Heart Failure Mortality in High-Income Nations: Diabetes, Disparities, and Unmet Challenges in the Modern Era

Abstract

Heart Failure Mortality in High-Income Nations: Diabetes, Disparities, and Unmet Challenges in the Modern Era 
    

Heart failure (HF) has grown into a major public health challenge, defying many of the improvements seen in other cardiovascular diseases, particularly in high-income countries. Over the past twenty years, there has been a dramatic shift in mortality patterns: while deaths from coronary heart disease (CHD) and stroke have steadily declined due to advances in acute care, public health interventions, and aggressive risk factor management, heart failure deaths have stagnated or even increased in many developed regions. This “HF mortality plateau” indicates not only clinical complexity and limitations in existing therapies, but also exposes persistent health system vulnerabilities and rising comorbidity burdens, particularly driven by diabetes, obesity, and aging populations.​ 

The growing prevalence and severity of HF are compounded by demographic transitions. The world's population is aging, and metabolic diseases like obesity and diabetes continue to accelerate globally. In high-income countries, where the expectation is for the greatest clinical resources and preventive capabilities, HF now accounts for an outsized share of cardiovascular mortality. Between 2025 and 2050, for instance, crude cardiovascular mortality is projected to rise sharply, and though age-standardized rates may show minor declines, the absolute number of deaths from HF will likely remain unchanged or increase due to the expanding base of at-risk elderly and chronically ill patients.​ 

Diabetes, in particular, has emerged as a critical amplifier of heart failure risk and mortality. Epidemiological studies show that individuals living with diabetes have up to double the risk of HF death compared to the general population, and this excess has not improved over recent decades, despite declines in other cardiovascular risks. This stagnation is not due to lack of medical innovation; rather, it reflects complex interactions between chronic metabolic damage, healthcare inequities, socioeconomic gradients, and underutilization or inaccessibility of lifesaving therapies.​ 

Moreover, changing epidemiological contexts—such as the transition from HFrEF to the more refractory HFpEF phenotype, and the additional complexity brought on by COVID-19 disruptions—underscore the urgency for renewed analysis and multifactorial strategies. The imperative is clear: contemporary heart failure must be recognized as both a consequence and a barometer of changing population health, clinical practice, and health system adaptability. This chapter aims to dissect the epidemiology, drivers, disparities, and mechanisms behind the HF mortality plateau and to present actionable recommendations on clinical, research, and public health fronts, with special attention to diabetic populations who remain at greatest risk. 
 

Epidemiological Overview 

Global and Regional Mortality Trends 

Recent analyses of cardiovascular mortality covering nearly three million deaths across multiple Western nations illuminate striking patterns. Standardized five-year intervals from 2000 forward show CHD and overall cardiovascular (CV) mortality fell by 11–32%, and stroke death rates also decreased, albeit with international variation. In contrast, HF mortality either plateaued or increased, with pronounced rises in regions such as Ontario, Canada, and only marginal improvements elsewhere. In the U.S., HF was a contributing cause in 425,147 deaths, accounting for roughly 45% of CV deaths as of 2022. Data from the past decade indicate not only that HF mortality is stable or rising, but that this trend is especially intractable among diabetic populations.​ 

Disparities by Diabetes Status 

Diabetes substantially magnifies the risk of HF death. Epidemiological studies consistently demonstrate that DM is associated with a twofold or greater incidence of HF, with an even higher risk for cardiovascular-related death among those suffering both conditions. For example, the Framingham study found that people with DM are 2.4–5 times more likely to develop HF. More than one-quarter of HF patients exhibit concurrent DM, with registries showing rates up to 40%, depending upon population demographics. Mortality rate ratios remain stubbornly elevated for diabetics—with crude rates for HF as a contributing cause at 61.2 per million in recent U.S. data. Notably, while death rates from stroke and heart attack in diabetics have improved, those for HF have not.​ 

Demographic and Geographic Gaps 

Disparities in HF mortality extend by gender (higher rates in females), race (highest in White individuals; fastest recent rises in Asian and Pacific Islander groups), urban-rural status, and socioeconomic gradients. Mortality post-2010 increased most rapidly among males and some minority groups, reflecting changing patterns of healthcare access and disease management.​ 
 

Drivers of Persistent Heart Failure Mortality 

Epidemiological Shifts and the Survival Paradox 

With advances in acute cardiovascular interventions—such as stenting, thrombolysis, and modern antihypertensives—more people are surviving heart attacks and strokes. However, this often leaves a large cohort of people living longer with residual cardiac damage, prone to chronic HF. Instead of dying acutely, individuals enter protracted courses of heart failure, shifting the makeup of cardiovascular mortality toward this end-stage diagnosis.​ 

Diabetes, Obesity, and the "Comorbidities Tsunami" 

Global diabetes prevalence has doubled in the past 15 years, reaching 463 million cases by 2019 and projected to balloon further. This, alongside parallel rises in obesity and hypertension, produces a comorbid burden uniquely hazardous for HF outcomes. DM contributes to HF by promoting myocardial fibrosis, microvascular dysfunction, glycotoxic damage, and renal impairment. Hospitalizations, arrhythmias, and pump failures are more frequent in diabetic patients. Moreover, the aging, obese population increasingly develops HFpEF (heart failure with preserved ejection fraction), a phenotype resistant to many traditional interventions.​ 

Mixed Progress in Heart Failure Therapy 

Modern drugs—ACE inhibitors, beta-blockers, ARNIs, MRAs, and SGLT2 inhibitors—have slashed mortality for HFrEF (reduced ejection fraction) but not HFpEF (preserved ejection fraction), which accounts for more than 50% of contemporary HF cases and especially affects older, diabetic, hypertensive women. HFpEF lacks proven mortality-reducing therapies. Moreover, high costs, insurance gaps, and prescriber inertia mean that even the best medicines are underutilized.​ 

Health System and Socioeconomic Barriers 

Systemic disadvantage persists for lower-income, racial minority, and rural patients: later diagnoses, poorer care continuity, and limited access to guideline-based therapies mean higher rates of avoidable death. Hospital-based, episodic models dominate over community-based, chronic management, with insufficient transition-of-care and follow-up programs.​ 

COVID-19 Effects 

The pandemic further aggravated HF risks, delaying routine care, exacerbating viral-related cardiac injury, and straining health resources worldwide.​ 

Underutilization of Novel Therapies 

Even where innovation is available, proven agents (SGLT2i, ARNI, MRAs, device therapy) are given to only a minority of eligible patients, hindered by cost, prescription inertia, insurance policies, and disparities in health system infrastructure.​ 
 

Mechanistic Considerations 

Pathophysiology: Why Diabetes Amplifies HF Mortality 

The interplay between DM and HF is complex, synergistic, and bidirectional. Chronic hyperglycemia induces myocardial fibrosis, impairs microvasculature, and causes autonomic imbalance, contributing to diastolic dysfunction, arrhythmias, and increased pump failure. In addition, insulin resistance and elevated insulin levels constrict compensatory cardiac mechanisms, triggering inflammatory cascades and worsening renal-cardiac interactions ("cardiorenal syndrome"). Patients with DM and HF show rapid disease progression and diminished response to standard HF therapies.​ 

HF Phenotypes: HFrEF vs. HFpEF 

While HFrEF (systolic dysfunction) benefits from multiple pharmacologic and device-based interventions, HFpEF (diastolic dysfunction) is growing fastest, particularly in high-risk groups—older women, diabetics, hypertensives, and obese individuals. The absence of proven life-prolonging therapies for HFpEF is now a major contributor to the persistence of HF mortality.​ 

Multinational Data and Trend Analysis 

CHD and Stroke: Areas of Success 

Public health investments, statin use, expanded antihypertensives, and acute reperfusion therapies have driven steady improvements in MI and stroke mortality for two decades. This success proves that coordinated, systems-level approaches can produce transformative population-wide change.​ 

Heart Failure: Mortality Plateau and Data Challenges 

In contrast, both prevalence and deaths from HF continue to climb, especially as populations age and the pool of survivors from acute cardiac events enters chronic failure. Death certificate data may understate the HF burden, yet hospitalization-based metrics confirm continued high rates of admissions and deaths—especially among diabetics.​ 

Diabetes—The Unchanging Multiplier 

Despite better glycemic management, diabetics continue to face a doubled risk of HF and HF mortality, with little improvement over the past decade. This lack of progress versus CHD marks a major therapeutic and research gap.​ 
 

Clinical Practice and Research Gaps 

Prevention 

Early, intensive management of risk factors—glycemia, blood pressure, obesity, and lifestyle—is fundamental. Community-based and multidisciplinary models outperform episodic hospital-based care, and need expansion globally.​ 

HFpEF: New Frontiers 

Significant research investment must address HFpEF, now the dominant heart failure phenotype. SGLT2 inhibitors show promise, but other strategies—precision medicine, anti-fibrotic agents, and biomarkers—are urgently needed.​ 

 
Chronic Disease Management and Equity 

Integrated, multidisciplinary heart failure clinics optimizing transition-of-care, remote monitoring, and social support show improved outcomes but require resource investment. Digital health and self-management can extend reach, but disparities in access must be addressed.​ 

Treatment Access and Affordability 

Universal, affordable access to all proven HF therapies and devices is imperative. This will require government procurement, insurance reform, and training programs for providers.​ 

Research Recommendations 

Stress must be placed on large-scale, phenotype-stratified studies, robust registry development, data harmonization, and translational insight sharing.​ 
 

Socioeconomic and Public Health Perspectives 

Social Determinants 

Social determinants—income, race, education, geography—powerfully shape HF risk, management, and survival. Addressing these factors through tailored interventions and community-based support reduces HF disparities and overall cardiovascular burdens.​ 

System Reform and Education 

Patient empowerment, workforce training, and re-engineered care pathways underpin all sustainable improvements. Telehealth, remote monitoring, expanded medication access, and resilient networks are necessary for both current care and future contingencies, as highlighted during the COVID-19 pandemic. 

 
Conclusion: 

The enduring challenge of heart failure mortality—especially within the context of diabetes, obesity, and aging—demands a paradigm shift in both medical and public health approaches. Contemporary data show that high-income countries, despite sophisticated health infrastructures, are struggling to make substantive progress against HF death rates. Improvements in acute coronary syndrome and stroke mortality have not extended to HF, which now claims the lives of ever-more patients with complex chronic profiles and substantial comorbidity burdens.​ 

Key mechanisms underlie this persistent threat. The increasing prevalence of diabetes and obesity synergistically accelerates both the onset and progression of HF, contributing to myocardial fibrosis, inflammatory cascades, and cardiac-renal dysfunction. Meanwhile, population aging ensures a growing pool of vulnerable individuals who, after surviving initial cardiovascular insults, face long-term declines in cardiac reserve. Healthcare systems face challenges of continuity: hospital-based, episodic care models are poorly suited for the chronic nature of heart failure, resulting in frequent readmissions, suboptimal long-term management, and unequal access to advanced therapies.​ 

Systemic disparities—whether by income, geography, gender, race, or education—further magnify the burden, particularly among diabetic patients. Despite the availability of life-extending therapeutics, their underutilization—due to cost, complexity, physician familiarity, and insurance gaps—constitutes a major lost opportunity. The COVID-19 pandemic has exacerbated these weaknesses, emphasizing the importance of resilient care pathways, digital health solutions, and universal access to essential medicines and devices. 

Moving forward, resolving the HF mortality plateau calls for multi-level action. Prevention must be prioritized by enhancing early risk factor control, integrating community-based chronic disease management, and erasing gaps in care that disproportionately affect the marginalized. For HFpEF and diabetic HF—now the dominant forms—intensive research, precision medicine, and innovative drug/device development are essential. In practice, broadening the reach of proven therapies and optimizing health system design for chronic care, transitions, and self-management will be pivotal. 

Ultimately, heart failure serves as both a sentinel and a challenge in modern cardiovascular and metabolic health. Its resistance to declining mortality spotlights wider issues of equity, healthcare delivery, and the limits of current knowledge. Nevertheless, with collective commitment from societies, clinicians, researchers, and policymakers, the next decade offers the potential not only for turning the tide against HF mortality but also for setting new standards in chronic disease management. This shift will require sustained investment, intelligent policy reform, and relentless innovation—ensuring that the benefits of modern medicine extend to every patient, particularly those with diabetes who remain most vulnerable to the consequences of heart failure.​ 
 

References: 

• Lippi, G. et al. (2020) ‘Global epidemiology and future trends of heart failure’, AMJ, 22 Mar.​ 

• Goh, RSJ. et al. (2024) ‘The burden of cardiovascular disease in Asia from 2025 to 2050’, PMC, 9 July.​ 

• Harikrishnan, S. et al. (2025) ‘One-year mortality and re-admission rate by disease’, Nature.​ 

• WHO (2025) ‘Cardiovascular diseases (CVDs)’, World Health Organization.​ 

• The Lancet (2025) ‘Time trends in mortality from heart failure and atherosclerotic CVD by diabetes status’, The Lancet, 7 Nov.​ 

• World Heart Federation (2025) ‘World Heart Report 2025’.​ 

• Shahzad, M. et al. (2025) ‘Trends and disparities in heart failure mortality with and without diabetes’, Nature.​ 

• Explorationpub.com (2025) ‘A comprehensive review on diabetes mellitus and heart failure’.