Mortality – ABC CARDIOL

ABCHF

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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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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ABC

Original Article

Systematic Review on the Safety of Physical Exercise in Hypertrophic Cardiomyopathy: Recommendations from the Brazilian Society of Cardiology

Ricardo Stein et al. Rodrigo Otávio Bougleux Alô Luiz Eduardo Fonteles Ritt Alexsandro Alves Fagundes … Anderson Donelli da Silveira Artur Haddad Herdy Clea Colombo Cristiano Faria Pisani Fabrício Braga Frank Nunes Luciana Sacilotto Marconi Gomes Silva Mauricio Milani Mauricio Pimentel Milena dos Santos Barros Campos Nágela Simão Vinhosa Nunes Pablo Marino Nascimento Susimeire Buglia José Ronyeryson dos Santos Evangelista Filipe Ferrari Leonardo Castro Luna

Abstract

Background

Although historically discouraged due to the risk of arrhythmias and sudden cardiac death (SCD), physical exercise (PE) may be safe and beneficial for individuals with hypertrophic cardiomyopathy (HCM).

Objective

To evaluate the association between PE and the incidence of mortality and arrhythmic events in adults with HCM, stratifying the analysis according to different types and intensities of exercise.

Methods

Systematic review of randomized clinical trials (RCTs) and observational studies identified in PubMed, Embase, and the Cochrane Library through December 2024. Studies including individuals exposed to different intensities of PE were eligible. Risk of bias was assessed using the RoB 2 and ROBINS-I tools, and certainty of evidence using GRADE. Recommendations were developed by an expert panel of the Brazilian Society of Cardiology.

Results

Eight studies (four RCTs and four observational studies; 9,744 participants) were included. None reported an increased risk of mortality or severe arrhythmic events associated with PE, even at moderate or vigorous intensities. Syncope was rare. Additionally, a Korean observational study involving more than 7,000 participants (mean age: 59 years) demonstrated reduced all-cause mortality with higher physical activity intensity (dose–response curve). In low-risk athletes, competitive sports were not associated with severe adverse events. The quality of evidence ranged from moderate to very low.

Conclusion

PE in HCM should be encouraged based on individualized assessment. In patients without high-risk criteria for SCD, benefits appear to outweigh risks. For higher-risk subgroups, recommendations are more cautious and based on expert consensus.

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Editorial

Mortality from Cardiomyopathies in Brazil

André Rodrigues Durães

Cardiomyopathies represent a heterogeneous group of heart muscle diseases that, although individually less prevalent than coronary artery disease, impose a substantial burden of morbidity and mortality on a global scale. Data from the Global Burden of Disease (GBD) 2021 estimate that cardiomyopathies were responsible for approximately 1.2 million deaths worldwide, with an age-standardized mortality rate of 14.3 per 100,000 inhabitants, and more than 28 million disability-adjusted life years (DALYs) lost annually.^, Despite therapeutic advances in recent decades, the epidemiological trajectory of these conditions remains marked by profound regional inequalities, both between countries on different continents and within the same national territory. It is in this context that the study by Silva et al. offers a timely and necessary contribution by analyzing the epidemiological profile, as well as the spatiotemporal evolution of mortality from cardiomyopathies in Brazil between 2001 and 2021.

This is an important ecological epidemiological study that used data from the Mortality Information System (SIM) to examine more than 200,000 deaths from cardiomyopathies over a two-decade period. The average mortality rate was observed to be 6.66 per 100,000 inhabitants, reaching 7.64 per 100,000 in 2004 and falling to 4.15 per 100,000 in 2020. A significant annual reduction of 1.86% (p<0.05) was observed, and spatial analysis revealed clusters of high mortality, mainly in the Central-West, South, and Southeast regions.

[…]

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IJCS

Original Article

Is Hypertension a Predictor of Mortality in People Living With HIV/AIDS?

Gustavo Eduardo Fante et al. Pedro Antonio Pagote Dall’Omo Karina Bobato do Valle Arcelio Benetoli … Jean Fernando Sandeski Zuber Camila Marineli Martins Erildo Vicente Muller

Abstract

Background:

Hypertension is a chronic non-communicable disease that increases cardiovascular risk and significantly contributes to mortality. It is one of the most prevalent conditions among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

Objectives:

The objective of this study was to investigate hypertension as a predictor of mortality in people living with HIV/AIDS, analyzing the association of prior diagnosis of hypertension with morbidity and mortality in this population.

Methods:

This retrospective cohort study evaluated the medical records of 1207 patients receiving treatment at the Specialized Care Service (SAE) of a city in the state of Paraná over 264 months.

Results:

Among patients diagnosed with HIV/AIDS, 13.1% had hypertension. During the analyzed period, 52 deaths were recorded (4.31%), 30.77% of which occurred among patients with hypertension (p = 0.0002). Lower survival was observed among patients with hypertension (p < 0.0001), and mortality was significantly higher among women with hypertension (p < 0.0001). The hazard ratio (HR) for the general population was 3.1 (95% confidence interval [CI]: 1.7–5.6), with an HR of 1.7 for men (95% CI: 0.7–3.7) and 8.2 for women (95% CI: 3.1–21.6).

Conclusions:

Hypertension was a significant predictor of mortality in people living with HIV/AIDS, with a particularly strong impact among women.

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Editorial

Sick Individuals and Sick Populations

Érique José Farias Peixoto de Miranda

The article by Lederman et al. discusses an epidemiological investigation of mortality from diseases of the circulatory, respiratory, and endocrine systems, as well as neoplasms, in the São Paulo Metropolitan Region (SPMR), analyzed using geoprocessing.

It is noteworthy that the study combined a database of over 1.3 million hospital records from a tertiary hospital with state mortality records through deterministic linkage. In other words, identical variables from the same patient present in the different databases were used to combine them, allowing for the tracking of long-term outcomes of patients frequently lost to care after hospital discharge.

[…]

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Original Article

Spatiotemporal Analysis of Mortality from Cardiomyopathies in Brazil between 2001 and 2021

Luiz Fernando Kubrusly et al. Ana Clara Abdo Lopes Fernanda Ritt de Souza Gustavo Ferrucio Dieter … Laura Nadolny Leonardo Moreira Dias Letícia Moreira Dias Luis Gustavo Machado Farias Roberto Oliveira Basso Vitória Naomi Okimura

Abstract

Background

Brazil presents regional variations in mortality from cardiomyopathies, influenced by demographic characteristics, socioeconomic inequalities, and differences in access to health services. Between 2001 and 2021, 272,448 deaths from the disease were recorded in the country.

Objective

To analyze, at the national level, the epidemiological profile and the spatiotemporal distribution of mortality from cardiomyopathies in Brazil, from 2001 to 2021.

Methods

Epidemiological study based on secondary data from the Mortality Information System (SIM/DATASUS) and population estimates from IBGE. Crude mortality rates were calculated per municipality. Temporal analysis was performed using Joinpoint, estimating the annual percentage change (APC). Spatial analysis used GeoDa, with Bayesian smoothing and evaluation of spatial autocorrelation using the Global Moran’s I and LISA indices. Statistical significance was set at p < 0.05.

Results

There were 272,448 deaths due to cardiomyopathies, predominantly in men (58.65%), individuals aged 80 or older (25.74%), white individuals (52.18%), married individuals (36.77%), and those with 1 to 3 years of completed schooling (21.91%). The average mortality rate was 6.66 per 100,000 inhabitants, reaching 7.64 per 100,000 in 2004 and falling to 4.15 per 100,000 in 2020. A significant annual reduction of 1.86% was observed (p < 0.05). Spatial analysis revealed clusters of high mortality, mainly in the Midwest, South, and Southeast regions, with Corumbá de Goiás standing out (49.34/100,000).

Conclusion

There was a significant reduction in mortality from cardiomyopathies, despite the persistence of critical areas that require targeted strategies for surveillance, early diagnosis, and appropriate management.

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Original Article

Epidemiology and Mortality of Valvular Heart Disease in Brazilian Adults: Findings from the ELSA-Brasil Cohort

Guilia Bevilacqua Schmitz et al. Eduardo Gatti Pianca Maria Do Carmo Pereira Nunes Bruce Bartholow Duncan … Murilo Foppa Angela Barreto Santiago Santos

Abstract

Background

Most of the current evidence on valvular heart disease (VHD) comes from high-income countries. Access to treatment and the impact of VHD on quality of life may vary substantially across nations, largely due to socioeconomic differences.

Objective

This study aimed to estimate the burden of VHD and its association with mortality in a middle-income country.

Methods

We included participants from the ELSA-Brasil cohort who underwent transthoracic echocardiography at baseline (3,267 participants; 1,539 males; mean age 60.6 ± 8.8 years) across six Brazilian states. Participants were categorized into three groups—no VHD, trace/mild VHD, and moderate/severe VHD—and their characteristics and associated factors were analyzed. P-values < 0.05 were considered statistically significant.

Results

Among all participants, 2.4% had moderate/severe VHD (including 7 participants with prosthetic valves), and 43.6% had trace/mild VHD. The most prevalent moderate/severe VHD was mitral regurgitation, followed by aortic and tricuspid regurgitation, with 56 participants (86%) presenting isolated valvular regurgitation. Moderate/severe VHD was more common in older individuals and was associated with a higher prevalence of most cardiovascular comorbidities, but with lower obesity rates. It was also associated with greater cardiac remodeling and reduced systolic function, with phenotypic variations depending on the affected valve. Moderate/severe VHD was linked to increased 10-year mortality (HR: 3.7; 95% CI [2.17–6.31]), independent of age, sex, and hypertension.

Conclusion

VHD is common among community-dwelling adults in this middle-income country and increases with age. Participants with moderate/severe VHD exhibited a greater burden of comorbidities, more pronounced cardiac remodeling, worse systolic function, and substantially reduced long-term survival.

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Original Article

Spatial Distribution of Patients in the Metropolitan Area of São Paulo Attending a Public Tertiary Cardiovascular Referral Hospital According to Diseases of the Circulatory, Respiratory, Endocrine, and Neoplastic Systems

Carlos Lederman et al. Sara Lopes de Moraes Antonio Carlos Pedroso de Lima Lucia Pereira Barroso … Lilian Cristina Correia Morais Magaly de Losso Perdigão Rosa Maria Vieira de Freitas Monica La Porte Teixeira Bernadette Cunha Waldvogel Marco Antonio Gutierrez Ligia Vizeu Barrozo Alfredo José Mansur

Abstract

Background

The spatial distribution of patients according to clinical characteristics, using geoprocessing techniques, enables the identification of disease clusters within a studied population. This approach supports the development of targeted interventions directed toward specific risk groups.

Objectives

To investigate geographical clusters of diseases of interest among patients attending a public tertiary hospital and to characterize their spatial distribution across the metropolitan area of São Paulo.

Methods

Based on the results of a previous study, two disease groups were defined: one representing the main diseases identified at the first hospital visit and another representing the main underlying causes of death. A detailed description is provided in the . Disease density was calculated by dividing the frequency of cases within each disease group by the population of each city/district and multiplying the result by 100,000 to enhance data visualization. Spatial data were subsequently analyzed and mapped to illustrate the spatial patterns and relationships identified in the study.

Results

Osasco and Taboão da Serra showed the highest density of underlying causes of death related to diseases of the circulatory system. Additionally, 12 cities/districts located at the borders of the study area showed no recorded neoplastic diseases.

Conclusions

Vargem Grande Paulista showed the highest case density for neoplasms as underlying causes of death and comorbidities. Notably, Embu das Artes, a city recognized for its extensive green areas, showed the highest density of diseases of the respiratory system.

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Editorial

Permanent Artificial Cardiac Pacemaker in the Treatment of Bradyarrhythmias Caused by Chagas Disease

Government programs aimed at eliminating vector-borne transmission of Chagas disease have had a strong impact on the prevalence of cardiac bradyarrhythmias secondary to this etiology and, consequently, on the number of pacemaker implants performed in Brazil.^– Data from the Brazilian Pacemaker Registry show that in 1995, of the 6,542 initial pacemaker implants reported, 30.2% were related to patients with Chagas disease. The proportion of patients with Chagas disease, however, decreased over time, and seven years later, when the 2002 data were presented, of the 11,347 initial implants reported, Chagas disease was reported as the etiology in 25.0% of cases. The total figures for the first 10 years of this century showed that Chagas disease accounted for 17.8% of initial pacemaker implants, falling to 11.7% in the latest publication of data from the Brazilian Pacemaker Registry, referring to the period from 2009 to 2014. Among the initial implants of conventional pacemakers performed at the Heart Institute-HC-FMUSP in the last six years (01/01/2020 to 31/12/2025), of the 2689 patients operated on, only 236 (8.8%) had Chagas disease as the etiology of their bradyarrhythmia, according to clinical and demographic data of consecutive patients undergoing procedures for implantation of electronic cardiac devices from 01/01/2020 to 31/12/2025 at Incor-HC-FMUSP.

A comparative analysis of the demographic and clinical data of 25,648 individuals with Chagas disease and 31,984 with degenerative heart disease who underwent conventional pacemaker implantation between 1995 and 2003 showed similarities between these two groups of individuals regarding sex distribution, with 47.8% women among those with Chagas disease and 48.5% in the degenerative disease group (p=0.186). On the other hand, a significant difference was observed when evaluating the average age of these two populations, with 58.6 ± 15.3 years for Chagas disease and 73.5 ± 12.6 for the degenerative disease group (p=0.001).

[…]

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IJCS

Letter to the Editor

Beyond the Numbers: A Critical Analysis of DATASUS on Cardiovascular Mortality

João Pedro Azevedo Lopes et al. João Emmanuel Coelho de Morais Pedro Pereira Tenório

Dear Editor,

We are writing to express our appreciation for the article “Epidemiological Analysis of Emergency Hospitalizations in Brazil Due to Cardiovascular Diseases From 2013 to 2023” by Luiz et al. This work is of great relevance, as it provides a robust and updated epidemiological overview (2013–2023) of Cardiovascular Diseases (CVD) in Brazil, which remain one of the country’s major public health challenges. The use of a decade of DATASUS data gives the study indispensable temporal breadth for long-term trend analysis, representing one of its greatest strengths.

[…]

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ABCIC

Original Article

Cardiovascular Complications in Patients with COVID-19 and Their Relationship with Mortality: An Echocardiographic Perspective

João Henrique Andrade de Almeida et al. Gustavo Miranda de Azevedo Ferreira Marina de Azevedo Martins Andrade Heloísa Marceliano Nunes Igor Brasil Costa

Abstract

Background:

Echocardiography plays a fundamental role in the diagnosis of cardiovascular diseases related to SARS-CoV-2 infection. Despite prior investigation in the literature, studies focusing on cardiovascular manifestations among patients from the Brazilian Legal Amazon region remain scarce.

Objectives:

To identify cardiovascular complications of COVID-19 in patients admitted to a hospital in the North Region of Brazil and their potential association with mortality.

Methods:

We conducted a retrospective cohort study including 25 medical records of adults diagnosed with COVID-19. These patients were admitted to a hospital in Belém, Pará, in Northern Brazil, between March 2020 and December 2020. Demographic and clinical characteristics, as well as echocardiographic findings, were extracted from the medical records. Statistical analyses were performed adopting a significance level of α < 0.05. The project was approved by the Research Ethics Committee (approval number: 5.540.025).

Results:

Among the 25 patients, 15 (60%) were male, with a mean age of 69.6 ± 14.4 years. Hypertension (n = 23; 92%) was the most prevalent cardiovascular risk factor, followed by diabetes (n = 11; 44%) and obesity (n = 8; 32%). We detected echocardiographic abnormalities in 20 (80%) individuals, with diastolic dysfunction being the most frequent (n = 18; 72%). All 7 patients who died showed abnormal echocardiography (p > 0.05). Atrial fibrillation or flutter (n = 5; 20%), decompensated heart failure (n = 3; 12%), and cardiogenic shock (n = 2; 8%) were the most common types of cardiovascular involvement.

Conclusions:

An increasing trend in COVID-19 mortality was observed among patients with cardiovascular complications. Nevertheless, the statistical power was limited by the small sample size.

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Original Article

Atrial Cardiomyopathy Detected by Electrocardiogram: Association with Stroke in a Brazilian Electronic Cohort

Filipe Antunes de Lêu et al. Gabriela Miana de Mattos Paixão Ana Cecilia Oliveira Carla Paula Moreira Soares … Paulo R. Gomes Peter Macfarlane Antônio Luiz Pinho Ribeiro

Abstract

Background

Atrial cardiomyopathy (AC) is a condition detectable by electrocardiogram (ECG) that may play a significant role in the pathophysiology of the etiology of strokes, independently of atrial fibrillation (AF).

Objectives

To evaluate the association between ECG markers of AC (prolonged P-wave duration >120 ms and P-terminal force in V1 (PTFV1) >4,000 µV·ms) as well as the occurrence of mortality and hospitalization due to stroke.

Methods

This retrospective cohort study included patients from Belo Horizonte who underwent ECGs between 2006 and 2018. Patients aged ≥40 years, in sinus rhythm, and without a previous history of stroke at baseline ECG were included. Clinical and ECG data were linked to mortality (SIM) and hospitalization (SIH) public databases. Cox regression was used to calculate hazard ratios (HRs), and incremental adjustment models for age, sex, cardiovascular risk factors, and left ventricular hypertrophy were employed. Statistical significance was set at p<0.05.

Results

245,588 patients were included. 26.3% had prolonged P-wave duration >120 ms, and 10.1% had elevated PTFV1 >4,000 µV·ms. Mean follow-up duration was 3.5 years. AC was associated with mortality and hospitalization due to stroke (HR 1.24; 95% CI, 1.12–1.36 for P-wave duration >120 ms; p4,000 µV·ms; p<0.001).

Conclusion

ECG markers of AC are associated with death or hospitalization due to stroke, as well as cardiovascular mortality and incident AF in a large, representative Brazilian cohort, highlighting their prognostic value.

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ABCIC

Brief Communication

Left Ventricular Outflow Tract Velocity-Time Integral (LVOT VTI) as a Marker of Cardiac Performance: Mortality Data of the ELSA-Brasil Cohort

Mariana de Castro Lopes et al. Altair Ivory Heidemann Jr Eduardo G. Pianca Bruce B. Duncan … Murilo Foppa Angela B.S Santos

Transthoracic Echocardiography (TTE) is a well-established tool for assessing cardiac function and hemodynamics. While Left Ventricular (LV) systolic and diastolic function are commonly used metrics, Cardiac Output (CO) remains central for evaluating hemodynamic status, especially in critical care settings. TTE-derived parameters, such as Left Ventricular Outflow Tract Velocity-Time Integral (LVOT VTI) and LVOT area, when combined with body habitus and heart rate, provide noninvasive estimates of cardiac output. However, the accuracy of CO calculations may decrease when multiple covariates are included, with LVOT diameter being a major source of error. In contrast, isolated LVOT VTI may represent a simpler and more reliable surrogate of cardiac performance.

Among patients with Heart Failure with reduced Ejection Fraction (HFrEF), LVOT VTI values below 12 cm or 8 cm have been associated with worse cardiovascular outcomes, with a progressive increase in risk as VTI decreases.^, Similarly, in intermediate to high-risk pulmonary embolism, LVOT VTI ≤ 15 cm has been associated with higher in-hospital mortality, cardiopulmonary arrest, shock, and need for reperfusion therapy. In secondary mitral regurgitation, LVOT VTI ≤ 17 cm predicts both cardiovascular and all-cause mortality. And in ambulatory adults with stable Coronary Artery Disease (CAD), LVOT VTI ≤ 18 cm was associated with heart failure hospitalization and mortality. Despite these findings, there is limited data to evaluate the usefulness of LVOT VTI in free-dwelling adults.

[…]

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ABC

Original Article

Implantation of Pacemakers in Patients with Chagas disease: A Case-Control Study of Associated Contextual Factors and Prognosis

Sâmara Fernandes Leite et al. Maria Carmo Pereira Nunes Cesar Augusto Taconeli Mathaus Henrique Reis Silva … Dardiane Santos Cruz Lea Campos Oliveira Ester Cerdeira Sabino Marco Paulo Tomáz Barbosa Antonio Luis Pinho Ribeiro Ariela Mota Ferreira Desirée Sant’Ana Haikal

Abstract

Background

Chronic Chagas cardiomyopathy (CCC) is the most severe manifestation of Chagas disease and may present with bradyarrhythmias requiring pacemaker (PM) implantation.

Objective

1. To identify contextual factors associated with PM implantation among individuals with CCC. 2. To assess the prognosis (death) in these groups over a 4-year follow-up period.

Method

1. Nested case-control study within the SaMi-Trop cohort. We matched cases (patients with CCC who had a PM implanted between waves 1 and 2 of the study) with controls at a 1:3 ratio, considering equivalence in baseline cardiac severity. Independent variables related to the municipal context were considered. Binary logistic regression was conducted. 2. Survival analysis to evaluate the prognosis of these groups, adjusted for clinical variables (Cox regression), considering death as the outcome. Conclusions were based on a significance level of 5%.

Results

The study included 46 cases and 138 controls. The odds of PM implantation were higher among individuals residing in municipalities with: larger population (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.3 to 9.6), higher coverage of the Family Health Strategy (OR: 5.3; 95% CI: 1.8 to 15.8), and with a lower number of electrocardiographs per thousand inhabitants (OR: 2.6; 95% CI: 1.0 to 6.6). Considering 4 years of follow-up, death was observed in 32.6% of cases and 21.2% of controls. Only ejection fraction affected survival (relative risk: 7.2; 95% CI: 3.6 to 14.2).

Conclusion

Contextual factors interfered with PM implantation. However, PM implantation did not influence death over 4 years of follow-up, which was associated only with ejection fraction.

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Editorial

Cardiac Amyloidosis and SGLT2 Inhibitors: Signal, Hope, and the Need for Randomized Evidence

Humberto Villacorta et al. Aline Sterque Villacorta

Heart failure secondary to cardiac amyloidosis remains one of the most challenging scenarios in contemporary cardiovascular medicine. Despite major advances in disease-modifying therapies for both transthyretin (ATTR) and light-chain (AL) amyloidosis, outcomes are still largely driven by progressive heart failure, renal dysfunction, and cardiovascular deaths. Conventional heart failure therapies are often poorly tolerated or ineffective in this restrictive cardiomyopathy, leaving clinicians with limited options to improve prognosis. In this context, the real-world analysis by Nunes et al. provides timely and provocative evidence supporting a potential role for sodium-glucose cotransporter 2 (SGLT2) inhibitors in this high-risk population.

Using data from the TriNetX global collaborative network, the authors evaluated more than 2,700 propensity score-matched patients with heart failure due to ATTR or AL amyloidosis. Across both amyloid subtypes, treatment with SGLT2 inhibitors was consistently associated with substantial reductions in all-cause mortality, hospitalization, and renal events at 12 months. The magnitude of benefit is striking: approximately 50% relative reduction in mortality and meaningful improvements in both heart failure and renal outcomes. These findings extend the growing body of observational data suggesting that the benefits of SGLT2 inhibition may transcend traditional heart failure phenotypes and etiologies, and may have a specific role in cardiac amyloidosis, as shown in .

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IJCS

Original Article

Endocarditis – A 27-Year Epidemiological Analysis of Mortality in Brazil

Leticia da Costa Santana Silva et al. Luana Yasmim Fernández Avelaneda Castanheira Maria Dalila Santos Salim Ruy Felipe Melo Viegas … Gilson Fernandes Ruivo Sheila Cavalca Cortelli Davi Romeiro Aquino Taciana Mara Rezende Fortes Viégas

Abstract

Background:

Infective endocarditis (IE) is frequently caused by viridans streptococci. Short-term in-hospital mortality in high-income settings ranges from 11% to 25%. In Brazil, rheumatic heart disease remains a leading valvular substrate; however, its declining prevalence in developing nations has limited country-specific analyses.

Objective:

To describe the epidemiological profile of mortality from IE in Brazil, characterizing its magnitude and temporal trend.

Methods:

We conducted a retrospective, exploratory epidemiological study with descriptive and analytic components using data from the Mortality Information System of the Department of Informatics of Brazil’s Unified Health System. Chi-square tests of independence were applied (p < 0.05), and results were summarized in tables and figures. Variables included International Statistical Classification of Diseases and Related Health Problems, 10th Revision categories, year of death, region, and sex.

Results:

From 1996 to 2022, 40,157 deaths associated with IE were recorded in Brazil (chi-square = 1,701.43). The Southeast region accounted for the greatest burden, with 21,429 deaths (53.36%; chi-square = 15,236.00). By sex (chi-square = 999.32), men were more affected than women (55.57% [22,315] vs 44.41% [17,835]); in 0.02% of records, sex was unspecified.

Conclusions:

IE remains a condition of national and international concern, with substantial mortality in Brazil over the last 27 years. This overview of mortality patterns highlights regional disparities and sex differences and can inform public-health strategies and evidence-based interventions.

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Original Article

Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Heart Failure and Transthyretin or Light Chain Amyloidosis: A Real-World Analysis

Rafael Amorim Belo Nunes et al. Leandro Menezes Alves da Costa Thiago Luis Scudeler Precil Diego Miranda Menezes Neves … Victor Augusto Hamamoto Sato Álvaro Avezum

Abstract

Background:

Evidence regarding the efficacy of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in amyloidosis-related heart failure (HF) remains limited.

Objective:

To evaluate the impact of SGLT2i in patients with amyloid transthyretin (ATTR) or amyloid light-chain (AL) amyloidosis and HF.

Methods:

By using global electronic medical record data, we identified patients aged ≥ 18 years with ATTR or AL amyloidosis and HF. After matching, outcomes were compared between patients treated with SGLT2i and matched controls, including 2,036 patients with ATTR amyloidosis and 692 patients with AL amyloidosis. Endpoints included 12-month all-cause mortality, hospitalization, and kidney outcomes. Statistical significance was defined as a two-sided p < 0.05.

Results:

A total of 96 (9.43%) deaths occurred among patients with ATTR amyloidosis in the SGLT2i group, compared to 196 (19.2%) in the control group (hazard ratio [HR], 0.52; 95% CI, 0.41-0.66). Hospitalization occurred in 387 (38.0%) patients receiving SGLT2i and in 505 (49.6%) controls (HR, 0.74; 95% CI, 0.65-0.84). Kidney outcomes were observed in 204 (20.0%) patients in the SGLT2i group and 298 (28.5%) in the control group (HR, 0.72; 95% CI, 0.60-0.86). Among patients with AL amyloidosis, 39 (11.2%) deaths occurred in the SGLT2i group and 80 (23.1%) in the control group (HR, 0.51; 95% CI, 0.34-0.74). Hospitalization occurred in 161 (46.5%) patients treated with SGLT2i and in 204 (58.96%) controls (HR, 0.71; 95% CI, 0.58-0.88). Kidney outcomes occurred in 86 (24.8%) patients in the SGLT2i group and 137 (39.6%) in the control group (HR, 0.60; 95% CI, 0.46-0.78).

Conclusion:

In patients with HF due to ATTR or AL amyloidosis, the use of SGLT2i was associated with lower all-cause mortality, hospitalization, and kidney outcomes.

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Original Article

Geographic Variation in Door-to-Needle Time among Patients with STEMI from the Metropolitan Region of Rio de Janeiro: Results of the EQUITY-MI Cohort

Eric Costa de Almeida et al. Felipe Neves Albuquerque Esmeralci Ferreira Roberto Pozzan … Pedro Pimenta de Mello Spineti Pâmela Sousa Monteiro Williana Oliveira de Araújo Rhayana Vitória da Rosa Silva Carla Maciel Caminhas Thales Cardoso Whately João Gabriel Monteiro Junqueira Denilson Campos de Albuquerque

Abstract

Background

There is a gap in information regarding the reperfusion strategies used and the evolution of patients with ST-segment elevation myocardial infarction (STEMI) in the state of Rio de Janeiro.

Objective

To assess thrombolysis time in the diverse regions of the state capital and metropolitan area of Rio de Janeiro, as well as the outcome of post-infarction heart failure.

Methods

EQUITY-MI is a prospective cohort study of patients diagnosed with STEMI and referred to a single reperfusion center. Continuous variables were analyzed using the Kruskal–Wallis test, and categorical variables were analyzed using the chi-square test. In order to estimate the effect of door-to-needle time (DNT), generalized linear regression models with gamma distribution and log link function were applied, in addition to quantile regression to estimate the effect at the 25%, 50%, and 75% quantiles, both adjusted for sex, age, race, and education level. The significance level applied was 0.05.

Results

The study included 457 patients, with a mean age of 60.4 years, 79% of whom received thrombolysis, with a median DNT of 77 minutes, and 20.9% were thrombolyzed within 30 minutes, with no statistical difference between regions (p = 0.23). The Baixada Fluminense region presented the highest adjusted mean DNT (165.9 minutes), with a time difference compared to the North Zone (0.61; 0.44 to 0.87; p = 0.003) and West Zone (0.69; 0.51 to 0.96; p = 0.022). It also presented the highest DNT in all intervals (Q25, Q50, Q75). After infarction, 63.5% of patients presented heart failure.

Conclusion

There was a general delay in DNT for patients included in the EQUITY-MI study, with worse systematic performance in the Baixada Fluminense region, in addition to a high incidence of post-infarction heart failure.

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Original Article

Impact of PM2.5 Air Pollution on Mortality from Circulatory System Diseases in the Neighborhoods of the City of Rio de Janeiro (2000-2019)

Paulo Henrique de Moura et al. Leandro Dias Gomes de Carvalho Paulo Henrique Godoy Lucia Helena Alvares Salis … Marina Silva Paez Mariane Branco Alves Luiz Francisco Pires Guimarães Maia Renata Libonati dos Santos Nelson Albuquerque de Souza e Silva

Abstract

Background

Air pollution by fine particulate matter with an aerodynamic diameter ≤ 2.5 μm (PM_2.5) is the main environmental risk factor associated with diseases of the circulatory system (DCS), ischemic heart disease (IHD), and cerebrovascular diseases (CBVD).

Objective

To estimate mortality rates from DCS, IHD, and CBVD (2000-2019) among residents of the 164 neighborhoods of Rio de Janeiro, according to PM_2.5 levels.

Methods

This retrospective ecological study used georeferenced satellite data classified into three PM_2.5 levels and mortality records from the Department of Information and Informatics of the Unified Health System for DCS, IHD, and CBVD among individuals of both sexes aged ≥ 20 years from 2000 to 2019. Age-adjusted mortality rates per 1,000 inhabitants were calculated, and comparative statistical analyses were performed by sex, PM_2.5 level, and age group (5% significance).

Results

Approximately 91% of the 4.7 million residents (≥ 20 years) live in areas with high or extreme PM_2.5 pollution. Deaths occurred up to 3.4 years earlier among men living in highly polluted areas compared with those in moderately polluted areas. The highest DCS mortality rates were observed in neighborhoods with high and extreme pollution (female = 3.9 ± 1.7; 95% CI = 3.5-4.2; male = 4.6 ± 2.1; 95% CI = 4.1-4.9), particularly in individuals aged ≥ 70 years. Significant associations were found between mortality rates and pollution levels for DCS (p = 0.019), IHD (p = 0.025), and CBVD (p = 0.002) in the 50-69-year age group when comparing moderately and extremely polluted areas. Intermediate/high social vulnerability was identified in 71% of neighborhoods, with an increasing socioenvironmental gradient linking higher vulnerability to higher PM_2.5 concentrations (R = 0.354; p = 0.001).

Conclusion

Mean PM_2.5 concentrations in the neighborhoods of Rio de Janeiro exceeded the World Health Organization’s recommended standard by a factor of four. Mortality from DCS is significantly higher and occurs earlier in areas with high or extreme levels of pollution.

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Editorial

Middle-Aged Women — A High-Risk Group for Post-Myocardial Infarction Mortality

Maria Antonieta Albanez A. de Medeiros Lopes et al. Mayara Viana Júlia Nóbrega Heitor N. Albanez A. de Medeiros Gláucia Maria Moraes de Oliveira

Cardiovascular diseases (CVD) remain the leading cause of death worldwide, with acute myocardial infarction (MI) accounting for significant morbidity and mortality. Despite substantial reductions in overall cardiovascular mortality, gender disparities persist, particularly affecting women in different demographic contexts. In this mini-editorial, we highlight recent evidence from an original study conducted in the Brazilian Unified Health System (SUS) in Curitiba, Brazil, which followed 4,896 patients hospitalized for acute MI between 2008 and 2015. This pioneering study demonstrated that middle-aged women (45 to 54.9 years) have a significantly higher risk of post-infarction mortality compared to men of the same age group, regardless of adjusted clinical factors. These data provide a critical warning about the need for differentiated, specific clinical approaches for this group (). The analysis of the Brazilian public cohort strengthens international evidence on the gender paradox in CVD. It reinforces the critical role of hormonal changes and psychosocial determinants in worsening the prognosis for women after MI. This contradicts the common assumption that women in this age group maintain natural cardiovascular protection, raising critical questions about the attention given to cardiovascular health at this vital stage of life.

The so-called “gender paradox” in CVD is well established, especially among younger women. Studies show that women under 50 have almost three times higher mortality after MI than men of the same age group, regardless of previous medical history, disease severity, or type of treatment.^, This paradox is remarkable, given that middle-aged women often have fewer traditional cardiovascular risk factors and tend to have better outcomes after percutaneous coronary intervention. The study findings are aligned with global and national data that indicate that women develop MI approximately 5 years later than men (mean age 65.1 vs. 60.3 years). Still, the protective effect of the female sex diminishes and reverses in the 45-54.9 age range. This period coincides with perimenopause and the onset of menopause, highlighting the importance of hormonal changes in increasing cardiovascular susceptibility.

[…]

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Original Article

Forecasting Ischemic Heart Disease, Stroke, and Peripheral Artery Disease Mortality in Brazil Through 2040: A Bayesian Modeling Approach

Pedro Rafael Vieira de Oliveira Salerno et al. Antoinette Cotton Bruno R. Nascimento Zhuo Chen … Gabriel Tensol Rodrigues Pereira Alexandre A. Abizaid Luis Augusto Palma Dallan Pedro Rafael Salerno Sadeer Al-Kindi Fanny Petermann-Rocha Salil V. Deo

Abstract

Background

Atherosclerotic cardiovascular disease — particularly ischemic heart disease (IHD), stroke, and peripheral artery disease (PAD) — is the leading cause of cardiovascular mortality in Brazil.

Objectives

This study aimed to project mortality trends for IHD, stroke, and PAD in Brazil through 2040.

Methods

Annual death counts (1990-2021) for IHD, stroke, and PAD among individuals aged 40-79 years were obtained from the Global Burden of Disease (GBD) 2021 study. Mid-year population estimates for both observed (1990-2021) and projected (2022-2040) periods were used. Crude and age-standardized mortality rates were calculated. Bayesian age-period-cohort models were applied to project mortality rates from 2022 to 2040. Relative percentage changes and estimated annual percentage changes (EAPCs) were computed. Projections (per 100,000 population) are reported as medians with 95% uncertainty intervals (UIs), and EAPCs include bootstrap-derived confidence intervals (CIs).

Results

Between 1990 and 2040, Brazil’s population aged 40-79 years is projected to grow by 237.82%. The age-standardized mortality rate for IHD is expected to decline by 14.16% [from 118.61 in 2021 to 101.82 in 2040 (95% UI, 0.36-203.27)] (EAPC: -0.83% [95% CI, -0.84 to -0.83]); and for stroke by 17.36% [from 84.58 to 69.90 (95% UI, 0-152.48)] (EAPC: -1.07% [95% CI, -1.10 to -1.04]). In contrast, PAD mortality is projected to increase by 10.99% [from 1.82 to 2.02 (95% UI, 0-5.03)] (EAPC: 0.45% [95% CI, 0.30-0.59]). Additionally, sex-specific age-standardized mortality rates showed considerable variation. For IHD, rates are projected to decline by 25.31% among men (EAPC: -1.56% [95% CI, -1.57 to -1.55]), while increasing by 4.12% among women (EAPC: 0.14% [95% CI, 0.13-0.16]). Stroke mortality is expected to decrease by 30.00% in men (EAPC: -1.94% [95% CI, -1.96 to -1.91]) and by 4.52% in women (EAPC: -0.33% [95% CI, -0.37 to -0.29]). In contrast, PAD mortality is projected to rise by 14.64% in men (EAPC: 0.55% [95% CI, 0.38 to 0.71]) and by 21.92% in women (EAPC: 0.91% [95% CI, 0.78-1.02]).

Conclusion

While mortality rates for IHD and stroke are projected to decline, PAD mortality is expected to rise — particularly among women — highlighting the urgent need for sex-specific and disease-specific public health interventions.

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Original Article

Assessment of the Accuracy of the ADHERE Score in a Brazilian Acute Heart Failure Cohort

Bruno Reznik Wajsbrot et al. Ana Luiza Ferreira Sales Andre Luis Sales Feitosa Carolina Pereira de Barros … Daniel Xavier de Brito Setta Felipe Neves de Albuquerque Marcelo Imbroinise Bittencourt Pedro Pimenta de Mello Spineti Simone Offrede Rego Denilson Campos de Albuquerque Roberto Esporcatte Ricardo Mourilhe-Rocha

Abstract

Background

Patients hospitalized for acute heart failure present a high mortality rate, so risk stratification for in-hospital death is of utmost importance. Risk scores can help physicians to identify patients at higher risk, but it is important to validate those scores in different populations, since sociodemographic characteristics may be very heterogeneous.

Objectives

This study aimed to evaluate the ADHERE (Acute Decompensated Heart Failure Registry) risk score in a Brazilian quaternary teaching care center.

Methods

This was a retrospective cohort study involving 304 patients with acute heart failure aged ≥ 18 years old, conducted between September 2019 and July 2022. The primary endpoint was the evaluation of the ADHERE score by analysis of the discriminatory index and classification. The secondary endpoint was the evaluation of other prognostic factors for in-hospital mortality. A p-value < 0.05 was considered statistically significant.

Results

ADHERE score presented a discriminatory index of 0.69. ADHERE classification index was suboptimal, since the score did not stratify mortality risk on five strata as proposed originally. Furthermore, the score underestimates risk in the studied population. Admission serum urea was the only isolated prognostic factor for the endpoint (OR 1.043; CI 95% 1.024-1.062; p<0.001).

Conclusion

The ADHERE risk score cannot be entirely validated in our cohort, since classification was not achieved despite an ideal discriminatory index. Admission serum Urea was the only independent risk factor associated with in-hospital mortality. Our study emphasizes the importance of correct external validation of a prognostic score, especially if the demographic and clinical characteristics of cohorts are not comparable.

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IJCS

Editorial

C-Reactive Protein as a Prognostic Tool in Acute Heart Failure: Evidence from Low-Resource Settings

Cristhian Espinoza Romero et al. Hernán Patricio García Mejía Fábio Fernandes

Acute heart failure (AHF) remains a leading cause of hospitalization and cardiovascular mortality worldwide, with an even greater burden in low- and middle-income countries. In Brazil, in-hospital mortality for AHF is approximately 12%, compared to 4% reported in high-income countries.^,

In this context, the prospective study by Ferigato et al., conducted at a public hospital in São Paulo, assessed the prognostic value of C-reactive protein (CRP) in patients with AHF. This investigation is particularly relevant given the structural limitations of the Brazilian public healthcare system, where conventional biomarkers such as natriuretic peptides are often unavailable. Therefore, CRP—a low-cost and widely accessible inflammatory marker—emerges as a promising alternative for risk stratification during hospitalization.

[…]

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