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Mortality due to Cardiovascular Diseases in Women and Men in the Five Brazilian Regions, 1980-2012

Abstract

Background:

Studies have shown different mortalities due to cardiovascular diseases (CVD), ischemic heart disease (IHD) and cerebrovascular diseases (CbVD) in the five Brazilian regions. Socioeconomic conditions of those regions are frequently used to justify differences in mortality due to those diseases. In addition, studies have shown a reduction in the differences between the mortality rates of the five Brazilian regions.

Objective:

To update CVD mortality data in women and men in the five Brazilian regions.

Methods:

Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and Ministry of Health. Risk of death was adjusted by use of the direct method, with the 2000 world standard population as reference. We analyzed trends in mortality due to CVD, IHD and CbVD in women and men aged ≥ 30 years in the five Brazilian regions from 1980 to 2012.

Results:

Mortality due to: 1) CVD: showed reduction in the Northern, West-Central, Southern and Southeastern regions; increase in the Northeastern region; 2) IHD: reduction in the Southeastern and Southern regions; increase in the Northeastern region; and unchanged in the Northern and West-Central regions; 3) CbVD: reduction in the Southern, Southeastern and West-Central regions; increase in the Northeastern region; and unchanged in Northern region. There was also a convergence in mortality trends due to CVD, IHD, and CbVD in the five regions.

Conclusion:

The West-Central, Northern and Northeastern regions had the worst trends in CVD mortality as compared to the Southeastern and Southern regions. (Arq Bras Cardiol. 2016; [online].ahead print, PP.0-0)

Keywords:
Cardiovascular Diseases; Mortality; Epidemiology; Brazil; Stroke; Myocardial Ischemia

Resumo

Fundamento:

Estudos mostraram diferentes mortalidades por doenças cardiovasculares (DCV), doença isquêmica do coração (DIC) e doenças cerebrovasculares (DCbV) nas cinco regiões do Brasil. Particularidades socioeconômicas entre as cinco regiões são frequentemente usadas para justificar diferenças na mortalidade por essas doenças. Estudos também mostraram redução das diferenças entre as taxas de mortalidade das cinco regiões do Brasil.

Objetivo:

Atualizar os dados de mortalidade por DCV em mulheres e homens nas cinco regiões do país.

Métodos:

Os dados populacionais e de mortalidade foram obtidos do Instituto Brasileiro de Geografia e Estatística e do Ministério da Saúde. O risco de morte foi ajustado pelo método da padronização direta, tendo como referência a população mundial em 2000. Foram analisadas as tendências da mortalidade por DCV, DIC e DCbV em mulheres e homens com ≥ 30 anos de idade nas cinco regiões do Brasil no período de 1980-2012.

Resultados:

Observou-se na mortalidade: 1) por DCV: redução nas regiões Norte, Centro-Oeste, Sul e Sudeste; aumento na região Nordeste; 2) por DIC: redução nas regiões Sudeste e Sul; aumento na região Nordeste; e inalterada nas regiões Norte e Centro-Oeste; 3) por DCbV: redução nas regiões Sul, Sudeste e Centro-Oeste; aumento na região Nordeste; e inalterada na região Norte. Observou-se também convergência das tendências da mortalidade por DCV, DIC e DCbV nas cinco regiões.

Conclusão:

As regiões Centro-Oeste, Norte e Nordeste tiveram as maiores taxas de mortalidade por DCV comparadas às regiões Sudeste e Sul. (Arq Bras Cardiol. 2016; [online].ahead print, PP.0-0)

Palavras-chave:
Doenças Cardiovasculares; Mortalidade; Epidemiologia; Brasil; Acidente Vascular Cerebral (AVC); Doença Isquêmica do Coração

Introduction

Cardiovascular diseases (CVD) are the major cause of death in men and women in the five Brazilian geoeconomic regions.11 Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40. The Southeastern and Southern regions had the highest adjusted coefficients of mortality due to CVD, ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) as compared to the Northern, Northeastern and West-Central regions.11 Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40. Mortality due to CVD in the Southeastern and Southern regions has a pattern similar to that observed in more developed countries, where CVD have a greater participation in the population overall mortality, and mortality due to IHD is more frequent than that due to CbVD. 22 Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations. Int J Cardiol. 2013;168(2):934-45.,33 Moran AE, Forouzanfar MH, Roth GA, Mensah GA, Ezzati M, Murray CJ, et al. Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the Global Burden of Disease 2010 study. Circulation. 2014;129(14):1483-92. Mortality due to CVD in the Northern, Northeastern and West-Central regions has a pattern similar to that observed in developing countries, where CVD have a proportionally smaller participation in the population overall mortality, and mortality due to CbVD is more frequent than that due to IHD.11 Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40.

2 Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations. Int J Cardiol. 2013;168(2):934-45.
-33 Moran AE, Forouzanfar MH, Roth GA, Mensah GA, Ezzati M, Murray CJ, et al. Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the Global Burden of Disease 2010 study. Circulation. 2014;129(14):1483-92. Similarly, the reduction in mortality due to CVD, IHD and CbVD was significantly higher in the Southeastern and Southern regions as compared to that in the Northern and West-Central regions, while the Northeastern region showed an increase in mortality due to those diseases.11 Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40.,44 Baena CP, Chowdhury R, Schio NA, Sabbag AE Jr, Guarita-Souza LC, Olandoski M, et al. Ischaemic heart disease deaths in Brazil: current trends, regional disparities and future projections. Heart. 2013;99(18):1359-64. Those two studies have shown an approximation of the trends in mortality due to CVD in the five regions. However, Souza et al.11 Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40. have assessed the mortality data due to CVD only until 2006, and Baena et al.44 Baena CP, Chowdhury R, Schio NA, Sabbag AE Jr, Guarita-Souza LC, Olandoski M, et al. Ischaemic heart disease deaths in Brazil: current trends, regional disparities and future projections. Heart. 2013;99(18):1359-64. have reported mortality data in the five regions only for IHD until 2010.

The present study aimed at assessing the trends in mortality due to CVD, IHD and CbVD, that is, if they are still maintained, in addition to updating data on mortality due to CVD in men and women in the five Brazilian regions from 1980 to 2012.

Methods

This ecological, retrospective study based on temporal series assessed mortality due to DC, IHD and CbVD in a population aged ≥ 30 years in the five Brazilian regions (Northern, Northeastern, West-Central, Southeastern and Southern) from 1980 to 2012. Mortality data were obtained from the Brazilian Ministry of Health web portal, www.datasus.gov.br.55 Ministério da Saúde. Datasus. Mortalidade Brasil. [Citado em 2015 Dez 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/niuf.def
http://tabnet.datasus.gov.br/cgi/deftoht...
The population data of the Brazilian Institute of Geography and Statistics (IBGE) were obtained from that same web portal. The deaths from 1990 to 1995 were classified according to the World Health Organization's International Classification of Disease (ICD), Ninth Revision (ICD-9), 1975, and adopted by the 20th World Health Assembly. According to ICD-9, diseases of the circulatory system (DCS) were encoded as 390 - 459, IHD were encoded as 410 - 414, and CbVD were encoded as 430 - 438. Mortality data from the year 1996 onwards were obtained from the Tenth Revision of ICD, and classified as follows: DCS were encoded as I00 - I99; IHD were encoded as I20 - I25; and CbVD were encoded as I60 - I69. For comparison purposes, mortality (per 100,000 inhabitants) was adjusted by using the direct standardization method, using as reference the 2000 world standard population.66 Segi M, Fujisaku S, Kurihara M, Narai Y, Sasajima K. The age-adjusted death rates for malignant neoplasms in some selected sites in 23 countries in 1954-1955 and their geographical correlation. Tohoku J Exp Med. 1960;72:91-103. Simple linear regression model was used to analyze and compare mortality trends. The dependent variables were DCS, IHD and CbVD, and the independent variable was year. The significance level adopted for the statistical tests was 5% (p < 0.05). The statistical program used was SAS (SAS Institute Inc., 1989-1996, Cary, NC, USA), 9.2 version.

Results

Overall mortality rates for men and for women due to CVD, IHD and CbVD, as well as the results of the simple linear regression analysis, are shown in Tables 1, 2, 3 and 4, respectively.

Table 1
Risk of death* * adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980). per 100,000 inhabitants due to cardiovascular diseases (CVD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions
Table 2
Risk of death* * adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980). per 100,000 inhabitants due to ischemic heart diseases (IHD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions
Table 3
Risk of death* * adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980). per 100,000 inhabitants due to cerebrovascular diseases (CbVD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions
Table 4
Simple linear regression model for mortality due to cardiovascular diseases (CVD), ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) in men and women in the period studied (1980-2012) in the five Brazilian regions

Mortality due to CVD increased in the Northeastern region from 1980 to 2012, as follows: 27% in the total population, 33% in men, and 18% in women. In the other regions, a reduction in mortality was observed in the total population, in men and in women. The reductions were more significant in the Southern and Southeastern regions, being greater than 95% in mortality from 1980 to 2012 (Table 1, Figure 1).

Figure 1
Simple linear regression analysis of mortality due to cardiovascular diseases (CVD) in individuals aged ≥ 30 years in the five Brazilian regions from 1980 to 2012.

The simple linear regression analysis showed: from 1980 to 2012, mortality due to IHD remained unaltered in the Northern (β = 0.02; Raj 2 = 0.045; p = 0.237) and West-Central (β = 0.01; Raj2 = 0.016; p = 0.478) regions; increased in the Northeastern region (β = 1.98; Raj2 = 0.897; p<0.0001); and decreased in the Southeastern (β = -4.63; Raj2 = 0.973; p < 0.0001) and Southern (β = -3.27; Raj2 = 0.851; p < 0.0001) regions (Tables 2 and 4; Figure 2). In men, mortality due to IHD increased in the Northern (β = 0.45; Raj2 = 0.160; p = 0.012), Northeastern [ β = 2.41 (95%CI: 2.10-2.75); Raj2 = 0.883; p < 0.0001] and West-Central (β = 0.43; Raj2 = 0.131; p = 0.039) regions. The most important increase occurred in the Northeastern region (128%), followed by the West-Central (22%), and Northern (7%) regions (Tables 2 and 4, Figure 3). In women, mortality due to IHD increased in the Northeastern region (β = 1.54; Raj2 = 0.900; p < 0.0001), and remained unaltered, but with a reduction trend, in the Northern (β = -0.17; Raj2 = 0.071; p = 0.071) and West-Central (β = -0.76; Raj2 = 0.061; p = 0.089) regions. The Northeastern region had the greatest increase in mortality due to IHD (55%) (Tables 2 and 4, Figure 3).

Figure 2
Simple linear regression analysis of mortality due to ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) in individuals aged ≥ 30 years in the five Brazilian regions from 1980 to 2012.

Figure 3
Simple linear regression analysis of mortality due to ischemic heart diseases (IHD) in men (M) and women (W) aged ≥ 30 years in the five Brazilian regions from 1980 to 2012.

Simple linear regression analysis showed that, from 1980 to 2012, mortality due to CbVD remained unaltered, but with a reduction trend, in the Northern region (β = -0.24; Raj2 = 0.840; p = 0.056), increased in the Northeastern region (β = 0.56; Raj2 = 0.381; p < 0.0001), and had a significant reduction in the Southeastern (β = -7.5; Raj2 = 0.924; p < 0.0001), Southern (β = -3.85; Raj2=0.905; p < 0.0001) and West-Central (β = -1,81; Raj2 = 0,562; p < 0,00) regions. Mortality due to CbVD increased in the Northeastern region by 15%, while significant reductions of 240% and 101% occurred in the Southeastern and Southern regions, respectively (Tables 3 and 4, Figure 2). In men, mortality due to CbVD increased in the Northeastern region (β = 0.95; Raj2 = 0.616; p < 0.0001), remained unaltered in the Northern region (β = 0; Raj2 = 0.020; p = 0.438), and decreased in the Southeastern (β = -8.27; Raj2 = 0.911; p < 0.0001), Southern (β = -4.13; Raj2 = 0.881; p < 0.0001) and West-Central (β = -1.72; Raj2 = 0.455; p < 0.0001) regions. In men, mortality due to CbVD increased in the Northeastern region by 26%, the most significant reductions of 216% and 88% occurring in the Southeastern and Southern regions, respectively (Tables 3 and 4, Figure 4). In women, mortality due to CbVD remained unaltered in the Northeastern region (β = 0; Raj2 = 0.044; p = 0.241), and decreased in the Northern (β = -0.60; Raj2 = 0.470; p<0.001), Southeastern (β = -6.74; Raj2 = 0.937; p < 0.0001), Southern (β = -3.56; Raj2 = 0.921; p < 0.0001) and West-Central (β = -1.91; Raj2 = 0.061; p < 0.0001) regions. In women, the reduction in mortality due to CbVD was more important in the Southeastern and Southern regions, 274% and 119%, respectively (Tables 3 and 4, Figure 4). The convergence of the trends in mortality due to IHD and CbVD observed in the five Brazilian regions resulted mainly from the reduction in mortality due to those diseases in the Southeastern and Southern regions. The convergence of mortality due to CbVD was significant from 1997 onwards, while, for IHD, that occurred only from 2007 onwards (Figure 5).

Figure 4
Simple linear regression analysis of mortality due to cerebrovascular diseases (CbVD) in men (M) and women (W) aged ≥30 years in the five Brazilian regions from 1980 to 2012.

Figure 5
Convergence of trends in mortality due to ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) in the five Brazilian regions from 1980 to 2012.

Discussion

This study showed the highest reductions in mortality due to CVD, IHD and CbVD in the Southeastern and Southern regions, while the Northeastern region had mortality due to those diseases increased. The results varied in the Northern and West-Central regions. Therefore, the Southeastern and Southern regions behaved similarly to the most developed countries, with a persistent trend of reduction in mortality due to CVD.77 Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J. 2014;35(42):2950-9. Erratum in: Eur Heart J. 2015;36(13):794.,88 Roth GA, Forouzanfar MH, Moran AE, Barber R, Nguyen G, Feigin VL, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med. 2015;372(14):1333-41.

On the other hand, the mortality trends of the other regions behaved similarly to those of developing countries. The population's more limited access to a more appropriate health care system, in addition to socioeconomic and cultural aspects, might justify those trends. For example, the control of risk factors accounted for at least a 50% reduction in mortality due to CVD in more developed countries.99 Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-98.

A recent report of the 2013 Brazilian National Health Research ( Pesquisa Nacional de Saúde - PNS) showed better performance of the Southeastern and Southern regions regarding the diagnosis and treatment of the major risk factors for CVD.1010 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde. [Citado em 2015 Jun 10]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
ftp://ftp.ibge.gov.br/PNS/2013/pns2013.p...
The PNS data showed a higher consumption of fruits and vegetables and greater practice of physical activity in the Southeastern and Southern regions. Regarding risk factors [systemic arterial hypertension (SAH), dyslipidemia and diabetes], the Southeastern and Southern regions showed: greater proportion of individuals aged ≥ 18 years measuring blood pressure; higher use of anti-hypertensive drugs; greater access to at least one medication obtained from the Popular Pharmacy Program; and more frequent measurement of serum glucose, total cholesterol and triglyceride levels.1010 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde. [Citado em 2015 Jun 10]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
ftp://ftp.ibge.gov.br/PNS/2013/pns2013.p...
Briefly, the population's access to the health care system was better in the Southeastern and Southern regions.

Similarly, regarding risk factor assessment, that PNS report showed that women performed better as compared to men, which can even intensify the already existing natural protection of women against the atherosclerotic process, and, thus, against cardiovascular events.

In addition, the better access to the health care system in the Southeastern and Southern regions can justify the greater reduction in mortality due to CbVD as compared to IHD. That results from the fact that the logistics involved in the diagnosis and treatment of SAH, the major risk factor for CbVD, is significantly less complex than that required for IHD. Ischemic heart diseases involve more risk factors, such as dyslipidemia, smoking habit, diabetes and SAH, and their diagnosis depend on more complex complementary tests.

In addition to the drug treatment complexity, there is limited availability of the intervention treatment, restricted to large urban centers. Such diagnostic and therapeutic limitations can justify the heterogeneity in the risk of death due to acute myocardial infarction in the different Brazilian regions.1111 Nicolau JC, Franken M, Lotufo PA, Carvalho AC, Marin Neto JA, Lima FG, et al. Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE). Arq Bras Cardiol. 2012;98(4):282-9.

Similarly, social inequalities and low educational level are additional conditions associated with higher mortality due to CVD.1212 Ishitani LH, Franco GC, Perpétuo IH, França E. [Socioeconomic inequalities and premature mortality due to cardiovascular diseases in Brazil]. Rev Saúde Pública. 2006;40(4):684-91.

13 Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):403-12.
-1414 Polanczyk CA, Ribeiro JP. Coronary artery disease in Brazil: contemporary management and future perspectives. Heart. 2009;95(11):870-6. The Southern and Southeastern regions have the highest urban developing indices, which is assessed by the progress of the regions in three basic dimensions: income, educational level and health.1515 Programa das Nações Unidas para o Desenvolvimento (PNUD). [Citado em 2015 Nov 11]. Disponível em: http://www.pnud.org.br/IDH/DH.aspx
http://www.pnud.org.br/IDH/DH.aspx...
,1616 Índice de Desenvolvimento Humano Municipal. Brasil. [Citado em 2015 Dez 8]. Disponível em: http://g1.globo.com/brasil/idhm-2013/platb/
http://g1.globo.com/brasil/idhm-2013/pla...
Half of the mortality due to CVD before the age of 65 years can be attributed to poverty.1313 Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):403-12. Similarly, the educational level has an inverse relationship with mortality due to CVD. Inadequate feeding, insufficient physical activity, alcohol consumption and smoking are important risk factors for DVC and more prevalent in the least favored social levels.1717 Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet. 2011;377(9781):1949-61. Therefore, primary and secondary prevention programs aimed at those population strata can significantly impact morbidity and mortality due to CVD. For example, the "Family Health Strategy" program facilitated actions for health promotion and perfected the process of prevention and early diagnosis of the major risk factors for CVD.1818 Ceccon RF, Meneghel SN, Viecili PR. Hospitalization due to conditions sensitive to primary care and expansion of the Family Health Program in Brazil: an ecological study. Rev Bras Epidemiol. 2014;17(4):968-77.

Another important point observed in our study was the convergence of the trends in mortality due to IHD and CbVD in the Brazilian regions. The convergence of the trends in mortality due to IHD occurred from 2007 onwards, while that due to CbVD occurred 10 years earlier. That behavior reflects in the earlier and steepest drop in mortality due to CbVD, resulting in the epidemiological transition phenomenon, which is predominance of mortality due to IHD over that due to CbVD.1919 Mansur AP, Lopes AI, Favarato D, Avakian SD, César LA, Ramires JA. Epidemiologic transition in mortality rate from circulatory diseases in Brazil. Arq Bras Cardiol. 2009;93(5):506-10.

This study's major limitations relates to the quality of Brazilian mortality data, such as errors related to the diagnosis and accuracy of death certificates, ill-defined causes of deaths and data inputting errors. The number of death certificates with symptoms, signs and ill-defined health conditions reported as cause of death is an indirect indicator of the data quality pattern. Despite the progressive improvement, the number of death certificates with those characteristics in the Northeastern, Northern and West-Central regions is still significant.2020 França E, de Abreu DX, Rao C, Lopez AD. Evaluation of cause-of-death statistics for Brazil, 2002-2004. Int J Epidemiol. 2008;37(4):891-901.,2121 Gaui EN, Oliveira GM, Klein CH. Mortality by heart failure and ischemic heart disease in Brazil from 1996 to 2011. Arq Bras Cardiol. 2014;102(6):557-65.

In addition, validation studies for mortality rate data are not available in most Brazilian states or cities. Thus, the reduction in the number of death certificates with symptoms, signs and ill-defined health conditions reported as cause of death can redirect to the increase in the number of death certificates due to CVD, and consequently, artificially reflect as an increase in mortality due to CVD in the Northeastern, Northern and West-Central regions.

Conclusion

The persistence of those mortality trends in the five Brazilian regions will lead, in a few years, to an inversion in the risk of death in the regions, making the Northeastern region, and to a lesser extent, the Northern and West-Central regions, those with the highest coefficients of mortality due to CVD. Thus, intensification of preventive public health policies for CVD and improvement in socioeconomic conditions, especially in the Northeastern region, might result in similar coefficients of mortality in the five Brazilian regions.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is not associated with any thesis or dissertation work.

References

  • 1
    Souza MF, Alencar AP, Malta DC, Moura L, Mansur AP. Serial temporal analysis of ischemic heart disease and stroke death risk in five regions of Brazil from 1981 to 2001. Arq Bras Cardiol. 2006;87(6):735-40.
  • 2
    Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations. Int J Cardiol. 2013;168(2):934-45.
  • 3
    Moran AE, Forouzanfar MH, Roth GA, Mensah GA, Ezzati M, Murray CJ, et al. Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the Global Burden of Disease 2010 study. Circulation. 2014;129(14):1483-92.
  • 4
    Baena CP, Chowdhury R, Schio NA, Sabbag AE Jr, Guarita-Souza LC, Olandoski M, et al. Ischaemic heart disease deaths in Brazil: current trends, regional disparities and future projections. Heart. 2013;99(18):1359-64.
  • 5
    Ministério da Saúde. Datasus. Mortalidade Brasil. [Citado em 2015 Dez 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/niuf.def
    » http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/niuf.def
  • 6
    Segi M, Fujisaku S, Kurihara M, Narai Y, Sasajima K. The age-adjusted death rates for malignant neoplasms in some selected sites in 23 countries in 1954-1955 and their geographical correlation. Tohoku J Exp Med. 1960;72:91-103.
  • 7
    Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J. 2014;35(42):2950-9. Erratum in: Eur Heart J. 2015;36(13):794.
  • 8
    Roth GA, Forouzanfar MH, Moran AE, Barber R, Nguyen G, Feigin VL, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med. 2015;372(14):1333-41.
  • 9
    Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-98.
  • 10
    Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde. [Citado em 2015 Jun 10]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
    » ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
  • 11
    Nicolau JC, Franken M, Lotufo PA, Carvalho AC, Marin Neto JA, Lima FG, et al. Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE). Arq Bras Cardiol. 2012;98(4):282-9.
  • 12
    Ishitani LH, Franco GC, Perpétuo IH, França E. [Socioeconomic inequalities and premature mortality due to cardiovascular diseases in Brazil]. Rev Saúde Pública. 2006;40(4):684-91.
  • 13
    Bassanesi SL, Azambuja MI, Achutti A. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol. 2008;90(6):403-12.
  • 14
    Polanczyk CA, Ribeiro JP. Coronary artery disease in Brazil: contemporary management and future perspectives. Heart. 2009;95(11):870-6.
  • 15
    Programa das Nações Unidas para o Desenvolvimento (PNUD). [Citado em 2015 Nov 11]. Disponível em: http://www.pnud.org.br/IDH/DH.aspx
    » http://www.pnud.org.br/IDH/DH.aspx
  • 16
    Índice de Desenvolvimento Humano Municipal. Brasil. [Citado em 2015 Dez 8]. Disponível em: http://g1.globo.com/brasil/idhm-2013/platb/
    » http://g1.globo.com/brasil/idhm-2013/platb/
  • 17
    Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet. 2011;377(9781):1949-61.
  • 18
    Ceccon RF, Meneghel SN, Viecili PR. Hospitalization due to conditions sensitive to primary care and expansion of the Family Health Program in Brazil: an ecological study. Rev Bras Epidemiol. 2014;17(4):968-77.
  • 19
    Mansur AP, Lopes AI, Favarato D, Avakian SD, César LA, Ramires JA. Epidemiologic transition in mortality rate from circulatory diseases in Brazil. Arq Bras Cardiol. 2009;93(5):506-10.
  • 20
    França E, de Abreu DX, Rao C, Lopez AD. Evaluation of cause-of-death statistics for Brazil, 2002-2004. Int J Epidemiol. 2008;37(4):891-901.
  • 21
    Gaui EN, Oliveira GM, Klein CH. Mortality by heart failure and ischemic heart disease in Brazil from 1996 to 2011. Arq Bras Cardiol. 2014;102(6):557-65.

Publication Dates

  • Publication in this collection
    18 July 2016
  • Date of issue
    Aug 2016

History

  • Received
    14 Aug 2015
  • Reviewed
    01 Apr 2016
  • Accepted
    01 Apr 2016
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