Persistent clinical and economic burden of rheumatic heart disease in southern Brazil despite universal and broad healthcare access

Background Rheumatic fever and Rheumatic Heart Disease (RHD) remain preventable causes of cardiovascular morbidity in middle-income countries. It remains uncertain whether universal healthcare ensures sustained secondary prevention and reduces severe outcomes. Southern Brazil, one of the country’s most developed regions with broad public health access, provides a relevant setting to assess whether healthcare access alone limits progression to advanced RHD. Purpose To evaluate hospitalization patterns, mortality trends, and economic impact of rheumatic fever and RHD in Southern Brazil between 2016 and 2025, assessing whether healthcare availability has reduced severe disease burden. Methods A population-based study using the Brazilian Unified Health System database analyzed hospitalizations for acute rheumatic fever and chronic RHD in Paraná, Santa Catarina, and Rio Grande do Sul from 2016 to 2025. Variables included admissions, in-hospital deaths, case-fatality rate, admission type, age distribution, and direct hospitalization costs. Rates were standardized per 100,000 inhabitants. Results A total of 11,995 hospitalizations were recorded, 63% as emergency admissions. More than 60% of RHD-related admissions were urgent, reinforcing the predominance of acute decompensation over planned care. In 2024, hospitalization rates reached 4.77 per 100,000 inhabitants in Santa Catarina. Paraná presented nearly eight severe admissions per 100,000 annually and the highest mortality rate, peaking at 0.62 per 100,000. There were 1,099 in-hospital deaths, increasing from 107 (2016) to 140 (2024). Overall case-fatality was 9.16%, reaching 11% in Paraná. Hospitalizations increased with age, peaking at 60–69 years, consistent with cumulative valvular damage. Mortality rose over time, and high case-fatality persisted despite healthcare coverage, suggesting limitations in secondary prevention. Total direct costs exceeded USD 32 million, >98% attributable to chronic RHD. Chronic admissions were ~11 times more expensive than acute rheumatic fever hospitalizations, accounting for most valvular expenditures. Overall, rheumatic conditions represent approximately 0.4% of all cardiovascular hospitalizations in Southern Brazil, representing ~1 in 250 cardiovascular hospitalizations, concentrated in advanced valvular disease. Thus, universal healthcare access alone may be insufficient without structured longitudinal secondary prevention strategies. Conclusion Despite universal healthcare availability, rheumatic fever and RHD remain persistent burdensome in Southern Brazil. The predominance of emergency admissions, persistent mortality, high case-fatality, and concentration of costs in advanced disease suggest gaps in sustained secondary prevention and long-term care. Strengthening primary care follow-up and ensuring uninterrupted benzathine penicillin may reduce preventable late-stage burden and improve system efficiency.Picture 1Picture 2