India is reeling under the burden of cardiovascular diseases. The current estimates indicate that cardiovascular diseases (CVDs) is the 2nd leading cause of mortality amongst all non-communicable diseases. Amongst all CVDs, medical experts have expressed their concern regarding heart failure which continues to be one of the most underrated and under-diagnosed heart conditions.
As a result, the condition has been silently and rapidly killing patients and leading to repeated hospitalizations, increasing the socio-economic burden on patients and their families.
Heart Failure (HF) is a progressive disease, in which the heart muscle weakens or becomes stiff overtime, which reduces its ability to pump properly. This reduces the amount of oxygen and nutrients circulated to vital organs of the body. Heart failure is becoming an epidemic in the country, affecting an estimated 8-10 million people in India.
Congestive heart failure as a condition places huge socio-economic burden on patients, failure to adhere to post-hospitalization treatment protocol results into frequent hospitalization leading to mortality. Understanding the factors that inhibit patient-care is essential in developing effective health care interventions.
According to the International Congestive Heart Failure (INTER-CHF) study the mortality in patients with heart failure in low-income and middle-income countries like India is greater compared to the western counterparts.
The marked variation in mortality is attributed to low awareness, economic disparity, ease of access to high quality healthcare facilities, environmental and genetic factors.
Close to 23% of heart failure patients die within one-year of diagnosis, with the burden of heart failure snowballing in India and the associated high death rates, it is necessary to recognize heart failure as a public health priority in the country. The disease has socio-economic and emotional implications on the patient and their families, impacting the overall quality of life.
Barriers to Care for Heart Failure Patients in India
Low Awareness
Limited health literacy is a major barrier to heart failure diagnosis and treatment. There is a huge gap in basic understanding of heart failure in India. People generally confuse heart failure with heart attack or other heart ailments.
Symptoms of heart failure like shortness of breath, swelling in ankles, knees and abdomen are also confused with signs of old age, this can lead to delayed diagnosis and the patient might reach the doctor at an advanced stage of the disease.
It is important to pay close attention to signs like shortness of breath, need for elevated pillows while sleeping, swollen ankles, legs or abdomen or increased night time urination etc. One must not ignore these symptoms and visit a cardiologist immediately.
Limited Access to Quality Healthcare
The Indian healthcare sector has seen improvements over the past couple of decades, but there is still a long way to go before we meet international standards. The improvements have not been uniform – inequities based on gender, rural vs. urban, and even social status. Around 60% of the hospitals in India are in the urban areas and cater to only 30% of the population. Only 13% of the rural population has access to a primary healthcare facility and less than 10% to a hospital.
In the case of heart failure at times patients in India are the sole-owner/bread-winners of the family and have burden of the caregivers and survival of family. They do not have access to quality healthcare. According to a WHO report the doctor patient ratio in India is 1:1000, this makes quality healthcare a challenge as there is lack of trained primary healthcare providers in most of the hospitals.
Possible Solutions
Need for Dedicated Heart Failure Clinics in India
Traditionally, treatment of heart failure was primarily targeted at relieving symptoms of congestion or increasing cardiac function. However, newer and advanced treatment options for heart failure which mostly comprise of combinational therapy are crucial for improved results.
While adhering to the medications prescribed by the doctor is important to improve the patient’s condition, heart failure patients require constant monitoring to evaluate the benefits of the treatment. This could only be made possible through dedicated heart failure clinics.
Heart failure clinics is a popular concept in the west. It involves well-trained nursing staff and primary healthcare providers specialized in heart failure treatment. According to the Transition-HF Study, programs that involved specialty nurses rather than community nurses, pharmacists or multi-disciplinary care providers had improved mortality and re-hospitalization outcomes.
Heart Failure Registries
A positive step in this direction is the formation of a National Heart Failure Registry, which would provide scientifically investigated data on demographics, clinical patterns, diagnostic and therapeutic strategies for patients. This would help in designing solutions in context of the barriers of care that currently exist. At present there are four heart failure registries in India –a Global Registry of which India is a part of, Trivandrum Heart Failure Registry (THFR), National Heart Failure Registry by Indian College of Cardiology (ICC) and CSI East India Registry.
Heart Failure can be managed effectively if India strengthens its pillars of healthcare. National programs concentrating on screening and detection of symptoms of heart diseases amongst the rural population, should be introduced. The need of the hour is for all stakeholders to come together to develop a community-level approach to raise awareness about this condition. It is important that the growing incidence of heart failure should beconsidered as a public health challenge to further reduce death rates and morbidity caused due to heart failure.
(Dr Sundeep Mishra is a Professor of Cardiology at AIIMS, Delhi)
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