- Design
- prospective, multicentre observational cohort with timed 24-hour surveillance periods, 180-day follow-up (THESUS-HF II)
- Population
- 1,578 adults with acute heart failure at 50 hospitals in 17 African countries; median age 56, 50.5% female, 97.8% of African descent
- Primary outcome
- aetiology, treatment patterns, readmission and all-cause mortality to 180 days
- Effect
- hypertensive heart disease 36.5%, cardiomyopathy 23.4%, ischaemic 23.3%; in-hospital mortality 8.7%, 30-day 11.1%, 180-day 20.6% (95% CI 18.4-23.0)
THESUS-HF II enrolled adults presenting with acute heart failure during timed surveillance periods at 50 hospitals across 17 African countries, using dyspnoea and congestion supported by electrocardiography, chest radiography and point-of-care echocardiography. Of 1,741 assessed, 1,578 were included between July 2024 and July 2025. Median age was 56 years, and the sexes were evenly split.
Almost two-thirds of presentations, 64.2%, were de novo. The leading causes were hypertensive heart disease at 36.5%, cardiomyopathy at 23.4% and ischaemic heart disease at 23.3%. Median ward stay was six days and in-hospital mortality 8.7%. All-cause mortality reached 11.1% at 30 days and 20.6% at 180 days.
What makes those figures instructive is the prescribing alongside them. At discharge, renin-angiotensin-aldosterone system inhibitors were given to 73.9%, beta blockers to 76.9%, mineralocorticoid receptor antagonists to 71.9% and SGLT2 inhibitors to 54.7%. Fewer than half reached target doses. The drugs were being started; they were not being titrated. A fifth of a cohort with a median age of 56 died within six months anyway.
Much of this is recognisable in Indian practice, where acute heart failure also presents younger than in Europe or North America and hypertensive and cardiomyopathic disease weigh heavily. The lesson that travels is not about which drug to choose but about what happens after discharge: uptitration to target, and a follow-up appointment that actually happens. Read the mortality figures with one caveat the authors flag, that 33.7% were lost to follow-up before 180 days, which makes the true figure uncertain in both directions.
- Book and confirm the post-discharge heart failure review before the patient leaves, not after
- Write the uptitration plan into the discharge summary with target doses, not just the starting prescription
- Treat hypertension aggressively in younger adults; it was the single leading cause here at 36.5%
- Use point-of-care echocardiography early where formal imaging is delayed; it carried the diagnosis in this study
- Interpret the 180-day mortality cautiously: a third of the cohort was lost to follow-up before that point
The statistics, in plain English
The gap between prescribing rates above 70% and target doses reached in under half is the actionable number here: starting a drug and titrating it are different achievements, and outcome benefit in heart failure trials comes from the doses those trials used. Loss to follow-up of 33.7% before 180 days is high enough to matter in both directions, since patients lost to follow-up may be those who died or those who recovered and stopped attending, so 20.6% should be read as an estimate with real uncertainty around it. This is an observational cohort with surveillance sampling rather than continuous enrolment, so presentation rates describe these catchments rather than national incidence.
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