Arq. Bras. Cardiol. 2025; 122(9): e20250444

Post-discharge Mortality in Heart Failure: Insights from a Multiple-Cause Analysis

Danielle Louvet Guazzelli, Monica S. Avila

DOI: 10.36660/abc.20250444i

This Short Editorial is referred by the Research article "Analysis of Mortality from Multiple Causes in Heart Failure Categorized by Ejection Fraction".

Heart failure (HF) ranks among the leading causes of hospital admission and death. Nevertheless, the factors precipitating mortality—particularly after a decompensation-related admission—are far more heterogeneous than once assumed. In the article “Multiple Cause of Death Analysis in Heart Failure According to Ejection Fraction” published in this issue of the Arquivos Brasileiros de Cardiologia, 519 patients hospitalised for decompensated HF between 2011 and 2019 had their death certificates examined with a multiple-cause-of-death (MCOD) approach. Over a mean follow-up of 2.9 years, 52 % of patients died; however, only 36 % of the 977 recorded mentions were cardiovascular, a proportion clearly lower than the 50% previously reported in Brazilian series. Sepsis, HF itself, and pneumonia were the most frequent specific causes, and—contrary to studies linking reduced ejection fraction to worse prognosis—survival did not differ across preserved, mildly reduced, or reduced ejection-fraction groups. Remarkably, code I50 (HF), historically the leading line on Brazilian death certificates (≈ 23 % of mentions),³ ranked only third, surpassed by sepsis and pneumonia.

The post-discharge period is characterized by heightened vulnerability and multiple competing threats. International registries already show 20–30 % mortality in the first year, with a growing dominance of non-cardiovascular causes in late deaths.^, The Brazilian study reinforces this shift. Although in-hospital lethality was 14.5 %, infections and respiratory complications accounted for most post-discharge deaths, mirroring patterns seen in trials of SGLT2 inhibitors and sacubitril/valsartan.^,

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