Letter by Ozair et al Regarding Article, "The Upcoming Epidemic of Heart Failure in South Asia".

To the Editor:

South Asia is rapidly emerging as a hotbed for cardiovascular disease, including heart failure (HF). In their excellent review, Martinez-Amezcua et al[1] describe a forthcoming epidemic of HF in this region. They also provide likely explanations and potential interventions for the same. Notably, they advocate for establishing HF clinics, creating chronic HF management programs, and expanding access to all types of HF therapies. These agendas stand mainly upon the shoulders of those fully exposed to the breadth and depth of HF management during their training. Therefore, the absolute lack of formal training in managing HF in South Asia, which this review does not mention, specifically warrants discussion.

In the United States, for the year 2020, 84 Accreditation Council for Graduate Medical Education-accredited programs provided 115 fellowship training positions in advanced heart failure and transplant cardiology for the 1010 graduates of the 231 cardiovascular disease (CVD) training programs.[2] In contrast, no such formal training programs in heart failure exists in South Asia. We conclude this after having (1) examined the databases of the 2 major counterparts of the Accreditation Council for Graduate Medical Education in India, the Medical Council of India, and the National Board of the Examination; (2) extensively searched websites of the leading South Asian cardiovascular institutes; and (3) informally surveyed our colleagues, with one of the authors being the current secretary of the Indian College of Cardiology.[3,4]

This is in stark contrast to the state of formal training in CVD and interventional cardiology (post-CVD residency) in South Asia. For instance, in India, 709 accredited positions in 3-year CVD training were offered in 2020.[3,4] Similarly, for interventional cardiology, although not still quantified due to lack of a central database, several training programs exist. Additionally, lack of an accrediting body in India currently for all such super-fellowships (post-CVD training) leads to significant heterogeneity in their quality.

South Asia is also plagued by the dearth of training in surgical heart transplant, with not a single formal fellowship program here. In contrast, Makdisi et al[5] found in a survey done in 2015 that of the 104 heart transplant centers functioning then in the United States, 45 responded, of which 26 were running such fellowships. However, even in United States, cardiothoracic transplant is not Accreditation Council for Graduate Medical Education-accredited fellowship, and it has been argued that the current level of training in several programs is inadequate for heart transplants.[5]

Such formal training programs, although much-needed currently, will soon become critical. The current estimated HF burden in India and Pakistan is 1.3 to 4.6 million and 2.8 million individuals, respectively.[1] Due to the socioeconomic transition that South Asian countries are in, with its accompanying lifestyle changes, coupled with increasing life expectancy and population size, HF burden will increase significantly in the future. Additionally, the prognosis of HF among South Asians has been demonstrably worse than in other regions. Thus, the need for specialists will only increase.

Although prevention must remain the backbone in resource-limited South Asian countries to reduce this burden, development of formal expertise will improve both acute and chronic management. Martinez-Amezcua et al[1] describe large gaps in the use of evidence-based therapy for HF in South Asia, with miserable proportions of patients receiving optimum care. The establishment of appropriate training programs will go a long way in reducing morbidity and mortality.

Thus, we strongly recommend the establishment of accredited fellowship programs in advanced heart failure and transplant cardiology and cardiothoracic transplant. As the coronavirus disease 2019 (COVID-19) pandemic has taught us, without urgent anticipatory action, a crisis looms near.

Disclosures

None.