ABC Heart Failure & Cardiomyopathy

Original Article

Shifting Patterns of Out-Of-Hospital Mortality and Premature Life Loss in Cardiomyopathies: A Nationwide Population-Based Study

Alvaro Perazzo et al. Gabriel Kaleb Martins Arina Peixoto Nobre Arthur Línniker Lopes de Oliveira Jose Roberto de Araújo Junior Gabriela Lucena Montenegro Carlos Eduardo Lucena Montenegro Patricia Bezerra Rocha Montenegro João Henrique Torres Flavio Feijó Deuzenny Tenório Diana Patrícia Lamprea Sepúlveda Samuel Padovani Steffen Sérgio Tavares Montenegro Fábio Antonio Gaiotto Fernando Moraes

Abstract

Background:

Cardiomyopathies are a major cause of cardiovascular mortality, presenting age-dependent phenotypes ranging from sudden cardiac death (SCD) to progressive heart failure. Despite declining mortality rates, gaps in prevention and access to advanced therapies may manifest as shifts in the place of death and persistent premature mortality.

Objectives:

To evaluate temporal trends in cardiomyopathy-related mortality in Brazil, assess age-related patterns in the place of death, and quantify premature mortality through years of life lost (YLL).

Methods:

This nationwide, population-based ecological study analyzed 369,570 deaths in Brazil (1996–2024) in which cardiomyopathy (ICD-10 I42) was the underlying cause. Temporal trends were assessed using Poisson regression, and associations between age and place of death were evaluated using odds ratios (OR). The YLL were calculated using national life tables.

Results:

Age-adjusted mortality declined by 1.7% annually (p<0.001). Hospital deaths decreased from 75% to 43%, whereas home deaths increased from 20% to 38%, with a significant inflection point around 2011. Public roadway deaths, used as a proxy for SCD, were more frequent among adults aged 20–39 years (4.8%) than among those aged ≥60 years (0.8%; OR 2.88, 95% CI 2.68–3.10). Total YLL reached 6.83 million years. Individuals aged 20–39 years accounted for only 5.5% of deaths but contributed 12.8% of total YLL, averaging 42.9 years lost per death.

Conclusions:

Despite declining mortality, out-of-hospital deaths have become more frequent. Excess YLL among young adults highlights gaps in SCD prevention. Age-tailored strategies are needed to reduce premature mortality.

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Abstract

Heart failure with preserved ejection fraction (HFpEF) is a prevalent clinical syndrome with a complex diagnosis, associated with various comorbidities and high rates of cardiovascular events. Cardiopulmonary exercise testing (CPET) plays an essential role in understanding the mechanisms of exercise limitation and in complementing the diagnosis of HFpEF, but it presents several gaps to be explored in risk prediction. This article reviews the literature on current pathophysiological, diagnostic, and prognostic aspects of HFpEF. Subsequently, the role of CPET in diagnosis and prognostic prediction in HFpEF is explored. A critical analysis of the main observational and cohort studies that used CPET in this setting is performed, selected after a qualified search on the PubMed platform. For diagnostic purposes, peak VO2 is not very specific, with a high diagnostic probability for values 20 ml/kg/min. However, when peak VO2 is evaluated together with other ventilatory parameters, there is an increase in the diagnostic value of CPET in HFpEF. For prognostic purposes, variables such as peak VO2, VE/VCO2 slope, and the presence of periodic ventilation correlate with a higher risk prediction. However, there are notable sample differences between studies in HFpEF, hindering the generalization of the use of CPET in clinical practice. This review concludes that conducting prospective studies with more rigorous patient selection and using some variables adjusted for body composition differences, such as lean VO2, may allow for better incorporation of CPET in risk stratification in HFpEF.

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Abstract

Heart failure (HF) remains a leading cause of hospitalization, mortality, and health-care burden worldwide. The post-discharge period following acute decompensated heart failure (ADHF) is characterized by a heightened risk of rehospitalization and death, particularly during the first 90 days, known as the “vulnerable phase.” Effective strategies for risk stratification and therapy optimization during this phase are crucial to improve outcomes.

Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP), are well-established biomarkers of myocardial stress. Beyond their diagnostic role, NPs have emerged as powerful prognostic tools for post-discharge risk assessment and as potential guides for therapy titration. Elevated NP levels at discharge and persistently high concentrations one week post-discharge strongly predict adverse outcomes. Evidence from the STRONG-HF trial demonstrated that early, intensive follow-up incorporating NP monitoring and rapid guideline-directed medical therapy (GDMT) up-titration significantly reduced mortality and rehospitalization. Serial NP measurements further enhance risk stratification by capturing dynamic changes over time. Although trials such as GUIDE-IT showed mixed results for NP-guided therapy using fixed targets, patients achieving lower NP levels consistently demonstrated better outcomes.

In conclusion, NPs provide incremental prognostic value beyond clinical assessment in the vulnerable post-discharge phase and throughout long-term management. Early and serial NP monitoring can identify high-risk patients and support GDMT optimization. Future research should refine timing, thresholds, and integration of NP-guided strategies into multimodal risk models to enhance personalized HF care and improve global patient outcomes.

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Original Article

Effect of Sacubitril/Valsartan on All-Cause Mortality Reduction in Patients Undergoing Cardiac Resynchronization Therapy: SALVA-CRT

Luiz Carlos Santana Passos et al. William Carvalho Jackson Pedro Barros-Pereira Clara Salles Figueiredo Gabriela Pio Dourado Fernanda Pinheiro Martin Tapioca Caio Rebouças Fonseca Cafezeiro

Abstract

Background

Cardiac resynchronization therapy (CRT) is indicated for patients with heart failure with reduced ejection fraction (HFrEF) receiving conventional triple therapy (CTT). Although sacubitril/valsartan (S/V) is a cornerstone of modern triple therapy (MTT) for HFrEF, its effectiveness in patients undergoing CRT implantation has not been adequately evaluated.

Objective

To compare all-cause mortality between CRT recipients on CTT and those on MTT, with a minimum follow-up of 1 year.

Methods

Prospective, observational cohort including patients undergoing a first CRT implantation. Inclusion criteria were left ventricular ejection fraction (LVEF) ≤35% and bundle branch block with QRS ≥150 ms, with prior use of either CTT or MTT. Patients who discontinued any medication, initiated a sodium-glucose cotransporter-2 inhibitor (SGLT2i), or crossed over between CTT and MTT during follow-up were excluded. Statistical analyses used the unpaired Student’s t test (p < 0.05 for significance). Cox regression was applied to variables potentially associated with the outcome (p < 0.1).

Results

From 2017 to 2022, 425 CRT implantations were performed; 58 (13.6%) patients were excluded. Of the 367 analyzed, 286 (78%) were on CTT and 81 (22%) on MTT. Mean age was 61 (±12) years; mean LVEF was 26% (±6); Chagas disease was the most prevalent etiology (34.3%). Mean follow-up was 58 (±8) months, with 62 deaths (16.9%): 59 (21%) in the CTT group and 3 (3.7%) in the MTT group. The HR was 1.27 (95% CI 1.17–1.39) for CTT and 0.18 (95% CI 0.06–0.58) for MTT. In multivariable analysis, CTT use was the only independent predictor of mortality (HR 5.83; 95% CI 1.81–18.70; p = 0.003).

Conclusion

MTT including S/V significantly reduced all-cause mortality in patients undergoing CRT implantation.

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Message from the Editor

With 20 years of existence, the Department of Heart Failure of the Brazilian Society of Cardiology (DEIC) launches, in 2021, its journal ABC Heart Failure and Cardiomyopathy (ABC HF). The new publication is an integral…

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