Heart Failure Among 173,000 Community-Dwelling Participants From 25 Low-, Middle-, and High-Income Countries in the PURE Study

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. (JACC. 2026;87:3506-3517) (c) 2026 by the American College of Cardiology Foundation.