Heart failure patients in India die 10 years earlier: study

Data from India’s first nationally representative heart failure registry with prospective follow-up data has found that heart failure patients in India are almost 10 years younger than their counterparts living in high-income countries. One in four heart failure patients in India die within one year of follow-up, with a wide variation in the one-year mortality rate based on the disease that causes heart failure. Heart failure is said to occur when the heart muscle fails to pump enough blood to meet the demands of the body.

A study which looked at one-year mortality rate of patients with heart failure enrolled consecutive patients admitted with the diagnosis of acute decompensated heart failure from January-December 2019. In total, 10,850 participants were enrolled in the National Heart Failure Registry (NHFR), which is a multicentric, hospital-based registry of heart failure patients from 53 centers across 24 States and two Union Territories in India. The registry has nine nodal centers with five participating centres under each of them. The Thiruvananthapuram-based Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) is the national coordinating centre for the national registry. “The baseline demographic and clinical characteristics, etiology, and one-year survival of heart failure patients may help to influence policies to reduce heart failure-related burden and mortality in India,” the NHFR registry website says.

The study, which was published in January 2025 in the journal Nature Communications, looked at one-year mortality among 10,845 patients with heart failure. At 7,800, ischemic heart disease was the predominant cause of heart failure (71.9%). Dilated cardiomyopathy was the second major cause of heart failure among 1,877 patients (17.3%), and rheumatic heart disease in 586 patients (5.4%) being the third leading cause of heart failure. Despite the predominance of ischemic heart disease, at 21.1%, the mortality rate at one year was relatively less dilated cardiomyopathy (23.7%). The other causes of heart failure were non-rheumatic valvular heart disease (1.9%), hypertrophic cardiomyopathy (0.9%), congenital heart disease (0.7%), peripartum cardiomyopathy (0.5%), restrictive cardiomyopathy (0.4%), and infective endocarditis (0.1%).

“Mortality rate of over 20% in one year is considered very high. Such high mortality rates are not seen in most common cancers such as breast cancer,” says Dr. Jeemon Panniyammakal, Additional Professor of Epidemiology at SCTIMST and the corresponding author of the paper. “Good and timely acute disease management of ischemic heart disease is one reason for longer survival of such patients. Not following medications and poor lifestyle are reasons for higher mortality in these patients.” 

A 2022 study of the same cohort of heart failure patients found that the 90 day mortality was 14.2%, with ischaemic heart disease being the primary disease cause (72%) followed by dilated cardiomyopathy (18%). Though ischemic heart disease patients accounted for most deaths even at one year — 1,649 —  among heart failure patients in the January 2025 study, the mortality rate was only 21.1%. In comparison, there were 444 deaths at one year among dilated cardiomyopathy, but the mortality rate was higher at 23.7%. In the case of rheumatic heart disease, though there were only 161 deaths in one year, the mortality rate was far higher at 27.5%. The mortality rate was high in infective endocarditis (50.0%), congenital heart disease (34.6%), and restrictive cardiomyopathy (36.8%) compared with other causes of heart failure.

In contrast to the reports from heart failure registries in high-income regions, the National Heart Failure Registry (NHFR) of India showed substantially higher mortality rates in heart failure patients with rheumatic heart disease, congenital heart disease, and infective endocarditis compared with ischemic heart disease. Compared with ischemic heart disease, mortality was two to five times higher in patients with rheumatic heart disease, congenital heart disease, and infective endocarditis.

“The high mortality associated with rheumatic heart disease and congenital heart disease in the NHFR cohort has important implications, especially in the low- and middle-income countries (LMIC) context,” they write. “Lack of awareness about acute rheumatic fever, poor compliance with penicillin prophylaxis, and late presentation contribute to the high prevalence of rheumatic heart disease in LMICs.”

“Patients with rheumatic heart disease require timely surgical corrections. Since the valves get affected by the disease, not replacing the valves on time will lead to heart failure and worsening of the disease,” says Dr. Panniyammakal.

According to the authors, in the case of people with congenital heart disease, not treating the disease early is a risk factor for the development of irreversible pulmonary hypertension, and subsequent ventricular dysfunction leading to heart failure. “Appropriate management of congenital heart disease early in life prevents pulmonary hypertension development and progression to heart failure,” they write.

“In our cohort, the lowest mortality was among patients with peripartum and hypertrophic cardiomyopathy (12-13%). The relatively lower mortality risk in hypertrophic cardiomyopathy, as observed in our cohort, is well documented, with low-risk hypertrophic cardiomyopathy patients experiencing a survival rate like the general population. Infective endocarditis was a disease with high mortality (50%) in the NHFR registry,” the authors write.

The mean age of heart failure patients ranged widely — 29.2 years in the case of peripartum cardiomyopathy patients to 61.9 years in patients with ischemic heart disease etiology. While women comprised one-third of all heart failure patients, the proportion of women was over 50% when the underlying disease cause was rheumatic valvular heart disease or congenital heart disease. Women were disproportionately higher with disease etiologies of non-rheumatic valvular heart disease, hypertrophic cardiomyopathy, and restrictive cardiomyopathy.