Executive Highlights
A comprehensive multi-national study spanning nine high-income jurisdictions has revealed a significant divergence in cardiovascular mortality trends. While deaths from coronary heart disease (CHD) and cerebrovascular disease have seen substantial declines over the past two decades, heart failure (HF) mortality remains a persistent and growing clinical burden. Key highlights include:
- Consistent declines in CHD mortality across all regions, with 5-year reductions ranging from -11.5% to -32.3%.
- Heart failure mortality reductions are significantly smaller than those for atherosclerotic diseases and, in some regions like Ontario, Canada, heart failure mortality is actually increasing.
- The mortality rate ratio for heart failure in patients with diabetes compared to those without has remained stagnant, showing no improvement in excess risk over the study period.
- A critical need for intensified clinical focus on heart failure prevention and management, particularly within the diabetic population.
The Shifting Landscape of Cardiovascular Mortality
For decades, the primary focus of cardiovascular medicine has been the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD), including myocardial infarction and stroke. Through the widespread use of statins, antiplatelet therapies, antihypertensive medications, and advanced revascularization techniques, healthcare systems have achieved remarkable success in reducing mortality from these conditions. However, as the population ages and the prevalence of metabolic disorders like diabetes mellitus continues to rise, a different manifestation of cardiovascular pathology—heart failure—has emerged as the new frontier in clinical medicine.
Diabetes mellitus is a potent driver of heart failure, contributing to both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) through mechanisms involving microvascular dysfunction, metabolic stress, and myocardial fibrosis. Despite the introduction of new therapeutic classes, the real-world impact on population-level heart failure mortality has remained unclear until now.
Study Design and Multi-National Methodology
The study, published in The Lancet Diabetes & Endocrinology, represents one of the most robust epidemiological efforts to date to quantify cause-specific cardiovascular mortality trends. Researchers assembled administrative datasets from nine high-income jurisdictions: five in Europe (including Scotland, Denmark, and Finland), Australia, two provinces in Canada (Ontario and Alberta), and South Korea. The follow-up period spanned from 2000 to 2023, encompassing over 1.30 billion person-years and 2.92 million cardiovascular deaths.
The primary objective was to examine trends in mortality for CHD, cerebrovascular disease, and heart failure, stratified by diabetes status. Using Poisson regression models, the investigators estimated mortality rates and mortality rate ratios (MRR), providing a clear picture of the ‘excess risk’ associated with diabetes over time. This methodology allowed for a nuanced comparison across diverse healthcare systems with varying approaches to chronic disease management.
The Divergence: Heart Failure vs. Atherosclerotic Disease
The results of the study demonstrate a striking disparity between the progress made in treating ASCVD and the relative stagnation in heart failure outcomes. In every jurisdiction studied, and regardless of diabetes status, CHD mortality rates fell consistently. These reductions reflect the ‘golden age’ of cardiology, where primary and secondary prevention strategies for atherosclerosis have reached high levels of penetration in clinical practice.
In contrast, the progress in heart failure mortality was much less pronounced. In nearly all jurisdictions, the 5-year percent changes for heart failure mortality were smaller than those for CHD and stroke. For instance, while Scotland showed some improvement in heart failure outcomes, other regions like Ontario, Canada, reported an actual increase in heart failure mortality rates. This suggests that the current strategies for managing heart failure are not keeping pace with the increasing complexity and prevalence of the condition.
The Diabetes Disparity
Perhaps the most concerning finding involves the intersection of diabetes and heart failure. While the excess risk of CHD mortality associated with diabetes (the mortality rate ratio) fell in three of the nine jurisdictions, the excess risk for heart failure mortality did not decrease in a single jurisdiction. The mortality rate ratio for heart failure in patients with diabetes remained stubbornly around 2.0, meaning that individuals with diabetes remain twice as likely to die from heart failure as those without the condition, a gap that has not narrowed in over twenty years.
This lack of progress highlights a ‘therapeutic lag.’ While we have successfully reduced the risk of macrovascular complications like heart attacks in diabetic patients, we have been less successful in addressing the specific pathophysiological pathways that lead to heart failure in this population.
Clinical and Biological Implications
Several factors may contribute to the lagging improvements in heart failure mortality. First, the rise of HFpEF, which is highly prevalent in patients with diabetes and obesity, has historically lacked the clear, mortality-reducing therapies that exist for HFrEF. Until the very recent validation of SGLT2 inhibitors and GLP-1 receptor agonists in this space, clinical options for HFpEF were largely limited to symptom management.
Second, the success in treating acute coronary syndromes (ACS) means that more patients are surviving their initial cardiac events but are left with damaged myocardium, eventually progressing to chronic heart failure. In this sense, heart failure is becoming the final common pathway for a population that is successfully surviving other cardiovascular threats.
Third, the study suggests that the clinical management of diabetes may still be overly focused on glycemic control (HbA1c) rather than comprehensive cardiovascular risk reduction that includes specific heart failure prevention. While glucose lowering is essential for preventing microvascular complications like retinopathy and nephropathy, it does not inherently protect the myocardium from the structural changes associated with diabetic cardiomyopathy.
Expert Commentary: Bridging the Implementation Gap
The stability of the heart failure mortality rate ratio suggests that our current medical infrastructure is failing to translate clinical trial successes into population-level survival gains for diabetic patients. The recent ‘pillar’ therapies for HFrEF—including ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors—offer significant mortality benefits, yet registry data often shows that many patients are not receiving these medications at target doses, or at all.
Furthermore, the diagnostic challenge of heart failure, particularly in the early stages or in the form of HFpEF, remains a barrier. Many patients with diabetes may have undiagnosed diastolic dysfunction that only becomes apparent during an acute decompensation. Experts suggest that a more proactive screening approach, perhaps utilizing biomarkers like NT-proBNP or more frequent echocardiographic assessment in high-risk diabetic cohorts, may be necessary to intervene earlier in the disease progression.
The data from Ontario serves as a cautionary tale. The increase in heart failure mortality there may reflect an aging population with multiple comorbidities that outpace the capacity of existing heart failure services. It underscores the need for health policy experts to allocate more resources toward specialized heart failure clinics and multidisciplinary care teams that include cardiologists, endocrinologists, and primary care physicians.
Conclusion: A Call for Targeted Heart Failure Strategies
The findings from this multi-national study provide a sobering reminder that the battle against cardiovascular disease is far from over. While the decline in atherosclerotic mortality is a triumph of modern medicine, the stagnation in heart failure outcomes—especially among those with diabetes—is a call to action.
Clinicians must shift from a reactionary model of heart failure care to a preventative one. This includes the early initiation of SGLT2 inhibitors in patients with type 2 diabetes and high cardiovascular risk, regardless of baseline HbA1c or the presence of established heart failure. For health systems, the focus must move toward integrated care pathways that recognize heart failure as a primary cause of mortality and morbidity in the 21st century. Without a concerted effort to address heart failure with the same rigor we applied to coronary artery disease, the mortality gap for people with diabetes will continue to persist.
Funding and Acknowledgments
This study was supported by the US Centers for Disease Control and Prevention, the Diabetes Australia Research Program, and the Victoria State Government Operational Infrastructure Support Program. The authors declare no competing interests related to the primary data analysis.
References
- Gong JY, Morton JI, Chen L, et al. Time trends in mortality from heart failure and atherosclerotic cardiovascular disease in people with and without diabetes: a multi-national population-based study. Lancet Diabetes Endocrinol. 2026 Jan;14(1):20-28.
- Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med. 2014;370(16):1514-1523.
- McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381(21):1995-2008.
- Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451-1461.