ABC | Volume 114, Nº2, February 2020

Original Article Fernandes et al. Heart failure trends in Less developed Brazil Arq Bras Cardiol. 2020; 114(2):222-231 Figure 6 – Trends in the mean length of stay (days) from heart failure hospitalizations in Paraiba (green) and Brazil (blue) from 2008 to 2017 2008 8 7 6 5 4 3 2 1 0 8 7 6 5 4 3 2 1 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Duration (days) Duration (days) Mean hospital stay (days) from Heart Failure in Paraiba (2008-2017) Mean hospital stay (days) from Heart Failure in Brazil (2008-2017) 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Table 4 – Total cost of HF hospitalizations (US$) and duration of HF admission (days) in Paraiba and Brazil, from 2008 to 2017 PARAÍBA BRAZIL Year Total cost with hospitalizations (US$) Duration of admission (days) Total cost with hospitalizations (US$) Duration of admission (days) 2008 1,762,825.91 5 77,940,473.93 6.5 2009 2,286,531.90 5.2 89,837,575.25 6.4 2010 2,541,429.71 5.3 92,835,802.31 6.5 2011 2,378,139.40 5.5 93,939,042.90 6.6 2012 1,939,284.53 5.6 91,509,632.22 6.7 2013 1,694,005.09 5.6 93,561,446.18 6.9 2014 1,578,506.24 6.1 96,199,113.56 7.1 2015 1,233,302.85 6.5 99,069,494.68 7.3 2016 1,249,580.27 7.2 102,181,019.88 7.4 2017 1,103,600.05 7.2 85,390,241.41 7.3 Total 17,767,205.95 5.9 ± 0.8 (mean ± SD) 922,463,842.32 6.9 ± 0.4 (mean ± SD) SD: standard deviation; Source of data: SUS Information System (DATASUS) and Brazilian Institute of Geography and Statistics (count of 2010) between 1992-1993 and 2008-2009, also reported a 15% increase in the previous 15% in-hospital mortality rate in Brazil. In the U.S., however, the in-hospital mortality rate decreased from 4.5% in 2001 to 2.9% in 2014 according to a study that included patients with a primary diagnosis of HF. 13 The decrease in the number of hospitalizations for HF during the study period, both in Paraiba and Brazil, is the most likely reason for the increased in-hospital mortality rate. Another plausible explanation could be the increased survival of HF patients, leading to a higher number of elderly patients, with more advanced HF and multiple comorbidities, and increased risk of death during hospitalization. Lastly, it is important to consider the lack of advanced therapies in less developed areas, as mechanical devices and heart transplantation, contributing to this trend of increased HF mortality rate in Paraiba, Brazil and LAC. Although there was an increase in the in-hospital mortality rate, absolute in-hospital mortality showed a significant decrease of 37.5% in Paraiba and 14.6% in Brazil for the same period. In the U.S., Bueno et al. 21 also observed a 50% decrease in the in-hospital mortality for HF in a population of elderly Medicare patients, from 1993 to 2008, and Ni and Xu, 22 a 30% decrease. Women represented 53% and 52% of the absolute mortality for HF in Paraiba and Brazil, respectively. The in‑hospital mortality for HF in Paraiba had a similar proportion of women (50.5%). In the U.S., in 2010, 54.6% of all HF deaths happened in women. 20 Hsich et al. 23 observed no difference in the in‑hospital mortality between women and men considering both the reduced and preserved ejection fraction groups. Between 2008 and 2017, the mean duration of hospitalization for HF was 5.9 (±0.8) days in Paraiba and 6.8 (±0.4) days in Brazil, with an increase of 44% and 12.3%, respectively. In the LAC, Bocchi et al. 2,24 found a mean hospital stay of 5.8 days between 1998 and 2012. Ciapponi et al. 10 reported an average of 7 days in 18 studies, and Godoy et al. 14 found an increase of 25% in the length of stay, from 8.8 229