PONE-D-25-07478Incidence and risk factors for heart failure in the ELSA-Brasil cohortPLOS ONE

Dear Dr. LÉDO,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Alanna Gomes da Silva, PhD

Academic Editor

PLOS ONE

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2. Please amend the manuscript submission data (via Edit Submission) to include authors Ana Paula Lédo and Roque Aras.

3. Please amend your authorship list in your manuscript file to include authors ANA PAULA DE OLIVEIRA PAULA LÉDO and Roque Aras Júnior.

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Additional Editor Comments:

This study addresses a highly relevant public health topic by investigating the incidence of heart failure (HF) and its associated factors within the ELSA-Brasil cohort. It is a pertinent and timely subject that can contribute to a deeper understanding of the cardiovascular disease burden in Brazil. However, the manuscript still requires substantial revisions in its rationale, updating of references, discussion structure, and methodological detail to strengthen its scientific consistency and argumentative coherence.

Abstract:

In the introduction of the abstract, the rationale for conducting the study should not be based solely on the absence or scarcity of previous research. It is recommended to reformulate this section to emphasize the relevance of the topic and the methodological strengths of the present study. Additionally, the conclusion in the abstract should clearly reflect the main findings.

Introduction:

The references used to contextualize the burden of disease—such as citations 5 and 6—are outdated (2018 and 2019 data, prior to the COVID-19 pandemic), which weakens the relevance of the discussion. It is advisable to incorporate more recent sources, such as the Global Burden of Cardiovascular Diseases and Risks, 1990–2022 (World Heart Federation, 2024), and to specify the year for each data point presented.

The use of informal in-text references (e.g., “In the HFA-ATLAS project...”, “data from the Olmsted County Study”) should be avoided to maintain formal academic style.

While the manuscript highlights the importance of HF as a public health issue in Brazil and acknowledges the potential of ELSA-Brasil, the rationale needs to be strengthened. It is essential to clearly identify the knowledge gaps this study aims to fill. For instance, which previous studies relied on specific subgroups or small samples? What are the limitations of those studies that justify the current analysis? Furthermore, the authors should highlight what is novel in their approach using ELSA-Brasil—whether it's the follow-up period, analytical strategy, or focus on particular subgroups or variables.

Importantly, the rationale states the need for more representative and large-scale studies on HF incidence in Brazil, yet the study population consists solely of federal public servants. This creates a conceptual inconsistency. The authors are encouraged to revise this section by emphasizing the relevance of investigating HF incidence and associated factors within a population that has specific characteristics (e.g., higher educational level, job stability, access to healthcare), while avoiding overgeneralization to the broader Brazilian population.

Lastly, the stated objective in the introduction should match the one presented in the abstract. Consistency is necessary.

Methods:

The methods section should be revised and aligned with the STROBE checklist for cohort studies. This includes a clear logical sequence and the proper description of key aspects such as the outcome definition, inclusion/exclusion criteria, bias control strategies, and handling of follow-up losses.

Discussion:

The discussion also contains outdated references—these should be replaced with more recent epidemiological data.

Lines 259–261: The statement that "Factors such as sex, age group, hypertension, and socioeconomic conditions have been associated with the development of the disease" is too superficial. The discussion should explain why these factors are associated, based on literature and the study’s findings.

Each new topic in the discussion should begin in a separate paragraph. For instance, line 262 discusses sex, while line 265 abruptly shifts to age within the same paragraph. This should be revised throughout the manuscript, including in the introduction.

The discussion on the lack of association between sex and HF is underdeveloped. Merely stating that the findings are consistent with a previous study is not analytically sufficient. The authors should explore whether this null result was expected, what hypotheses might explain it in the context of the studied population, whether confounders were adequately controlled for, and what implications this has for the literature or for health policy. The same applies to age, race/skin color, overweight, and obesity. The discussion should address the implications and potential explanations for these findings—not just describe them.

Lines 269–274: This paragraph largely repeats the study results and lacks interpretation. The discussion should avoid unnecessary repetition of findings already presented in the results section and instead focus on their interpretation and relevance. Furthermore, race/skin color is mentioned descriptively but not discussed in depth, which should be corrected.

Limitations:

While the limitation related to the cohort composition (public servants) is valid, it should be complemented by other potential sources of bias and methodological limitations, such as: selection bias (healthy worker effect); loss to follow-up; reliance on self-reported variables; relatively low number of incident cases to date; follow-up period that may not capture late-onset HF cases.

Conclusion:

It is recommended to remove the term “vulnerable groups,” as not all of the groups mentioned (e.g., older adults, individuals with obesity) fit this definition in public health.

The phrase “key predictors at different stages of follow-up” is vague and should be clarified—what predictors, and during which stages? The conclusion should be more objective and better aligned with the study’s main findings, emphasizing their practical and scientific implications.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: The manuscript presents a valuable contribution to the understanding of heart failure in the ELSA-Brasil cohort. The research question is important, the methodology is rigorous, and the statistical analysis is appropriate for the data. The results are presented clearly, and the discussion is insightful. However, I believe some minor revisions could strengthen the manuscript further.

Methods Section: The methodology is generally clear, but I suggest providing more detail on how heart failure was diagnosed and classified within the cohort. Clarifying whether the diagnosis was made based on clinical criteria, imaging, or biomarkers would improve the reproducibility of the study.

Statistical Analysis: The statistical methods are well explained. One suggestion is to include a more detailed explanation of how missing data were handled in the analyses, as this information is crucial for evaluating the robustness of the results.

Conclusion: The conclusions are well supported by the data, but I would encourage the authors to discuss more explicitly how these findings could inform public health strategies in Brazil or similar settings, particularly regarding prevention and management of heart failure.

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Reviewer #1: No

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Incidence and risk factors for heart failure in the ELSA-Brasil cohort

PONE-D-25-07478R1

Dear Dr. Lédo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Alanna Gomes da Silva, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: