3.2 Incident heart failure hospitalizations by ethnicity 137 DISCUSSION We presented several findings here using data from a national hospital discharge database in Malaysia. First, comparisons by sex have revealed that women had persistently lower incidence rates of HF hospitalization compared to men but both experienced similar reductions across time. Second, we found that the agestandardised incidence rates for HF hospitalizations have been declining at an annual rate of 1%. This decline was driven by patient older than 65 years. However, the absolute burden has increased by a-third in ten years. Third, we found that Malaysian patients of Indian ethnicity had distinctly higher incidence rates and younger age of onset than other ethnic groups but also exhibited greater decline in incidence compared to other ethnicities. Another noteworthy finding was that lower incidence rates in women was not observed in this ethnic subgroup. This study is among the first to report on the time trends of incident HF hospitalizations in Asia. The closest data available for comparison was the total HF hospitalizations (i.e. not restricted to incident cases) for Singapore, a neighbouring country with an ethnic diversity and health system comparable to Malaysia.[17,18] The authors found that the burden of HF hospitalizations was increasing by 38% from 1991 to 1998.[17,18] A decade later, we have found that the incidence of HF hospitalizations has been steadily decreasing irrespective of sex. This gradual decline is consistent to those reported in industrialized countries including Australia, the Netherlands and Scotland which saw HF hospitalizations peak and declining since the early 1990s.[19–21] These findings potentially reflect the doubling of percutaneous coronary intervention rates and increase in use of secondary preventive medications after myocardial infarction, thus contributing to an overall reduction in risk of HF hospitalization. [22,23] Further, a smaller extent of this decrease in incidence can be explained by improvements in the awareness, treatment and control of classical risk factors such as that seen in hypertension.[24] Men had consistently higher incidence of HF hospitalization compared to women. In relation to risk factors, tobacco smoking appears to explain a large extent of higher risks of HF hospitalization in men with a 30-fold higher current smoking prevalence than women (43.0% versus 1.4% among persons >18 years in 2015) whereas risk factors such as diabetes and hypertension were largely comparable between men and women.[25,26] For other metabolic risk factors however, women
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