Latin America – ABC CARDIOL

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Editorial

Women's Cardiovascular Health: A Current Challenge

Paolo Blanco Villela et al. Larissa Franco de Andrade

The growing attention paid to women’s cardiovascular health reflects a necessary paradigm shift in contemporary medicine. This transformation is based on evidence that cardiovascular diseases (CVD) are the leading cause of death among women, accounting for approximately 35% of all global female deaths, surpassing mortality from all cancers combined.

Despite the expansion of awareness campaigns and advances in scientific knowledge on the subject, a worrying stagnation in the reduction of the global burden of these diseases has been observed in the last decade. Women still face less recognition of their cardiovascular risk, delays in diagnosis, and less access to evidence-based therapies.^, In Latin America and the Caribbean (LAC), this scenario is even more challenging, as the presence of social and structural inequalities imposes additional barriers to the diagnosis and adequate treatment of CVD.^,

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Original Article

Cardiovascular Disease and Risk Factors in Women in Latin America and the Caribbean

Claudio T. Mesquita et al. Amalia Peix Diana I. Rodríguez Karen A. Dueñas-Criado … Claudia Gutiérrez-Villamil Adriana Puente Teresa Massardo Isabel Berrocal Andrea Astesiano Roberto N. Agüero Ryenne Bañolas Enrique Hiplan Mayra Sánchez Ana Ma. Barreda Vanessa V. Gómez Cynthia Fernández Silvia Portillo Yariela Herrera Aurelio Mendoza Miguel Kapitan Carlos Castellanos Enrique Estrada-Lobato Diana Paez

Abstract

Background

Cardiovascular disease (CVD) remains the leading cause of death among women in Latin America and the Caribbean (LAC), with ischemic heart disease as the primary contributor. Despite this burden, women’s health programs in the region have traditionally prioritized cancer prevention, often neglecting CVD.

Objective

To analyze the burden of CVD and the distribution of cardiovascular risk factors among women in LAC, highlighting sex-related differences and regional disparities.

Methods

This study analyzed epidemiological data on CVD mortality and cardiovascular risk factors across LAC countries, including behavioral, metabolic, and female-specific risk factors, and conducted comparisons with selected countries outside the region.

Results

Women in LAC showed a higher prevalence of sedentary lifestyle, dyslipidemia, elevated fasting blood glucose, and overweight/obesity, whereas smoking was more frequent among men. Female-specific risk factors – such as teenage pregnancy, preterm birth, gestational diabetes, and hypertensive disorders of pregnancy – were highly prevalent yet under-recognized, largely shaped by socioeconomic determinants. In 2021, COVID-19 temporarily surpassed ischemic heart disease and stroke as the leading cause of death in the Americas (176.7 deaths per 100,000 population), highlighting the vulnerability of women with underlying cardiometabolic risk. Premature CVD mortality varied widely, with the highest female probabilities of death between ages 30 and 70 observed in Haiti (21.9%) and Guyana (15.2%), associated with poorly controlled hypertension and elevated cholesterol, respectively. In contrast, Canada showed the lowest premature mortality (1.7%), reflecting stronger healthcare systems and lower prevalence of metabolic risk factors.

Conclusion

CVD remains the leading cause of mortality among women in LAC, marked by substantial regional disparities and a significant burden of both traditional and female-specific risk factors. These findings highlight the urgent need for sex-specific, context-sensitive strategies that integrate cardiovascular prevention into comprehensive women’s health policies, moving beyond cancer-centered approaches.

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Original Article

Operative Experience and Clinical Outcomes in Cardiac Myxoma Patients: A Retrospective Single-Center Study

Heleutério da Conceição Nicolau Madogolele et al. Manuela Cristina Ribeiro Dias Barroso Hernán Patricio García Mejía Cristhian Espinoza … Vinicius Machado Correia Vagner Madrini José Augusto Duncan Ricardo Ribeiro Dias Fábio Fernandes

Abstract

Background

Cardiac myxoma is the second most common primary cardiac tumor; however, contemporary single-center series integrating operative strategy with clinical outcomes remain limited.

Objectives

To describe the operative approaches and clinical outcomes of patients undergoing surgical resection of cardiac myxomas at a single center.

Methods

We conducted a retrospective review of 74 consecutive patients who underwent surgical resection of histologically confirmed cardiac myxomas between 2014 and 2024 at a tertiary referral center in Brazil. Clinical, imaging, surgical, and follow-up data were collected. The primary outcome was the incidence of thromboembolic events. A significance level of 5% was adopted for all statistical analyses.

Results

The median age was 60 years (range 52-66), and 68.9% of patients were female. Median follow-up was 60 months (interquartile range 40-79). Thromboembolic events occurred in 14 patients (18.9%), including stroke (13.5%), embolic myocardial infarction (2.7%), and pulmonary embolism (2.7%). In multivariable Cox analysis, diabetes was independently associated with a lower hazard of thromboembolic events (HR 0.11; 95% CI 0.006-0.740; p < 0.05), whereas postoperative atrial fibrillation was associated with a higher thromboembolic risk (HR 6.74; 95% CI 1.490-30.510; p < 0.05). Tumor recurrence occurred in 2.7% of cases. Only one death was recorded during follow-up.

Conclusion

Cardiac myxomas are associated with significant thromboembolic and hemodynamic risks. Early surgical resection provides excellent long-term outcomes and should be considered even in asymptomatic patients. In our cohort, tumor morphology showed a non-significant trend toward a higher risk of thromboembolic events.

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Original Article

The Cost of Medical Management in Advanced Heart Failure: A Latin American Perspective

Livia Adams Goldraich et al. Ana Paula Beck da Silva Etges Laura Caroline Tavares Hastenteufel Dayanna Machado Lemos … Andreas Zuckermann Mandeep R. Mehra Carisi Anne Polanczyk Nadine Clausell

Abstract

Background

The financial burden faced by patients with advanced heart failure (HF) who are ineligible for heart transplantation or lack have access to advanced therapy with left ventricular assist devices (LVADs) has not been described in Latin American.

Objective

To conduct a microcosting study in patients who were otherwise eligible for LVAD therapy who did not have access to it.

Methods

We evaluated the direct costs of care in a cohort of advanced HF patients treated at a Brazilian public hospital who were candidates for LVAD therapy (and ineligible for transplantation) but lacked access to the procedure. A patient-level cost analysis was performed from the time LVAD need was identified until death or end of follow-up. The total cost per patient was calculated using the time-driven activity-based costing methodology and expressed in international dollars (Int$). Patients were stratified by disease severity and all-cause mortality to assess cost variability.

Results

Conclusions

This study highlights the financial burden associated with ongoing medical management of advanced HF in patients who would otherwise be eligible for LVAD therapy. These findings provide a basis for evaluating the cost-effectiveness of device-based, life-saving interventions in selected advanced HF populations.

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Editorial

The Hidden Cost of Denied Access: Advanced Heart Failure in Latin America

Fernanda Almeida Andrade

Advanced heart failure (AHF) represents the terminal stage of the syndrome, characterized by refractoriness to currently available pharmacological and non-pharmacological strategies. It is a condition associated with high morbidity and mortality rates and a disproportionate consumption of healthcare resources, imposing a substantial burden on both healthcare systems and families. With population aging and the increased survival of individuals with chronic heart disease, the prevalence of AHF is projected to grow steadily, with escalating impact on direct costs (hospitalizations, advanced therapies, intensive support) and indirect costs (loss of productivity and social dependency).^,

In high-income countries, costly interventions such as heart transplantation and long-term mechanical circulatory support have become consolidated therapeutic pillars that can alter the natural history of the disease. Heart transplantation remains the gold standard of treatment, although its practical application is limited by donor shortages and a high proportion of clinically ineligible patients. Within this therapeutic gap, left ventricular assist devices (LVADs) have progressively emerged as increasingly effective alternatives, particularly as destination therapy. The introduction of continuous-flow technologies and, more recently, magnetically levitated pumps, such as the HeartMate 3, has redefined prognosis, providing survival beyond five years in specialized centers.

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Editorial

How Can We Expand Knowledge to Improve Women's Cardiovascular Health in Latin America?

Maria Alayde Mendonça Rivera et al. Carolina María Artucio Glaucia Maria Moraes de Oliveira

Latin America (LA) is characterized by enormous cultural diversity due to its multiplicity of languages (Spanish, Portuguese, French, English, Dutch, and countless indigenous languages), ethnicities (white, black, indigenous), beliefs, climates, religions, and customs. This variability is observed between countries and within each country in the region, making them unique, even though they share a geographic area and numerous historical facts. There is evidence that the epidemiological and nutritional transition has been more heterogeneous in LA than in other areas of the world, which contributes to a significant variability between countries and their subregions not only in the prevalence of different cardiovascular (CV) risk factors (RFs), but in CV mortality as well. Currently, 51% of the 659 744 000 inhabitants (UN, 2022) are women in LA and the Caribbean.

According to the Global Burden of Diseases (GBD) 2021, the leading causes of death in Latin American women in 2021 were related to the COVID-19 pandemic, which reduced life expectancy in the region by approximately three years, more markedly in LA and the Caribbean (). Regarding noncommunicable diseases (NCD), peculiarities in the death rates per 100 000 inhabitants in LA and the Caribbean, and in Southern LA were observed in 2021. CV disease, followed by neoplasms, is responsible for the highest death rates per 100 000 inhabitants in the Caribbean, Tropical LA, and Southern LA, where this ranking is inverse in Chile. Diabetes and kidney diseases, followed by CVD, account for the highest death rates per 100 000 inhabitants in Central LA. In contrast, neoplasms, followed by mental illnesses, predominate in Andean LA.

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Editorial

Challenges and Perspectives for Cardiology in the Developing World: Joint Views from Africa and Latin America

Mauer A. A. Gonçalves et al. Humberto Morais Gláucia Maria Moraes de Oliveira Cláudio Tinoco Mesquita

How to face challenges and promote improvements?

In 2017, a survey revealed that 18% of the 33 participating African countries had no registered cardiologists.^, Across Africa, there are approximately 2000 registered cardiologists for a population of 1.2 billion inhabitants. There is a scarcity of cardiac surgery and interventional cardiology services, with around 22 cardiothoracic centers in Africa, and 30% of African countries lack artificial cardiac stimulation therapies and cardiac electrophysiology.^– The lack of qualified human resources is a critical obstacle. The region faces a shortage of health professionals equipped to handle CVD. The specialized training process is lengthy and inadequate, contributing to this gap.^, Compared to Africa, Latin America has a great number of estimated cardiologists: 25000 to 30000. According to the 2023 Brazilian Medical Demographics study, the cardiology field has 20324 licensed professionals. Angola, an African low- to middle-income country with an estimated population of 34.0 million inhabitants, has made notable efforts in training specialists in cardiology and cardiac surgery. There are currently around 100 registered cardiologists, including 4 interventional cardiologists and 5 cardiologists who autonomously implant cardiac stimulation devices. There are also 10 cardiac surgeons, all of whom were trained abroad.

Reducing the burden of CVD in Latin America and Africa requires a multi-faceted approach that addresses various factors. For instance, collaboration with middle- and high-income countries plays a crucial role in establishing specialized centers and training professionals. However, the sustainability of these centers is challenged by economic fluctuations and political instabilities, affecting the continuity of these services.^, Inclusive health policies are crucial to ensure equitable access to medical services and medications for CVD. Expanding health insurance coverage and providing accessible therapies are fundamental steps in this direction. Partnerships between countries, both North-South and South-South, are essential to strengthen specialized workforces and improve cardiovascular care.^,,

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Review Article

Cardiovascular Disease in Latin American Women Gaps and opportunities

Karen Alexandra Dueñas-Criado et al. Angela Herrara Peña Maria Juliana Rodriguez-González Astrid Fajardo

Abstract

Cardiovascular disease (CVD) remains the leading cause of death in women. This review will address the known disparities in cardiovascular care concerning diagnosing and treating of heart disease in Latin American (LA) women. Gender-specific differences regarding the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Today, we identify that women have cardiovascular risk factors (CRFs), specifying the traditional, emerging, unique, or sex-specific determinants and the social and biological determinants that play a leading role in the prevention of CVD. The purpose of this article is to review the literature on cardiovascular disease in LA women, focusing on ischemic heart disease (IHD), valve disease (VD), heart failure, and cardiac rehabilitation (CR), where disparities continue to affect outcomes. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in CVD.

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Letter to the Editor

A Simple Clinical Risk Score to Predict Post-Discharge Mortality in Chinese Patients Hospitalized with Heart Failure

Guillermo Alberto Arana Morales et al. Hugo Alpaca-Salvador Ricardo Salazar-Ramírez

We have read with great interest the article published by Wang et al. on the clinical risk score to predict mortality in Chinese patients hospitalized for heart failure (HF). The authors developed a scale with five variables to predict mortality from HF after hospital discharge within one year: age, female sex, New York Heart Association (NYHA) score >3, left atrial diameter, and body mass index; with good predictive ability. One limitation of the study is the design of random division into two groups, one for the development of the predictive model and the other to evaluate its performance, which, when drawn from the same cohort, have similar characteristics and therefore the predictive performance may be overestimated.

A very interesting aspect of the study is that it focuses on the evaluation of patients with HF at hospital discharge, uses simple, easily assessable predictive variables, and predicts mortality at one year. There are a variety of studies of prognostic scores for HF, in outpatient, hospitalized, or emergency patients, and they predict mortality during hospitalization, within the first 30 days, or a year; many of them with biases that limit their validity.

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Original Article

Hospital Mortality from Myocardial Infarction in Latin America and the Caribbean: Systematic Review and Meta-Analysis

Leonardo Alves et al. Patrícia K. Ziegelmann Victor Ribeiro Carisi Polanczyk

Abstract

Background:

Most cardiovascular deaths occur in low- and middle-income countries and myocardial infarction is one of the main life-threatening conditions.

Objective:

We assessed all-cause in-hospital mortality in patients admitted for myocardial infarction (STEMI and NSTEMI) in Latin America and the Caribbean from 2000 onward.

Methods:

We systematically searched in electronic bibliographic databases for cohort studies which reported in-hospital mortality due to STEMI and NSTEMI. A meta-analysis was performed and a p-value < 0.05 was considered significant.

Results:

We identified 38 studies (29 STEMI, 3 NSTEMI and 6 both). Pooled STEMI in-hospital mortality was 9.9% (95% CI: 9.1 – 10.7). Heterogeneity was not trivial (I² = 74% and prediction interval = 6.6 – 14.5). The percentage of reperfusion therapy and decade explain part of the heterogeneity (I² = 54%). The higher the rate of reperfusion therapy, the lower the in-hospital mortality (coefficient = −0.009, 95% CI: −0.013 to −0.006, p<0.001). This mortality was higher in the first decade as compared with the second (coefficient = −0.14, 95% CI: −0.27 to −0.02, p=0.047). Pooled NSTEMI in-hospital mortality was 6.3% (95% CI: 5.4 – 7.4) and heterogeneity was null.

Conclusion:

Pooled STEMI in-hospital mortality in low- and middle-income countries was high in comparison with rates reported in high income countries. To improve these estimates, higher use of reperfusion therapy must be pursued. Pooled NSTEMI in-hospital mortality was similar to the ones found in high-income countries; however, it was based on few studies and most of them were carried out in two countries.

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Original Article

Recent Developments and Current Status of Transcatheter Aortic Valve Replacement Practice in Latin America – the WRITTEN LATAM Study

Fernando Luiz de Melo Bernardi et al. Henrique Barbosa Ribeiro Luis Nombela-Franco Enrico Cerrato … Gabriel Maluenda Tamim Nazif Pedro Alves Lemos Matias Sztejfman Pablo Lamelas Dario Echeverri Marcelo Antonio Cartaxo Queiroga Lopes Fábio Sândoli de Brito Jr Alexandre A. Abizaid José A. Mangione Helene Eltchaninoff Lars Søndergaard Josep Rodes-Cabau

Abstract

Background:

Transcatheter aortic valve replacement (TAVR) is a worldwide adopted procedure with rapidly evolving practices. Regional and temporal variations are expected to be found.

Objective:

To compare TAVR practice in Latin America with that around the world and to assess its changes in Latin America from 2015 to 2020.

Methods:

A survey was applied to global TAVR centers between March and September 2015, and again to Latin-American centers between July 2019 and January 2020. The survey consisted of questions addressing: i) center’s general information; ii) pre-TAVR evaluation; iii) procedural techniques; iv) post-TAVR management; v) follow-up. Answers from the 2015 survey of Latin-American centers (LATAM15) were compared with those of other centers around the world (WORLD15) and with the 2020 updated Latin-American survey (LATAM20). A 5% level of significance was adopted for statistical analysis.

Results:

250 centers participated in the 2015 survey (LATAM15=29; WORLD15=221) and 46 in the LATAM20. Combined centers experience accounted for 73 707 procedures, with WORLD15 centers performing, on average, 6- and 3-times more procedures than LATAM15 and LATAM20 centers, respectively. LATAM centers performed less minimalistic TAVR than WORLD15 centers, but there was a significant increase in less invasive procedures after 5 years in Latin-American centers. For postprocedural care, a lower period of telemetry and maintenance of temporary pacing wire, along with less utilization of dual antiplatelet therapy was observed in LATAM20 centers.

Conclusion:

Despite still having a much lower number of procedures, many aspects of TAVR practice in Latin-American centers have evolved in recent years, followingthe trend observed in developed country centers.

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Review Article

Stroke Prevention in Atrial Fibrillation: Focus on Latin America

Ayrton R. Massaro et al. Gregory Y. H. Lip

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention.

The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events.

The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region.

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Artigo Original

Dietary Interventions and Blood Pressure in Latin America – Systematic Review and Meta-Analysis

Caroline Cantalejo Mazzaro et al. Flávia Caroline Klostermann Bruna Olandoski Erbano Nicolle Amboni Schio … Luiz César Guarita-Souza Marcia Olandoski José Rocha Faria-Neto Cristina Pellegrino Baena

Background:

High blood pressure is the major risk factor for cardiovascular disease. Low blood pressure control rates in Latin American populations emphasize the need for gathering evidence on effective therapies.

Objective:

To evaluate the effects of dietary interventions on blood pressure in Latin American populations.

Methods:

Systematic review. Electronic databases (MEDLINE/PubMed, Embase, Cochrane Library, CINAHL, Web of Science, Scopus, SciELO, LILACS and VHL) were searched and manual search for studies published up to April 2013 was performed. Parallel studies about dietary interventions in Latin American adult populations assessing arterial blood pressure (mm Hg) before and after intervention were included.

Results:

Of the 405 studies identified, 10 randomized controlled trials were included and divided into 3 subgroups according to the proposed dietary intervention. There was a non-significant reduction in systolic blood pressure in the subgroups of mineral replacement (-4.82; 95% CI: -11.36 to 1.73) and complex pattern diets (-3.17; 95% CI: -7.62 to 1.28). Regarding diastolic blood pressure, except for the hyperproteic diet subgroup, all subgroups showed a significant reduction in blood pressure: -4.66 mmHg (95% CI: -9.21 to -0.12) and -4.55 mmHg (95% CI: -7.04 to -2.06) for mineral replacement and complex pattern diets, respectively.

Conclusion:

Available evidence on the effects of dietary changes on blood pressure in Latin American populations indicates a homogeneous effect of those interventions, although not significant for systolic blood pressure. Samples were small and the quality of the studies was generally low. Larger studies are required to build robust evidence.

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