Drug Therapy

IJCS

Letter to the Editor

Access to Guideline-Directed Heart Failure Therapy in Brazil: Methodological and Policy Considerations

While the study’s findings are valuable, some methodological aspects could affect how we interpret them. The analysis is based solely on the presence of medications in Municipal Lists of Essential Medicines (REMUMEs), rather than on actual dispensing records or pharmacy inventory data. However, the fact that a medication is on an official list does not mean that patients can actually receive it in practice. Local procurement rules, supply chain issues, and prescribing practices can significantly affect the availability of drugs when patients need them. Conversely, medications absent from REMUMEs may still be accessible through other mechanisms within SUS. Therefore, relying solely on documentary evidence may not fully reflect the real accessibility of HF therapies. Dispensing records or pharmacy-level availability data could provide a more accurate representation of patient access.

Another important point to consider is how we understand the limited use of newer HF treatments, particularly angiotensin receptor–neprilysin inhibitors and sodium–glucose cotransporter-2 inhibitors. These treatments are often provided through specific national programs, such as the Specialized Pharmaceutical Assistance Component (CEAF), rather than being included in REMUMEs. Consequently, assessing REMUMEs alone may underestimate the availability of these agents within the broader SUS framework. Moreover, the regulatory and reimbursement processes for drugs like dapagliflozin and sacubitril/valsartan have changed quickly in recent years. This makes it especially important to understand how long they have been available.

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Original Article

Evidence-Based Pharmacological Treatment for Heart Failure in Brazil

Luísa Preiss Marques da Rocha et al. Kathleen Asturian Isabel Machado Canabarro Lidia Einsfeld Diogo Pilger

Abstract

Background:

Heart failure (HF) affects an estimated 64 million individuals globally. Current guideline-directed medical therapy (GDMT) comprises four cornerstone pharmacological medications proven to reduce hospitalization and/or mortality: renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i).

Objective:

This study aimed to describe, through an exploratory analysis, access to HF drug therapy in Primary Health Care in Brazil, via the Brazilian Unified Health System (SUS).

Methods:

This was a descriptive, cross-sectional study based on data extracted from Municipal Lists of Essential Medicines (REMUMEs) published on official municipalities’ websites from Brazilian metropolitan regions in June 2024.

Results:

A total of 387 municipalities were included, of which only 50.9% had a REMUME publicly available. Among these, 61.4% had been published within the previous 2 years. The frequency of each drug class was as follows: angiotensin-converting enzyme inhibitors in 92.4% of municipalities, angiotensin II receptor blockers in 80.2%, cardioselective beta-blockers in 91.9%, and MRAs in 85.8%. No REMUME simultaneously included all four GDMT medications. In 22.3% of the metropolitan cities, only two or fewer drug classes were available to patients’ access.

Conclusion:

The remarkable variability in the composition of REMUMEs, along with the frequent omission of at least one of the four essential pharmacological pillars, indicates a potential suboptimal management of HF at the population level. Given the importance of comprehensive pharmacological treatment in HF, these findings highlight ongoing challenges in access to essential medicines within the SUS, even in metropolitan areas.

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Original Article

Evaluation of Different Therapeutic Approaches for Acute Coronary Syndromes in Patients Undergoing Chronic Dialysis: A Retrospective Cohort Study

Matheus Eduardo França et al. Ana Luiza de Fragas Franciani Rodrigues da Rocha Leonardo Claudino Ribeiro Silvia R. Froes Toniazzo

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of death among individuals with chronic kidney disease (CKD), particularly those undergoing dialysis, accounting for approximately 40% of deaths. The prevalence of ischemic coronary disease among patients undergoing hemodialysis over the age of 45 reaches 41%.

Objective:

To analyze outcomes of symptomatic coronary artery disease (CAD) in patients undergoing chronic dialysis, stratified by invasive assessment, and treated with one of three approaches: medical therapy alone (MTA), percutaneous coronary intervention (PCI), or coronary artery bypass grafting.

Methods:

This was a retrospective, analytical, observational cohort study based on data from electronic medical records collected between 2013 and 2023, including a total of 68 patients. Quantitative variables were analyzed using one-way Analysis of Variance (ANOVA), and qualitative variables were assessed using Pearson’s chi-square test. A p-value <0.05 was considered statistically significant.

Results:

The mean age was 60.2 ± 13.1 years, with a male predominance of 42 patients (62.8%). The highest mortality was observed in the MTA group with 25 deaths (69.4%), followed by PCI with 10 deaths (56.6%), and the lowest in the coronary artery bypass grafting group with six deaths (42.9%). Among patients who did not use statins, 19 (82.6%) died (p < 0.01). The lowest rate of readmission due to coronary syndrome occurred in the MTA group (two patients; 18.2%), while the highest was in the PCI group (six patients; 54.5%) (p = 0.02).

Conclusion:

Although no statistically significant difference in mortality was found among the three therapeutic strategies, MTA was associated with lower rates of readmission and repeat cardiac catheterization. In contrast, PCI was linked to a higher risk of readmission due to coronary syndrome.

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Review Article

One Size Does Not Fit All: The Need to Rethink the Metabolic Syndrome in Women

Maria Cristina Costa de Almeida et al. Marildes Luiza Castro Larissa Espíndola Neto Luciana Nicolau Aranha … Thaís Salim Gláucia Maria Moraes de Oliveira

Abstract

Metabolic syndrome (MetS) is increasing at epidemic proportions worldwide. MetS and its components are frequent among Brazilian women (41.8%). Women are affected by changes in adipose tissue distribution, lipid profile, insulin resistance (IR), and vascular remodeling during their lives. These changes result from the lack of estrogen after menopause. There have been various attempts to propose a uniform origin for the clustering of the MetS components, including genetics, IR, obesity, lifestyle, sleep disturbances, inflammation, fetal and neonatal programming, and disturbed circadian rhythm of the body functions. The proinflammatory and prothrombotic state in MetS is well-defined. Socioeconomic and lifestyle-related factors are also essential triggers of MetS, which is associated with a higher risk for coronary artery diseases (CAD) and stroke in women. Population measures in health and community medicine, such as continuing education on the importance of lifestyle change to reduce cardiovascular risks from early childhood, are fundamental strategies. Statins reduce high-sensitivity C-reactive protein blood levels and treat high cholesterol. According to the patient, hypoglycemic agents, such as dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1(GLP-1a), and sodium-glucose transport protein 2 (SGLT2) inhibitors, in addition to metformin, have their indication due to their beneficial cardiometabolic and vascular effects. Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) should be the first choice to treat hypertension in postmenopausal womem. The recognition of the different gender- and age-specific risk factors, allowing for specific and targeted interventions, is fundamental, especially for women.

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Original Article

Subclinical Systolic Dysfunction during Chemotherapy for Breast Cancer

Geanne Maria Holanda de Menezes Barroso et al. Júlio César Oliveira Costa Teles Paulo Victor de Jesus Silva Karin Yasmin Santos Fonseca … Vinícius Antônio Santos Aragão Marília Marques Aquino Enaldo Vieira de Melo Karina Oliveira Ferreira Ronnei José Feitosa de Assis Michel Fabiano Silva Alves Antônio Carlos Sobral Sousa Joselina Luzia Menezes Oliveira

Abstract

Background

Cardiotoxicity is the main complication related to cancer therapy. Studies indicate that global longitudinal strain is an early detector of subclinical dysfunction of the left ventricle, preceding the decline in ejection fraction (EF). However, the reproducibility of such methodology has not been tested outside specialized centers.

Objectives

To assess the frequency of subclinical cardiotoxicity and to compare global longitudinal strain and EF measurements during the clinical course of patients undergoing chemotherapy for breast cancer.

Methods

This was an observational prospective study of 78 adult women who underwent serial echocardiograms (baseline and 1, 3, and 6 months after the beginning of chemotherapy), to evaluate biplane and 3D EF and global longitudinal strain. Cardiotoxicity and subclinical dysfunction were defined according to American Society of Echocardiography/European Association of Cardiovascular Imaging criteria. Statistical significance was set at p < 0.05.

Results

The mean age of the patients was 50.1 ± 11.48 years. The frequency of subclinical cardiotoxicity (defined by global longitudinal strain) was 14.9% after 30 days of chemotherapy, 16.7% after 3 months, and 19.7% after 6 months, compared to 4.5%, 3%, and 6.6%, respectively, when clinical cardiotoxicity was determined according to EF. The group that developed subclinical cardiotoxicity by 30 days (group A) had a higher frequency of clinical cardiotoxicity at 3 months (p=0.028) and a lower mean biplane EF after 30 days (p= 0.036) than the group that showed no evidence of subclinical cardiotoxicity (group B).

Conclusion

Subclinical cardiotoxicity was frequent and began early, being associated with a drop in EF during the clinical course.

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Case Report

High-Grade Pleomorphic Sarcoma of the Left Atrium after Incomplete Resection and Adjuvant Chemotherapy

Ricardo J. Razera et al. Amanda Mendonça de Araújo Viviane Pereira Bernardes Fernanda Miranda Moisés … Leonardo Santos Mundim Rogério A. Araújo

Introduction

Primary cardiac tumors are extremely rare, found in only 0.02% of all autopsies. These tumors are malignant in only 25% of the cases, 75% of which are sarcomas, frequently affecting young people with no risk factors.² The median overall survival is less than 1 year,³ ranging from 9 to 16 months,^, with rapid proliferation and deaths caused by arrhythmias, thrombosis, pulmonary embolism, and, most importantly, heart failure. Due to its rarity, reports in the literature about the best treatment are scarce, especially in malignant tumors.¹ The aim of the present work is to report a case of an undifferentiated pleomorphic sarcoma (UPS) in the left atrium in which surgical treatment was associated with chemotherapy, with an overall and progression-free survival of neoplastic disease higher than the median described in previous manuscripts.

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Review Article

Physical Exercise in the Management of Erectile Dysfunction in Patients with Heart Failure

Ana Gonzáles et al. Tales de Carvalho Leonardo Andreato Sabrina Sties Anelise Sonza

Abstract

Erectile dysfunction (ED) is a highly prevalent problem that affects the quality of life, prognosis and survival of patients with heart failure (HF). In the management of ED, physical exercise is a therapeutic strategy that reduces disease-related symptoms and optimizes drug use. However, the repercussions of physical exercise on ED in individuals with HF still need to be elucidated. In this sense, the objective of this study was to evaluate the effects of physical exercise on erectile function (EF) in HF patients. This was a systematic review conducted according to PRISMA guidelines. Patients with HF, male and ejection fraction ≤ 45% were submitted to physical exercise of different modalities. The search for scientific articles was conducted in the electronic databases (PubMed, LILACS, Cochrane-Library, Science Direct) from the inception until October 2018, according to the MeSH dictionary descriptors, which were suitable for all databases. Results: Three studies were analyzed, includinng 99 male subjects, age ranging from 53 years (± 7.48) to 58 years (± 12). Seventy subjects were submitted to a physical exercise program and 29 were in the control group. In all studies, physical exercise showed positive results in the management of ED regardless of erectile dysfunction (ED) classification status and intensity of exercise used. It was concluded that physical exercise of different intensities was considered an effective therapeutic intervention to improve EF in individuals with HF and ED.

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