Why do poor patients have poor outcomes? Shedding light on the neglected facet of poverty and heart failure.

What does poor even mean? Poor means lacking sufficient financial resources, as in ‘the poor people from our community’. Poor also means low quality, as in ‘received poor medical treatment’. Finally, poor means deserving of pity: ‘conditions are shocking, poor patients!’. Poverty is dreadful. Economically disadvantaged individuals have less quality of life, access to healthcare and generally fewer opportunities in their life. Unsurprisingly, then, income level predicts the outcome of patients with heart failure,1 just like age and left ventricular ejection fraction. But unlike several heart failure predictors of risk, the causal link between poverty and worse prognosis in heart failure patients is not straightforward. Although poverty could be—and is—a marker of limited access to healthcare and lower education, in a disease with rising costs, this explanation seems incomplete. There is a complex and intricate interplay between individual and family income, education and literacy, healthcare structure and access to care, adherence to interventions and clinical outcomes (figure 1). Expensive therapies have been proven to benefit patients with heart failure in a range of clinical scenarios. Devices such as cardiac resynchronisation therapy, implantable cardioverter defibrillator and left ventricular assist device, and medications such as dapagliflozin and sacubitril/valsartan, have entered the clinical armamentarium and improve relevant endpoints. In this circumstance, in a disease with many new, exciting and expensive treatments, the high cost of new therapies could widen the disparity and prognostic gap between rich and poor patients with heart failure. Importantly, simple and cost-saving pharmacological and multidisciplinary strategies have also been shown to improve hard outcomes in heart failure. If access to therapies—costly or inexpensive—leads to better outcomes, …