Coronary artery disease encompasses acute coronary syndromes and chronic coronary disease, making it one of the leading causes of hospital admissions. Acute myocardial infarction results in an average of 12 deaths per day in Portugal, with the country reporting over 10000 episodes each year.22 In 2021, countries within the Organization for Economic Co-operation and Development (OECD) reported varying mortality rates from myocardial infarction, with Portugal ranking 55% below the average. This reflects the significant investments made over the past two decades to enhance the organization and quality of care provided during the acute phase of the disease.23 In 2022, the number of deaths from ischemic heart disease rose compared to 2021 (6826 deaths vs. 6622 deaths, a rise of 3.1%). This was accompanied by a 2.7% increase in crude mortality rate (65.3 vs. 63.6 deaths per 100000 inhabitants). However, mortality from acute myocardial infarction decreased by 0.7% (3908 deaths vs. 3936 deaths). Nevertheless, the number of deaths from acute myocardial infarction in individuals under 70 years old grew.

Acute HF stands out as a cause of hospital admissions and is associated with high mortality and morbidity rates: one in every 25 patients hospitalized with a primary diagnosis of HF does not survive the initial admission, and one in every 10 dies within thirty days after being admitted.24,25

The epidemiological data on HF available in Portugal comes primarily from studies conducted over two decades ago. A recent global systematic review reports an average prevalence of HF in adults of 3.4%, with significant variation among different populations.26 Of the 22 studies reporting the prevalence of HF in adults, three were conducted in Portugal: the EPICA, EPICA-RAM, and EPI-PORTO studies. Notably, all three reported a high prevalence of HF, ranking among the five highest in the this review. In fact, 20 years ago, the EPICA study estimated an overall prevalence of HF in mainland Portugal at 4.4%. More recently, the PORTHOS study,27 conducted in 2023, revealed that the estimated prevalence of HF in mainland Portugal among adults over 50 is 16.5%. This prevalence is 2.3 times higher in women than in men and increases sharply with age, reaching around 30% in individuals aged 70 and older. This means that approximately one in six Portuguese individuals over 50 live with HF, representing a significant disease burden for both the National Health Service (NHS) and society as a whole. Another significant finding of the study was the predominance of HF with preserved ejection fraction, which had an estimated prevalence of 15.2%. This phenotype, often underdiagnosed and misunderstood, is the most common type of HF in the studied population, highlighting the need for targeted diagnosis and treatment strategies. The study also revealed a high number of undiagnosed HF cases: nine out of 10 patients with HF were unaware of their condition, indicating a substantial gap in early detection and referral for appropriate treatment. This underscores the urgency of optimizing diagnostic strategies, particularly in primary healthcare settings.28

Sudden death accounts for 20% of global mortality, with the incidence of SCD in Portugal being about one per 1000 inhabitants per year. Additionally, it is estimated to account for approximately 50% of deaths from cardiac causes, with atherosclerotic CAD artery disease being the most common etiology (approximately 35% of cases). Remarkably, the causes of these deaths are largely preventable.29–31

Although AF is not typically the direct cause of sudden death, it is the most common cardiac arrhythmia and plays a crucial role in increasing the risk of severe cardiovascular events. AF is a significant risk factor for stroke and other thromboembolic complications, and it is associated with higher mortality and a poorer quality of life. The FAMA Epidemiological Study (Study on the Prevalence of Atrial Fibrillation in Portugal), which included 10447 individuals, estimated the prevalence of AF in Portugal at 2.5% among individuals aged 40 or older, regardless of gender or geographical area. Due to its design, this study was unable to capture paroxysmal forms of the disease, leading to the assumption that it underestimates true prevalence. Prevalence tends to increase with age, reaching 6.6% in patients aged 70–79 years and 10.4% in patients over 80 years.32 However, it can also affect young individuals, especially those with another heart condition, and it may be the initial manifestation of this health problem.

Valvular diseases, including aortic stenosis and mitral insufficiency, are common, particularly among the elderly. The global prevalence of aortic stenosis in individuals over 75 years of age is 12.4%, while the prevalence of severe forms of the disease is estimated to be 3.4%,33 with the only available treatment being surgical or percutaneous intervention.34 Estimates from 2018 indicated that there were approximately 115000 patients in Europe and 2500 in Portugal eligible for transcatheter aortic valve implantation (TAVI) each year.35 These numbers are expected to increase significantly as the indications for TAVI expand to include patients with progressively lower surgical risk. In terms of mitral insufficiency, it is currently the most common vascular heart disease, regardless of its severity, with a prevalence of 1.7%, rising to 10% among individuals over 75 years of age.36 This disease remains the second leading cause of valvular surgery in European countries, and the secondary form, which is associated with other heart diseases, is currently the most common.37

See Table 1.

See Table 2.

There is considerable difficulty in obtaining comprehensive, representative, and up-to-date epidemiological data in Portugal regarding both CVD and the associated risk factors. The absence of precise and current data highlights the urgent need to revise surveillance strategies and improve the collection of epidemiological information for CVD and its risk factors. Without a solid foundation of information, formulating public health policies and implementing prevention and treatment programs become extremely challenging, potentially compromising the effectiveness of necessary interventions aimed at reducing the burden of CVD and its risk factors in the population.

In Portugal, the network of cardiovascular healthcare is organized into three levels based on the degree of specialization. The public hospital network has remained stable, with plans for some new hospitals in the future, although they are still in the early stages of development. In contrast, the private sector has experienced significant growth, increasing the number of hospitals in both metropolitan (Lisbon and Porto) and rural areas.

The distribution of dedicated cardiovascular healthcare facilities in Portugal, both public and private, is as follows (Table 3).47

Overall, it is evident that we are positively aligned with our European counterparts in this regard. However, when focusing exclusively on the public healthcare network, which provides over three-quarters of cardiovascular care, the number of centers performing TAVI decreases to 0.8 centers per million inhabitants, while the number of centers offering cardiac surgery drops to 0.7 centers per million inhabitants.

In terms of equipment, there is still a significant gap in investment. Various deficiencies persist: according to OECD data, in 2021, Portugal had only 30 advanced imaging devices per million inhabitants – specifically, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). This figure is notably lower than the OECD average of 48 and the numbers in Spain (44), Italy (76), and Greece (80).23 This shortfall contributes to the challenges of accessing these imaging studies within the public healthcare system, negatively impacting cardiology practice (Table 4).

Investment in these diagnostic tools is essential to keep pace with technological advancements in cardiology, ensuring state-of-the-art support for diagnosis, decision-making, and intervention planning, and ultimately leading to improved health outcomes.

On the healthcare professionals’ front, and according to the latest ESC Atlas of Cardiology,47 in 2023 Portugal had 588 practicing cardiologists, with a stronger gender balance – 42.2% of cardiologists were female, compared to the European average of 29%.48 This equates to approximately 57 cardiologists per million inhabitants, below the EU average of 101.4 per million. Portugal also lags significantly behind countries like Spain, Greece, and Italy, which have 84, 297, and 226 cardiologists per million inhabitants, respectively.49 Data from the Central Administration of the Health System indicates that the distribution of cardiologists is uneven, with a majority concentrated in the Lisbon and Tagus Valley region and the North. Together they account for three-quarters of all cardiologists. In contrast, areas such as Alentejo, Algarve, and some inland regions face significant shortages. Portugal has only nine interventional cardiologists per million inhabitants, which is notably below the EU average of 13.5.50 Additionally, Portugal has also a considerably lower number of electrophysiologists, with just 3.7 per million inhabitants, compared to 4.7 per million in ESC member countries. A similar trend is seen in cardiac surgery, where there are 7.4 cardiac surgeons per million inhabitants (of which 18% are female), compared to an EU average of 12.1 per million (Table 5).51

It is noted that the primary shortcoming in Portugal is not in infrastructure, but rather in human resources and advanced imaging equipment.

Since Portugal's healthcare system is built on a public model through the NHS, with complementary inputs from private and social systems, it is essential to analyze indicators of public service availability to evaluate healthcare accessibility.

According to the Portuguese Health Regulatory Authority, 19642 initial cardiology consultations were conducted in hospitals during the second half of 2023 (+0.3% compared to 2022), along with 4329 scheduled cardiac surgeries (+5.8% compared to 2022), indicating increased activity in this area compared to the corresponding period in the previous year.52 The legally defined guaranteed maximum response time (TMRG),53 based on priority level, was exceeded in 91.8% of initial consultations (up from 88.5% in 2022) and 33.2% of cardiac surgeries (up from 28.0% in 2022). By the end of 2023, 23448 patients were on the waiting list for consultations (up from 15406 in 2022), with median waiting times longer than in the same period last year (119.9 days vs. 104 days). Additionally, 2724 patients were waiting for cardiac surgery (down from 2880 in 2022). These figures indicate worsening access to cardiology services, despite an increase in response capacity. Regarding equity in access, geographically, the most affected region is Greater Lisbon, with 44.6% of cardiac surgeries failing to meet the TMRG, compared to 24.9% in the North and 29.7% in the Center. Although the overall picture is poor across mainland Portugal, the Algarve leads in unmet TMRG for consultations, with an almost 100% non-compliance rate (98.8%). These data reflect broad territorial trends but do not capture the disparities between inland and coastal areas. For consultations, it is also worth noting that after the COVID-19 pandemic, the pattern of primary healthcare appointments shifted significantly: in 2019, only 31% of consultations were conducted remotely, whereas this figure has now risen to 48%.23 This strategy may also be relevant in other specialty areas, such as cardiology.

In this field, it is also important to analyze comparative access to various invasive cardiological procedures, including percutaneous coronary interventions (Table 6), the implantation of percutaneous valves (Table 7) and cardiac devices (Table 8), and cardiac surgery (Table 9).

The comparative results on coronary percutaneous interventions reflect the lower prevalence of coronary disease in our population.

In 2022, Portugal performed 144 TAVI procedures per million inhabitants, exceeding the EU average of 138.47,48 However this figure is not adjusted for demographic differences; in that year, 24% of Portugal's population was over 65, compared to 21% in the EU, and this predominance of elderly individuals affects the demand for TAVI procedures. Despite the growth in interventions in recent years, the number of procedures remains well below the population's needs, which is particularly concerning. In 2018, the estimated annual number of eligible candidates in Portugal was 2516 (over 200 per million inhabitants), potentially rising to 3900 with the expected expansion of indications.35 A national study evaluating different scenarios for the use of this technique in Portugal estimated that the annual need ranges from 189 to 391 procedures per million inhabitants, highlighting a significant gap between the population's needs and the actual procedures performed.54

Regarding cardiac devices or electrophysiology interventions, the national reality is expressed according to Table 8.47

It is important to note that the comparative interpretation of this data should not be taken literally, as the observed differences may be attributed to factors such as healthcare organization, national adoption of techniques and procedures, demographic and epidemiological factors, and the methods used for data collection.

The analysis of access to complementary means of diagnosis and therapy (MCDT), particularly regarding the availability of non-invasive cardiovascular imaging techniques (CT, MRI, standard and advanced echocardiography, and nuclear medicine), is not included here due to the lack of systematic information on access in this area. This lack of data highlights a substantial weakness in the system. Notably, only very recently (Dispatch No. 12876-C/2024, dated October 29) was access to cardiac CT, coronary calcium scoring, natriuretic peptides, Doppler echocardiograms, and 24-hour ambulatory blood pressure monitoring regulated for primary health care. This regulation is expected to address the existing inequity that has regressed current clinical practice to standards from decades past. However, access to MRI remains limited to hospital settings.

In terms of access and costs, Portugal is one of the European countries that places the greatest burden on users concerning direct healthcare expenses. Users are responsible for 37% of the total costs (including out-of-pocket expenses and health insurance), nearly double the OECD average of 22%.23 This is particularly significant because half of the ‘out-of-pocket’ expenses are associated with outpatient care, which includes chronic pharmacological therapies and the demand for specialized cardiology consultations in the private sector. As previously mentioned, these services face challenges in terms of access within the public system.

The availability and accessibility of innovative cardiovascular treatments, such as novel procedures and new drugs, are essential components for the development of cardiovascular care. Access to leading-edge invasive therapies has already been addressed in the previous section. In Portugal, entry into the market of breakthrough pharmacological therapies has been evaluated by the European Federation of Pharmaceutical Industries and Associations through the Patient W.A.I.T. Indicator (Waiting to Access Innovative Therapies), which assesses the rate of drugs with reimbursement compared to the total number of drugs approved for marketing at the national level. In this regard, Portugal is above the EU average, with 50% compared to 43%. The greatest challenge regarding access to drug innovation is the average time until reimbursement begins. The distribution of this time, measured from European Medicines Agency approval to local prior approval by the Portuguese regulatory authority, INFARMED, is 710 days in Portugal, compared to 661 days in Spain, 424 days in Italy, or 344 days in the United Kingdom.55

In terms of access to medications, it is crucial to ensure that the population has access to effective, safe, and affordable medications at manageable prices. In this context, the ‘generification’ of certain outpatient therapies in the cardiovascular field, such as oral anticoagulants, has made a positive contribution to this goal.

Similarly, regarding medication for cardiovascular conditions and associated risk factors, it is important to note that drugs for hypertension or dyslipidemia (the latter of which is subject to only 37% reimbursement of the selling price) do not qualify for the maximum reimbursement rates available for other chronic conditions, such as diabetes. This creates a barrier to the effective management of these diseases, a challenge that also extends to other cardiovascular issues like HF and AF.

In conclusion, the provision of healthcare in the cardiovascular field has improved, with an increase in consultations, procedures, and surgeries performed, as well as a growing number of professionals in this area. However, it still falls short of population needs and lags behind the reality in countries with similar economic levels. In terms of infrastructure, growth has primarily occurred through an increase in offerings in the private sector. Nevertheless, significant challenges remain concerning the responsiveness of the NHS to the defined guaranteed maximum response times. While there is access to major pharmacological therapies, it is delayed compared to European counterparts, with the reimbursement of a product taking approximately two years.

Additionally, limited unofficial information is available regarding areas such as waiting lists for invasive cardiology procedures, MCDTs, and medical devices, which hinders a more concrete evaluation in these areas.

Analyzing healthcare expenditure in Portugal, particularly that associated with CVDs, is complex due to the limited availability of information sources, especially regarding their economic impact. However, a general overview can still be outlined based on existing data.

In 2023, Portugal's GDP reached EUR 265.5 billion. In the same year, current healthcare expenditure was EUR 26.6 billion, which accounts for approximately 10% of GDP.57 This figure underscores the importance of health to the country's economy and aligns with trends observed in other European nations. Furthermore, total costs per patient are projected to rise by 34% by 2036. This significant increase in the disease-related cost burden in the medium term highlights the need for more effective health policies and increased investment in the prevention of CVD, considering their substantial impact on overall morbidity and mortality.

The costs associated with CVD in Portugal are considerable, representing a significant portion of healthcare expenditures:

• •

  In 2016, the total cost of atherosclerosis amounted to EUR 1.9 billion, which is approximately 0.7% of Portugal's GDP and 11% of healthcare expenditure3;

• •

  In 2014, the direct and indirect costs of HF were EUR 299 million and EUR 106 million, respectively, representing approximately 0.2% of Portugal's GDP and 2% of total healthcare expenditure58;

• •

  In 2013, the total cost associated with AF was EUR 140 million, representing approximately 0.1% of Portugal's GDP and 1% of total healthcare expenditure.59

In 2021, the annual per capita cost of CVDs in Portugal was EUR 428 (adjusted for purchasing power parity), placing it just above Cyprus and Croatia. In comparison, the EU average was EUR 630, totaling EUR 3.772 billion across all member states.60 In Portugal, the adjusted costs related to healthcare and social security associated with CVDs accounted for 8.5% of total healthcare spending, ranking just above Croatia and Latvia and below the EU average of 10.6%. Cost segmentation shows that hospital and informal care consume the most resources. These figures illustrate the significant economic impact of CVD in Portugal. If current trends continue in the medium term, it is expected that expenditure on CVD will remain high and may even rise in the future, largely due to demographic changes and advancements in medical technology and science.

Overall, the costs associated with major CVDs in Portugal represent more than 1% of our GDP, considering the direct, indirect, and opportunity costs involved.

The increasing prevalence of these diseases underscores the urgent need for prevention. Investment in this area should be prioritized upstream – before the disease manifests – rather than downstream, where the focus is on treatment once the disease is already established. This preventive investment can take various forms, including the promotion of healthy lifestyles, early detection and management of risk factors, and the implementation of effective public health policies. By preventing the population from developing these diseases, we also avoid the associated treatment and management costs, allowing for better allocation of available resources.

In summary, the economic impact of CVD in Portugal is significant and projected to rise. It is imperative to invest more effectively in prevention strategies to mitigate the rising prevalence and associated costs. Furthermore, ensuring access to specialized cardiological care that aligns with best practices and scientific advancements is essential.

Given the sensitivity of health data, ensuring its privacy and security is essential. Rigorously structured data governance frameworks, such as the General Data Protection Regulation, guarantee that health data are used ethically and securely.

The harmonization of health data with the European Health Data Space is essential for improving interoperability, security, and the effective use of health data within the EU. This process involves standardizing the collection, storage, and sharing of health data, which facilitates medical research, informs health policy development, and enables the delivery of high-quality care.

Cardiovascular health data play a strategic role in various areas of healthcare. It enhances patient care, advances medical research, supports public health initiatives, drives innovation, and informs policy-making. The strategic use of this data, along with robust privacy and security measures, has the potential to significantly improve cardiovascular health outcomes and reduce the overall CVD burden. Portugal should prioritize integrating its health data into this European network, ensuring the necessary interoperability and security for efficient federated health data analysis.

The SPC, through its National Center for Data Collection in Cardiology (CNCDC), has pioneered the establishment of structured clinical registries at the national level for acute myocardial infarction and Interventional Cardiology. These initiatives serve as a model for the collection and dissemination of data in various other areas of cardiovascular pathology. However, the quality and representativeness of these registries depend on the voluntary participation of researchers from national cardiology centers, which limits their effectiveness in shaping health policies.

The establishment of mandatory national registries, similar to those already in place for other conditions and leveraging the experience of scientific societies, would be both advisable and more effective. This is the position of the SPC, which intends to work with the competent authorities to identify suitable solutions for their implementation.