The Article by Callender et al. (2014) “Heart failure care in Low and Middle income countries”, PLOS (online) available at  conducted  the broadest study yet in about 31 countries using a systematic review and meta-analysis of about 49 published and 4 unpublished studies of approximately 240 thousand hospitalizations for acute and chronic heart failure within a 19 year time frame (Jan 1995-March 2014).

The need for this study cannot be overemphasized as Heart failure has been shown to be a major public health issue in High-Income Countries (HIC) that typically consumes 1%-2% of health care resources but unfortunately in Low and Middle-Income Countries (LMIC) the information about the disease burden is scant although many experts have predicted that it may soon become a public health issue. The article revealed a lot of information which will be of immense benefit in the planning of health systems and further research but is not without its deficiencies.

 The authors were able to determine that heart failure was already placing a considerable burden on health systems evident by the relatively long duration of hospital stay which was 10 days on average and in-hospital mortality rate of 8.3% which is high when compared to 6.7% and 4% obtainable in studies done in Europe and the USA respectively.

There was also evidence to suggest that the mean age of first presentation, 63 years in LMICs had a direct relationship with Human Development Index (HDI) as the mean age of presentation from HICs at 73 years was significantly higher.

The results of the study also revealed that medication use was suboptimal as only about 57% of patients were prescribed with Angiotensin Converting Enzyme Inhibitors(ACEI), 34% with Beta Blockers and 32% with mineralocorticoid receptor agonists, The 3 most recommended drugs in treatment guidelines as at the time the study was conducted.

The authors surmised from the data that while Ischaemic Heart Disease (IHD) was still the leading cause of Heart Failure in LMICs similar to HICs, there was a significant increase in aetiology due to Hypertension especially in African and South American populations.

These 2 major Non-communicable disease aetiology featuring with a fair percentage of communicable diseases such as infective heart disease, HIV associated cardiomyopathy, and Chagas disease suggest that there is a double burden of disease for countries in the midst of epidemiologic transition.

While the article gives a compelling argument for the challenges of management of heart failure in LMIC, it is still deficient as most data collation were based on hospital based studies and only 1 population based study, Especially in regions where most people still do not have access to health institutions and a fair number of people live in hard to reach areas. This is sure to put some doubt about the degree of accuracy of the findings.

Furthermore, either on purpose or by omission, there is bias towards child population in LMICs which is unfortunate given the significance of nutritional anaemias and anaemic heart failure in paediatric age group. This is particularly telling for a study in LMICs which are predominantly young populations.

The study seems to embrace a 1 glove fits all approach when it proffers suggestions for  Treatment and management outcomes which will quite challenging given the genetic and demographic variations amongst the study population.

The information is also not enough to make deductions on the economic burden on LMICs in terms of reduced workforce and productivity.

In conclusion, the article highlights the burden of heart failure in LMICs and also the challenges of optimal medication for therapeutic purposes using clearly presented data, and will be of immense benefit to stakeholders in the planning of health systems in LMIC.

It also serves as a springboard board upon which further studies can build upon and improve on the gaps in population coverage, critical demographic groups and proffering solutions to this emergent problem. 

Written by Dr. Abdulsalam Abu-Talib


Callender T, Woodward M, Roth G, Farzadfar F, Lemarie J, Gicquel S et al. Heart Failure Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. PLoS Medicine. 2014;11(8):e1001699.

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