Geographic variation in heart failure infrastructure capacity and cardiovascular disease burden in europe: a cross-sectional analysis
S Pradeep Kundur, A Malik, K Manivannan, A Shahzad, A Mathew, A F Shaikh, A RaiAbstract
Background
Heart failure (HF) represents a growing public health burden across Europe, with substantial variation in prevalence, hospitalisation, and mortality. Persistent East–West disparities in cardiovascular outcomes have been reported, with higher cardiovascular mortality in Eastern Europe. Data from the ESC Atlas demonstrate wide inter-country variation in HF-specific infrastructure. However, the extent to which regional infrastructure differences align with population-level cardiovascular disease burden remains incompletely characterised. We therefore assessed regional differences in HF infrastructure using a composite Heart Failure Infrastructure Index (HFII) and examined associations with major HF-related cardiovascular disease categories.
Methods
A cross-national ecological study was conducted across 19 European countries (10 Eastern, 9 Western). Publicly available data from the ESC Atlas of Cardiology and Eurostat were used to derive seven HF-related infrastructure indicators per million population, encompassing diagnostic, biomarker, functional testing, rehabilitation, specialist service, decongestion, and cardiac magnetic resonance imaging capacity. Indicators were standardised as z-scores and aggregated into the HFII. Primary outcomes were national rates (per 100,000 population) of ischaemic heart disease (IHD), hypertensive heart disease (HHD), non-rheumatic valvular heart disease (NRVHD), and cardiomyopathy/myocarditis (CM/MYO). Inter-regional comparisons used Welch’s t-tests. Multivariable linear regression assessed associations between region and disease burden, adjusting for GDP per capita and HFII.
Results
Western Europe demonstrated a significantly higher HFII than Eastern Europe (mean 0.51 vs −0.47; p = 0.006), driven by greater availability of spiroergometry (p = 0.017), HF exercise programmes (p = 0.027), and dedicated HF centres (p = 0.012). Eastern Europe exhibited substantially higher burdens of IHD (168.9 vs 54.1 per 100,000; p < 0.001), HHD (30.1 vs 9.3; p = 0.006), and CM/MYO (13.7 vs 3.7; p = 0.001), while NRVHD showed less consistent regional separation. In multivariable analysis, Western Europe remained independently associated with lower IHD burden (β = −78.8, p = 0.017), explaining 70% of outcome variance (R² = 0.70). A similar inverse association was observed for CM/MYO but did not reach statistical significance (β = −7.01, p = 0.086; R² = 0.51).
Conclusion
Marked regional disparities in HF infrastructure persist, coinciding with a higher burden of HF-associated cardiovascular disease in Eastern Europe. Lower infrastructure capacity clusters with greater disease prevalence, suggesting that outcome disparities reflect broader structural and preventive health system factors. As an cross-sectional study, these findings support integrated strategies combining investment in HF infrastructure with strengthened cardiovascular prevention and further population-level research into the drivers of this persistent gap.Heart Failure Infrastructure IndexFor image description, please refer to the figure legend and surrounding text.Cardiovascular Disease BurdenFor image description, please refer to the figure legend and surrounding text.