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Trends in Mortality Rate from Cardiovascular Disease in Brazil, 1980-2012

Abstract

Background:

Studies have questioned the downward trend in mortality from cardiovascular diseases (CVD) in Brazil in recent years.

Objective:

to analyze recent trends in mortality from ischemic heart disease (IHD) and stroke in the Brazilian population.

Methods:

Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. Risk of death was adjusted by the direct method, using as reference the world population of 2000. We analyzed trends in mortality from CVD, IHD and stroke in women and men in the periods of 1980-2006 and 2007-2012.

Results:

there was a decrease in CVD mortality and stroke in women and men for both periods (p < 0.001). Annual mortality variations for periods 1980-2006 and 2007-2012 were, respectively: CVD (total): -1.5% and -0.8%; CVD men: -1.4% and -0.6%; CVD women: -1.7% and -1.0%; DIC (men): -1.1% and 0.1%; stroke (men): -1.7% and -1.4%; DIC (women): -1.5% and 0.4%; stroke (women): -2.0% and -1.9%. From 1980 to 2006, there was a decrease in IHD mortality in men and women (p < 0.001), but from 2007 to 2012, changes in IHD mortality were not significant in men [y = 151 + 0.04 (R2 = 0.02; p = 0.779)] and women [y = 88-0.54 (R2 = 0.24; p = 0.320).

Conclusion:

Trend in mortality from IHD stopped falling in Brazil from 2007 to 2012.

Keywords:
Cardiovascular Diseases / epidemiology; Mortality / trends; Myocardial Ischemia; Brain Ischemia.

Resumo

Fundamento:

Estudos questionaram a tendência de queda da mortalidade por doenças cardiovasculares (DCV) no Brasil nos últimos anos.

Objetivo:

analisar as tendências recentes na mortalidade por doença isquêmica do coração (DIC) e doenças cerebrovasculares (DCbV) na população brasileira.

Métodos:

dados de mortalidade e população foram obtidos do Instituto Brasileiro de Geografia e Estatística e Ministério da Saúde. O risco de morte foi ajustado pelo método direto, tendo como referência a população mundial de 2000. Foram analisadas, nos períodos de 1980-2006 e 2007-2012, as tendências da mortalidade em mulheres e homens.

Resultados:

houve diminuição da mortalidade por DCV e DCbV em mulheres e homens para ambos os períodos (p < 0,001). As variações anuais de mortalidade para os períodos de 1980-2006 e 2007-2012 foram, respectivamente: DCV total: -1,5% e -0,8%; DCV homens: -1,4% e -0,6%; DCV mulheres: -1,7% e -1,0%; DIC homens: -1,1% e 0,1%; DIC mulheres: -1,5% e 0,4%; DCbV homens: -1,7% e -1,4%; DCbV mulheres: -2,0% e -1,9%. De 1980 a 2006, houve diminuição da mortalidade por DIC em homens e mulheres (p < 0,001), mas de 2007-2012, as mudanças na mortalidade por DIC não foram significativas em homens [y = 151 + 0.04 (R2 = 0.02; p = 0,779)] e mulheres [y = 88-0.54 (R2 = 0,24; p = 0,320)].

Conclusão:

A tendência da mortalidade por DIC parou de cair no Brasil de 2007 a 2012.

Palavras-chave:
Doenças Cardiovasculares / epidemiologia; Mortalidade / tendências; Isquemia Miocárdica; Isquemia Encefálica

Introduction

Cardiovascular diseases (CVD) are the main cause of death in the Brazilian population.11 Mansur AP, Favarato D, Souza MF, Avakian SD, Aldrighi JM, César LA, et al. Trends in death from circulatory diseases in Brazil between 1979 and 1996. Arq Bras Cardiol. 2001;76(6):497-510. Erratum in: Arq Bras Cardiol. 2001;77(2):204.,22 Mansur AP, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61. CVDs are responsible for at least 20% of deaths in our population over 30 years old. In the South and Southeast regions of the country, the rate of mortality from CVD was even greater than in other regions.33 Souza MFM, Alencar AP, Malta DC, Moura L, Mansur Ade P. 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. Previous studies have shown consistent data about the downward trend in the mortality rate from CVD in Brazil.44 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.,55 Mansur AP, Favarato D, Avakian SD, Ramires JA. Trends in ischemic heart disease and stroke death ratios in Brazilian women and men. Clinics (Sao Paulo). 2010;65(11):1143-7. Deaths by cerebrovascular diseases (CBVD) had greater reduction in mortality rate when compared to ischemic heart disease (IHD).44 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. A recent update in CVD mortality data in Brazil and in the metropolitan region of São Paulo showed a downward trend in the rate of mortality from IHD and CBVD between 1990 and 2009.22 Mansur AP, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61. In Brazil, starting in 1987, deaths from IHD were, in men, higher than deaths from CBVD. In women, however, this difference was only noticed as of 1999. Both causes of death showed a downward trend in the period of 1980 - 2009, but this trend was more evident in deaths from CBVD. However, in men, from 2007 to 2009, the mortality rate adjusted by age from IHD remained unaltered. Nevertheless, due to the period of only three years, it was not possible to establish a real trend in mortality. This study updated the rate of mortality from cardiovascular diseases in Brazil until 2012. Trends in rate of mortality from CVD, IHD and CBVD in the period of 2007-2012 were also analysed and compared to previous years.

Methods

Rates of mortality from CVD, IHD and CBVD, in Brazil, from 1980 to 2012 and in the periods of 1980-2006 and 2007-2012 were analysed. The data about mortality were obtained on the Ministry of Health of Brazil's website www.datasus.gov.br. Population data, from the Brazilian institute of Geography and Statistics (IBGE), were obtained on the same website. Deaths from 1990 to 1995 were classified according to ICD-9, 9th Review Conference of the International Classification of Diseases (ICD) of 1975, adopted by the 20th World Health Assembly. Starting in 1996, the mortality data were obtained in the 10th review of the International Classification of Diseases. Diseases of the circulatory system (CDs) were grouped in codes 390 to 459, IHDs in codes 410 to 414, and CBVDs in codes 430 to 438, in the 9th review of the ICD. Mortality data, starting in 1996, was classified by the 10th review of the ICD. CDs are grouped in codes 100-199, IHDs in codes 120 to 125, and CBVDs in codes 160 to 169. Mortality after 30 years of age, according to gender, per 100,000 inhabitants, was analysed in the following age groups: 30-39 years of age; 40-49 years of age; 50-59 years of age; 60-69 years of age; 70-79 years of age and ≥ 80 years of age. For comparison, mortality was adjusted by direct method for the age according to standard world population of the year 2000.66 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 was used to analyse the temporal evolution of mortality rate associated to CVD, IHD, and CBVD, followed by the comparison of slopes of regression lines. The level of significance was p < 0.05. The statistical software used was Primer of Biostatistics, version 4.02.9.77 Glantz SA. Primer of biostatistics, version 4.02. New York: McGraw-Hill; 1996.

Results

From 1980 to 2012, there was a decrease in mortality from CVD, IHD and CBVD in men and women (Table 1). The results of the linear regression for such period were: CVD total: y = 627.4-8.0 (R2 = 0.98. p < 0.001), CVD men: y = 684.4-8.6 (R2 = 0.94. p < 0.001), CVD women: y = 593.9-7.6 (R2 = 0.95. p < 0.001), IHD total: y = 181-2.0 (R2 = 0.23. p < 0.001), IHD men: y = 219.2-2.3 (R2 = 0.93, p < 0.001), IHD women: y = 144.9-1.8 (R2 = 0.95. p < 0.001), CBVD total: y = 181.3-2.8 (R2 = 0.69, p < 0.001), CBVD men: y = 231.6-2.9 (R2 = 0.91, p < 0.001), CBVD women: y = 171.3-2.7 (R2 = 0.94, p < 0.001). The comparison of linear regressions between men and women showed a larger reduction in mortality from CVD (p = 0.031) and IHD (p < 0.001) in men, but no significant reduction in CBVD (p = 0.228) (Figure 1). The percentage of reduction of death from CVD, IHD, and CBVD between 1980-2012, 1980-2006 and 2007-2012 are shown in Table 2.

Table 1
Risk of death* * adjusted by direct method for the standard world population in 2000 , var(%) = percentage variation (2012/1980). from cardiovascular diseases (CVD), ischemic heart disease (IHD), and cerebrovascular diseases (CBVD), per 100.000 inhabitants, and the total variation in the period of observation (1980-2012), in men (M) and women (W), in Brazil.

Figure 1
Analysis of the simple linear regression and comparison between the lines of regression of mortality from cardiovascular diseases (CVD), ischemic heart diseases (IHD), and cerebrovascular diseases (CBVD) between men and women, in the period of 1980 to 2012.

Table 2
Percentage variation of the risk of death adjusted for the age of cardiovascular diseases (CVD), ischemic heart diseases (IHD) and cerebrovascular diseases (CBVD) from 1980 to 2012, and for the periods of 1980 to 2006 and 2007 to 2012

The annual alterations in mortality for the periods of 1980-2007 and 2007-2012 were respectively: CVD total: -1.5% e -0.8%, CVD men: -1.4% e -0.6%, CVD women: -1.7% e -1.0%, IHD total: -0.90% e -0.08%, IHD men: -1.1% e 0.1%, IHD women: -1.5% e -0.4%, CBVD total: -1.26% e -1.60%, CBVD men: -1.7% e -1.4% and CBVD women: -2.0% e -1.9%. From 1980 to 2006, there was a decrease in mortality from CVD, IHD, and CBVD in men and women (p < 0.001 for all comparisons) (Figure 2). Results of the linear regression for the period of 1980-2006 were: CVD total: y = 625.9-7.8 (R2 = 0.40. p < 0.001), CVD men: y = 707.5-8.4 (R2 = 0.91. p < 0.001), CVD women: y = 544.2-7.3 (R2 = 0.92. p < 0.001), IHC total: y = 180.1-2.0 (R2 = 0.16. p = 0.003), IHC men: y = 220.8-2.3 (R2 = 0.89. p < 0.001), IHC women: y = 140.5-1.7 (R2 = 0.91. p < 0.0001), CBVD total: y = 180.1-2.7 (R2 = 0.56. p < 0.001), CBVD men: y = 198.1-2.7 (R2 = 0.94. p < 0.001), and CBVD women: y = 162.2-2.6 (R2 = 0.91. p < 0.001). The comparison of the linear regression lines between men and women showed greater reduction in IHD (p = 0.002) in men, but no significant reduction for CVD (p = 0.120) and CBVD (p = 0.708) (Figure 2).

Figure 2
Analysis of the simple linear regression and comparison between the lines of regression of the mortality from cardiovascular diseases (CVD), ischemic heart diseases (IHD), and cerebrovascular diseases (CBVD) between men and women, for the periods of 1980 to 2006 and 2007 to 2012.

From 2007 to 2012, there was reduction in mortality from CVD and CBVD in men and women, and the results of the linear regressions for this period were: CVD total: y = 394.2-4.1 (R2 = 0.01. p =0.753), CVD men: y = 460.1-3.7 (R2 = 0.66. p = 0.049), CVD women: y = 329-4.5 (R2 = 0.72. p = 0.033), CBVD total: y = 101.3-2.1 (R2 = 0.05. p =0.495), CBVD men: y = 116.4-1.9 (R2 = 0.90. p = 0.004), and CBVD women: y = 86.7-2.1 (R2 = 0.90. p = 0.003). However, no significant alterations in IHD mortality were observed: IHD total: y = 119.3-.25 (R2 = 0.02. p = 0.978), IHD men: y = 151 + 0.04 (R2 = 0.15. p = 0.779), IHD women: y = 87.7-.54 (R2 = 0.24. p = 0.320). The comparisons of linear regressions between men and women did not show differences in mortality trends for CVD (p = 0.713), IHD (p = 0.374) e CBVD (p = 0.591).

Discussion

This study showed a trend in the reduction of mortality from cardiovascular diseases from 1980 to 2012, but in the analysis of the period of 2007-2012 no reduction in mortality from IHD was observed in men or women.

Studies showed a trend in the reduction of mortality from cardiovascular diseases in several countries, especially in the more developed countries of Western Europe, USA, and Canada.88 Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J. 2014;35(42):2950-9.

9 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.
-1010 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322. Erratum in: Circulation. 2015;131(24):e535. A recent update showed significant reduction in mortality from CVDs in all states of the USA.1010 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322. Erratum in: Circulation. 2015;131(24):e535. However, only a small reduction in mortality from IHD was observed in young adults, especially women.1111 Wilmot KA, O'Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation. 2015;132(11):997-1002. Despite the significant discrepancies between death rates from CVD in Europe, many European countries also had an increase or small reduction in mortality from CVD.1212 Nichols M, Townsend N, Scarborough P, Rayner M. Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980-2009. Eur Heart J. 2013;34(39):3017-27. Control of the risk factor, and improvements in clinical and interventional treatments are the main justifications for the reduction in mortality in more developed countries.1313 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.,1414 Braunwald E. The ten advances that have defined modern cardiology. Trends Cardiovasc Med. 2014;24(5):179-83. Just as in our study, a reduction of mortality from such diseases was also observed in developing countries.1515 Souza MFM, Gawryszewski VP, Orduñez P, Sanhueza A, Espinal MA. Cardiovascular disease mortality in the Americas: current trends and disparities. Heart. 2012;98(16):1207-12. Even with population changes in these countries, such as increase and aging of the population, the trends in mortality from CVD have been maintained with the adjustment of the coefficient for age, gender and specific disease (IHD or CBVD).99 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. Our study showed significant and constant reduction in the mortality from CBVD in the period of 1980 to 2012. This was, most likely, due to an increased facility in diagnosis and treatment of the main risk factor for such diseases - the systemic arterial hypertension (SAH). In 2013, the diagnosis of SAH was 21.2% for the population over 18 years old and >50% for individuals over 65 years old. Almost 70% of these patients with SAH had some kind of medical assistance and 36% took at least one medication for hypertension in the Brazilian government program Programa Farmácia Popular (Popular Pharmacy Program).1616 Instituto Brasileiro de Geografia e Estatística (IBGE). Indicadores IBGE. [Acesso em 2015 dez 12]. Disponível em: ftp://ftp.ibge.gov.br/trabalho_e_rendimento/pesquisa
ftp://ftp.ibge.gov.br/trabalho_e_rendime...

On the other hand, the complexity of the factors involved in the pathophysiology of the atherosclerosis process largely increases the challenge of preventing IHDs. SAH control has great impact on the morbidity and mortality of CBVDs, while diagnosis and treatment of IHDs involve other risk factors, such as dyslipidemia, smoking, and diabetes, many times unknown until the first coronary event. Associated to the complexity of clinical treatment, there is the limited availability of interventional treatment, restricted to large urban centers. The result is the big heterogeneity of the risk of death from acute myocardial infarction in the different regions of Brazil.1717 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):282-289 2. However, in the period between 2007 and 2012, the justifications for a halt in the downward trend in mortality from IHD are unknown. Socioeconomic aspects and decreased access to adequate healthcare system by the less privileged population for diagnosis and treatment of IHDs may be impacting on the change observed in the trend of mortality from such diseases. Baena et al.1818 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 shown an increase in mortality from IHD in the North and Northeast regions, which are known to be underprivileged in Brazil. In mortality from CVD,1919 Mackenbach JP, Cavelaars AE, Kunst AE, Groenhof F. Socioeconomic inequalities in cardiovascular disease mortality; an international study. Eur Heart J. 2000;21(14):1141-51.

20 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.

21 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):370-9.
-2222 Polanczyk CA, Ribeiro JP. Coronary artery disease in Brazil: contemporary management and future perspectives. Heart. 2009;95(11):870-6. studies have also shown the significance of social inequalities and discrepancies in level of education of the population. Half of the causes of death from CVD, before 65 years of age, can be attributed to poverty. Likewise, low levels of education contribute to poverty, which further increases the rate of mortality from CVD. Malnourishment, little physical activity, alcohol consumption and smoking are other important risk factors for CVD, and are more prevalent in less privileged layers of the population.2323 Nogueira MC, Ribeiro LC, Cruz OG. [Social inequalities in premature cardiovascular mortality in a medium-size Brazilian city]. Cad Saude Publica. 2009;25(11):2321-32.,2424 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, the institution of public policies of prevention of CVD should be intensified to reinstate a downward trend in mortality from CVD. Environmental, occupational, behavioral and metabolic factors were responsible for almost 90% of disability-adjusted life years (DALYs) and deaths from CVD.2525 Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(10010):2287-323.

The limitations of this study relate to the quality of the Brazilian data about mortality, such as errors related to diagnosis and precision of death certificates, deaths associated with unknown causes and data entry errors. The number of death certificates containing a diagnosis for the cause of death, such as poorly defined symptoms, signs and health conditions is an indirect indicator of the standard quality of data. These certificates, despite progressive improvement, are still significant in the Northeast, north and Midwest regions in Brazil, but not in the South or Southeast.2626 França E, Abreu DX, Rao C, Lopez AD. Evaluation of cause-of-death statistics for Brazil, 2002-2004. Int J Epidemiol. 2008;37(4):891-901.-2727 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. Validation studies for the data about mortality are not available in the majority of states and cities in Brazil.

Conclusion

As opposed to CBVD, the trend in mortality from IHD stopped going down in Brazil in the last six years. It is necessary to intensify healthcare policies about the control of the main risk factors so as to reinstate the downward trend in mortality rate from IHD.

  • 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
    Mansur AP, Favarato D, Souza MF, Avakian SD, Aldrighi JM, César LA, et al. Trends in death from circulatory diseases in Brazil between 1979 and 1996. Arq Bras Cardiol. 2001;76(6):497-510. Erratum in: Arq Bras Cardiol. 2001;77(2):204.
  • 2
    Mansur AP, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61.
  • 3
    Souza MFM, Alencar AP, Malta DC, Moura L, Mansur Ade P. 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.
  • 4
    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.
  • 5
    Mansur AP, Favarato D, Avakian SD, Ramires JA. Trends in ischemic heart disease and stroke death ratios in Brazilian women and men. Clinics (Sao Paulo). 2010;65(11):1143-7.
  • 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
    Glantz SA. Primer of biostatistics, version 4.02. New York: McGraw-Hill; 1996.
  • 8
    Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J. 2014;35(42):2950-9.
  • 9
    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.
  • 10
    Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322. Erratum in: Circulation. 2015;131(24):e535.
  • 11
    Wilmot KA, O'Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation. 2015;132(11):997-1002.
  • 12
    Nichols M, Townsend N, Scarborough P, Rayner M. Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980-2009. Eur Heart J. 2013;34(39):3017-27.
  • 13
    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.
  • 14
    Braunwald E. The ten advances that have defined modern cardiology. Trends Cardiovasc Med. 2014;24(5):179-83.
  • 15
    Souza MFM, Gawryszewski VP, Orduñez P, Sanhueza A, Espinal MA. Cardiovascular disease mortality in the Americas: current trends and disparities. Heart. 2012;98(16):1207-12.
  • 16
    Instituto Brasileiro de Geografia e Estatística (IBGE). Indicadores IBGE. [Acesso em 2015 dez 12]. Disponível em: ftp://ftp.ibge.gov.br/trabalho_e_rendimento/pesquisa
    » ftp://ftp.ibge.gov.br/trabalho_e_rendimento/pesquisa
  • 17
    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):282-289 2.
  • 18
    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.
  • 19
    Mackenbach JP, Cavelaars AE, Kunst AE, Groenhof F. Socioeconomic inequalities in cardiovascular disease mortality; an international study. Eur Heart J. 2000;21(14):1141-51.
  • 20
    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.
  • 21
    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):370-9.
  • 22
    Polanczyk CA, Ribeiro JP. Coronary artery disease in Brazil: contemporary management and future perspectives. Heart. 2009;95(11):870-6.
  • 23
    Nogueira MC, Ribeiro LC, Cruz OG. [Social inequalities in premature cardiovascular mortality in a medium-size Brazilian city]. Cad Saude Publica. 2009;25(11):2321-32.
  • 24
    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.
  • 25
    Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(10010):2287-323.
  • 26
    França E, Abreu DX, Rao C, Lopez AD. Evaluation of cause-of-death statistics for Brazil, 2002-2004. Int J Epidemiol. 2008;37(4):891-901.
  • 27
    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
    24 May 2016
  • Date of issue
    July 2016

History

  • Received
    06 Aug 2015
  • Reviewed
    21 Oct 2015
  • Accepted
    19 Feb 2016
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