THESUS-HF II enrolled adults presenting with acute heart failure during timed surveillance periods at 50 hospitals in 17 African countries between July 2024 and July 2025, identifying cases by acute breathlessness and congestion supported by electrocardiography, chest radiography and point-of-care echocardiography. Of 1,578 patients, half were women and the median age was 56 years (IQR 40 to 69). Nearly two thirds — 64.2% — were presenting for the first time. The leading causes were hypertensive heart disease (36.5%), cardiomyopathy (23.4%) and ischaemic heart disease (23.3%).

In-hospital mortality was 8.7% (95% CI 7.3 to 10.2) over a median six-day stay. All-cause mortality was 11.1% at 30 days and 20.6% (18.4 to 23.0) at 180 days. One in five of a cohort whose median age is 56 was dead within six months.

Prescribing at discharge was not the obvious explanation. Renin-angiotensin-aldosterone system inhibitors went to 73.9%, beta blockers to 76.9%, mineralocorticoid receptor antagonists to 71.9% and SGLT2 inhibitors to 54.7% — respectable initiation rates. But target doses were reached in fewer than half. The gap was titration, not initiation, and the authors report that short-term outcomes were not explained by demographic, aetiological or echocardiographic differences.

The pattern will be familiar to anyone practising in India: young patients, hypertensive heart disease leading, first presentation as the common one, drugs started but never uptitrated, and follow-up that does not hold. A third of the cohort — 33.7% — was lost to follow-up before 180 days.

Book and confirm the titration visit before discharge; starting the four drugs is not the hard part.
Record the target dose for each agent in the discharge summary, not just the starting dose.
Treat a first presentation of heart failure in a patient in their fifties as a prompt to look hard for hypertensive heart disease.
Build a mechanism for chasing non-attenders — a third of this cohort was lost within six months.
Use point-of-care echocardiography at presentation where formal imaging will be delayed.

Why it matters

The failure point in heart failure care has moved from which drugs to whether anyone gets them to target dose.

The statistics, in plain English

This is an observational cohort, so the mortality figures describe what happened rather than what any treatment caused. The 33.7% lost to follow-up before 180 days matters: if those patients did worse than those who returned — plausible — then 20.6% understates true mortality. The presentation rate of 0.03 per 10,000 adults per week is a surveillance estimate from timed sampling windows and should not be read as a population incidence.