Heart Failure – ABC CARDIOL

ABC

Special Article

Cardiovascular Statistics – Brazil 2026

Gláucia Maria Moraes de Oliveira et al. Luisa Campos Caldeira Brant Carisi Anne Polanczyk Deborah Carvalho Malta … Andreia Biolo Bruno Ramos Nascimento Maria de Fatima Marinho de Souza Andrea Rocha De Lorenzo Antonio Aurélio de Paiva Fagundes Júnior Arthur Gus Manfro Beatriz D. Schaan Christina Grüne de Souza e Silva Fábio Morato de Castilho Fernando Henpin Yue Cesena Gabriel Porto Soares Gesner Francisco Xavier Junior Jose Augusto Soares Barreto Filho Lucia Campos Pellanda Luciana Nicolau Aranha Luis Eduardo Paim Rohde Luiz Guilherme Passaglia Marcelo Martins Pinto-Filho M. Julia Machline-Carrion Marcio Sommer Bittencourt Octavio M. Pontes Neto Paolo Blanco Villela Paulo Henrique Godoy Renato Azeredo Teixeira Ricardo Stein Roney Orismar Sampaio Thais Rocha Salim Thomas A. Gaziano Pablo Perel Gregory A. Roth Antonio Luiz Pinho Ribeiro

Cardiovascular Statistics – Brazil was established to provide a periodic, comprehensive, evidence-based assessment of cardiovascular health in Brazil and to support clinical practice, research, public health planning, and policy development. Developed under the auspices of the Brazilian Society of Cardiology, the initiative brings together a multidisciplinary network of investigators from academic institutions across the country who are responsible for reviewing, analyzing, and interpreting data from multiple complementary sources. Since its first edition in 2020, Cardiovascular Statistics – Brazil has sought not only to quantify the burden of cardiovascular diseases (CVDs) and their risk factors but also to identify temporal trends, regional disparities, gaps in care, and emerging challenges for the Brazilian health system. The project is modeled on international initiatives such as the American Heart Association’s Heart Disease and Stroke Statistics Update, while incorporating data sources and perspectives that reflect Brazil’s unique epidemiological, demographic, and healthcare characteristics.

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ABCHF

Viewpoint

The Adipokine Hypothesis: Does it Play a Major or Minor Role in HFpEF?

Luís Beck-da-Silva et al. Flávio D. Fuchs

We read with great interest the paper “The Adipokine Hypothesis of Heart Failure With a Preserved Ejection Fraction”.

The adipokine hypothesis explores biological mechanisms beyond the well-known risk factors for heart failure with preserved ejection fraction (HFpEF). The article presents a well-supported hypothesis based on data from bench research, animal studies, preclinical findings, and epidemiological evidence. The biological plausibility of the hypothesis is sound. However, certain considerations merit further discussion regarding the interpretation of HFpEF risk factors.

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ABC

Original Article

Percutaneous Axillary Intra-Aortic Balloon Pump Implantation in Patients Hospitalized with Heart Failure: Initial Brazilian Experience

Bruno Alves da Mota Rocha et al. Pedro H. M. C. de Melo Luis Mapa Rafael Nunes Oliveira … Antônio Fernando Freire Hernán Patricio García Mejía Vanessa Corcioli Bellini Liliane Kopel Silvia Gelás Lage Fabiana Goulart Marcondes-Braga Sandrigo Mangini Monica S. Ávila Iascara Wozniak de Campos Fernando Bacal Fábio Sândoli de Brito Jr Alexandre A. Abizaid Pedro Felipe Gomes Nicz

Abstract

Background

The intra-aortic balloon pump (IABP) is the most widely used mechanical circulatory support device for patients with advanced heart failure (HF) in our setting. However, femoral implantation restricts patient mobility during support.

Objective

To report the initial experience of a Brazilian advanced HF referral center with percutaneous axillary IABP implantation.

Methods

Consecutive patients hospitalized for HF who underwent percutaneous axillary IABP implantation at a tertiary cardiology referral center were included. A p-value < 0.05 was considered statistically significant.

Results

Between December 2020 and December 2023, 22 patients underwent percutaneous axillary IABP implantation. The mean age was 53 ± 10.7 years. All patients were hospitalized with refractory HF and were listed for heart transplantation. The procedure was successfully performed in all patients selected for the axillary approach. The median duration of support was 15 days (interquartile range: 7–28 days). Observed complications included device migration (18.2%), limb ischemia (9.1%), and isolated infectious and neurological events. Half of the patients either underwent heart transplantation or were successfully weaned from mechanical support.

Conclusion

The initial experience with percutaneous axillary IABP implantation demonstrated that the technique is feasible, safe, and reproducible. Further studies are needed to establish the role of this strategy within the continuum of care for patients hospitalized with advanced HF while awaiting heart transplantation.

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ABC

Editorial

HFREF Therapy: Randomized Evidence and Real-World Perspectives

Daniella Motta da Costa Dan

Abstract

Heart failure with reduced ejection fraction (HFrEF) has seen significant therapeutic advances with the consolidation of the four pharmacological pillars that modify prognosis. The widespread use of these therapies is associated with a substantial reduction in cardiovascular death and hospitalizations for heart failure, supporting contemporary strategies for rapid introduction and subsequent optimization to target or maximum tolerated doses. In this context, sacubitril/valsartan demonstrated prognostic benefit in PARADIGM-HF and a greater reduction in NT-proBNP in PIONEER-HF. However, different results were observed in other settings, such as PARADISE-MI and LIFE, helping to define the populations in which its benefit was demonstrated. The study published in this issue of the Arquivos Brasileiros de Cardiologia evaluated, in a real-world observational cohort, patients with HFrEF treated with maximum doses of sacubitril/valsartan, enalapril, or losartan. Compared to the group treated with enalapril or losartan, sacubitril/valsartan was not associated with a statistically significant reduction in hospitalization or mortality, although it was associated with an improvement in functional class. These findings should be interpreted considering methodological limitations, such as observational design, lack of randomization, limited number of events, and heterogeneity of the comparator group. Real-world studies broaden the understanding of the effectiveness, applicability, and implementation of therapies and should be analyzed in conjunction with the consolidated evidence from randomized clinical trials.

Heart failure (HF) is a complex and serious syndrome associated with high hospitalization and mortality rates. In heart failure with reduced ejection fraction (HFrEF), large clinical trials have established four pharmacological pillars that modify the prognosis: beta-blockers, which attenuate the activation of the sympathetic nervous system; inhibition of the renin-angiotensin system, through the use of angiotensin receptor and neprilysin inhibitors (ARNIs), angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs); mineralocorticoid receptor antagonists (MRAs); and sodium-glucose cotransporter type 2 inhibitors (SGLT2i).^,

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ABC

Letter to the Editor

Treatment of Heart Failure in Brazil: Where Cost-Effectiveness Studies and Public Access Data to Therapies Meet

Henrique Iahnke Garbin et al. Fernando Luis Scolari Andreia Biolo

Heart failure (HF) remains a leading cause of hospitalization and cardiovascular mortality in Brazil. In recent years, new prognostically modifying pharmacological therapies have been shown to reduce cardiovascular mortality, HF hospitalizations, and improve quality of life. In this context, the availability of these therapies in the public health system becomes a determining factor in improving clinical outcomes at the population level. A recent systematic review on the cost-effectiveness of HF therapies in Brazil demonstrated that several pharmacological interventions, including mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and angiotensin-neprilysin receptor inhibitors, have high economic attractiveness in the national scenario. Dapagliflozin, for example, showed an incremental cost-effectiveness ratio of Int$ 9,000/QALY, and is considered cost-effective.

Interestingly, Brazilian population-based evidence reinforces the clinical impact of these strategies, supporting the cost-effectiveness study. One analysis evaluated the temporal evolution of cardiovascular mortality and hospitalizations for heart failure after the implementation of the public access program for dapagliflozin in Brazil. The policy was initially approved for patients with type 2 diabetes mellitus or established cardiovascular disease aged ≥ 65 years. The medication was also made available to patients ≥ 18 years with heart failure with reduced ejection fraction, type 2 diabetes mellitus, or chronic kidney disease, upon presentation of a specialized medication report. The population-based study demonstrated a reduction in cardiovascular mortality trends (a 6.6% reduction in 2022, 4.7% in 2023, and 5.9% in 2024 compared to 2017) and hospitalizations for heart failure (a 23.8% reduction in 2024 compared to 2017) after the availability and access to medication in patients aged ≥ 65 years.

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ABC

Original Article

Effects of Pacemakers on Ventricular Functions and Early Variables Associated with Induced Cardiomyopathy

Sanjeev Kumar et al. Chandra Bhan Meena Navida Babbar Anil Bhandari … Dhananjay Singh Shekhawat Ankita Meel

Abstract

Background

Right ventricular (RV) pacing can alter ventricular mechanics and may lead to ventricular dysfunction, even in patients with preserved baseline left ventricular ejection fraction (LVEF) and structurally normal hearts.

Objective

This study examines the hemodynamic effects of right ventricular pacing on left ventricular function and volume, and identifies early variables associated with pacemaker-induced left ventricular dysfunction and cardiomyopathy in patients with dual-chamber RV pacemakers.

Methods

The study enrolled patients undergoing dual-chamber RV pacemaker implantation without any structural abnormality of the heart. Data on biventricular functions, LV volumes, and global longitudinal strain (GLS) were collected with 2D, speckle tracking, and 3D echocardiography. Paired continuous variables were compared using two-sided tests with a significance level of 0.05.

Result

Out of 75 patients, 20 experienced LV systolic dysfunction, 15 developed PIVD, and five developed PICM. In comparison to the control group, patients with PICM had lower GLS (17.02 vs. 19.27; p<0.05), wider QRS width (139.57 vs. 102.75; p < 0.05), and greater ventricular pacing percentage (VP%; 94.32 vs. 84.03; p = 0.06).

Conclusion

RV pacing resulted in a substantial decline in LV systolic function in the short and long term. Concurrently, RV functions declined over the long term (six months). Diminished GLS at seven days, a broader pre-implantation QRS complex, and an elevation in VP% are early indicators of PIVD and PICM. Routine patient monitoring for these indicators can be beneficial for timely intervention on a case-by-case basis.

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ABC

Research Letter

Cardiac Resynchronization Therapy in Cardio-Oncology: Real-World Evidence of Benefit in Cancer Patients with Heart Failure

Catarina Gregório et al. Andreia Magalhães Beatriz Silva Inês Araújo … Marta Vilela Pedro Marques João de Sousa Miguel Nobre Menezes Fausto J. Pinto Manuela Fiuza

Introduction

Heart failure (HF) is a major cause of morbidity and mortality among patients with cancer. The incidence of HF in this high-risk population is increasing, partly due to the cardiotoxic effects associated with contemporary cancer therapies. Despite substantial advances in oncological treatments and the growing number of cancer survivors, HF remains a major determinant of adverse clinical outcomes.

Cardiac resynchronization therapy (CRT) is an established treatment that improves symptoms and reduces mortality in patients with chronic HF. However, patients with a history of cancer have been frequently excluded or underrepresented in pivotal CRT trials, resulting in a significant evidence gap regarding the efficacy and safety of CRT in this population. Concerns related to comorbidities, cancer prognosis, and procedural risk may further contribute to the underutilization of CRT in clinical practice.

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ABCHF

Viewpoint

What We Choose to Fund Defines Who We Choose to Save: Pediatric Heart Failure in Emerging Economies

Carolina Vieira de Campos et al. Luiz Fernando Caneo Tamara J. Pimenta Desiree S. Machado

Management of pediatric advanced heart failure (HF) in low- to middle-income countries faces substantial and interconnected challenges, including severely limited access to specialized care, a shortage of adequately trained healthcare professionals, delayed referrals, and high mortality rates. These systemic constraints significantly restrict both the availability and the effectiveness of life-saving therapies for children with end-stage HF.

A deeper understanding of mechanical circulatory support (MCS) in emerging economies – illustrated here through the Brazilian experience – provides a valuable foundation for identifying structural, logistical, and ethical barriers to care. Such analysis also informs the development of strategies aimed at the sustainable and equitable expansion of advanced HF therapies for children.

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ABCHF

Editorial

ABC Heart Failure & Cardiomyopathy: Management Review and Indexing Perspectives

Germano Emílio Conceição-Souza

Introduction – context and mission

ABC Heart Failure & Cardiomyopathy (ABC HF) was established in 2021 as a specialized journal within Brazilian Society of Cardiology’s (SBC) family of scientific journals. The creation of ABC HF responded to a longstanding request from the Department of Heart Failure (DEIC-SBC) for a dedicated platform for disseminating high-quality research in the fields of heart failure and cardiomyopathies, including their various diagnostic and therapeutic approaches.

The mission of ABC HF goes beyond merely publishing scientific articles. The journal aims to create an environment that encourages the production and dissemination of knowledge, thereby strengthening scientific exchange and establishing itself as a reliable source of information for researchers and healthcare professionals in Portuguese-speaking countries and Latin America, regions that are particularly affected by the significant impact of heart failure.

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IJCS

Letter to the Editor

Prognostic Value of C-reactive Protein (CRP) in Patients With Acute Heart Failure (AHF) Admitted to General Wards in Brazil

Vanessa Souza Silva Medrado et al. João Emmanuel Coelho de Morais Domingos Sávio de Oliveira e Silva João Pedro Lopes Azevedo … Thalisson Gonçalves Almeida Pedro Pereira Tenório

Dear Editor,

We read with great interest the article by Ferigato et al. investigating the prognostic value of C-reactive protein (CRP) in patients with acute heart failure (AHF) admitted to general wards in Brazil. We would like to congratulate the authors for addressing a topic of substantial practical relevance: the search for accessible biomarkers in settings where gold-standard tools, such as natriuretic peptides, have inconsistent availability.

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IJCS

Original Article

Assessment of Adherence to Drug Therapy in Patients with Heart Failure Followed at a Specialized Outpatient Clinic

Breno Gabriel Araújo Sampaio de Jesus et al. Felipe Barros Oliveira Felipe Caires Araújo Meira Lívia Brito Oliveira … Fabio Figueirêdo Costa Adriana Lopes Latado

Abstract

Background:

Heart failure (HF) is a severe syndrome with high global prevalence. Despite safe and effective pharmacological therapies, its prognosis remains unfavorable, and low treatment adherence is the leading cause of rehospitalizations and worse outcomes.

Objective:

To assess treatment adherence and its determinants in patients with HF followed at cardiology outpatient clinics of a specialized hospital.

Methods:

A single-center, cross-sectional, observational study was conducted, with data collection via in-person interviews. Treatment adherence was measured using the Brief Medication Questionnaire (BMQ). Variables associated with adherence with p < 0.10 were included in a multivariate model, considering a significance level of 5%.

Results:

A total of 200 patients were included; 79.6% showed low adherence according to the BMQ, and 52.6% showed low adherence in the “regimen” domain. Only 3 (1.6%) patients presented no barriers to adherence. In multivariate analysis, being married (odds ratio [OR] 0.40; 95% confidence interval [CI] 0.16–0.96; p = 0.042), prior acute coronary syndrome (ACS) (OR 0.21; 95% CI 0.08–0.51; p < 0.001), education level (OR 0.90; 95% CI 0.82–0.98; p = 0.018), higher number of prescribed medications (OR 1.44; 95% CI 1.03–2.05; p = 0.037), and HF with improved ejection fraction (OR 2.76; 95% CI 1.06–7.63; p = 0.042) were independent predictors of low adherence.

Conclusion:

Low therapeutic adherence among patients with HF is prevalent and influenced by socioeconomic factors, social support, polypharmacy, and clinical characteristics. The results reinforce the need for health education and the simplification of therapeutic regimens.

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ABC

Letter to the Editor

Non-dihydropyridine Calcium Channel Blockers in Atrial Fibrillation with Mildly Reduced Ejection Fraction: Caution is Still Advised

Jefferson Luis Vieira et al. Carlos Eduardo Lucena Montenegro

Conclusion

Given the lack of robust safety and benefit data for NDHP-CCBs in patients with HFmrEF and the existence of prognostically aligned alternatives, the current recommendation may be interpreted permissively and lead to potentially detrimental practices. Furthermore, the Second Universal Definition of Heart Failure provides additional conceptual support for this proposal by recognizing that patients with mildly reduced EF constitute a distinct biological phenotype and by discouraging therapeutic reasoning based solely on arbitrary LVEF thresholds. We advocate that the guideline explicitly reinforce the non-recommendation of verapamil/diltiazem when LVEF <50%, until specific studies in HFmrEF validate their safety and prognostic neutrality.

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ABC

Letter to the Editor

Pulmonary Regurgitation in Heart Failure: Causality or a Marker of Disease Severity?

Kayihan Karaman et al. Metin Karayakali

1. Severe Group Imbalance and Statistical Power

The striking disparity in group sizes—272 (No PR) and 162 (Mild PR) versus only 20 (Moderate PR) and 36 (Severe PR)—raises serious concerns about the statistical power of the multivariate models. In a multivariate model featuring five predictors (PR severity, age, LVEF, PASP, and hemoglobin), the reliability of the derived coefficients for the smaller subgroups may be compromised by the lack of statistical power. This imbalance raises additional concerns regarding the precision and stability of the reported regression coefficients (β=0.48 for pro-BNP and β=−0.39 for 6MWT). We urge the authors to report 95% confidence intervals for all beta coefficients and to consider bootstrap-based sensitivity analyses to assess the robustness.

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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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ABCHF

Original Article

Unrecognized Chronic Kidney Disease and the Therapeutic Gap in Outpatients with Heart Failure and Reduced Ejection Fraction

Felipe Lopes Grillo et al. Julia Rosembach Bruscato Felipe Storm Ross Eduardo Zanetti Bergamaschi … Gabriel Della Torres Marinho Juliana Berndt Nunes Rosane Carolina Paes De Lira Lidia Ana Zytynski Moura

Abstract

Background

Chronic kidney disease (CKD) is common in heart failure with reduced ejection fraction (HFrEF), but its true prevalence may substantially exceed formal diagnosis, contributing to undertreatment with guideline-directed medical therapy (GDMT).

Objectives

To determine the prevalence of unrecognized CKD in an HFrEF outpatient clinic, compare optimized medical therapy (OMT) according to renal status and KDIGO stages, and identify independent predictors of OMT.

Methods

Analytical cross-sectional study including 469 patients with HFrEF (LVEF ≤ 40%) followed between 2019–2022 with calculable eGFR (CKD-EPI 2021). Classification: no CKD (eGFR ≥ 60; n = 307), hidden CKD (eGFR < 60 without documentation; n = 104), and recognized CKD (formal documentation; n = 58). OMT was defined as RAAS blockade + beta-blocker + MRA at ≥ 50% of target doses.

Results

CKD affected 34.5% by eGFR, but only 15.1% had documentation – 64% were hidden, predominantly G3a (82%) and G3b (64%). OMT followed a monotonic gradient across KDIGO stages: G1 56.5%, G2 48.1%, G3a 38.4%, G3b 24.1%, G4 18.5% (Cochran–Armitage p < 0.001). Spironolactone was the most affected therapy (84.7% vs. 60.3%; p < 0.001). In multivariable analysis, recognized CKD was associated with lower OMT (OR 0.47; 95% CI 0.23–0.92; p = 0.03), along with age (OR 0.95/year; p < 0.001), while diabetes was paradoxically associated with higher OMT (OR 1.90; p = 0.003).

Conclusion

Nearly two-thirds of CKD cases in HFrEF are unrecognized, concentrated in moderate stages where therapeutic benefit is greatest. Routine calculation of eGFR is a simple intervention to reduce this gap.

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ABCHF

Review Article

Palliative Care in Patients with Advanced Heart Failure: An Integrative Review

Irving Gabriel Araújo Bispo et al. Clara Verrone da Silva Gabriela Tobias Gonçalves Pereira Victoria Paulino de Mello Lopez

Abstract

The term advanced heart failure (HF) defines a profile of patients with severe symptoms, recurrent decompensations, and cardiac dysfunction despite optimized therapy. The clinical course of advanced HF is difficult to predict, and identifying the appropriate moment for integrating palliative care (PC) remains a challenge. To conduct an integrative review on the incorporation of palliative care in patients with advanced HF, highlighting the main differences in quality-of-life outcomes based on the most recent clinical studies. The topic was defined and the guiding question formulated according to the PICO model. A systematic search was performed for studies in Portuguese, Spanish, and English in the PubMed, LILACS, and SciELO databases, published in the last five years. The descriptors used were “heart failure,” “palliative care,” and “elderly patient.” A total of 54 articles were identified; after applying the inclusion and exclusion criteria, 9 studies were selected. Patients with advanced HF present a high symptom burden (pain, dyspnea, fatigue, anxiety, and depression). Early introduction of PC, ideally at critical points in the disease trajectory, enables symptom relief, reduced hospitalizations, and improved communication between families and healthcare teams. Early integration of palliative care should be understood as an essential strategy in the management of advanced heart failure. We emphasize the substantial gap that persists in the early introduction of palliative care in advanced HF, which requires coordinated, multidisciplinary action. It is essential that healthcare teams and public policies recognize PC as a fundamental and humanized component of advanced HF treatment, ensuring maximum comfort, dignity, and well-being for patients.

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IJCS

Original Article

Echocardiographic Changes Associated With Sacubitril/Valsartan Therapy in Patients With Heart Failure With Reduced Ejection Fraction (HFrEF): A Descriptive 12-Month Follow-Up Analysis

Marcely Bonatto et al. Ana Karyn Ehrenfried de Freitas Caio Berwanger Takatuzi Luiz Gustavo Esmanhoto Franco … Danielle Rodrigues Vendramini Luka David Lechinewski Gustavo Gavazzoni Blume Lidia Zytynski Moura

Abstract

Background:

Although randomized controlled trials have demonstrated the efficacy of Sacubitril/Valsartan in heart failure (HF), real-world evidence regarding its impact on cardiac remodeling, particularly in Heart Failure With Reduced Ejection Fraction (HFrEF), remains limited.

Objectives:

This real-world study aimed to evaluate echocardiographic changes, including ejection fraction (EF), in a cohort of patients with HFrEF treated at a public hospital in Curitiba, Brazil, and to assess clinical outcomes at 6 and 12 months of follow-up.

Methods:

Longitudinal data were collected from 200 patients with HFrEF at baseline and at 6- and 12-month follow-up. Echocardiographic assessments included EF, left ventricular (LV) dimensions, and other cardiac parameters. Clinical outcomes included HF-related hospitalizations and New York Heart Association (NYHA) functional class.

Results:

Sacubitril/Valsartan therapy was associated with improvements in EF, with the median increasing from 28% at baseline to 31.5% at 6 months and 34% at 12 months (Teichholz method). Structural remodeling was observed, including reductions in LV end-systolic and end-diastolic dimensions, as well as left atrial (LA) diameter. HF-related hospitalization rates decreased from 31.8% at baseline to 20.6% at 6 months and 11.3% at 12 months. NYHA functional class improved, with the proportion of patients in Classes III and IV decreasing from 53.2% at baseline to 17.4% at 6 months. Renal function remained stable throughout treatment. Improvements in EF were associated with a lower risk of hospitalization at 6 months (OR = 0.95) and 12 months (OR = 0.93), whereas a larger LA diameter was associated with a higher risk of hospitalization at 12 months (OR = 1.06).

Conclusions:

Sacubitril/Valsartan therapy was associated with improvements in EF, echocardiographic parameters, and NYHA functional class, as well as reductions in hospitalization rates. These findings underscore the role of the therapy in promoting reverse remodeling and suggest that its clinical benefits may extend beyond direct effects on cardiac structure.

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IJCS

Editorial

AI-Enhanced ECGs for the Diagnosis of HFpEF: A Promising Frontier, But Not Yet a Standalone Solution

Humberto Villacorta

Heart Failure with preserved Ejection Fraction (HFpEF) is among the most challenging syndromes in contemporary cardiology. Despite accounting for nearly half of all heart failure cases, HFpEF remains chronically underdiagnosed and is associated with significant morbidity and mortality.^, The diagnosis of HFpEF is challenging and relies on clinical history, natriuretic peptide measurements, and echocardiography. Diagnostic scores have been developed that integrate these three key elements.^, Echocardiography is indispensable for identifying structural and functional criteria, but its availability and cost make population-level screening impractical in many healthcare systems. In addition, in many places, a comprehensive echocardiogram is not performed. Likewise, natriuretic peptides are not always available. Therefore, new solutions to facilitate diagnosis are welcome.

In this context, the systematic review and meta-analysis presented in this issue of International Journal of Cardiovascular Sciences, provide important insights into an increasingly discussed alternative: Artificial Intelligence-enhanced Electrocardiography (AI-ECG). Drawing from more than 170,000 patients across three observational studies, the authors report a pooled sensitivity of 0.89, specificity of 0.80, and an AUC of 0.89 for AI-ECG in detecting HFpEF. These findings suggest that deep learning models can extract subtle electrical signatures associated with diastolic dysfunction – signals that may be visually imperceptible on standard ECGs. The appeal is clear: the ECG is universal, inexpensive, rapid, and deeply embedded in clinical workflows. If Artificial Intelligence could reliably identify patients requiring echocardiographic confirmation, screening strategies might be revolutionized.

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ABC

Review Article

Impact of Catheter Ablation on LVEF in Patients with Atrial Fibrillation and Heart Failure with Reduced Ejection Fraction: A Systematic Review

Antonio Maria Zacarias Araújo Monteiro et al. Maria Giovanna da Cruz Tocantins Jéssica Batista Souza Renan de Jesus da Silva Albuquerque … João Vitor Ferreira de Oliveira Roni Oliveira Pinheiro Ster Marques de Lima Silva

Abstract

Atrial fibrillation (AF) is a condition that frequently affects patients with heart failure with reduced ejection fraction (HFrEF) and is associated with worsening left ventricular ejection fraction (LVEF) and unfavorable clinical outcomes. Catheter ablation has been proposed as a strategy to restore sinus rhythm; however, its effects on LVEF remain heterogeneous in the literature. To evaluate the impact of catheter ablation, compared with medical therapy, on LVEF in patients with AF and HFrEF. A systematic review of randomized clinical trials was conducted in accordance with the PRISMA guidelines. The primary outcome was improvement in LVEF, while secondary outcomes included cardiovascular mortality, all-cause mortality, and hospitalizations due to heart failure. Other exploratory outcomes were also considered. The included randomized clinical trials demonstrated improvement in LVEF among patients undergoing catheter ablation compared with those receiving medical therapy. In the CAMERA-MRI study, an absolute increase of 18.3% in LVEF was observed after six months. In the CASTLE-AF trial, catheter ablation was also associated with a lower incidence of cardiovascular mortality and heart failure hospitalizations. In the absence of a meta-analysis, no quantitative synthesis of the effects was performed. The available evidence from individual randomized trials suggests that catheter ablation may be associated with improvement in LVEF and more favorable clinical outcomes in patients with AF and HFrEF. However, given the lack of quantitative synthesis, these findings should be interpreted with caution.

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ABCIC

Review Article

My Approach to Echocardiographic Assessment of Left Ventricular Filling Pressures: From Ambiguity to Precision With New Guidelines

Marco Stephan Lofrano Alves et al. Larissa Maria Vosgerau Marcelo Vitola Dreckmann Roberto D´Ávila Martins … Cláudia Biondo Zanlorensi Eduardo Henrique Bonotto

Abstract

The echocardiographic estimation of left ventricular (LV) filling pressures is a cornerstone in the assessment of heart failure, particularly in patients with heart failure with preserved ejection fraction (HFpEF). The 2016 American Society of Echocardiography/European Association of cardiovascular Imaging algorithm standardized this evaluation using key variables, but a substantial proportion of cases remained indeterminate in clinical practice. The recent update of the American guideline reorganized the approach into a hierarchical framework, incorporating age-related adjustments and formalizing the role of left atrial strain (LAS) as a tie-breaking parameter, while also providing a more detailed characterization of special clinical scenarios. In parallel, the 2024 British Society of Echocardiography guideline emphasizes the pathophysiological interpretation of ventricular filling, complementing the operational framework proposed by the American document. Multicenter studies with invasive validation support these updates, establishing LAS as a robust marker of increased filling pressures. In this article, we present My Approach to echocardiographic assessment of LV filling pressures, based on an initial morphofunctional evaluation, followed by structured screening (Step 1) and further refinement (Step 2) incorporating LAS and additional parameters. We also provide a comparison between guidelines, discuss common pitfalls and algorithm limitations, and include case-based videos for practical application.

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ABCHF

Original Article

Prognostic Value of Growth Differentiation Factor-15 in Heart Failure: A Systematic Review with Meta-Analysis

Lorena dos Santos Marreto Rimolo et al. Humberto Villacorta

Abstract

Background

Growth differentiation factor-15 (GDF-15) has emerged as a promising biomarker in heart failure (HF), reflecting multiple pathophysiological mechanisms, including inflammation, oxidative stress, and cardiac remodeling. However, evidence regarding its prognostic value remains inconsistent.

Objective

To systematically evaluate the association between circulating levels of GDF-15 and adverse clinical outcomes, including all-cause mortality and HF hospitalization.

Methods

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed, Embase, Cochrane Library, and Web of Science were searched through April 2025. Studies reporting baseline levels of GDF-15 and adjusted hazard ratios (HRs) for mortality and/or HF hospitalization were included. Pooled HRs were calculated using a random-effects model (DerSimonian and Laird method). Statistical heterogeneity was assessed using Higgins’ I² statistic, and publication bias was evaluated using Egger’s test.

Results

Seven studies (n = 10,578 patients [mean age, 67 ± 11 years; 58% male]) met the inclusion criteria. Increased levels of GDF-15 were significantly associated with increased all-cause mortality (pooled HR, 2.72; 95% CI, 1.55-4.17; p < 0.001; I² = 49%) and HF hospitalization (HR, 2.43; 95% CI, 1.79-3.30; p < 0.001). Subgroup analyses demonstrated consistent associations across different HF phenotypes. Funnel plot assessment and Egger’s test (p = 0.12) showed no evidence of publication bias.

Conclusions

Higher circulating levels of GDF-15 are independently associated with increased risks of mortality and HF hospitalization. Incorporating GDF-15 into multimarker prognostic models may improve risk stratification and support earlier, more individualized management strategies in HF.

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ABCIC

Case Report

Giant Atrial Myxoma in a Pregnant Patient: A Case Report

Roberto Ramos Barbosa et al. Caio Badiani Prando Victor Macedo Bianchini Lucas Crespo de Barros … Larissa Novaes Paganini Gracielly Barros Darlan Dadalt Sergio Luis Santos Guedes Vinicius Eduardo Araújo Costa Marcus Gustavo Tito Tiago Bernardo Nery Marcio Vinicius de Nardi de Angeli Maria Eduarda Vichi Gomes Viana Mariana Oliveira Roncato João Paulo Moulin Auad Guilherme Freitas Fernandes de Oliveira Renato Giestas Serpa Osmar Araujo Calil Luiz Fernando Machado Barbosa

Introduction

Atrial myxoma is the most prevalent primary heart tumor.^, Clinical manifestations of myxomas are usually nonspecific, and they may present with dyspnea, fatigue, reduced functional capacity, edema, and, eventually, cerebral embolic events with focal neurological deficits. Although they are classified as benign neoplasms, most commonly located in the left atrium, they can cause obstruction of intracardiac blood flow and, when friable, systemic embolism with consequent tissue ischemia.^,

In spite of higher prevalence in women (65%), diagnosis during pregnancy is considered uncommon, with greater challenges in treatment and an increased risk of fetal death. We report the case of a pregnant patient with a complication of atrial myxoma that manifested during labor.

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Research Letter

Reversibility of Heart Failure after Catheter Ablation in Patients with Ventricular Pre-Excitation-Induced Cardiomyopathy

Samuel Santos Boa Morte et al. Luiz Pereira de Magalhães Jussara de Oliveira Pinheiro Duarte Alex Teixeira Guabiru … Adimeia Souza Santos Eduardo Faria Soares de Magalhães Roque Aras

Introduction

Ventricular pre-excitation is characterized by the presence of an atrioventricular accessory pathway, predisposing patients to cardiac arrhythmias that may lead to syncope, palpitations, or sudden death. Although rare, a possible complication is the development of heart failure (HF), referred to as pre-excitation–induced cardiomyopathy. It has been suggested that the eccentric ventricular activation caused by the accessory pathway leads to mechanical ventricular dyssynchrony, resulting in structural alterations and ventricular dysfunction. Case reports have described improvement of HF after catheter ablation of the accessory pathway. It is important to alert the medical community to this rare entity, which should be considered in patients with ventricular pre-excitation and reduced ejection fraction, as it represents a potentially reversible cause of HF following ablation.

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Research Letter

16-Year Evolution of Acute Orally Transmitted Chagas Disease: Report of an Autochthonous Case Progressing to Chagasic Cardiomyopathy

Monica Regina Hosannah Silva e Silva et al. Jorge Augusto de Oliveira Guerra Jessica Vanina Ortiz Matheus Martins Monteiro … Katia do Nascimento Couceiro Maria das Graças Vale Barbosa Guerra João Marcos Bemfica Barbosa Ferreira

Introduction

Chagas disease (CD) is caused by Trypanosoma cruzi, a protozoan with a complex life cycle found in dozens of species of triatomine insects (kissing bugs) and mammals. The World Health Organization (WHO) included CD among the neglected tropical diseases in 2006.

Humans can become infected through contact with insect feces containing T. cruzi or through other mechanisms, including the ingestion of contaminated food. The clinical presentation of CD varies between its two phases: acute and chronic. In the acute phase, individuals are usually oligosymptomatic, presenting with nonspecific signs and symptoms. However, a minority may develop more severe manifestations such as hepatosplenomegaly, myocarditis, or meningoencephalitis. The chronic phase comprises three well-defined clinical forms: indeterminate, cardiac, and digestive.^–

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