3.2 Incident heart failure hospitalizations by ethnicity 139 We found distinct ethnic differences in incidences for HF hospitalization, where Malaysians of Indian ethnicity present with the highest incidence and with earlier onset. This result coincides with a recent published review that shown people of South Asian origins were at higher risk of developing HF and at a younger age, compared to the other ethnic groups.[34] Elevated risks of ischaemic heart disease amongst both South Asians and people of South Asian descent have been described and characterised by high rates of glucose intolerance, hyperinsulinaemia, central obesity and raised fasting lipids.[35,36] Indeed, higher prevalence of diabetes and abdominal obesity in this subpopulation is known in Malaysia (prevalence of 34.9% and 63.5% in Indians vs 15.2% and 45.4% in the overall population).[32] Another notable finding from this study is the diminished protective effect of being female for the Indian subgroup; i.e. the women have the same risks for first HF hospitalization as Indian men. Given that being overweight or obese and low levels of physical activity were more prevalent amongst women in this ethnic subgroup[37,38], it appears that this cardiometabolic feature plays a substantial role to overall risk of developing downstream HF. Nonetheless, we have shown that incidence in this group is declining more rapidly than the others, indicating that these background risks were amenable to treatment and lifestyle modifications. Lastly, part of the observed ethnic differences in HF hospitalization rates may be partly explained by socioeconomic differences, where the Chinese, who had the lowest incidence were more socioeconomically advantaged compared to other ethnic groups which in turn impacts living conditions, lifestyle and dietary choices.[22,39] Implications for practice and policy Malaysia is among several high-performing Southeast Asian countries which set out to reform their health care systems.[18] Hospitalization for HF poses substantial economic burden to its healthcare expenditure.[40] We have shown that the incidence of HF hospitalization was decreasing in parallel with an increase in absolute counts of new cases. From the clinical practice viewpoint, this reduction in incidence is likely a reflection of increase in guideline-adherent management after myocardial infarction together with a smaller extent in improvements in control of cardiovascular risk factors.[24,41] From the policy perspective, clear gaps in the healthcare resources supply-demand chain exists as the HF disease burden escalates; through a combination of increasing new cases and prolonged survival of existing patients. This
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