The impact of country income level on the management of heart failure with preserved ejection fraction: an international survey

Abstract

INTRODUCTION: To assess how national income level influences global variation in the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). METHODS: A web-based survey on HFpEF diagnosis and treatment was distributed worldwide from May to July 2023 through email, scientific societies, and social networks. Respondents provided demographic information and details on diagnostic practices, resource availability, and treatment approaches. Countries were categorized according to the 2023 World Bank income classifications: high-income countries (HICs), upper-middle-income countries (UMICs), lower-middle-income countries (LMICs), and low-income countries (LICs). RESULTS: 1459 physicians from 91 countries completed the survey (median age 42 years; 61% male). Income level influenced the type of clinician managing HFpEF, with cardiologists more frequently involved in UMICs and LMICs/LICs than HICs. Respondents in HICs reported a higher proportion of HFpEF among their HF patients (40% vs 30% elsewhere; P < .001). Use of natriuretic peptides varied significantly across settings, as did the availability of echocardiographic parameters required for HFpEF assessment, which was highest in HICs. Screening for coronary artery disease in new HFpEF cases ranged from 22% in LMICs/LICs to 40% in UMICs. Availability of ACE inhibitors, ARBs, MRAs, and loop diuretics showed clear income-related differences, while SGLT2 inhibitors were widely available across all groups (88%). Multi-disciplinary HF programmes were most common in HICs (62%) and least common in LMICs/LICs (24%; P < .001). CONCLUSION: National income level is associated with major differences in diagnostic testing, medication access, specialist involvement, and multi-disciplinary care for HFpEF. These disparities highlight the need for scalable, resource-adapted strategies to optimize HFpEF care globally.