Africa's largest acute heart failure study finds a median patient age of 56

Contemporary data on the aetiology, management and outcomes of acute heart failure across Africa are scarce [s1], and the study designed to fix that describes the gap it was addressing as outdated data on access to care and missing information on the incidence, aetiology, availability and affordability of heart failure medicines [s2]. THESUS-HF II was published in The Lancet on 30 August, and the finding most likely to be repeated from it is a demographic one: the median age of a patient admitted with acute heart failure across 17 African countries was 56 [s1].

What the study did

THESUS-HF II was a prospective, multicentre, observational cohort study conducted in 50 hospitals across 17 African countries [s1]. Adults aged 18 or older presenting with acute heart failure were enrolled during seven 24-hour surveillance periods within an eight-week, site-specific window [s1]. Acute heart failure was identified by acute dyspnoea and congestion, supported by electrocardiography, chest radiography and point-of-care echocardiography [s1].

The design measures presentation rates per 10,000 people in each hospital's adult catchment population per week, treatment patterns including discharge medication, readmission and all-cause mortality to 180 days [s1]. It was registered with the Pan African Clinical Trial Registry as PACTR202410553810557 [s1].

The study was coordinated by the Pan-African Society of Cardiology, and its published protocol describes a two-part structure: a platform collecting data on each hospital's catchment population, staffing, cardiology services, diagnostic tools and access to essential heart failure treatments, and the prospective observational study itself [s2].

What it found

Between 1 July 2024 and 31 July 2025, 1,741 patients were assessed for eligibility and 1,578 were included [s1]. Of 1,570 with sex recorded, 793 (50.5%) were female and 777 (49.5%) male; 1,533 of 1,567 (97.8%) were of African descent [s1]. Median age was 56.0 years (IQR 40.0–69.0) [s1].

The weekly acute heart failure presentation rate was 0.03 per 10,000 people (95% CI 0.02–0.05) overall, and 0.02 per 10,000 (0.01–0.04) for de novo acute heart failure [s1]. De novo presentations accounted for 1,007 of 1,568 (64.2%) — that is, most patients were being admitted with heart failure for the first time [s1].

The leading causes were hypertensive heart disease in 576 of 1,578 (36.5%), cardiomyopathy in 370 (23.4%) and ischaemic heart disease in 367 (23.3%) [s1].

Median ward stay was 6.0 days (IQR 4.0–10.0) and in-hospital mortality was 8.7% (95% CI 7.3–10.2; 134 of 1,542) [s1]. Of 1,567 patients in time-to-event analyses, 528 (33.7%) were lost to follow-up before 180 days [s1].

The prescribing finding, and its qualifier

At discharge, renin-angiotensin-aldosterone system inhibitors were prescribed to 1,014 of 1,373 patients (73.9%), beta blockers to 1,053 of 1,369 (76.9%), mineralocorticoid receptor antagonists to 982 of 1,366 (71.9%) and SGLT2 inhibitors to 743 of 1,359 (54.7%) [s1].

Those are not the numbers a reader primed by the phrase "medicines access gap" would expect. Roughly three-quarters of patients left hospital on three of the four guideline drug classes, and more than half on the fourth.

The qualifier is in the same sentence of the paper: target doses were reached in fewer than half of patients [s1]. Prescription and dose are different things: a discharge prescription at a fraction of the target dose is a partially delivered therapy, and the gap between the two figures is where the remaining work sits.

Ischaemic disease at 23%

The linked Comment in the same issue is titled "Acute heart failure in Africa: new causes, unchanged outcomes" [s3]. The "new causes" phrasing points at the aetiology table. Hypertensive heart disease remains the single largest cause at 36.5%, but ischaemic heart disease at 23.3% is now nearly level with cardiomyopathy [s1]. A disease profile in which nearly a quarter of acute heart failure is ischaemic is an epidemiological transition in progress.

The median age of 56 [s1] is the other half of that picture. Acute heart failure in this cohort is a disease of working-age adults, which changes what it costs a household and what it costs an economy relative to the same diagnosis in a population where the median patient is in their late seventies.

What the study cannot establish

This is an observational cohort, not a trial, and it cannot attribute outcomes to treatment. Loss to follow-up before 180 days was 33.7% [s1], which is high enough that the reported longer-term mortality must be read with real caution about who was not found.

The presentation rates rest on estimates of each hospital's adult catchment population, and hospital catchments in settings with mixed formal and informal care-seeking are approximations. Enrolment happened during seven 24-hour surveillance windows per site rather than continuously [s1], which is an efficient design for a rate estimate and a sparse one for capturing seasonal or episodic variation. And 50 hospitals in 17 countries able to run point-of-care echocardiography are not a random sample of African hospitals.

What to watch

The paper reports the study as completed with substudies ongoing [s1]. The number worth following is the distance between prescription and target dose, because it is the one that is actionable without new drugs, new hospitals or new money.

Sources

• Aetiology, management, and outcomes of acute heart failure in 17 African countries (THESUS-HF II): a prospective, multicentre, observational cohort study, The Lancet, 30 August 2026
• Generating Important Insights into the Spectrum and Outcomes of Acute Heart Failure Across the African Continent: The Sub-Saharan Africa Survey of Heart Failure (THESUS-HF II), Global Heart, 23 July 2025
• Acute heart failure in Africa: new causes, unchanged outcomes, The Lancet, 30 August 2026