Ischemic and hemorrhagic cerebrovascular disease in Brazil: mortality trends and correlation with socioeconomic index over 20 years

Abstract

The article analyzes mortality trends due to cerebrovascular disease (CBVD) in Brazil. regions and federation units. from 2000 to 2019. and its correlation with the municipal human development index (MHDI) and social vulnerability index (SVI). It has an ecological design and describes-time series of deaths. The codes for DCBV. according to ICD-10. were divided into three groups: ischemic (CBVDI). hemorrhagic (CBVDH) and unspecified (CBVDU). The Southeast had the highest total number of deaths. In the stratified analysis.-general decreasing trend was observed in Brazil for CBVDH and CBVDU with an increase in the North and Northeast in CBVDI and CBVDH. For the MHDI. there was-strong positive correlation between AAPC (annual percentage change of the total period) and mortality trends rate for CBVDH from 40 years of age and for CBVDI in those over 80 years of age. There was no correlation between the AAPC of the SVI and mortality trends rate between the disease groups. It is concluded that the trend towards an increase in deaths from CBVDI and CBVDH in the North and Northeast is possibly related to economic and social inequality in these regions. The decrease in CBVDU seems to reflect an increase in CBVDI. which could mean an improvement in mortality registrations.

Keywords:
Ischemic Stroke; Hemorrhagic Stroke; Death Certificates; Development Indicators

Resumo

O estudo analisa a tendência da mortalidade por doença cerebrovascular (DCBV) no Brasil, regiões e unidades da federação, de 2000 a 2019, e a correlação com índice desenvolvimento humano municipal (IDHM) e índice de vulnerabilidade social (IVS). Tem delineamento ecológico e descreve uma série temporal de óbitos. Os códigos para causas por DCBV, segundo CID-10, foram divididos em três grupos: isquêmica (DCBVI), hemorrágica (DCBVH) e não especificada (DCBVNE). O Sudeste apresentou o maior número total de óbitos. A análise estratificada mostrou tendência geral de decréscimo na mortalidade por DCBVH e DCBVNE, no Brasil, com aumento no Norte e Nordeste para DCBVI e DCBVH. Para o IDHM houve correlação positiva forte entre a variação percentual anual do período total (AAPC) e a tendência da taxa de mortalidade para DCBVH, a partir de 40 anos, e para DCBVI em maiores de 80 anos. Não houve correlação entre AAPC do IVS e a tendência da taxa de mortalidade entre os grupos de causas. Conclui-se que a tendência ao aumento de óbitos por DCBVI e DCBVH no Norte e Nordeste, possivelmente, está relacionada a desigualdade econômica e social nestas regiões. O decréscimo da DCBVNE parece refletir no aumento da DCBVI, que pode significar melhoria dos registros no Sistema de Informação de Mortalidade.

Palavras-chave:
Acidente vascular cerebral; Mortalidade; Indicadores de Desenvolvimento

Resumen

El estudio analiza la tendencia de la mortalidad por enfermedad cerebrovascular (ECBV) en Brasil, regiones y unidades de la federación, de 2000 a 2019, y su correlación con el índice de desarrollo humano municipal (IDHM) y el índice de vulnerabilidad social (IVS). Tiene un diseño ecológico y describe una serie temporal de muertes. Los códigos de causas de ECBV, según la CIE-10, se dividieron en tres grupos: isquémico (ECBVI), hemorrágico (ECBVH) y no especificado (ECBVNE). El sureste tuvo el mayor número total de muertes. El análisis estratificado mostró una tendencia general de disminución de la mortalidad por ECBVH y ECBVNE en Brasil, con aumento en el Norte y Nordeste para ECBVI y ECBVH. Para el IDH, hubo una fuerte correlación positiva entre la variación porcentual anual (VPCA) del periodo total y la tendencia de la tasa de mortalidad para ECBVH, a partir de los 40 años de edad, y para ECBVI en mayores de 80 años. No hubo correlación entre la VPCA del IVS y las tendencias de la tasa de mortalidad entre los grupos de causas. Se concluye que la tendencia al aumento de muertes por ECBVI y ECBVH en el Norte y Nordeste posiblemente esté relacionada con la desigualdad económica y social en estas regiones. La disminución de la ECBVNE parece reflejarse en el aumento de la ECBVI, lo que puede significar mejores registros en el Sistema de Información de Mortalidad.

Palabras clave:
Accidente cerebrovascular; Mortalidad; Indicadores de desarrollo

Introduction

Cerebrovascular disease is the second leading cause of death worldwide. accounting for 10.2% of all deaths in 2016. with 4.9% of deaths being attributed to ischemic stroke (IS) and 5.2% to hemorrhagic stroke (HS)¹.

In 2019. more than 6 million people died from stroke worldwide and it is estimated that this number could reach 10 million-year by 2060². In middle-income countries such as Brazil it is estimated that the percentage of deaths from stroke will decrease from 15.2%. in 2016. to 12.8% in 2060. while in low-income countries forecasts suggest an increase over the same period from 5.2% to 10.0%³.

The stroke case fatality rate is around 15% within 1 month. 25% within 1 year and 50% within 5 years. and approximately 40% of stroke survivors become disabled between 1 month and 5 years after stroke⁴. Case fatality rates for HS are around 55% within 1 year and 70% within 5 years⁵.

Prevalence of stroke in Brazil varies from study to study and across states. from 1.3% to 6.8%^6-8. This wide variation has been explained by the continental proportions of the country. socioeconomic inequality⁹ and differences in data analysis methods between studies.

Death certificates registered in the country’s mortality information system (SIM. acronym in Portuguese) provide-considerable amount of information for analysis and disease surveillance. enabling monitoring of deaths by disease and the calculation of projections for Brazil’s health system¹⁰.

Most studies in the literature on stroke include all the codes of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) inherent to the disease. Strokes that may cause brain damage result in increased morbidity and are therefore more likely to be involved in the underlying cause of death. However. some studies fail to separate IS and HS. which both affect different age groups differently and have different risk factors. thus hampering the interpretation of results¹¹.

The Human Development Index (HDI) was introduced in 1990. when the United Nations Development Programme (UNDP) launched the first Human Development Report. In 2012. UNDP Brasil. together with the Institute of Applied Economic Research (IPEA) and the João Pinheiro Foundation. adapted the HDI method to create the municipal HDI (MHDI). used to assess the country’s 5.565 municipalities. The MHDI was calculated using data from the last three demographic censuses conducted by the Brazilian Institute of Geography and Statistics (IBGE) - 1991. 2000 and 2010 - and based on the municipal grid in 2010¹². The Social Vulnerability Index (SVI) creates-synthetic indicator of the absence or insufficiency of essential resources needed to ensure well-being and quality of life. The method used resembles that of the MHDI. The data available from 2017 include the same indicators used between 2000 and 2010.

The calculation of indicators. dimensions and indices is based on crude data produced by the National Household Sample Survey (PNAD) between 2011 and 2015¹³.

These two indicators enable the monitoring of human development and trends in social vulnerability at municipal level. providing important inputs to shape public policies and evaluate their effectiveness.

Studies investigating the association between socioeconomic indicators and risk of stroke among adults have produced conflicting results. with both positive and negative correlations^13.14. In Brazil. these indicators show the same discrepancies at national level and across regions¹⁵.

The objective of this study was therefore to analyze trends in deaths from IS and HS in Brazil at national. regional and state level and their correlation with the MHDI and SVI during the period 2000-2019.

Method

a) Study design. population and period

We conducted an ecological time series study of deaths during the period 2000-2019 where the underlying cause was stroke.

b) Data collection and sources

We collected data on causes of death due to stroke based on the ICD-10 codes from individual databases in the SIM and on other conditions and factors recorded on death certificates. For the purposes of this study. we included strokes that may cause brain damage which. in principle. are detectable by neuroimaging. The ICD-10 codes for these diseases include unspecified causes such as hemorrhage or ischemia. The causes were therefore categorized into three groups: a) ischemic stroke (IS) - I63 (cerebral infarction). I67.3 (progressive vascular leukoencephalopathy). I67.8 (other specified cerebrovascular diseases - acute cerebrovascular insufficiency and cerebral ischemia) and I69.3 (sequelae of cerebral infarction); b) hemorrhagic stroke (HS) - I60 (subarachnoid hemorrhage). I61(intracranial hemorrhage). I62 (other nontraumatic intracranial hemorrhage). I69.0 (sequelae of subarachnoid hemorrhage). I69.1 (sequelae of intracranial hemorrhage) and I69.2 (sequelae of other nontraumatic intracranial hemorrhage); and c) unspecified hemorrhagic ischemic or hemorrhagic stroke (US) - I64 (stroke not specified as hemorrhagic or ischemic). I67.9 (unspecified stroke). I69.4 (sequelae of stroke not specified as hemorrhagic or ischemic) and I69.8 (sequelae of other cerebrovascular diseases and unspecified sequelae).

While the database of the national health system’s Department of Informatics (DATASUS) considers stroke to be codes I60-I69. the pathophysiology and etiology of some of these causes are very particular and. in other cases. detectable brain damage does not occur. For this reason. the following codes were excluded: I65 (occlusion and stenosis of precerebral arteries not resulting in cerebral infarction). I66 (occlusion and stenosis of cerebral arteries not resulting in cerebral infarction). I67.0 (dissection of cerebral arteries. nonruptured). I67.1 (cerebral aneurysm. nonruptured). I67.2 (cerebral atherosclerosis). I67.4 (hypertensive encephalopathy). I67.5 (moyamoya disease). I67.6 (nonpyogenic thrombosis of intracranial venous system without cerebral infarction). and I67.7 (cerebral arteritis. not elsewhere classified). Code I68 (cerebrovascular disorders in diseases classified elsewhere) was also excluded because it refers to diseases with defined etiology without necessary identifiable brain damage.

The study population consisted of adults divided into the following age groups: 20-39 years; 40-59 years; 60-79 years; 80 years and over; and overall (all age groups).

Two social and economic development indicators were selected for correlation: i) the MHDI. which measures the same key dimensions of human development as the HDI: life expectancy. education and income. The MHDI tailors the HDI methodology to the Brazilian context and the availability of national indicators. The closer to 1 the better the MHDI; ii) the SVI consists of three dimensions - urban infrastructure. human capital. and income and employment - representing three sets of assets that determine well-being in contemporary societies. In contrast to the MHDI. the closer to 1 the worse the indicator.

The HDI data were obtained from the 2010 Atlas of Human Development¹² and the SVI data were taken from the 2010 Atlas of Social Vulnerability¹⁶. The MHDI and SVI were calculated for the census years (2000 and 2010) and based on crude PNAD data (2011-2015).

c) Statistical analysis

We calculated standardized annual crude rates of mortality per 100.000 population¹⁷ using the direct method. based on the overall population during the period 2000-2019. regardless of sex. The population data was extracted from the DATASUS website¹⁸. National and regional mortality rates were standardized by age group and sex for each group of causes. The analyses were performed using R.

Temporal trend analysis was performed using the joinpoint regression model to identify statistically significant points of inflection and annual percent change in mortality rates between 2000 and 2019. This method allows the researcher to detect trends (stationary. upward or downward) in each indicator. joinpoints. and annual percent change (APC) and average annual percent change (AAPC). The number of joinpoints was calculated using the permutation test with Bonferroni correction. adopting-95% confidence interval (95% CI) and 5% significance level. These analyses were conducted using Joinpoint Regression 4.5.0.1 (National Cancer Institute. USA)¹⁹.

We calculated AAPC for the socioeconomic indicators and respective dimensions over the study period in each state. The correlation between the AAPC of the mortality rates was assessed across the groups of causes of death from stroke and AAPC for the socioeconomic indicators and their respective dimensions by age group.

Results

There were 1.924.715 deaths from the underlying causes studied. distributed as follows: IS - 361.072 (19%); HS - 442.434 (22%); US - 1.121.209 (59%). The Southest accounted for the largest share of overall deaths (44.13%). followed by the Northeast (26.10%). South (18.83%). Midwest (5.76%) and North (5.18%) (Table 1).

Table 1
Deaths from stroke by sex and age group. Brazil and regions, 2000-2019

			HEMORRHAGIC STROKE						ISCHEMIC STROKE						UNSPECIFIED STROKE						STROKE
Region	Age Group	Sex	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	Total sex/ Age Group
BRZSIL	20-39	Women	3.38	965	1.77	609	2.29	14749	0.42	121	0.54	187	0.47	3013	1.51	432	0.64	220	0.98	6309	24071	1.25
	20-39	Men	3.23	891	1.89	643	2.38	14953	0.51	142	0.50	171	0.46	2876	1.62	447	0.78	266	1.19	7466	25295	1.31
	20-39	Total	3.31	1856	1.83	1252	2.33	29702	0.47	263	0.52	358	0.46	5889	1.57	879	0.71	486	1.08	13775	49366	2.56
	40-59	Women	20.10	3381	11.93	3237	15.82	70381	5.04	841	4.82	1307	4.48	19920	21.45	3582	7.06	1917	12.76	56794	147095	7.64
	40-59	Men	23.18	3723	14.16	3543	17.62	72373	7.11	1108	7.40	1853	6.74	27705	31.23	4866	11.25	2815	19.15	78660	178738	9.29
	40-59	Total	21.59	7104	13.00	6780	16.68	142754	6.04	1949	6.06	3160	5.56	47625	26.17	8448	9.07	4732	15.83	135454	325833	16.93
	60-79	Women	44.92	3253	35.67	4856	40.90	80961	40.39	2925	41.03	5586	39.32	77826	159.51	11542	68.09	9270	114.91	227447	386234	20.07
	60-79	Men	59.97	3607	46.03	5162	51.74	84876	58.94	3545	65.02	7291	57.57	94443	246.04	14798	115.28	12927	182.29	299026	478345	24.85
	60-79	Total	51.75	6860	40.35	10018	45.81	165837	48.81	6470	51.86	12877	47.59	172269	198.77	26340	89.40	22197	145.44	526473	864579	44.92
	80 and over	Women	132.03	1169	109.37	2890	114.59	74958	300.31	2659	240.42	6353	234.41	81906	1062.76	9410	472.32	12481	726.23	253756	410620	21.33
	80 and over	Men	126.68	792	136.20	2212	131.91	29183	278.80	1743	270.13	4387	241.29	53383	1062.25	6641	589.64	9576	866.72	191751	274317	14.25
	80 and over	Total	129.81	1961	119.58	5102	121.30	104141	291.40	4402	251.73	10740	237.08	135289	1062.55	16051	516.97	22057	780.69	445507	684937	35.59
	TOTAL							442434						361072						1121209	1924715	100.00
NORTH	20-39	Women	1.91	39	1.54	49	1.76	940	0.34	7	0.44	14	0.27	156	1.37	28	0.85	27	1.21	649	1745	0.09
	20-39	Men	2.56	53	1.60	51	2.05	1096	0.19	4	0.25	8	0.27	146	1.50	31	1.22	39	1.40	750	1992	0.10
	20-39	Total	2.24	92	1.57	100	1.90	2036	0.27	11	0.35	22	0.27	302	1.44	59	1.04	66	1.31	1399	3737	0.19
	40-59	Women	13.36	145	12.10	231	12.68	3468	2.34	21	4.50	86	2.80	767	23.50	211	9.58	183	15.44	4223	8458	0.44
	40-59	Men	13.26	237	11.53	221	12.36	3480	3.26	31	5.74	110	3.90	1097	27.48	261	12.89	247	19.86	5591	10168	0.53
	40-59	Total	13.31	382	11.82	452	12.52	6948	2.81	52	5.12	196	3.36	1864	25.54	472	11.24	430	17.68	9814	18626	0.97
	60-79	Women	41.76	128	35.81	253	38.73	3718	24.14	74	42.47	300	29.81	2861	157.91	484	87.62	619	131.34	12607	19186	1.00
	60-79	Men	39.26	125	48.01	326	43.89	4209	24.50	78	61.27	416	36.98	3546	206.95	659	139.04	944	191.47	18361	26116	1.36
	60-79	Total	40.48	253	41.79	579	41.31	7927	24.32	152	51.68	716	33.39	6407	182.90	1143	112.82	1563	161.39	30968	45302	2.35
	80 and over	Women	86.33	44	130.02	139	120.72	1771	155.01	79	248.81	266	171.17	2511	674.96	344	680.01	727	843.64	12376	16658	0.87
	80 and over	Men	95.33	41	153.64	129	124.91	1499	104.63	45	303.71	255	174.15	2090	625.45	269	870.64	731	978.17	11739	15328	0.80
	80 and over	Total	90.45	85	140.41	268	122.61	3270	131.95	124	272.96	521	172.51	4601	652.30	613	763.87	1458	904.17	24115	31986	1.66
	TOTAL							20181						13174						66296	99651	5.18
NORDESTE	20-39	Women	2.34	179	1.80	175	1.93	3458	0.41	31	0.52	51	0.43	765	1.74	133	0.87	85	1.28	2292	6515	0.34
	20-39	Men	2.46	179	2.25	210	2.13	3648	0.43	31	0.48	45	0.42	723	1.95	142	1.06	99	1.50	2575	6946	0.36
	20-39	Total	2.40	358	2.02	385	2.03	7106	0.42	62	0.50	96	0.42	1488	1.85	275	0.97	184	1.39	4867	13461	0.70
	40-59	Women	13.63	562	11.95	837	13.51	15034	3.52	145	4.61	323	3.84	4269	22.98	948	8.91	624	16.01	17821	37124	1.93
	40-59	Men	15.36	570	15.00	941	14.95	14955	3.99	148	6.85	430	5.20	5205	27.84	1033	13.59	853	20.95	20955	41115	2.14
	40-59	Total	14.45	1132	13.39	1778	14.19	29989	3.74	293	5.67	753	4.48	9474	25.28	1981	11.12	1477	18.35	38776	78239	4.06
	60-79	Women	31.26	595	35.80	1185	36.69	18608	23.01	438	35.41	1172	30.04	15235	142.15	2706	92.90	3075	134.71	68320	102163	5.31
	60-79	Men	41.77	664	46.94	1242	46.08	19162	30.26	481	55.60	1471	41.19	17127	198.27	3152	4053.00	4053	197.44	82104	118393	6.15
	60-79	Total	36.04	1259	40.75	2427	40.92	37770	26.31	919	44.38	2643	35.06	32362	167.69	5858	119.68	7128	162.97	150424	220556	11.46
	80 and over	Women	67.63	220	105.67	701	97.44	9447	104.52	340	187.53	1244	154.42	14972	645.59	2100	677.76	4496	827.85	80263	104682	5.44
	80 and over	Men	61.22	164	124.26	511	105.34	7140	107.51	288	237.09	975	167.01	11320	643.58	1724	848.43	3489	988.92	67030	85490	4.44
	80 and over	Total	64.74	384	112.79	1212	100.69	16587	105.87	628	206.50	2219	159.60	26292	644.68	3824	743.07	7985	894.12	147293	190172	9.88
	TOTAL							91452						69616						341360	502428	26.10
SUDESTE	20-39	Women	4.37	547	1.86	261	2.73	7446	0.44	55	0.55	77	0.53	1439	1.46	183	0.47	66	0.84	2282	11167	0.58
	20-39	Men	4.04	489	1.93	271	2.76	7350	0.59	72	0.58	81	0.52	1376	1.56	189	0.64	90	1.04	2765	11491	0.60
	20-39	Total	4.21	1036	1.89	532	2.75	14796	0.52	127	0.56	158	0.52	2815	1.51	372	0.55	156	0.94	5047	22658	1.18
	40-59	Women	24.04	1896	12.44	1500	17.76	36294	5.81	458	4.93	595	4.91	10026	21.21	1673	6.40	772	11.45	23391	69711	3.62
	40-59	Men	28.37	2066	15.37	1697	20.62	38441	8.50	619	7.88	870	7.85	14642	34.68	2526	10.86	1199	18.95	35332	88415	4.59
	40-59	Total	26.12	3962	13.84	3197	19.12	74735	7.10	1077	6.34	1465	6.31	24668	27.68	4199	8.53	1971	15.03	58723	158126	8.22
	60-79	Women	48.18	1683	35.71	2311	42.46	39829	43.77	1529	41.04	2656	41.21	38658	163.08	5687	57.55	3724	102.59	96238	174725	9.08
	60-79	Men	67.32	1867	46.76	2444	55.68	41847	67.50	1872	65.74	3436	63.51	47734	262.03	7267	98.48	5147	170.54	128174	217755	11.31
	60-79	Total	56.65	3550	40.65	4755	48.34	81676	54.27	3401	52.08	6092	51.13	86392	206.87	12954	75.84	8871	132.81	224412	392480	20.39
	80 and over	Women	175.18	623	106.47	1390	121.71	20405	386.07	1373	232.32	3033	241.73	40525	1319.89	4694	360.01	4700	623.67	104558	165488	8.60
	80 and over	Men	179.75	383	144.23	1106	147.61	14296	402.68	858	249.87	1916	256.13	24806	1425.82	3038	431.66	3310	739.47	71618	110720	5.75
	80 and over	Total	176.89	1006	120.45	2496	131.20	34701	392.29	2231	238.82	4949	247.00	65331	1359.58	7732	386.52	8010	666.08	176176	276208	14.35
	TOTAL							205908						179206						464358	849472	44.13
SUL	20-39	Women	3.09	130	1.60	75	2.02	1809	0.50	21	0.51	24	0.46	409	1.14	48	0.70	33	0.74	667	2885	0.15
	20-39	Men	2.52	104	1.38	65	1.95	1737	0.46	19	0.42	20	0.43	382	1.26	52	0.53	25	0.92	822	2941	0.15
	20-39	Total	2.81	234	1.49	140	1.98	3546	0.48	40	0.47	44	0.44	791	1.20	100	0.62	58	0.83	1489	5826	0.30
	40-59	Women	19.68	537	9.76	396	14.56	10226	5.75	157	4.61	187	4.78	3356	19.35	528	6.14	249	11.28	7926	21508	1.12
	40-59	Men	23.20	602	11.01	418	15.87	10449	8.48	220	7.66	291	7.12	4688	29.41	763	9.45	359	17.84	11747	26884	1.40
	40-59	Total	21.40	1139	10.36	814	15.19	20675	7.08	377	6.09	478	5.91	8044	24.25	1291	7.74	608	14.46	19673	48392	2.51
	60-79	Women	54.57	645	33.46	752	41.84	13481	63.79	754	44.41	998	49.59	15977	177.06	2093	64.56	1451	119.83	38608	68066	3.54
	60-79	Men	69.11	676	42.19	796	51.50	13880	90.58	886	72.13	1361	71.81	19351	292.19	2858	111.45	2103	197.55	53239	86470	4.49
	60-79	Total	61.15	1321	37.44	1548	46.24	27361	75.92	1640	57.06	2359	59.71	35328	229.20	4951	85.96	3554	155.23	91847	154536	8.03
	80 and over	Women	194.35	223	111.99	484	117.11	41241	652.77	749	308.67	1334	359.83	19424	1634.10	1875	471.33	2037	845.96	45666	106331	5.52
	80 and over	Men	221.21	152	126.38	327	137.97	4370	659.26	453	334.69	866	365.28	11570	1864.28	1281	582.03	1506	989.77	31350	47290	2.46
	80 and over	Total	204.41	375	117.38	811	124.83	45611	655.20	1202	318.41	2200	361.85	30994	1720.31	3156	512.79	3543	899.14	77016	153621	7.98
	TOTAL							97193						75157						190025	362375	18.83
CENTRO-OESTE	20-39	Women	3.32	70	1.79	49	2.20	1096	0.33	7	0.77	21	0.49	244	1.90	40	0.33	9	0.84	419	1759	0.09
	20-39	Men	3.24	66	46.00	46	2.29	1122	0.79	16	0.62	17	0.51	249	1.62	33	0.47	13	1.13	554	1925	0.10
	20-39	Total	3.28	136	1.74	95	2.24	2218	0.55	23	0.69	38	0.50	493	1.76	73	0.40	22	0.98	973	3684	0.19
	40-59	Women	22.79	241	12.93	273	16.91	5359	5.67	60	5.50	116	4.74	1502	21.00	222	4.22	89	10.83	3433	10294	0.53
	40-59	Men	23.74	248	13.32	266	16.62	5048	8.62	90	7.61	152	6.83	2073	27.10	283	7.86	157	16.58	5035	12156	0.63
	40-59	Total	23.27	489	13.12	539	16.77	10407	7.14	150	6.52	268	5.76	3575	24.03	505	5.99	246	13.64	8468	22450	1.17
	60-79	Women	56.63	202	40.35	355	45.92	5325	36.44	130	52.28	460	43.94	5095	160.35	572	45.58	401	100.68	11674	22094	1.15
	60-79	Men	77.48	275	45.65	354	53.69	5778	64.24	228	78.27	607	62.12	6685	242.86	862	87.68	680	159.34	17148	29611	1.54
	60-79	Total	67.03	477	42.83	709	49.66	11103	50.30	358	64.46	1067	52.69	11780	201.50	1434	65.30	1081	128.92	28822	51705	2.69
	80 and over	Women	152.06	59	130.81	176	129.55	2094	304.12	118	353.78	476	276.79	4474	1023.20	397	387.22	521	673.91	10893	17461	0.91
	80 and over	Men	159.91	52	134.56	139	145.23	1878	304.45	99	363.03	375	278.17	3597	1011.75	329	522.76	540	774.41	10014	15489	0.80
	80 and over	Total	155.64	111	132.44	315	136.52	3972	304.27	217	357.80	851	277.40	8071	1017.98	726	446.09	1061	718.57	20907	32950	1.71
	TOTAL							27700						23919						59170	110789	5.76

			HEMORRHAGIC STROKE						ISCHEMIC STROKE						UNSPECIFIED STROKE						STROKE
Region	Age Group	Sex	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	Total sex/ Age Group
NORTHEAST	20-39	Women	2.34	179	1.80	175	1.93	3458	0.41	31	0.52	51	0.43	765	1.74	133	0.87	85	1.28	2292	6515	0.34
	20-39	Men	2.46	179	2.25	210	2.13	3648	0.43	31	0.48	45	0.42	723	1.95	142	1.06	99	1.50	2575	6946	0.36
	20-39	Total	2.40	358	2.02	385	2.03	7106	0.42	62	0.50	96	0.42	1488	1.85	275	0.97	184	1.39	4867	13461	0.70
	40-59	Women	13.63	562	11.95	837	13.51	15034	3.52	145	4.61	323	3.84	4269	22.98	948	8.91	624	16.01	17821	37124	1.93
	40-59	Men	15.36	570	15.00	941	14.95	14955	3.99	148	6.85	430	5.20	5205	27.84	1033	13.59	853	20.95	20955	41115	2.14
	40-59	Total	14.45	1132	13.39	1778	14.19	29989	3.74	293	5.67	753	4.48	9474	25.28	1981	11.12	1477	18.35	38776	78239	4.06
	60-79	Women	31.26	595	35.80	1185	36.69	18608	23.01	438	35.41	1172	30.04	15235	142.15	2706	92.90	3075	134.71	68320	102163	5.31
	60-79	Men	41.77	664	46.94	1242	46.08	19162	30.26	481	55.60	1471	41.19	17127	198.27	3152	4053.00	4053	197.44	82104	118393	6.15
	60-79	Total	36.04	1259	40.75	2427	40.92	37770	26.31	919	44.38	2643	35.06	32362	167.69	5858	119.68	7128	162.97	150424	220556	11.46
	80 and over	Women	67.63	220	105.67	701	97.44	9447	104.52	340	187.53	1244	154.42	14972	645.59	2100	677.76	4496	827.85	80263	104682	5.44
	80 and over	Men	61.22	164	124.26	511	105.34	7140	107.51	288	237.09	975	167.01	11320	643.58	1724	848.43	3489	988.92	67030	85490	4.44
	80 and over	Total	64.74	384	112.79	1212	100.69	16587	105.87	628	206.50	2219	159.60	26292	644.68	3824	743.07	7985	894.12	147293	190172	9.88
	TOTAL							91452						69616						341360	502428	26.10
SOUTHEAST	20-39	Women	4.37	547	1.86	261	2.73	7446	0.44	55	0.55	77	0.53	1439	1.46	183	0.47	66	0.84	2282	11167	0.58
	20-39	Men	4.04	489	1.93	271	2.76	7350	0.59	72	0.58	81	0.52	1376	1.56	189	0.64	90	1.04	2765	11491	0.60
	20-39	Total	4.21	1036	1.89	532	2.75	14796	0.52	127	0.56	158	0.52	2815	1.51	372	0.55	156	0.94	5047	22658	1.18
	40-59	Women	24.04	1896	12.44	1500	17.76	36294	5.81	458	4.93	595	4.91	10026	21.21	1673	6.40	772	11.45	23391	69711	3.62
	40-59	Men	28.37	2066	15.37	1697	20.62	38441	8.50	619	7.88	870	7.85	14642	34.68	2526	10.86	1199	18.95	35332	88415	4.59
	40-59	Total	26.12	3962	13.84	3197	19.12	74735	7.10	1077	6.34	1465	6.31	24668	27.68	4199	8.53	1971	15.03	58723	158126	8.22
	60-79	Women	48.18	1683	35.71	2311	42.46	39829	43.77	1529	41.04	2656	41.21	38658	163.08	5687	57.55	3724	102.59	96238	174725	9.08
	60-79	Men	67.32	1867	46.76	2444	55.68	41847	67.50	1872	65.74	3436	63.51	47734	262.03	7267	98.48	5147	170.54	128174	217755	11.31
	60-79	Total	56.65	3550	40.65	4755	48.34	81676	54.27	3401	52.08	6092	51.13	86392	206.87	12954	75.84	8871	132.81	224412	392480	20.39
	80 and over	Women	175.18	623	106.47	1390	121.71	20405	386.07	1373	232.32	3033	241.73	40525	1319.89	4694	360.01	4700	623.67	104558	165488	8.60
	80 and over	Men	179.75	383	144.23	1106	147.61	14296	402.68	858	249.87	1916	256.13	24806	1425.82	3038	431.66	3310	739.47	71618	110720	5.75
	80 and over	Total	176.89	1006	120.45	2496	131.20	34701	392.29	2231	238.82	4949	247.00	65331	1359.58	7732	386.52	8010	666.08	176176	276208	14.35
	TOTAL							205908						179206						464358	849472	44.13
SUL	20-39	Women	3.09	130	1.60	75	2.02	1809	0.50	21	0.51	24	0.46	409	1.14	48	0.70	33	0.74	667	2885	0.15
	20-39	Men	2.52	104	1.38	65	1.95	1737	0.46	19	0.42	20	0.43	382	1.26	52	0.53	25	0.92	822	2941	0.15
	20-39	Total	2.81	234	1.49	140	1.98	3546	0.48	40	0.47	44	0.44	791	1.20	100	0.62	58	0.83	1489	5826	0.30
	40-59	Women	19.68	537	9.76	396	14.56	10226	5.75	157	4.61	187	4.78	3356	19.35	528	6.14	249	11.28	7926	21508	1.12
	40-59	Men	23.20	602	11.01	418	15.87	10449	8.48	220	7.66	291	7.12	4688	29.41	763	9.45	359	17.84	11747	26884	1.40
	40-59	Total	21.40	1139	10.36	814	15.19	20675	7.08	377	6.09	478	5.91	8044	24.25	1291	7.74	608	14.46	19673	48392	2.51
	60-79	Women	54.57	645	33.46	752	41.84	13481	63.79	754	44.41	998	49.59	15977	177.06	2093	64.56	1451	119.83	38608	68066	3.54
	60-79	Men	69.11	676	42.19	796	51.50	13880	90.58	886	72.13	1361	71.81	19351	292.19	2858	111.45	2103	197.55	53239	86470	4.49
	60-79	Total	61.15	1321	37.44	1548	46.24	27361	75.92	1640	57.06	2359	59.71	35328	229.20	4951	85.96	3554	155.23	91847	154536	8.03
	80 and over	Women	194.35	223	111.99	484	117.11	41241	652.77	749	308.67	1334	359.83	19424	1634.10	1875	471.33	2037	845.96	45666	106331	5.52
	80 and over	Men	221.21	152	126.38	327	137.97	4370	659.26	453	334.69	866	365.28	11570	1864.28	1281	582.03	1506	989.77	31350	47290	2.46
	80 and over	Total	204.41	375	117.38	811	124.83	45611	655.20	1202	318.41	2200	361.85	30994	1720.31	3156	512.79	3543	899.14	77016	153621	7.98
	TOTAL							97193						75157						190025	362375	18.83
CENTRO-OESTE	20-39	Women	3.32	70	1.79	49	2.20	1096	0.33	7	0.77	21	0.49	244	1.90	40	0.33	9	0.84	419	1759	0.09
	20-39	Men	3.24	66	46.00	46	2.29	1122	0.79	16	0.62	17	0.51	249	1.62	33	0.47	13	1.13	554	1925	0.10
	20-39	Total	3.28	136	1.74	95	2.24	2218	0.55	23	0.69	38	0.50	493	1.76	73	0.40	22	0.98	973	3684	0.19
	40-59	Women	22.79	241	12.93	273	16.91	5359	5.67	60	5.50	116	4.74	1502	21.00	222	4.22	89	10.83	3433	10294	0.53
	40-59	Men	23.74	248	13.32	266	16.62	5048	8.62	90	7.61	152	6.83	2073	27.10	283	7.86	157	16.58	5035	12156	0.63
	40-59	Total	23.27	489	13.12	539	16.77	10407	7.14	150	6.52	268	5.76	3575	24.03	505	5.99	246	13.64	8468	22450	1.17
	60-79	Women	56.63	202	40.35	355	45.92	5325	36.44	130	52.28	460	43.94	5095	160.35	572	45.58	401	100.68	11674	22094	1.15
	60-79	Men	77.48	275	45.65	354	53.69	5778	64.24	228	78.27	607	62.12	6685	242.86	862	87.68	680	159.34	17148	29611	1.54
	60-79	Total	67.03	477	42.83	709	49.66	11103	50.30	358	64.46	1067	52.69	11780	201.50	1434	65.30	1081	128.92	28822	51705	2.69
	80 and over	Women	152.06	59	130.81	176	129.55	2094	304.12	118	353.78	476	276.79	4474	1023.20	397	387.22	521	673.91	10893	17461	0.91
	80 and over	Men	159.91	52	134.56	139	145.23	1878	304.45	99	363.03	375	278.17	3597	1011.75	329	522.76	540	774.41	10014	15489	0.80
	80 and over	Total	155.64	111	132.44	315	136.52	3972	304.27	217	357.80	851	277.40	8071	1017.98	726	446.09	1061	718.57	20907	32950	1.71
	TOTAL							27700						23919						59170	110789	5.76

			HEMORRHAGIC STROKE						ISCHEMIC STROKE						UNSPECIFIED STROKE						STROKE
Region	Age Group	Sex	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	2000 rate1	n	2019 rate1	n	2000-2019 rate1	n	Total sex/ Age Group
SOUTH	20-39	Women	3.09	130	1.60	75	2.02	1809	0.50	21	0.51	24	0.46	409	1.14	48	0.70	33	0.74	667	2885	0.15
	20-39	Men	2.52	104	1.38	65	1.95	1737	0.46	19	0.42	20	0.43	382	1.26	52	0.53	25	0.92	822	2941	0.15
	20-39	Total	2.81	234	1.49	140	1.98	3546	0.48	40	0.47	44	0.44	791	1.20	100	0.62	58	0.83	1489	5826	0.30
	40-59	Women	19.68	537	9.76	396	14.56	10226	5.75	157	4.61	187	4.78	3356	19.35	528	6.14	249	11.28	7926	21508	1.12
	40-59	Men	23.20	602	11.01	418	15.87	10449	8.48	220	7.66	291	7.12	4688	29.41	763	9.45	359	17.84	11747	26884	1.40
	40-59	Total	21.40	1139	10.36	814	15.19	20675	7.08	377	6.09	478	5.91	8044	24.25	1291	7.74	608	14.46	19673	48392	2.51
	60-79	Women	54.57	645	33.46	752	41.84	13481	63.79	754	44.41	998	49.59	15977	177.06	2093	64.56	1451	119.83	38608	68066	3.54
	60-79	Men	69.11	676	42.19	796	51.50	13880	90.58	886	72.13	1361	71.81	19351	292.19	2858	111.45	2103	197.55	53239	86470	4.49
	60-79	Total	61.15	1321	37.44	1548	46.24	27361	75.92	1640	57.06	2359	59.71	35328	229.20	4951	85.96	3554	155.23	91847	154536	8.03
	80 and over	Women	194.35	223	111.99	484	117.11	41241	652.77	749	308.67	1334	359.83	19424	1634.10	1875	471.33	2037	845.96	45666	106331	5.52
	80 and over	Men	221.21	152	126.38	327	137.97	4370	659.26	453	334.69	866	365.28	11570	1864.28	1281	582.03	1506	989.77	31350	47290	2.46
	80 and over	Total	204.41	375	117.38	811	124.83	45611	655.20	1202	318.41	2200	361.85	30994	1720.31	3156	512.79	3543	899.14	77016	153621	7.98
	TOTAL							97193						75157						190025	362375	18.83
MIDWEST	20-39	Women	3.32	70	1.79	49	2.20	1096	0.33	7	0.77	21	0.49	244	1.90	40	0.33	9	0.84	419	1759	0.09
	20-39	Men	3.24	66	46.00	46	2.29	1122	0.79	16	0.62	17	0.51	249	1.62	33	0.47	13	1.13	554	1925	0.10
	20-39	Total	3.28	136	1.74	95	2.24	2218	0.55	23	0.69	38	0.50	493	1.76	73	0.40	22	0.98	973	3684	0.19
	40-59	Women	22.79	241	12.93	273	16.91	5359	5.67	60	5.50	116	4.74	1502	21.00	222	4.22	89	10.83	3433	10294	0.53
	40-59	Men	23.74	248	13.32	266	16.62	5048	8.62	90	7.61	152	6.83	2073	27.10	283	7.86	157	16.58	5035	12156	0.63
	40-59	Total	23.27	489	13.12	539	16.77	10407	7.14	150	6.52	268	5.76	3575	24.03	505	5.99	246	13.64	8468	22450	1.17
	60-79	Women	56.63	202	40.35	355	45.92	5325	36.44	130	52.28	460	43.94	5095	160.35	572	45.58	401	100.68	11674	22094	1.15
	60-79	Men	77.48	275	45.65	354	53.69	5778	64.24	228	78.27	607	62.12	6685	242.86	862	87.68	680	159.34	17148	29611	1.54
	60-79	Total	67.03	477	42.83	709	49.66	11103	50.30	358	64.46	1067	52.69	11780	201.50	1434	65.30	1081	128.92	28822	51705	2.69
	80 and over	Women	152.06	59	130.81	176	129.55	2094	304.12	118	353.78	476	276.79	4474	1023.20	397	387.22	521	673.91	10893	17461	0.91
	80 and over	Men	159.91	52	134.56	139	145.23	1878	304.45	99	363.03	375	278.17	3597	1011.75	329	522.76	540	774.41	10014	15489	0.80
	80 and over	Total	155.64	111	132.44	315	136.52	3972	304.27	217	357.80	851	277.40	8071	1017.98	726	446.09	1061	718.57	20907	32950	1.71
	TOTAL							27700						23919						59170	110789	5.76

• n: The values for the period 2000-2019 are based on the total number of deaths divided by the total population throughout the period by sex and age groups. 1 Mortality rate/100,000 population.

Women accounted for 50.29% of deaths. The 60-79 age group accounted for the largest proportion of deaths (44.92%). followed by the 80 years and over group (35.59%). 40-59 age group (16.93%) and 20-39 group (2.56%). When the data were stratified by sex. the only age group in which the proportion of women was higher than the proportion of men was the 80 years and over group. Mortality was higher in the Southeast. South and Midwest (Table 1).

The results of the stratified analysis of deaths by group of causes and region over the whole study period (AAPC) revealed-general downward national trend in HS and US and-stationary trend for IS. However. when the data were stratified by period (APC). there was an increase in mortality from 2015. This increase was more pronounced in the two oldest age groups. An upward trend in IS was observed across all regions except the Northeast. US showed-significant upward trend in the North and Northeast from 2000 to 2007 in the 80 and over age group. while HS increased between 2000 and 2017 in the North and over the whole period in the Northeast in this age group (Table 2).

Table 2
Annual percent change (APC) and average annual percent change (AAPC) in standardized hemorrhagic, ischemic unspecified stroke mortality rates by age group. Brazil and regions, 2000-2019.

	HS						IS						US
Region	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value
BRAZIL	20-39	-2.8	2000	2008	-4.5	(-5.2 to -3.7) p<0.001	20-39	0.3	2000	2006	-2.8	(-4.7 to -0.8) p=0.007	20-39	-3.9	2000	2019	-3.9	(-4.3 to -3.4) p<0.001
	20-39		2008	2019	-1.5	(-1.9 to -1.0) p<0.001	20-39		2006	2019	1.8	(1.2 to 2.3) p<0.001
	40-59	-2.7	2000	2019	-2.7	(-2.9 to -2.5) p<0.001	40-59	0.1	2000	2005	-2.6	(-3.9 to -1.1) p=0.002	40-59	-5.3	2000	2012	-4.6	(-5.0 to -4.2) p<0.001
							40-59		2005	2016	-0.2	(-0.6 to 0.2) p=0.354	40-59		2012	2019	-6.5	(-7.3 to -5.6) p<0.001
							40-59		2016	2019	6.0	(2.2 to 9.9) p=0.005	60-79	-4.3	2000	2008	-1.9	(-2.3 to -1.3) p<0.001
	60-79	-1.1	2000	2004	0.8	(-1.1 to 2.8) p=0.398	60-79	0.5	2000	2016	-0.5	(-0.6 to -0.4) p<0.001	60-79		2008	2016	-5.1	(-5.6 to -4.5) p<0.001
	60-79		2004	2011	-2.5	(-3.5 to -1.4) p<0.001	60-79		2016	2019	6.4	(4.1 to 8.7) p<0.001	60-79		2016	2019	-8.5	(-1.1 to -5.9) p<0.001
	60-79		2011	2019	-0.8	(-1.5 to -0.1) p=0.020
	80 and over	-0.2	2000	2010	-1.0	(-1.5 to -0.5) p<0.001	80 and over	-0.6	2000	2004	-5.5	(-7.2 to -3.7) p<0.001	80 and over	-4.1	2000	2004	-4.7	(-6.0 to -3.2) p<0.001
							80 and over		2004	2015	-0.2	(-0.5 to 0.2) p=0.455	80 and over		2004	2007	1.7	(-4.2 to 7.9) p=0.549
	80 and over		2010	2019	0.8	(0.2 to 1.4) p=0.013	80 and over		2015	2019	3.3	(1.38 to 5.2) p=0.003	80 and over		2007	2016	-4.0	(-4.3 to -3.5) p<0.001
													80 and over		2016	2019	-9.1	(-1.1 to -6.7) p<0.001
NORTH	20-39	-1.8	2000	2003	-8.8	(-2.3 to 8.2) p=0.271	20-39	3.6	2000	2019	3.6	(2.20 to 5.1) p<0.001	20-39	-3.0	2000	2008	0.1	(-2.4 to 2.7) p=0.952
	20-39		2003	2019	-0.4	(-1.3 to 0.5) p=0.360							20-39		2008	2019	-5.2	(-6.6 to -3.6) p<0.001
	40-59	-0.8	2000	2019	-0.8	(-1.1 to -0.3) p<0.001	40-59	4.1	2000	2014	0.2	(-1.0 to 1.5) p=0.723	40-59	-5.2	2000	2014	-3.4	(-4.4 to -2.3) p<0.001
							40-59		2014	2019	15.7	(7.9 to 2.4) p<0.004	40-59		2014	2019	-10.0	(-1.4 to -4.9) p<0.001
	60-79	0.6	2000	2011	-0.7	(-1.8 to 0.3) p=0.164	60-79	4.7	2000	2013	0.3	(-1.0 to 1.8) p=0.607	60-79	-2.9	2000	2007	0.8	(-0.9 to 2.7) p=0.318
	60-79		2011	2019	2.4	(0.54 to 4.2) p=0.014	60-79		2013	2019	14.8	(9.6 to 20.2) p<0.001	60-79		2007	2015	-2.7	(-4.3 to -0.9) p=0.006
													60-79		2015	2019	-9.6	(-1.3 to -5.4) p<0.001
	80 and over	1.8	2000	2008	2.4	(1.1 to 3.7) p<0.001	80 and over	5.5	2000	2013	1.2	(-0.3 to 2.8) p=0.123	80 and over	0.7	2000	2007	5.8	(4.2 to 7.5) p<0.001
	80 and over		2008	2011	-3.8	(-1.9 to 15.4) p=0.640							80 and over		2007	2015	0.5	(-1.0 to 2.1) p=0.491
	80 and over		2011	2017	9.0	(5.9 to 12) p<0.001	80 and over		2013	2019	15.3	(9.3 to 21.5) p<0.004	80 and over		2015	2019	-7.5	(-1.0 to -3.9) p<0.001
	80 and over		2017	2019	-11.4	(-2.7 to 8.4) p=0.208
Nordeste	20-39	-0.6	2000	2008	-2.2	(-3.3--1.1) p<0.001	20-39	0.5	2000	2003	-10.2	(-1.9-0.04) p=0.051	20-39	-3.5	2000	2009	-2.5	(-3.3--1.5) p<0.001
	20-39		2008	2019	0.7	(-0.0-1.4) p=0.053	20-39		2003	2019	2.6	(2-3.2) p<0.001	20-39		2009	2012	-7.7	(-2.0-6.42) p=0.234
													20-39		2012	2015	3.6	(-1.0-19.5) p=0.585
													20-39		2015	2019	-7.6	(-1.0--4.2) p<0.001
	40-59	0.0	2000	2005	2.6	(0.9-4.3) p=0.005	40-59	1.7	2000	2004	-2.2	(-5.9-1.6) p=0.232	40-59	-4.3	2000	2007	-2.0	(-3.1--0.7) p=0.003
	40-59		2005	2019	-0.9	(-1.2--0.6) p<0.001	40-59		2004	2019	2.8	(2.3-3.3) p<0.001	40-59		2007	2019	-5.6	(-6.0--5.1) p<0.001
	60-79	0.9	2000	2005	4.0	(1.6-6.4) p=0.002	60-79	2.9	2000	2019	2.9	(2.6-3.2) p<0.001	60-79	-1.8	2000	2007	2.5	(1.2-3.8) p<0.001
	60-79		2005	2019	-0.2	(-0.6-0.2) p=0.311							60-79		2007	2019	-4.2	(-4.7--3.7) p<0.001
	80 and over	3.0	2000	2019	3.0	(2.4-3.6) p<0.001	80 and over	3.6	2000	2019	3.6	(3.3-4) p<0.001	80 and over	0.9	2000	2007	7.5	(5.0-9.9) p<0.001
													80 and over		2007	2019	-2.8	(-3.7--1.7) p<0.001
Sudeste	20-39	-4.0	2000	2008	-5.4	(-6.2--4.6) p<0.001	20-39	0.6	2000	2003	4.4	(-3.6-13) p=0.269	20-39	-4.6	2000	2019	-4.6	(-5.1--4.0) p<0.001
	20-39		2008	2016	-1.7	(-2.6--0.6) p=0.003	20-39		2003	2006	-6.1	(-2.2-13.2) p=0.477
	20-39		2016	2019	-6.3	(-1.0--1.7) p=0.012	20-39		2006	2019	1.3	(0.6-2.0) p=0.001
	40-59	-3.4	2000	2019	-3.4	(-3.5--3.1) p< 0.001	40-59	-0.2	2000	2014	-1.2	(-1.4--0.8) p<0.001	40-59	-5.8	2000	2019	-5.8	(-6.0--5.5) p<0.001
							40-59		2014	2019	2.4	(0.5-4.4) p=0.016
	60-79	-1.7	2000	2008	-1.1	(-1.7--0.4) p=0.005	60-79	-0.3	2000	2016	-0.9	(-1.0--0.6) p<0.001	60-79	-5.2	2000	2009	-3.7	(-4.1--3.2) p<0.001
	60-79		2008	2011	-4.4	(-1.2-4.3) p=0.287	60-79		2016	2019	3.0	(-0.5-6.7) p=0.094	60-79		2009	2019	-6.5	(-6.8--6.0) p<0.001
	60-79		2011	2019	-1.3	(-2.0--0.6) p<0.001
	80 and over	-2.2	2000	2003	-6.7	(-1.0--3.1) p=0.002	80 and over	-2.6	2000	2002	-12.6	(-1.8--6.2) p=0.002	80 and over	-6.4	2000	2004	-10.3	(-1.2--7.9) p<0.001
	80 and over		2003	2007	-2.8	(-6.1-0.6) p=0.092	80 and over		2002	2005	-5.2	(-1.1-1.5) p=0.112	80 and over		2004	2009	-3.2	(-5.7--0.6) p=0.018
	80 and over		2007	2017	-0.3	(-0.8-0.2) p=0.159	80 and over		2005	2016	-1.1	(-1.5--0.6) p<0.001	80 and over		2009	2019	-6.3	(-6.8--5.6) p<0.001
	80 and over		2017	2019	-3.4	(-1.3-7.3) p=0.472	80 and over		2016	2019	1.9	(-1.3-5.2) p=0.222
Sul	20-39	-3.8	2000	2009	-5.5	(-7.0--3.9) p<0.001	20-39	0.2	2000	2019	0.2	(-0.6-1.2) p=0.579	20-39	-3.4	2000	2019	-3.4	(-4.0--2.7) p<0.001
	20-39		2009	2019	-2.1	(-3.5--0.7) p=0.006
	40-59	-3.7	2000	2003	1.0	(-3.7-5.9) p=0.662	40-59	-0.9	2000	2007	-4.1	(-6.1--2.1) p=0.001	40-59	-5.8	2000	2005	-6.5	(-8.2--4.7) p<0.001
	40-59		2003	2006	-8.0	(-1.6-1.9) p=0.100	40-59		2007	2010	3.6	(-1.3-24.4) p=0.675	40-59		2005	2016	-3.7	(-4.3--3.1) p<0.001
	40-59		2006	2019	-3.8	(-4.2--3.3) p< 0.001	40-59		2010	2016	-4.0	(-7.3--0.5) p=0.028	40-59		2016	2019	-12.1	(-1.6--7.8) p<0.001
							40-59		2016	2019	8.9	(0.1-18.5) p=0.049
	60-79	-2.7	2000	2004	-0.9	(-3.8-2.2) p=0.533	60-79	-1.2	2000	2011	-2.0	(-2.3--1.5) p<0.001	60-79	-5.2	2000	2008	-2.9	(-3.3--2.3) p<0.001
	60-79		2004	2011	-4.9	(-6.3--3.4) p<0.001	60-79		2011	2015	-6.7	(-1.0--3.1) p=0.002	60-79		2008	2016	-4.7	(-5.2--4.0) p<0.001
	60-79		2011	2019	-1.6	(-2.5--0.6) p<0.001	60-79		2015	2019	6.8	(4.5-9.2) p<0.001	60-79		2016	2019	-12.8	(-1.5--1.0) p<0.001
	80 and over	-3.2	2000	2002	-12.8	(-2.4-0.4) p=0.056	80 and over	-3.0	2000	2006	-7.8	(-9.6--5.9) p<0.001	80 and over	-6.4	2000	2004	-9.3	(-1.0--7.7) p<0.001
	80 and over		2002	2012	-4.1	(-4.8--3.4) p<0.001	80 and over		2006	2011	-0.1	(-3.8-3.9) p=0.962	80 and over		2004	2010	-2.4	(-3.4--1.3) p<0.001
	80 and over		2012	2019	1.2	(0.1-2.3) p=0.032	80 and over		2011	2015	-6.2	(-1.2-0.2) p=0.057	80 and over		2010	2016	-5.3	(-6.2--4.2) p<0.001
							80 and over		2015	2019	4.3	(0.3-8.5) p=0.039	80 and over		2016	2019	-12.0	(-1.4--9.4) p<0.001
Centro-Oeste	20-39	-2.9	2000	2012	-4.7	(-6.0--3.3) p<0.001	20-39	0.9	2000	2012	-4.0	(-5.7--2.2) p<0.001	20-39	-7.1	2000	2015	-4.3	(-5.5--3.0) p<0.001
	20-39		2012	2019	0.1	(-3.1-3.5) p=0.939	20-39		2012	2019	9.8	(5.2-14.7) p<0.001	20-39		2015	2019	-16.9	(-2.5--6.7) p=0.004
	40-59	-2.9	2000	2019	-2.9	(-3.2--2.5) p<0.001	40-59	-0.5	2000	2014	-3.3	(-4.0--2.6) p<0.001	40-59	-7.5	2000	2016	-5.5	(-5.8--5.0) p<0.001
							40-59		2014	2019	8.0	(4.1-12.1) p<0.001	40-59		2016	2019	-17.4	(-2.3--1.1) p<0.001
	60-79	-1.6	2000	2019	-1.6	(-2.1--1.1) p<0.001	60-79	2.0	2000	2004	4.4	(-2.6-11.8) p=0.204	60-79	-6.2	2000	2015	-3.9	(-4.3--3.5) p<0.001
							60-79		2004	2014	-2.9	(-4.6--1.1) p=0.003	60-79		2015	2019	-14.1	(-1.7--1.0) p<0.001
							60-79		2014	2019	10.7	(5.6-15.9) p<0.001
	80 and over	0.3	2000	2019	0.3	(-0.1-0.7) p=0.183	80 and over	1.7	2000	2013	-2.1	(-3.1--1.1) p<0.001	80 and over	-5.0	2000	2015	-2.9	(-3.2--2.4) p<0.001
							80 and over		2013	2019	10.5	(6.6-14.4) p<0.001	80 and over		2015	2019	-12.6	(-1.5--9.3) p<0.001

	HS						IS						US
Region	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value
NORTHEAST	20-39	-0.6	2000	2008	-2.2	(-3.3 to -1.1) p<0.001	20-39	0.5	2000	2003	-10.2	(-1.9 to 0.04) p=0.051	20-39	-3.5	2000	2009	-2.5	(-3.3 to -1.5) p<0.001
	20-39		2008	2019	0.7	(-0.0 to 1.4) p=0.053	20-39		2003	2019	2.6	(2 to 3.2) p<0.001	20-39		2009	2012	-7.7	(-2.0 to 6.42) p=0.234
													20-39		2012	2015	3.6	(-1.0 to 19.5) p=0.585
													20-39		2015	2019	-7.6	(-1.0 to -4.2) p<0.001
	40-59	0.0	2000	2005	2.6	(0.9 to 4.3) p=0.005	40-59	1.7	2000	2004	-2.2	(-5.9 to 1.6) p=0.232	40-59	-4.3	2000	2007	-2.0	(-3.1 to -0.7) p=0.003
	40-59		2005	2019	-0.9	(-1.2 to -0.6) p<0.001	40-59		2004	2019	2.8	(2.3 to 3.3) p<0.001	40-59		2007	2019	-5.6	(-6.0 to -5.1) p<0.001
	60-79	0.9	2000	2005	4.0	(1.6 to 6.4) p=0.002	60-79	2.9	2000	2019	2.9	(2.6 to 3.2) p<0.001	60-79	-1.8	2000	2007	2.5	(1.2 to 3.8) p<0.001
	60-79		2005	2019	-0.2	(-0.6 to 0.2) p=0.311							60-79		2007	2019	-4.2	(-4.7 to -3.7) p<0.001
	80 and over	3.0	2000	2019	3.0	(2.4 to 3.6) p<0.001	80 and over	3.6	2000	2019	3.6	(3.3 to 4) p<0.001	80 and over	0.9	2000	2007	7.5	(5.0 to 9.9) p<0.001
													80 and over		2007	2019	-2.8	(-3.7 to -1.7) p<0.001
SOUTHEAST	20-39	-4.0	2000	2008	-5.4	(-6.2 to -4.6) p<0.001	20-39	0.6	2000	2003	4.4	(-3.6 to 13) p=0.269	20-39	-4.6	2000	2019	-4.6	(-5.1 to -4.0) p<0.001
	20-39		2008	2016	-1.7	(-2.6 to -0.6) p=0.003	20-39		2003	2006	-6.1	(-2.2 to 13.2) p=0.477
	20-39		2016	2019	-6.3	(-1.0 to -1.7) p=0.012	20-39		2006	2019	1.3	(0.6 to 2.0) p=0.001
	40-59	-3.4	2000	2019	-3.4	(-3.5 to -3.1) p<0.001	40-59	-0.2	2000	2014	-1.2	(-1.4 to -0.8) p<0.001	40-59	-5.8	2000	2019	-5.8	(-6.0 to -5.5) p<0.001
							40-59		2014	2019	2.4	(0.5 to 4.4) p=0.016
	60-79	-1.7	2000	2008	-1.1	(-1.7 to -0.4) p=0.005	60-79	-0.3	2000	2016	-0.9	(-1.0 to -0.6) p<0.001	60-79	-5.2	2000	2009	-3.7	(-4.1 to -3.2) p<0.001
	60-79		2008	2011	-4.4	(-1.2 to 4.3) p=0.287	60-79		2016	2019	3.0	(-0.5 to 6.7) p=0.094	60-79		2009	2019	-6.5	(-6.8 to -6.0) p<0.001
	60-79		2011	2019	-1.3	(-2.0 to -0.6) p<0.001
	80 and over	-2.2	2000	2003	-6.7	(-1.0 to -3.1) p=0.002	80 and over	-2.6	2000	2002	-12.6	(-1.8 to -6.2) p=0.002	80 and over	-6.4	2000	2004	-10.3	(-1.2 to -7.9) p<0.001
	80 and over		2003	2007	-2.8	(-6.1 to 0.6) p=0.092	80 and over		2002	2005	-5.2	(-1.1 to 1.5) p=0.112	80 and over		2004	2009	-3.2	(-5.7 to -0.6) p=0.018
	80 and over		2007	2017	-0.3	(-0.8 to 0.2) p=0.159	80 and over		2005	2016	-1.1	(-1.5 to -0.6) p<0.001	80 and over		2009	2019	-6.3	(-6.8 to -5.6) p<0.001
	80 and over		2017	2019	-3.4	(-1.3 to 7.3) p=0.472	80 and over		2016	2019	1.9	(-1.3 to 5.2) p=0.222
Sul	20-39	-3.8	2000	2009	-5.5	(-7.0--3.9) p<0.001	20-39	0.2	2000	2019	0.2	(-0.6-1.2) p=0.579	20-39	-3.4	2000	2019	-3.4	(-4.0--2.7) p<0.001
	20-39		2009	2019	-2.1	(-3.5--0.7) p=0.006
	40-59	-3.7	2000	2003	1.0	(-3.7-5.9) p=0.662	40-59	-0.9	2000	2007	-4.1	(-6.1--2.1) p=0.001	40-59	-5.8	2000	2005	-6.5	(-8.2--4.7) p<0.001
	40-59		2003	2006	-8.0	(-1.6-1.9) p=0.100	40-59		2007	2010	3.6	(-1.3-24.4) p=0.675	40-59		2005	2016	-3.7	(-4.3--3.1) p<0.001
	40-59		2006	2019	-3.8	(-4.2--3.3) p< 0.001	40-59		2010	2016	-4.0	(-7.3--0.5) p=0.028	40-59		2016	2019	-12.1	(-1.6--7.8) p<0.001
							40-59		2016	2019	8.9	(0.1-18.5) p=0.049
	60-79	-2.7	2000	2004	-0.9	(-3.8-2.2) p=0.533	60-79	-1.2	2000	2011	-2.0	(-2.3--1.5) p<0.001	60-79	-5.2	2000	2008	-2.9	(-3.3--2.3) p<0.001
	60-79		2004	2011	-4.9	(-6.3--3.4) p<0.001	60-79		2011	2015	-6.7	(-1.0--3.1) p=0.002	60-79		2008	2016	-4.7	(-5.2--4.0) p<0.001
	60-79		2011	2019	-1.6	(-2.5--0.6) p<0.001	60-79		2015	2019	6.8	(4.5-9.2) p<0.001	60-79		2016	2019	-12.8	(-1.5--1.0) p<0.001
	80 and over	-3.2	2000	2002	-12.8	(-2.4-0.4) p=0.056	80 and over	-3.0	2000	2006	-7.8	(-9.6--5.9) p<0.001	80 and over	-6.4	2000	2004	-9.3	(-1.0--7.7) p<0.001
	80 and over		2002	2012	-4.1	(-4.8--3.4) p<0.001	80 and over		2006	2011	-0.1	(-3.8-3.9) p=0.962	80 and over		2004	2010	-2.4	(-3.4--1.3) p<0.001
	80 and over		2012	2019	1.2	(0.1-2.3) p=0.032	80 and over		2011	2015	-6.2	(-1.2-0.2) p=0.057	80 and over		2010	2016	-5.3	(-6.2--4.2) p<0.001
							80 and over		2015	2019	4.3	(0.3-8.5) p=0.039	80 and over		2016	2019	-12.0	(-1.4--9.4) p<0.001
Centro-Oeste	20-39	-2.9	2000	2012	-4.7	(-6.0--3.3) p<0.001	20-39	0.9	2000	2012	-4.0	(-5.7--2.2) p<0.001	20-39	-7.1	2000	2015	-4.3	(-5.5--3.0) p<0.001
	20-39		2012	2019	0.1	(-3.1-3.5) p=0.939	20-39		2012	2019	9.8	(5.2-14.7) p<0.001	20-39		2015	2019	-16.9	(-2.5--6.7) p=0.004
	40-59	-2.9	2000	2019	-2.9	(-3.2--2.5) p<0.001	40-59	-0.5	2000	2014	-3.3	(-4.0--2.6) p<0.001	40-59	-7.5	2000	2016	-5.5	(-5.8--5.0) p<0.001
							40-59		2014	2019	8.0	(4.1-12.1) p<0.001	40-59		2016	2019	-17.4	(-2.3--1.1) p<0.001
	60-79	-1.6	2000	2019	-1.6	(-2.1--1.1) p<0.001	60-79	2.0	2000	2004	4.4	(-2.6-11.8) p=0.204	60-79	-6.2	2000	2015	-3.9	(-4.3--3.5) p<0.001
							60-79		2004	2014	-2.9	(-4.6--1.1) p=0.003	60-79		2015	2019	-14.1	(-1.7--1.0) p<0.001
							60-79		2014	2019	10.7	(5.6-15.9) p<0.001
	80 and over	0.3	2000	2019	0.3	(-0.1-0.7) p=0.183	80 and over	1.7	2000	2013	-2.1	(-3.1--1.1) p<0.001	80 and over	-5.0	2000	2015	-2.9	(-3.2--2.4) p<0.001
							80 and over		2013	2019	10.5	(6.6-14.4) p<0.001	80 and over		2015	2019	-12.6	(-1.5--9.3) p<0.001

	HS						IS						US
Region	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value	Age Group	AAPC	PERIOD		APC	CI/p-value
													80 and over		2007	2019	-2.8	(-3.7 to -1.7) p<0.001
SOUTH	20-39	-3.8	2000	2009	-5.5	(-7.0 to -3.9) p<0.001	20-39	0.2	2000	2019	0.2	(-0.6 to 1.2) p=0.579	20-39	-3.4	2000	2019	-3.4	(-4.0 to -2.7) p<0.001
	20-39		2009	2019	-2.1	(-3.5 to -0.7) p=0.006
	40-59	-3.7	2000	2003	1.0	(-3.7 to 5.9) p=0.662	40-59	-0.9	2000	2007	-4.1	(-6.1 to -2.1) p=0.001	40-59	-5.8	2000	2005	-6.5	(-8.2 to -4.7) p<0.001
	40-59		2003	2006	-8.0	(-1.6 to 1.9) p=0.100	40-59		2007	2010	3.6	(-1.3 to 24.4) p=0.675	40-59		2005	2016	-3.7	(-4.3 to -3.1) p<0.001
	40-59		2006	2019	-3.8	(-4.2 to -3.3) p<0.001	40-59		2010	2016	-4.0	(-7.3 to -0.5) p=0.028	40-59		2016	2019	-12.1	(-1.6 to -7.8) p<0.001
							40-59		2016	2019	8.9	(0.1 to 18.5) p=0.049
	60-79	-2.7	2000	2004	-0.9	(-3.8 to 2.2) p=0.533	60-79	-1.2	2000	2011	-2.0	(-2.3 to -1.5) p<0.001	60-79	-5.2	2000	2008	-2.9	(-3.3 to -2.3) p<0.001
	60-79		2004	2011	-4.9	(-6.3 to -3.4) p<0.001	60-79		2011	2015	-6.7	(-1.0 to -3.1) p=0.002	60-79		2008	2016	-4.7	(-5.2 to -4.0) p<0.001
	60-79		2011	2019	-1.6	(-2.5 to -0.6) p<0.001	60-79		2015	2019	6.8	(4.5 to 9.2) p<0.001	60-79		2016	2019	-12.8	(-1.5 to -1.0) p<0.001
	80 and over	-3.2	2000	2002	-12.8	(-2.4 to 0.4) p=0.056	80 and over	-3.0	2000	2006	-7.8	(-9.6 to -5.9) p<0.001	80 and over	-6.4	2000	2004	-9.3	(-1.0 to -7.7) p<0.001
	80 and over		2002	2012	-4.1	(-4.8 to -3.4) p<0.001	80 and over		2006	2011	-0.1	(-3.8 to 3.9) p=0.962	80 and over		2004	2010	-2.4	(-3.4 to -1.3) p<0.001
	80 and over		2012	2019	1.2	(0.1 to 2.3) p=0.032	80 and over		2011	2015	-6.2	(-1.2 to 0.2) p=0.057	80 and over		2010	2016	-5.3	(-6.2 to -4.2) p<0.001
							80 and over		2015	2019	4.3	(0.3 to 8.5) p=0.039	80 and over		2016	2019	-12.0	(-1.4 to -9.4) p<0.001
MIDWEST	20-39	-2.9	2000	2012	-4.7	(-6.0 to -3.3) p<0.001	20-39	0.9	2000	2012	-4.0	(-5.7 to -2.2) p<0.001	20-39	-7.1	2000	2015	-4.3	(-5.5 to -3.0) p<0.001
	20-39		2012	2019	0.1	(-3.1 to 3.5) p=0.939	20-39		2012	2019	9.8	(5.2 to 14.7) p<0.001	20-39		2015	2019	-16.9	(-2.5 to -6.7) p=0.004
	40-59	-2.9	2000	2019	-2.9	(-3.2 to -2.5) p<0.001	40-59	-0.5	2000	2014	-3.3	(-4.0 to -2.6) p<0.001	40-59	-7.5	2000	2016	-5.5	(-5.8 to -5.0) p<0.001
							40-59		2014	2019	8.0	(4.1 to 12.1) p<0.001	40-59		2016	2019	-17.4	(-2.3 to -1.1) p<0.001
	60-79	-1.6	2000	2019	-1.6	(-2.1 to -1.1) p<0.001	60-79	2.0	2000	2004	4.4	(-2.6 to 11.8) p=0.204	60-79	-6.2	2000	2015	-3.9	(-4.3 to -3.5) p<0.001
							60-79		2004	2014	-2.9	(-4.6 to -1.1) p=0.003	60-79		2015	2019	-14.1	(-1.7 to -1.0) p<0.001
							60-79		2014	2019	10.7	(5.6 to 15.9) p<0.001
	80 and over	0.3	2000	2019	0.3	(-0.1 to 0.7) p=0.183	80 and over	1.7	2000	2013	-2.1	(-3.1 to -1.1) p<0.001	80 and over	-5.0	2000	2015	-2.9	(-3.2 to -2.4) p<0.001
							80 and over		2013	2019	10.5	(6.6 to 14.4) p<0.001	80 and over		2015	2019	-12.6	(-1.5 to -9.3) p<0.001

• *Statistical significance (p<0.05). Mortality rate/100,000 population. AAPC: Average Annual Percent Change; APC: Annual Percent Change

The largest reductions in IS and HS mortality were found in the below 60-year age group. In contrast. the oldest age group showed an increase in mortality rates in the North and Northeast.-stationary trend in the Midwest and downward trend in the South and Southeast. The US mortality rate showed-downward trend across all age groups in the Midwest. Southeast and South. In contrast. in the 80 and over age group there was-substantial increase in rates in the states of Amazonas. Maranhão. Piauí. Paraíba. Alagoas and Sergipe (Figure 1).

Figura 1
AAPC das rates de mortalidade padronizada por DCBV hemorrágica. isquêmica e não especificada. segundo faixa etária. nas UF. para o período de 2000-2019.

The results of the analysis of the socioeconomic development indicators showed that AAPC for MHDI represented an increase across all states. The largest increase occurred in the North and Northeast. The dimension with the largest AAPC was education. The state with the highest MHDI in 2019 was the Federal District (0.86) (Table 3).

Table 3
Average annual percent change (AAPC) and absolute SVI and MHDI and their dimensions by state in 2000 and 2019.

STATE	YEAR	AAPC	SVI	AAPC	SVI ICOME	AAPC	SVI INFRA	AAPC	SVI CAPITAL	AAPC	MHDI	AAPC	MHDI INCOME	AAPC	MHDI LONG	AAPC	MHDI EDU
RONDÔNIA	2000	-4.59	0.49	-2.08	0.40	-9.10	0.61	-4.75	0.47	1.62	0.54	0.33	0.69	0.98	0.35	3.66	0.65
	2019		0.18		0.06		0.22		0.26		0.75		0.85		0.70		0.72
ACRE	2000	-2.08	0.61	-1.01	0.54	-1.69	0.74	-4.37	0.53	1.75	0.52	0.40	0.69	0.82	0.33	3.96	0.61
	2019		0.36		0.35		0.32		0.40		0.74		0.82		0.73		0.68
AMAZONAS	2000	-3.20	0.66	-1.63	0.66	-4.07	0.71	-5.01	0.60	1.78	0.52	0.39	0.69	0.80	0.32	4.20	0.61
	2019		0.33		0.34		0.27		0.37		0.74		0.83		0.74		0.67
RORAIMA	2000	-3.19	0.46	-1.84	0.37	-2.56	0.55	-4.56	0.46	1.22	0.60	0.39	0.72	0.71	0.46	2.56	0.65
	2019		0.27		0.24		0.26		0.33		0.77		0.83		0.77		0.70
PARÁ	2000	-3.79	0.62	-1.54	0.64	-5.74	0.64	-4.52	0.57	1.66	0.52	0.49	0.73	0.63	0.32	3.98	0.60
	2019		0.29		0.21		0.28		0.37		0.72		0.83		0.69		0.66
AMAPÁ	2000	-3.80	0.54	-0.58	0.53	-12.25	0.58	-3.99	0.50	1.19	0.58	0.24	0.71	0.66	0.42	2.61	0.64
	2019		0.23		0.06		0.26		0.39		0.74		0.83		0.73		0.67
TOCANTINS	2000	-3.92	0.55	-2.87	0.42	-3.11	0.62	-5.12	0.61	1.79	0.53	0.63	0.69	0.72	0.35	3.73	0.61
	2019		0.25		0.18		0.24		0.33		0.76		0.83		0.73		0.70
MARANHÃO	2000	-3.19	0.68	-1.54	0.69	-4.74	0.70	-4.16	0.66	1.88	0.48	0.72	0.65	0.99	0.31	4.09	0.53
	2019		0.35		0.26		0.33		0.45		0.71		0.81		0.70		0.62
PIAUÍ	2000	-3.14	0.55	-1.94	0.38	-5.08	0.64	-4.02	0.63	1.93	0.48	0.88	0.68	0.81	0.30	4.19	0.56
	2019		0.28		0.13		0.30		0.41		0.72		0.81		0.68		0.67
CEARÁ	2000	-3.27	0.53	-2.80	0.37	-4.39	0.60	-3.98	0.63	1.60	0.54	0.71	0.71	0.67	0.38	3.39	0.59
	2019		0.26		0.17		0.28		0.34		0.75		0.83		0.73		0.69
RIO GRANDE DO NORTE	2000	-3.04	0.51	-1.67	0.33	-2.62	0.59	-4.02	0.61	1.44	0.55	0.64	0.70	0.83	0.40	2.72	0.61
	2019		0.29		0.21		0.28		0.37		0.74		0.83		0.68		0.71
PARAÍBA	2000	-2.18	0.53	-2.12	0.30	-1.32	0.63	-3.66	0.66	1.73	0.51	0.75	0.67	0.90	0.33	3.36	0.58
	2019		0.32		0.21		0.31		0.43		0.72		0.82		0.66		0.68
PERNAMBUCO	2000	-2.57	0.56	-1.30	0.41	-1.26	0.64	-4.32	0.64	1.54	0.54	0.50	0.71	0.73	0.37	3.33	0.62
	2019		0.33		0.29		0.29		0.40		0.74		0.82		0.72		0.69
ALAGOAS	2000	-2.95	0.61	-1.45	0.39	-3.75	0.75	-3.94	0.68	1.96	0.47	0.55	0.65	0.93	0.28	4.31	0.57
	2019		0.33		0.20		0.36		0.43		0.70		0.81		0.65		0.64
SERGIPE	2000	-2.75	0.53	-1.02	0.36	-4.36	0.63	-3.89	0.60	1.60	0.52	0.62	0.68	0.87	0.34	3.23	0.60
	2019		0.30		0.16		0.30		0.43		0.72		0.82		0.65		0.69
BAHIA	2000	-3.10	0.55	-1.43	0.37	-4.72	0.63	-4.09	0.67	1.70	0.51	0.61	0.68	0.90	0.33	3.53	0.59
	2019		0.28		0.15		0.27		0.42		0.72		0.83		0.67		0.68
MINAS GERAIS	2000	-3.19	0.40	-2.32	0.28	-3.58	0.46	-4.66	0.47	1.13	0.62	0.41	0.76	0.55	0.47	2.46	0.68
	2019		0.20		0.13		0.19		0.27		0.79		0.86		0.76		0.75
ESPÍRITO SANTO	2000	-2.95	0.40	-2.30	0.27	-2.39	0.46	-4.47	0.45	0.99	0.64	0.36	0.78	0.47	0.49	2.05	0.69
	2019		0.21		0.18		0.19		0.25		0.78		0.86		0.73		0.76
RIO DE JANEIRO	2000	-1.89	0.41	-1.35	0.45	-0.55	0.39	-4.74	0.39	1.07	0.66	0.35	0.74	0.79	0.53	2.01	0.75
	2019		0.28		0.40		0.16		0.27		0.82		0.88		0.78		0.80
SÃO PAULO	2000	-2.23	0.39	-1.90	0.41	-1.41	0.37	-5.03	0.38	0.88	0.70	0.36	0.79	0.45	0.58	1.86	0.76
	2019		0.23		0.33		0.15		0.22		0.84		0.88		0.84		0.81
PARANÁ	2000	-3.14	0.37	-3.30	0.25	-2.30	0.43	-4.83	0.42	1.00	0.65	0.44	0.75	0.51	0.52	1.94	0.70
	2019		0.18		0.16		0.17		0.20		0.80		0.87		0.76		0.78
SANTA CATARINA	2000	-3.99	0.29	-3.93	0.15	-0.81	0.37	-4.92	0.36	0.91	0.67	0.40	0.81	0.33	0.53	1.99	0.72
	2019		0.13		0.10		0.14		0.14		0.82		0.89		0.78		0.79
RIO GRANDE DO SUL	2000	-1.98	0.33	-2.74	0.20	2.16	0.40	-4.80	0.39	0.99	0.66	0.46	0.80	0.49	0.51	1.94	0.72
	2019		0.20		0.24		0.16		0.20		0.80		0.89		0.73		0.80
MATO GROSO DO SUL	2000	-4.35	0.42	-2.70	0.29	-4.67	0.51	-4.91	0.46	1.17	0.61	0.41	0.75	0.60	0.45	2.47	0.69
	2019		0.18		0.14		0.19		0.21		0.78		0.86		0.73		0.76
MATO GROSSO	2000	-3.33	0.43	-3.11	0.32	-1.15	0.52	-4.90	0.44	1.28	0.60	0.36	0.74	0.49	0.43	2.90	0.69
	2019		0.22		0.23		0.21		0.21		0.78		0.85		0.75		0.75
GOIÁS	2000	-2.99	0.46	-2.54	0.46	-2.54	0.48	-4.46	0.44	1.18	0.62	0.32	0.77	0.46	0.44	2.80	0.69
	2019		0.24		0.27		0.20		0.25		0.78		0.86		0.76		0.74
DISTRITO FEDERAL	2000	-1.91	0.38	-2.18	0.43	-0.18	0.38	-4.71	0.34	0.81	0.73	0.23	0.81	0.43	0.58	1.72	0.81
	2019		0.26		0.40		0.17		0.21		0.86		0.90		0.83		0.86

STATE	YEAR	AAPC	SVI	AAPC	SVI ICOME	AAPC	SVI INFRA	AAPC	SVI CAPITAL	AAPC	MHDI	AAPC	MHDI INCOME	AAPC	MHDI LONG	AAPC	MHDI EDU
ALAGOAS	2000	-2.95	0.61	-1.45	0.39	-3.75	0.75	-3.94	0.68	1.96	0.47	0.55	0.65	0.93	0.28	4.31	0.57
	2019		0.33		0.20		0.36		0.43		0.70		0.81		0.65		0.64
SERGIPE	2000	-2.75	0.53	-1.02	0.36	-4.36	0.63	-3.89	0.60	1.60	0.52	0.62	0.68	0.87	0.34	3.23	0.60
	2019		0.30		0.16		0.30		0.43		0.72		0.82		0.65		0.69
BAHIA	2000	-3.10	0.55	-1.43	0.37	-4.72	0.63	-4.09	0.67	1.70	0.51	0.61	0.68	0.90	0.33	3.53	0.59
	2019		0.28		0.15		0.27		0.42		0.72		0.83		0.67		0.68
MINAS GERAIS	2000	-3.19	0.40	-2.32	0.28	-3.58	0.46	-4.66	0.47	1.13	0.62	0.41	0.76	0.55	0.47	2.46	0.68
	2019		0.20		0.13		0.19		0.27		0.79		0.86		0.76		0.75
ESPÍRITO SANTO	2000	-2.95	0.40	-2.30	0.27	-2.39	0.46	-4.47	0.45	0.99	0.64	0.36	0.78	0.47	0.49	2.05	0.69
	2019		0.21		0.18		0.19		0.25		0.78		0.86		0.73		0.76
RIO DE JANEIRO	2000	-1.89	0.41	-1.35	0.45	-0.55	0.39	-4.74	0.39	1.07	0.66	0.35	0.74	0.79	0.53	2.01	0.75
	2019		0.28		0.40		0.16		0.27		0.82		0.88		0.78		0.80
SÃO PAULO	2000	-2.23	0.39	-1.90	0.41	-1.41	0.37	-5.03	0.38	0.88	0.70	0.36	0.79	0.45	0.58	1.86	0.76
	2019		0.23		0.33		0.15		0.22		0.84		0.88		0.84		0.81
PARANÁ	2000	-3.14	0.37	-3.30	0.25	-2.30	0.43	-4.83	0.42	1.00	0.65	0.44	0.75	0.51	0.52	1.94	0.70
	2019		0.18		0.16		0.17		0.20		0.80		0.87		0.76		0.78
SANTA CATARINA	2000	-3.99	0.29	-3.93	0.15	-0.81	0.37	-4.92	0.36	0.91	0.67	0.40	0.81	0.33	0.53	1.99	0.72
	2019		0.13		0.10		0.14		0.14		0.82		0.89		0.78		0.79
RIO GRANDE DO SUL	2000	-1.98	0.33	-2.74	0.20	2.16	0.40	-4.80	0.39	0.99	0.66	0.46	0.80	0.49	0.51	1.94	0.72
	2019		0.20		0.24		0.16		0.20		0.80		0.89		0.73		0.80
MATO GROSO DO SUL	2000	-4.35	0.42	-2.70	0.29	-4.67	0.51	-4.91	0.46	1.17	0.61	0.41	0.75	0.60	0.45	2.47	0.69
	2019		0.18		0.14		0.19		0.21		0.78		0.86		0.73		0.76
MATO GROSSO	2000	-3.33	0.43	-3.11	0.32	-1.15	0.52	-4.90	0.44	1.28	0.60	0.36	0.74	0.49	0.43	2.90	0.69
	2019		0.22		0.23		0.21		0.21		0.78		0.85		0.75		0.75
GOIÁS	2000	-2.99	0.46	-2.54	0.46	-2.54	0.48	-4.46	0.44	1.18	0.62	0.32	0.77	0.46	0.44	2.80	0.69
	2019		0.24		0.27		0.20		0.25		0.78		0.86		0.76		0.74
DISTRITO FEDERAL	2000	-1.91	0.38	-2.18	0.43	-0.18	0.38	-4.71	0.34	0.81	0.73	0.23	0.81	0.43	0.58	1.72	0.81
	2019		0.26		0.40		0.17		0.21		0.86		0.90		0.83		0.86

• AAPC: Average Annual Percent Change. APC: Annual Percent Change. SVI: social vulnerability index. MHDI: municipal human development index. Infra: infrastructure. Long: longevity. Edu: education

AAPC for SVI represented-decrease across all regions. The largest negative AAPC was found in Rondônia (-4.59%). followed by Mato Grosso do Sul (-4.35%) and Santa Catarina (-3.99%). The lowest AAPC in 2019 were found in states in the Southeast. South and Midwest. The SVI dimension with the largest negative AAPC was urban infrastructure. with values of -12.25% in Amapá and -9.1% in Rondônia (Table 3).

The findings show-strong positive correlation between trends in MHDI over the study period (AAPC) and trends in HS mortality in the 40-59-year age group and above and trends in IS mortality in the 80 years and over age group. All the dimensions of the MHDI showed-similar positive correlation. except for income. which did not show any correlation with IS. US mortality showed-strong positive correlation with MHDI across all its dimensions (Table 4).

Table 4
Correlation between AAPC for stroke type mortality rate and AAPC for MHDI. SVI and their dimensions by age group. Brazil. 2000-2019.

AGE GROUP	TYPE	INDICATORS
		SVI	SVI INCOME	SVI CAPITAL	SVI INFRA	MHDI	MHDI INCOME	MHDI EDU	MHDI LONG
20-39	HEMORRHAGIC	-0.331 (P=0.092)1	0.109 (P= 0.591)1	0.312 (P=0.113)1	-0.490 (P=0.01)2	0.438 (P=0.022)1	0.329 (P= 0.094)1	0.438 (P=0.022)1	0.350 (P=0.073)1
	ISCHEMIC	0.108 (P=0.591)2	-0.157 (P=0.431)2	-0.017 (P=0.933)2	0.034 (P=0.866)2	0.321 (P=0.103)2	0.186 (P= 0.351)2	0.308 (P=0.118)2	0.161 (P=0.421)2
	UNSPECIFIED	0.134 (P=0.503)2	0.441 (P= 0.022)2	0.192 (P=0.335)2	-0.114 (P=0.569)2	0.189 (P=0.343)2	0.221 (P= 0.267)2	0.151 (P=0.449)2	0.167 (P=0.402)2
40-59	HEMORRHAGIC	-0.183 (P=0.359)2	0.275 (P= 0.164)2	0.399 (P=0.041)2	-0.487 (P=0.011)2	0.8907 (P<0.001)2	0.565 (P= 0.003)2	0.867 (P<0.001)2	0.797 (P=0.001)2
	ISCHEMIC	-0.130 (P=0.517)1	0.143 (P= 0.477)1	0.142 (P=0.479)1	-0.246 (P=0.215)2	0.531 (P=0.004)1	0.192 (P= 0.339)1	0.531 (P=0.004)1	0.408 (P=0.035)1
	UNSPECIFIED	0.033 (P=0.872)1	0.404 (P= 0.037)1	0.399 (P=0.039)1	-0.445 (P=0.021)2	0.459 (P=0.015)1	0.507 (P= 0.007)1	0.436 (P=0.023)1	0.389 (P=0.045)1
60-79	HEMORRHAGIC	-0.327 (P=0.095)2	0.363 (P= 0.064)2	0.479 (P=0.012)2	-0.663 (P<0.001)2	0.766 (P<0.001)2	0.393 (P= 0.043)2	0.736 (P<0.001)2	0.700 (P<0.001)2
	ISCHEMIC	-0.194 (P=0.332)1	0.329 (P= 0.094)1	0.251 (P=0.207)1	-0.340 (P=0.083)2	0.458 (P=0.016)1	0.069 (P= 0.729)1	0.451 (P=0.018)1	0.432 (P=0.025)1
	UNSPECIFIED	0.063 (P=0.754)1	0.526 (P= 0.005)1	0.643 (P<0.001)1	-0.412 (P=0.033)2	0.725 (P<0.001)1	0.665 (P<0.001)1	0.679 (P<0.001)1	0.658 (P<0.001)1
80 and over	HEMORRHAGIC	- 0.258 (P=0.194)1	0.461 (P= 0.015)1	0.575 (P=0.002)1	-0.630 (P<0.001)2	0.713 (P<0.001)1	0.448 (P= 0.019)1	0.669 (P<0.001)1	0.760 (P<0.001)1
	ISCHEMIC	-0.123 (P=0.539)1	0.331 (P= 0.092)1	0.239 (P=0.231)1	-0.459 (P=0.017)2	0.686 (P<0.001)1	0.281 (P= 0.156)1	0.692 (P<0.001)1	0.539 (P=0.004)1
	UNSPECIFIED	-0.144 (P=0.469)2	0.459 (P= 0.017)2	0.567 (P=0.002)2	-0.616 (P<0.001)2	0.905 (P<0.001)2	0.648 (P< 0.001)2	0.875 (P<0.001)2	0.755 (P<0.001)2

• ¹ Pearson's correlation coefficient. ² Spearman's correlation coefficient. AAPC: Average Annual Percent Change. APC: Annual Percent Change. SVI: social vulnerability index. MHDI: municipal human development index. Infra: infrastructure. Long: longevity. Edu: education

There was no correlation between trends in SVI (AAPC) and trends in mortality rates across all groups of disease and age groups. Infrastructure was the only SVI dimension to show-negative (moderately significant) correlation with HS and US mortality rates in the three oldest age groups. In contrast. income showed weak and moderately significant positive correlations with US and capital showed moderately significant positive correlations with HS and US in the 40-59 year age group and above (Table 4).

Discussion

In general. the findings show-stationary trend for IS and-reduction in HS mortality at national level over the study period. This is consistent with World Health Organization (WHO) projections³.

Brazil’s first stroke unit was created in Joinville. Santa Catarina in 1997. In 2008. the Ministry of Health issued Ministerial Order 665/2012 creating stroke referral services across the country²⁰. Between 1998 and 2017. the country saw rapid expansion in the number of family health teams. Studies have shown an association between this expansion and reduced mortality from stroke²¹.

Despite the trends in IS and HS revealed by the present study. the number of deaths from stroke remain high across the country. with rates higher than those found in developed countries and some of the highest rates in Latin America^22.23. According to the Global Burden of Disease study (GBD). the country with the highest mortality rate was Uruguay (102/100.000). followed by Brazil (60.47/100.000). Chile (57.95/100.000) and Argentina (57.78/100.000)²⁴.

Our findings show that the only age group in which the proportion of deaths was higher among women than men was 80 years and over. De Souza et al. reported similar results in-study investigating stroke mortality between 1996 and 2015²⁵. These findings are also consistent with results found in North America and Europe²⁶. Factors explaining higher mortality among women in this age group include increased susceptibility to systemic arterial hypertension (SAH) in postmenopausal women²⁷ and atrial fibrillation. which is-risk factor that leads to-fourfold increase in the likelihood of IS in around 60% of women aged over 75²⁸. The higher proportion of women in this age group can also be explained by the fact that women live longer than men²⁹.

IS mortality rates were higher in older age groups while HS mortality was higher in the youngest age group. These findings are consistent with those reported by De Moraes et al.. who studied stroke mortality in young patients (10-49 years) in the South and Southeast of Brazil. finding that 76% of deaths were from HS³⁰. Risk of death from stroke is substantially higher in the older population than in other age groups. This can be partially explained by accumulation of risk factors in this group. such as SAH. diabetes. alcoholism. smoking and unhealthy eating habits³¹.

IS and HS mortality was higher in the Southeast and South. although the findings show-significant downward trend in these regions. In contrast. the North and Northeast showed lower rates with-significant upward trend. The higher rates in more developed states may be explained by the greater influence of chronic conditions in the mortality profile in these more populous regions²⁵. In contrast. stroke mortality may be lower in more socially vulnerable regions because of mortality from other poverty-related diseases. such as infectious and parasitic diseases³².

Higher AAPC for IS mortality rates in the North and Northeast is consistent with the findings of-study by Mansur and Guimarães. who analyzed cardiovascular mortality in Brazil also using SIM data. although over-different period^33.34. According to the authors. these regions show lower consumption of fruit and vegetables and regular exercise rates. and higher rates of physical inactivity. self-reported poor health and SAH³⁵. In addition. according to the 2019 National Health Survey. people living in the Northeast have poorer access to at least one blood pressure medication in popular pharmacies and-higher prevalence of stroke³⁶. Furthermore. the regions in Brazil with the highest prevalence of obesity are the North. Northeast and Midwest³⁷. The combination of these factors results in increased risk for stroke³⁸ and may explain the results found for these regions by the present study.

Unlike the findings reported by Lotufo et al.. who found-50% reduction in the proportion of deaths due cerebrovascular disease below 70 years of age between 1990 and 2015³⁹. our results show that reductions in IS mortality were highest in the 80 years and over group. The opposite was the case for HS mortality rates. which only increased in the oldest age group among men. These findings are also inconsistent with the results of-study by Passos et al.⁴⁰. who found-substantial progressive decline in stroke mortality across all age groups. This may be explained by method differences. especially the stroke cause inclusion criteria. Other studies included all ICD-10 codes for stroke^11.41. while the present study included only strokes that may cause brain damage which. in principle. are detectable by neuroimaging (IS and HS).

During the period 2015-2019. there was-reduction in the pace of decline in four of the six targets proposed in 2011⁴² and now monitored under the Strategic Action Plan to Combat Chronic Diseases and Non-Communicable Diseases in Brazil 2021-2030:-2% per year reduction in premature death (30-69 years) from noncommunicable diseases (NCDs); 30% decrease in smoking prevalence; stabilization of obesity among adults; and-10% rise in the recommended consumption of fruit and vegetables⁴³. This may partially explain the increase in IS mortality across all regions from 2015 observed in the present study.

Our findings reveal-reduction in HS mortality at national level. which is consistent with the results of-study by Oliveira GMM et al.⁴⁴ using data from the 2017 GBD. However. it is important to highlight that disadvantaged regions such as the Northeast and North showed-positive AAPC in the 80 years and over age group and that APC in the North between 2011 and 2017 reached + 9.0.

The downward national trend in US mortality may be explained by improvements in the completion of death certificates⁴⁵; however. US still account for most deaths from stroke recorded on death certificates in the SIM databases. This downward trend was less pronounced in the North and Northeast in the three youngest age groups. and an upward trend was observed in the 80 year and over group. Garritano et al. also found-higher proportion of deaths from US when compared with deaths from IS and HS. with rates of over 15% in older adults in the North¹¹. while Jorge et al. found rates over 20% in the North and Northeast⁴⁶. Key problems in these regions include poor access to health care related to their huge geographic area and cultural factors influencing behavior of local communities⁴⁷. The quality of SIM data is also poorer in these regions⁴⁸.

Deaths from US remain-challenge for estimating stroke mortality. Rolim and Martins investigated the use of cranial computed tomography (CT scan) in patients admitted to hospital with suspected stroke using data from the country’s hospital information system. The authors reported that the scan was not performed in 73% of cases. despite half of the admissions being to hospitals with-scanning machine. Paradoxically. not performing the scan was not the main factor used for classifying the condition as US. rather TC scans were more common in the group classified as not specified⁴⁹.

Based on the literature. it is likely that the leading cause of death from stroke nationally and across regions is IS. due to the higher prevalence of this type⁵⁰. The downward trend in US. slight increase in HS and substantial increase in IS mortality found by this study in the North and Northeast corroborate this hypothesis. As mentioned above. improvement in the quality of SIM data in these regions may have contributed to the downward trend in deaths from US. with-consequent rise in IS mortality.

The positive correlations found between all dimensions of the MHDI and the three groups of causes studied may be explained by the fact that in 2000 the largest variations in the index occurred in areas where it was lowest. These improvements were therefore not sufficient to cause-positive impact on mortality when the causes of stroke are analyzed alone. Positive correlations have been observed in medium-to-high-income countries but not in high-income countries. where HDIs have been higher for longer and access to specialized care services is better⁵¹.

The positive correlations between HS and US and income and employment and human capital suggest that mortality increases with increasing social vulnerability. These dimensions are linked mainly to education. employment and income. which are factors associated with stroke⁵². In contrast. there was-negative correlation between HS and US and infrastructure. The infrastructure dimension reflects access to basic sanitation services and urban mobility. which is linked to place of residence and has-significant impact on well-being and access to health services. These findings may reflect poor utilization of services due to lack of information about available services.

The main limitation of this study is the quality data in the SIM databases. However. only 198 deaths from stroke in our sample had missing information. corresponding to-less than 1% loss. This is-reflection of the efforts made by the Ministry of Health through partnerships with state and municipal governments to improve data quality. such as the Regional Inequalities Reduction Project. Infant Mortality Reduction Project in the Northeast and Legal Amazon and Ill-Defined Cause Reduction Project in 2005⁵³. This study is the first of its kind in Brazil to consider only ICD-10 codes for stroke with brain damage that is detectable by neuroimaging. thus exclusively encompassing IS and HS and excluding codes that represent risk factors that do not necessarily cause brain damage. This fact and the methods used to analyze the variables. particularly joinpoint regression. may explain the differences between our results and those of other studies on death from stroke.

Conclusions

Although in general stroke mortality in Brazil showed-downward trend during the period 2000-2019. the results of the analysis by groups of causes. regions and age group reveal distinct realities in-country with continental proportions and deep inequalities. In disadvantaged regions (the North and Northeast). the findings show an upward trend in IS and HS mortality. with increases being more pronounced in individuals aged over 60. Progressive increases in the MHDI and decreases in the SVI across the country have yet to have an impact on mortality rates. especially in disadvantaged regions. In contrast to the stabilization of IS mortality. the downward trend in US appears to reflect improvements in SIM data quality.

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• Chief Editors:
  Maria Cecília de Souza Minayo. Romeu Gomes. Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  20 Oct 2025
• Date of issue
  2025

History

• Received
  09 Dec 2023
• Accepted
  27 Apr 2024
• Published
  29 July 2024