Related Experiment Video
Updated: Oct 13, 2025
Cutoff Value of Phase Angle by Bioelectrical Impedance Analysis at Admission as a Prognostic Factor in Patients with Acute Heart Failure
Published on: June 10, 2025
Heart failure quantified by underlying cause and multiple cause of death in Brazil between 2006 and 2016
Paolo Blanco Villela1, Sonia Carvalho Santos2, Glaucia Maria Moraes de Oliveira2
1Department of Cardiology, Federal University of Rio de Janeiro, Rua Rodolpho Paulo Rocco 255 / 8o. Andar, Ilha do Fundão, Rio de Janeiro, RJ, 21941-913, Brazil. pbvillela@gmail.com.
Insights
Heart failure (HF) is significantly underreported as a cause of death in Brazil. Analyzing HF as a multiple cause of death reveals its impact is nearly three times higher than when considered the underlying cause.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- The Global Burden of Disease (GBD) excludes heart failure (HF) estimates, classifying it as a 'garbage code' due to its nature as a common endpoint for various diseases.
- This study addresses the underestimation of HF's mortality impact in Brazil by analyzing its role as both an underlying and multiple cause of death.
Purpose of the Study:
- To analyze the interactions between underlying and multiple causes of death related to heart failure (HF) in Brazil.
- To compare HF mortality data across different geographic regions and sexes from 2006 to 2016.
Main Methods:
- A descriptive study utilizing historical death certificate (DC) data from Brazil (2006-2016).
- International Classification of Diseases (ICD) code I50 was used to identify HF as an underlying or multiple cause of death.
- Data were analyzed and visualized by geographic region to compare with national trends.
Main Results:
- Over 1 million death certificates mentioning ICD code I50 were analyzed.
- Heart failure (HF) was identified as a multiple cause of death nearly three times more frequently than as an underlying cause, a consistent trend over the study period.
- The Southeast region recorded the highest number of HF-related deaths, followed by the Northeast and North regions. Comorbidities like diabetes, COPD, and stroke were noted in a small percentage of DCs.
Conclusions:
- Considering HF solely as the underlying cause of death leads to a significant underestimation of its mortality burden in Brazil.
- HF's presence in nearly three times more deaths when analyzed as a multiple cause highlights its complex nature and impact on mortality trends.
- Recognizing HF as a complex syndrome with multiple contributing factors is crucial for effective public health management and accurate mortality analysis.
Background:
The Global Burden of Disease (GBD) does not produce estimates of heart failure (HF) since this condition is considered the common end to several diseases (i.e., garbage code). This study aims to analyze the interactions between underlying and multiple causes of death related to HF in Brazil and its geographic regions, by sex, from 2006 to 2016.
Methods:
Descriptive study of a historical series of death certificates (DCs) related to deaths that occurred in Brazil between 2006 and 2016, including both sexes and all age groups. To identify HF as the underlying cause of death or as a multiple cause of death, we considered the International Classification of Diseases (ICD) code I50 followed by any digit. We evaluated the deaths and constructed graphs by geographic region to compare with national data.
Results:
We included 1,074,038 DCs issued between 2006 and 2016 that included code I50 in Parts I or II of the certificate. The frequency of HF as the multiple cause of death in both sexes was nearly three times higher than the frequency of HF as an underlying cause of death; this observation remained consistent over the years. The Southeast region had the highest number of deaths in all years (about 40,000 records) and approximately double the number in the Northeast region and more than four times the number in the North region. Codes of diseases clinically unrelated to HF, such as diabetes mellitus, chronic obstructive pulmonary disease, and stroke, were mentioned in 3.11, 2.62, and 1.49% of the DCs, respectively.
Conclusions:
When we consider HF as the underlying cause of death, we observed an important underestimation of its impact on mortality, since when analyzed as a multiple cause of death, HF is present in almost three times more deaths recorded in Brazil from 2006 to 2016. The mentioning of conditions with little association with HF at the time of the death highlights the importance of HF as a complex syndrome with multiple components that must be considered in the analysis of mortality trends for implementation of public health management programs.
Related Concept Videos
01:17Pathophysiology of Heart Failure
01:27Heart Failure I: Introduction
01:29Heart Failure II: Pathophysiology
01:26Imbalances in Cardiac Output
CHF can occur due to the failure of either side of the heart. Left-side failure leads to pulmonary congestion—the right side continues to send...
01:26Heart Failure III: Clinical Manifestations
01:30Heart Failure IV: Classification and Diagnostic Evaluation