Introduction
Heart failure, a complex clinical syndrome marked by the heart’s inability to pump or fill adequately, imposes a profound human and economic toll. Symptoms such as dyspnea, fatigue, and fluid retention lead to frequent hospitalizations, diminished quality of life, and increased mortality. With population aging, urbanization, and shifts in cardiovascular risk factors, quantifying HF’s global burden and its underlying causes is vital for guiding health policy, resource allocation, and clinical practice.
2. Data Source and Methodology
This analysis synthesizes estimates from the Global Burden of Disease (GBD) Study 2021, encompassing:
- Prevalence: Number of individuals living with HF annually.
- Age-Standardized Prevalence Rate (ASPR): Prevalence per 100,000, standardized to a reference population.
- Etiology Attribution: Proportion of HF cases due to IHD, HHD, cardiomyopathy, chronic obstructive pulmonary disease (COPD), rheumatic heart disease, and other causes.
- Regional Breakdown: Seven GBD super-regions covering 204 countries and territories.
- Time Frame: Trends from 1990 to 2021.
3. Global Trends in HF Prevalence
3.1 Absolute Case Counts
In 1990, an estimated 45.5 million people worldwide had HF. By 2021, this climbed to 56.5 million (95% UI: 49.7–63.7 million), reflecting population growth, aging, and improved survival with cardiovascular disease.
3.2 Age-Standardized Rates
The global ASPR increased from 647.9 (556.3–739.9) per 100,000 in 1990 to 682.7 (602.8–766.8) per 100,000 in 2021, indicating a genuine rise in HF burden beyond demographic shifts.
3.3 Sex and Age Patterns
- Sex Differences: Males accounted for 29.2 million HF cases in 2021, while females accounted for 27.3 million.
- Age Distribution: Prevalence remains low under age 40, surges after 60, and peaks in the oldest age groups, underscoring aging as a key driver.
4. Etiological Shifts in HF
4.1 Ischemic Heart Disease Takes Lead
By 2021, IHD became the predominant cause of HF globally, responsible for 33.8% (28.4–38.3%) of cases. This surpasses HHD’s share of 22.6% (19.0–27.1%) and reflects the rising prevalence of atherosclerotic disease associated with urbanization and lifestyle changes.
4.2 Cardiomyopathies, COPD, and Rheumatic Disease
- Cardiomyopathies: Account for 8.2% (7.0–9.6%) of HF cases, including dilated, hypertrophic, and restrictive forms.
- COPD-Related HF: Contributes significantly in regions with high smoking rates and air pollution.
- Rheumatic Heart Disease: Though declining globally, it remains important in low-income settings.
4.3 Regional Variations in Etiology
- Sub-Saharan Africa: Hypertensive heart disease surpasses IHD as the leading cause, driven by uncontrolled blood pressure and limited access to antihypertensive therapy.
- High-Income Regions: IHD predominates, but improved cardiac care has modulated related HF burden.
5. Regional Disparities in HF Prevalence
| GBD Super-Region | ASPR per 100,000 in 2021 | Change since 1990 |
| North Africa & Middle East | 780.5 (658.7–907.6) | +4% |
| Central Europe, Eastern Europe | ~750 | +6% |
| Latin America & Caribbean | ~700 | +2% |
| Southeast Asia, East Asia, Oceania | ~690 | +5% |
| South Asia | 600.1 (526.5–671.4) | −2% |
| Sub-Saharan Africa | ~650 | +1% |
| North America & Australasia | ~680 | +3% |
North Africa and the Middle East exhibit the highest ASPR, reflecting rapid urbanization, dietary shifts, and suboptimal risk factor control. South Asia’s slight decline may result from targeted hypertension programs and evolving communicable-to-noncommunicable disease transition.
6. Years Lived with Disability (YLDs)
Global HF YLD rates have paralleled prevalence trends, with an increasing nonfatal disease burden due to improved survival. Although exact 2021 YLD estimates for HF alone are limited, GBD 2019 reported an age-standardized HF YLD rate of 63.92 per 100,000, with modest declines in high-income countries but rising rates in low- and middle-income regions.
7. Public Health Implications
7.1 Prevention and Risk Factor Management
- IHD Prevention: Strengthen lipid and hypertension screening, accelerate smoking cessation, and promote heart-healthy diets and physical activity.
- HHD Control: Expand community blood pressure monitoring and ensure affordable access to diuretics, ACE inhibitors, and other antihypertensives.
- COPD Reduction: Enforce tobacco control policies, reduce ambient and household air pollution, and scale up early diagnosis.
7.2 Early Detection and Care Delivery
- Deploy point-of-care natriuretic peptide testing in primary care, especially in underserved areas.
- Integrate echocardiography services into district hospitals and mobile clinics.
7.3 Equitable Resource Allocation
- Prioritize HF registry establishment to monitor regional trends and health system performance.
- Expand telemedicine networks linking rural providers with cardiology specialists.
7.4 Policy and Financing
- Embed HF screening and management within Universal Health Coverage benefit packages.
- Advocate for differential pricing or bulk procurement of evidence-based HF therapies to improve affordability.
Conclusion
Heart failure global prevalence and years lived with disability have risen steadily from 1990 to 2021, driven by aging populations, increasing ischemic heart disease, and persistent regional disparities. The shifting etiological landscape—particularly the ascendancy of IHD—underscores the need for comprehensive, region-tailored prevention and management strategies. By fortifying Heart Failure risk factor control, enhancing early diagnosis, and ensuring equitable access to guideline-directed therapies, the worldwide community can arrest the escalating HF burden and mitigate its profound human and economic impact.
