Is all heart failure the same around the globe ?

If one were to ask the question ‘Is all heart failure [HF] the same around the globe? ’ on the basis of contemporary guidelines, it is obvious that the answer could easily be ‘yes’—on the basis of broad definitions. However, one cannot ignore the fact that the majority of clinical trialsofnewpharmacological agents anddeviceshavegravitated towards predominantly men with an ischaemic aetiology and impaired left ventricular systolic function. There is, therefore, a lack of evidence to support new therapeutic modalities for the treatment of those with preserved systolic function and women with heart failure. Also there is little appreciation of the different pathways to the syndrome in the developing world, with potentially more women than men being affected and presenting at a much younger age. Recent data from the sub-Saharan Africa Survey of Heart Failure (THESUS-HF), the first and largest multi-centre registry of acute heart failure in Africa to date, have characterized the causes and short-term outcomes in 1006 Africans with heart failure, from12 tertiary cardiology centres in nine sub-Saharan Africa countries. It is apparent from THESUS-HF that there are major differences between the epidemiology of acute decompensated heart failure in subSaharan Africa compared with North America and Europe (Table 1). One of the most striking features is the relative youth of the African patients affected with acute heart failure (mean age 52 years). Acute heart failure strikes the generation of breadwinners and caregivers in African patients, thereby having major economic implications. The younger African patients with acute heart failure have a lower frequency of ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and renal insufficiency compared with elderly heart failure sufferers in developed countries. The manuscript by Sliwa et al. in this issue of the European Heart Journal is an analysis of the THESUS registry (Sliwa, Eur Hear J 2013) reporting predictors of either readmission or death, compared with otherregions. In themodel thatexcludesregion, ahistoryofmalignancy and severe lung disease, admission systolic blood pressure, heart rate and signs of congestion, kidney function (BUN), and echocardiographic ejection fractionarepredictorsofoutcome.Forthemostpart, themain predictors for these adverse outcomes are similar in sub-Saharan Africa as in the rest of the world although with some notable exceptionssuchastheassociationofHIVstatuswithmortalityand lackofpredictionbysodiumforbothreadmissionanddeath. Interestingly, sodium was not found to be a predictor of mortality in the current study (as is the case of readmission and death), suggesting again that neurohormonal activation involving the renin–angiotensin system may have a lesser role in the HF process in sub-Saharan Africa, a finding in line with the reduced efficacy of ACE inhibitors in African Americans, suggesting that other therapies such as combination of hydralazine and nitrates should be further explored in this population. Despitebeingoneof themostcommoncauses forhospital admissions bothgloballyand insub-SaharanAfrica,ourknowledgeof thepathophysiology of acute HF is limited. In the study on 1006 Africans with AHF the predictivemodels for60-day readmissionordeathand180-daymortality