Letter to the Editor Mode of death in chronic systolic heart failure: Chagas cardiomyopathy versus systemic arterial hypertension Reinaldo B. Bestetti ⁎, Ana Paula Otaviano, João Paulo Fantini, Augusto Cardinalli-Neto, Marcelo A. Nakazone, Paulo R. Nogueira Department of Cardiology and Cardiovascular Surgery, Hospital de Base, São José do Rio Preto City, Brazil article info Article history: Received 7 April 2014 Accepted 12 April 2014 Available online xxxx Keywords: Chagas disease: heart failure Sudden cardiac death Mode of death Systemic arterial hypertension Betablockers With regard to the letter by Veloso [1], we would like to empha- size that our study [2] was comprised of patients with chronic systol- ic heart failure (CHF) secondary to systemic arterial hypertension (SAH) with mild to moderate symptoms; by contrast, Freitas et al. [3] studied patients with more severe forms of the syndrome. We ruled out concomitant coronary disease (CAD) in patients with SAH by coronary angiography and/or myocardium scintigraphy; Freitas et al. [3] did not perform such exams routinely. We gave Betablocker therapy routinely for patients with CHF due to SAH; Freitas et al [3] did not provide routine Betablocker therapy for their patients with CHF secondary to SAH. We compared prognosis of patients with CHF secondary to Chagas cardiomyopathy directly with that of pa- tients with CHF due to SAH; Freitas et al. [3] compared the prognosis of CHF secondary to Chagas cardiomyopathy with those of several types of cardiomyopathies concomitantly. Therefore, the statement that “the concept of a poorer prognosis of patients with CHF due to Chagas disease in comparison to those with hypertensive cardiomy- opathy (not necessarily patients with CHF due to SAH) was already demonstrated” is not correct. Veloso [1] stressed that our explanation for the worst prognosis of Chagas cardiomyopathy patients with CHF regarding the less frequent use of Betablocker therapy, as well as a lower dose of Betablockers in those partially able to take the drug, could be an indication of the major role played by sudden cardiac death (SCD) in driving total mor- tality. It has long been recognized, however, that Betablocker therapy decreases not only SCD, but also pump failure death [4]. Therefore, we still believe that lack of Betablocker therapy not necessarily increased the risk of just SCD in our patients. Veloso [1] stated that SCD is the principal mechanism of death in patients with chronic Chagas disease, quoting older studies that did not include patients with overt CHF or patients with CHF not treated with angiotensin converting enzyme-inhibitor or Betablockers. Studies performed in the current era have demonstrated that SCD is not the most important mode of death in chronic Chagas disease. For example, Gonçalves et al. [5] clearly demonstrated that SCD af- fected only 17% of patients, whereas death due to CHF was found in 50% of patients of a population-based longitudinal cohort comprised of patients with chronic Chagas disease. Furthermore, Ayub-Ferreira et al. [6] studying patients with CHF due to Chagas cardiomyopathy with mild to moderate CHF showed that SCD and CHF death victim 31% and 38% of patients, respectively. In Patients in the New York Heart Association Class III or IV, SCD and CHF death affected 15% and 57% of patients, respectively, in the study by Ayub-Ferreira et al. [6]. Veloso [1] believes that the presence of ventricular premature contractions (VPC) on the resting ECG as well as the higher use of amiodarone in the Chagas disease group in comparison to SAH pa- tients would indicate a higher risk for malignant ventricular arrhyth- mias, what could explain the higher mortality observed in Chagas disease group. However, it is well known that the presence of VPC on the resting ECG has not independently been associated with SCD in patients with chronic Chagas disease. Furthermore, in patients with CHF secondary to Chagas cardiomyopathy, amiodarone use has been associated with increased mortality due to pump failure death, but not with SCD [6]. On the basis of the facts outlined earlier, it becomes difficult to believe that SCD was the principal cause of the higher mortality observed in Chagas disease patients in our study, as suggested by Veloso [1]. Irrespective of the mode of death, what is impor- tant is that lack of appropriate Betablocker therapy could have deprived Chagas disease patients of the benefits of these drugs in counteracting the deleterious effect of catecholamine on the myo- cardium [7,8], and the consequent potential beneficial effects on mortality [9,10]. International Journal of Cardiology xxx (2014) xxx–xxx ⁎ Corresponding author at: Rua Jerônimo Panazollo, 434, Zip code: 14096-430 Ribeirão Preto City, Brazil. Tel.: +55 36037013; fax: +55 1636037005. E-mail address: rbestetti44@gmail.com (R.B. Bestetti). IJCA-18043; No of Pages 2 http://dx.doi.org/10.1016/j.ijcard.2014.04.142 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: Bestetti RB, et al, Mode of death in chronic systolic heart failure: Chagas cardiomyopathy versus systemic arterial hypertension, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.142