Heart failure among 173,000 community-dwelling participants from 25 low-, middle-, and high-income countries in the PURE Study

Authors

• Isabelle Johansson Bartolini, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden. Electronic address: isabelle.johanssonbartolini@phri.ca.
• Philip Joseph, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada. Electronic address: philip.joseph@phri.ca.
• Shofiqul Islam, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
• Shameena P. Ramachan, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
• Annika Rosengren, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine/Östra, Gothenburg, Sweden.
• Iolanthé M. Kruger, Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom Campus, Potchefstroom, South Africa.
• Yasin M. Mazapuspavina, Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia.
• Jephat Chifamba, University of Zimbabwe Faculty of Medicine and Health Sciences, Department of Biomedical Sciences, Harare, Zimbabwe.
• Rita Yusuf, BRAC James P. Grant School of Public Health, Dhaka, Bangladesh.
• Lia M. Palileo-Villanueva, UP College of Medicine, University of the Philippines, Manila, Philippines.
• Ahmad Bahonar, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
• Afzalhussein Yusufali, Tamani Foundation, Matemwe, Zanzibar, Tanzania.
• Biyan Wang, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
• Yilin Huan, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
• Hu Bo, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
• Camilo Felix, Grupo de Investigación CENIEC, Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador.
• Nizahat Z. Zaidi, Aga Khan University, Stadium Road, Karachi, Pakistan.
• Kairat Davletov, Population Health Research Center, Al-Farabi Kazakh National University, Research Institute of Cardiology and Internal Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
• Rasha Khatib, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine.Follow
• Jose P. Lopez-Lopez, Masira Research Institute, Universidad de Santander, Bucaramanga, Colombia.
• Hassan Mir, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada.
• Katarzyna Zatońska, Division of Population Studies and Prevention of Noncommunicable Diseases, Wroclaw Medical University, Wroclaw, Poland.
• Erkin Mirrakhimov, Kyrgyz State Medical Academy, Bishek, Kyrgyzstan; College of Medicine, Korea University, Seoul, Korea.
• Fernando Lanas, Universidad de La Frontera, Temuco, Chile.
• Khalid F. Alhabib, Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
• Kamala Rammohan, Department of Pulmonary Medicine, Government Medical College, Kollam, Kerala, India; Health Action by People, Thiruvananthapuram Kerala, India.
• Koon K. Teo, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
• Viswanathan Mohan, Madras Diabetes Research Foundation (ICMR-Collaborating Centre of Excellence) and Dr Mohan's Diabetes Specialties Centre (IDF Centre of Excellence in Diabetes Care), Chennai, India.
• Ahmet Temizhan, Department of Cardiology, Faculty of Medicine, Health Sciences University, Bilkent City Hospital, Ankara, Turkey.
• Anna Kontsevaya, National Research Center for Preventive Medicine, Moscow, Russian Federation.
• et al

Recommended Citation

Johansson Bartolini I, Joseph P, Islam S, et al. Heart Failure Among 173,000 Community-Dwelling Participants From 25 Low-, Middle-, and High-Income Countries in the PURE Study. J Am Coll Cardiol. Published online April 15, 2026. doi:10.1016/j.jacc.2026.02.5085

Abstract

Background: Most population studies examining heart failure (HF) have been conducted in Western high-income countries (HICs), with limited comparable data from lower-income settings.

Objectives: The aims of this study were to describe differences in HF incidence and 30-day, 1-year, and 5-year case fatality rates among HF patients from countries at different income levels and in different global regions and to examine the impact of common and potentially modifiable risk factors for incident HF.

Methods: This analysis of the PURE (Prospective Urban Rural Epidemiology) study included 172,653 individuals from 25 HICs, upper middle-income countries (UMICs), lower middle-income countries (LMICs), and low-income countries (LICs) and 8 geographic regions of the world, followed for a median of 15 years. Age- and sex-standardized HF incidence, as well as 30-day, 1-year, and 5-year HF case fatality, were compared by income group and by geographic region. The population attributable fractions (PAFs) for incident HF related to 13 cardiometabolic, lifestyle, socioeconomic, environmental, and psychosocial risk factors were also estimated.

Results: The standardized rate of incident HF was 0.39 (95% CI: 0.36-0.41) per 1,000 person-years overall; the rate was highest in UMICs (0.58; 95% CI: 0.52-0.64), followed by HICs (0.36; 95% CI: 0.30-0.43), then LMICs (0.34; 95% CI: 0.30-0.38), and then LICs (0.26; 95% CI: 0.22-0.30). Among regions, the highest HF incidence was in sub-Saharan Africa (1.18; 95% CI: 0.95- 1.41) and Europe and Central Asia (0.86; 95% CI: 0.72-1.00) and lowest in South Asia (0.19; 95% CI: 0.15-0.22). Thirty-day case fatality was highest in LICs (59%) and lowest in HICs (11%); it was highest in South Asia (63%) and sub-Saharan Africa (63%) and lowest in North America (12%). Five-year case fatality after HF diagnosis was highest in LICs (77%) and lowest in HICs (28%); it was highest in South Asia (81%) and sub-Saharan Africa (75%) and lowest in North America (25%). More than 71% of the PAF for HF was attributable to the 13 modifiable risk factors studied, the largest being hypertension (PAF = 25%).

Conclusions: HF incidence and associated mortality vary substantially across countries at different levels of economic development and by geographic region. Hypertension is the largest population-level risk factor for HF globally. Preventive measures, early diagnosis, and access to guideline-directed medical therapy should be prioritized to reduce global disparities in HF incidence and mortality.

Document Type

Article

PubMed ID

42017880