijayaraghavan G, Bahuleyan CG, et al. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: the Trivandrum Heart Failure Registry. Eur J Heart Fail. 2015;17(8):794–800.
- McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. (DAPA-HF) N Engl J Med. 2019;381(21):1995–2008.
- Armstrong PW, Pieske B, Anstrom KJ, Ezekowitz J, Hernandez AF, Butler J, et al. Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2020 May 14;382(20):1883–1893.
- Harikrishnan S, Sanjay G, Agarwal A, Kumar NP, Kumar KK, Bahuleyan CG, et al. One-year mortality outcomes and hospital readmissions of patients admitted with acute heart failure: Data from the Trivandrum Heart Failure Registry in Kerala, India. Am Heart J. 2017;189:193–9.
- Sanjay G, Jeemon P, Agarwal A, Viswanathan S, Sreedharan M, Vijayaraghavan G, et al. In-Hospital and Three-Year Outcomes of Heart Failure Patients in South India: The Trivandrum Heart Failure Registry. J Card Fail. 2018;24(12):842–8.
- Harikrishnan S, Jeemon P, Sanjay G, Agarwal A, Viswanathan S, Sreedharan M, et al. Five-year mortality and readmission rates in patients with heart failure in India: Results from the Trivandrum heart failure registry. Int J Cardiol. 2020;S0167-5273(20)33921–8.