Letter regarding the article ‘evaluating early cardiology involvement and survival outcomes across NT-proBNP levels: an island-wide retrospective cohort study’

Dear Editor, Dr. Brown and colleagues provide important real-world data linking NT-proBNP strata with one-year mortality and report an association between earlier cardiology involvement and improved survival.1 We would like to offer several comments regarding the methodology of this study. First, the exclusive use of all-cause mortality without consideration of competing risks or cause-specific death may obscure how early cardiology involvement influences heart failure related vs non-cardiovascular deaths. In recent heart-failure cohorts, non-cardiovascular mortality can account for a substantial proportion of deaths and differs by ejection fraction phenotype as well as comorbidity burden,2 so analyses that ignore competing risks can misestimate event probabilities and treatment effects. Because hospitalizations in HFpEF arise from both cardiovascular and non-cardiovascular causes, and each carries a similarly elevated risk of subsequent mortality, contemporary analyses increasingly distinguish these categories to clarify their prognostic significance and to highlight the need for treatment strategies that address not only cardiac congestion but also the comorbid medical illnesses that drive non-cardiovascular events.3