ABC | Volume 114, Nº2, February 2020

Viewpoint Arq Bras Cardiol. 2020; 114(2):313-318 Lopes et al. Treatment of aortic stenosis in elderly individuals in Brazil Figure 1 – Absolute prevalence of Non-rheumatic calcific aortic valve disease in Brazil from 1990 to 2017 (Global Burden of Disease 2017). 7 Regarding the causes of death in Brazil, non-rheumatic valvular diseases rose from the 10th position in 1990 to the 9th position in 2017. Although the age-standardized mortality associated with these valvular diseases has remained relatively stable, a considerable increase was observed for degenerative aortic valvular disease. The mortality rate at all ages due to non‑rheumatic valvular diseases increased significantly by 87.5% (95%II: 63.5 – 96.9%) (Figure 2), with a large contribution from the population over the age of 70 years, especially in relation to Non-rheumatic calcific aortic valve disease, which showed a 108% increase in this age group in the evaluated period. 7 These trends have also resulted in increased proportional mortality associated with Non-rheumatic calcific aortic valve disease in both sexes (Figure 3), suggesting a striking contribution from the changes in the age profile of the population in recent decades to the global burden of valvular disease in Brazil, with a notable impact by the aging of the population. 6 Additionally, GBD 2017 data suggest that socioeconomic development is also a determinant of some types of valvular diseases, notably Non-rheumatic calcific aortic valve disease: percentage changes in age-standardized mortality rates from 1990 to 2017 correlated significantly with the sociodemographic development index (SDI) of the Brazilian states in these years (1990: r 2 = 0.17, p = 0.005; 2017: r 2 = 0.23, p = 0.003) (Figure 4), and a similar pattern was observed for morbidity, with significant correlations between disability-adjusted life years (DALY) and the SDI in the period. 6 These trends are in line with those observed for cardiovascular disease in general in Brazil and in other Portuguese-speaking countries. 8 However, it should be noted that primary epidemiological data on degenerative aortic valvular disease in Brazil are still scarce, and most estimates derive from statistical modeling. Despite the progressive increase in the prevalence and disease burden associated with degenerative valvular diseases in the country, the number of annual hospitalizations by the SUS for treatment of valvular heart disease remained stable between 2008 and 2018, with a modest increase in costs of around 40%, not adjusted for the inflation in the period 9 (Table 1). At the beginning of the period evaluated in this time series (2008), the first TAVI implantation was performed in Brazil, and current data from the RIBAC national registry, organized by the SBHCI, compute over 800 procedures, with rates of success and complications exceeding those in the literature. 10,11 The approximate cost per transfemoral implantation is estimated at R$ 82,826.38, with the prosthesis corresponding to about 80% of this amount. 12 Conitec defended that the budgetary impact estimate was not the main determinant for its unfavorable opinion, but gave evidence contrary to this assertion when insisted on maintaining the estimate at levels completely dissonant from the reality of health care in Brazil, especially concerning the SUS. The new budgetary impact estimate was calculated after public consultation but was presented without emphasis in the final report (restricted to two lines on page 25), hindering its visibility, while the prior estimate modified by Conitec after the public consultation continued to be largely detailed on a table over several pages (for example, pages 17, 18, and 19), leading the reader to an inaccurate conclusion that this would still be the estimate that the commission considered to be correct. The new estimate reduced the budgetary impact by more than 300 million reais per year. The Conitec considered that the budgetary impact would still be high, but did not indicate with clarity which levels were considered acceptable. Also unclear were the reasons why Conitec abandoned its first budgetary impact estimate without adopting the new estimate presented by the petitioner, which was based on the reality of health care in Brazil through its expert panel, indicating a far more feasible impact in view of the Ministry of Health budget and the provision of medical procedures to 314