Temporal and spatial variation in hospitalizations and mortality from acute myocardial infarction in Brazil during the COVID-19 pandemic period (2020–2023)

Abstract

Background

The COVID-19 pandemic emerged as a major public health challenge, not only due to the high number of victims but also because of the significant rise in cardiovascular emergencies associated with the infection. We investigated the temporal and spatial variation in hospitalizations (2020–2023) and deaths (2020–2022) from Acute Myocardial Infarction (AMI) in Brazil during the COVID-19 pandemic.

Methods

We analyzed hospitalizations (between 2015 and 2023) and deaths (between 2015 and 2022), using data from the Mortality Information System (SIM) and the Hospital Information System (SIH) of the Brazilian Ministry of Health. Percentage change was calculated to assess whether there was an increase or decrease in hospitalizations and deaths from AMI, considering the average of the previous five years. Additionally, a Joinpoint regression model was applied to evaluate temporal trends before and after the onset of the pandemic. Spatial variations were visualized through choropleth maps.

Results

A consistent rise in AMI hospitalizations was observed nationwide, with percentage increases of 13.4% in 2020, 21.2% in 2021, 36.9% in 2022, and 30.9% in 2023. The Central-West region showed the highest growth rates. Regarding mortality, there was a reduction in AMI deaths in 2020 (-3.0%), followed by increases in 2021 (2.2%) and 2022 (4.6%), particularly in the North and Central-West regions. Temporal trend analysis revealed a significant increase in AMI hospitalizations in Brazil (APC = 5.7%; p < 0.05). The most pronounced growth was observed in the Central-West (APC = 10.4%; p < 0.05) and North (APC = 6.3%; p < 0.05) regions. For mortality, trends were stable during the pre-pandemic period in Brazil and in most regions, but they increased in the pandemic period in the North (APC = 2.6%; p < 0.05) and Central-west (APC = 1.6%; p < 0.05) regions.

Conclusion

Overall, this study identified an increase in the number of hospitalizations (between 2020 and 2023) and deaths (between 2020 and 2022) due to AMI in Brazil, highlighting COVID-19’s significant impact on cardiovascular health. The findings underscore the urgent need for stronger investments in health infrastructure, as well as strategic interventions to mitigate the effects of the pandemic and reduce hospitalizations and deaths in the coming years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-026-05883-w.

Introduction

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, was one of the greatest global public health challenges of the 21st century. From the first reported cases in Wuhan, China, in late 2019, to the declaration of the end of the Public Health Emergency of International Concern by the World Health Organization (WHO) in May 2023, more than 778 million cases and approximately seven million deaths occurred worldwide [1, 2]. Brazil was among the most affected countries, with over 39 million cases and 716,000 deaths [3].

The COVID-19 pandemic unfolded amid major demographic and structural transitions that have reshaped global morbidity and mortality patterns. Many countries are experiencing demographic and epidemiological transitions marked by longer life expectancy and declining mortality from infectious diseases. At the same time, deaths related to chronic conditions, especially cardiovascular diseases such as acute myocardial infarction (AMI) are increasing [4, 5].

AMI remains a leading cause of death and disability worldwide, imposing a heavy burden on healthcare systems. In 2021, approximately nine million deaths were attributed to ischemic heart disease, making it the world’s top cause of mortality [6]. In Brazil, AMI is the primary cause of death, with 300,000 to 400,000 cases annually and one death estimated for every five to seven cases [7].

The pandemic profoundly affected the prevention and management of many diseases, including those related to cardiovascular health. Measures to contain the virus, such as social distancing, limited access to public spaces, and the interruption of healthcare services, disrupted routine care [8, 9]. Consequently, delayed diagnosis and treatment, service reorganization, and fear of infection may have contributed to increased AMI prevalence and mortality [10]. Although SARS-CoV-2 primarily affects the respiratory system, it can also cause serious cardiovascular complications, including myocarditis, arrhythmias, cardiac injury, and AMI [11].

Previous studies have shown similar impacts of the pandemic on the diagnosis of other diseases, such as leprosy [12], tuberculosis [13], and schistosomiasis [14], as well as on cardiovascular disease (CVD) lethality in general [15] and in-hospital mortality from CVD during the first pandemic year [16]. However, no nationwide study has yet examined AMI hospitalization and mortality trends in Brazil across the entire pandemic period (2020–2023).

Brazilian national guidelines underscore the importance of continuously monitoring the evolution of acute coronary syndromes and optimizing patient care pathways throughout the national health system [17]. Complementarily, the European Society of Cardiology in 2022, emphasizes the substantial global impact of the pandemic on cardiovascular disease epidemiology, diagnostic processes, and clinical management [18]. Within this framework, a systematic assessment of hospitalization and mortality trends related to AMI in Brazil during the COVID-19 pandemic is crucial to elucidate how healthcare service disruptions, changes in healthcare-seeking behavior, and the direct cardiovascular effects of SARS-CoV-2 have shaped national outcomes.

From this perspective, this study aimed to evaluate the temporal and spatial variation in hospitalizations (from 2020 to 2023) and deaths (from 2020 to 2022) due to AMI in Brazil during the COVID-19 pandemic. Unlike previous reports focused on the initial months of the crisis, this study provides a nationwide, 4-year longitudinal analysis (2020–2023), offering new insights into regional inequalities and the long-term epidemiological shifts in AMI outcomes in Brazil.

Methods

Type and area of study

This is an ecological study using spatial, spatiotemporal, and temporal trend analysis based on secondary data obtained at the Mortality Information System (SIM) website and at the Hospital Information System (SIH).

The Federative Republic of Brazil located in South America, is the largest country on the continent, with an area of 8,515,767.049 km². The Brazilian population encompasses approximately 203 million people. Politically and administratively, the country is divided into 27 federative units (26 states and 1 Federal District), with Brasília as its capital. For political and operational purposes, these units are grouped into five regions (North, Northeast, Southeast, South, and Central-West), each with distinct geographic and cultural characteristics, as well as significant socioeconomic disparities [19].

Variables and data sources

The variables analyzed included all cases of hospitalizations due to AMI between 2015 and 2023 and deaths due to AMI from 2015 to 2022. Mortality data were used up to 2022, corresponding to the most recent update available in SIM at the time of data collection. Data collection was based on code I21 from Chapter IX – Diseases of the Circulatory System, according to the 10th Revision of the International Classification of Diseases (ICD-10).

The data used are publicly available and provided by DATASUS, the Health Ministry of Brazil. Hospitalization data for AMI were obtained from the SIH, while mortality data for AMI were extracted from the SIM. Hospitalizations in which AMI was recorded as the primary diagnosis and deaths in which AMI was recorded as the underlying cause of death were selected.

Data analysis

Descriptive analysis was performed using GraphPad Prism version 8.0. Categorical variables were described by absolute and relative frequencies, and numerical variables by measures of central tendency and dispersion. Mortality and hospitalization rates for AMI were calculated considering the annual deaths as numerator, multiplied by the constant 100,000 inhabitants, and the estimated resident population as denominator. Population data were based on the Population Projections and the 2022 National Census from the Brazilian Institute of Geography and Statistics (IBGE).

Percentage of change (P-score)

To evaluate the variations in the number of hospitalizations and deaths due to AMI during COVID-19 pandemic across all Brazilian states, the percentage of change (P-score) was calculated based on variables provided by SIH and SIM. This percentage calculation has been previously used to analyze morbidity rates and other indicators, as reported in studies on leprosy [12], tuberculosis [13], and schistosomiasis [20]. By comparing expected and observed values, it is possible to assess increases or decreases in disease occurrence and/or mortality over time and space [12, 21]. The percentage change was calculated using the difference between the total number of observed deaths and the total number of expected deaths as the numerator, and the total number of expected deaths as the denominator, multiplied by 100.

Expected values for the study variables in 2020, 2021, 2022, and 2023 were calculated using the mean of the previous five years (2015–2019 for 2020; 2016–2020 for 2021; 2017–2021 for 2022; and 2018–2022 for 2023) and then compared to the observed values during each pandemic year. Based on this comparison, the percentage of change for each studied year was calculated. Positive percentage values indicate an increase in hospitalizations or deaths, while negative values indicate a reduction of these rates compared to expected values. The percentage of changes were evaluated by region, state, and country and presented as bar graphs. The pre-pandemic period was defined as 2015–2019, while the pandemic period comprised 2020–2022 for mortality and 2020–2023 for hospitalizations.

Time series analysis

Temporal trend analysis by region of Brazil, sex and age group was performed using hospitalization and mortality rates for AMI as dependent variables and year as the independent variable. The Poisson regression method was used via Joinpoint Regression Program version 5.2.0. This statistical technique uses log-transformed rates to identify inflection points (Joinpoints) that describe significant changes in trend patterns. Joinpoint analysis finds the best model by testing whether multiple line segments (with several Joinpoints) better explain the trend than a single straight line (0 Joinpoint) [22].

Statistical significance for model selection was based on the Monte Carlo permutation method, considering a p-value < 0.05 and 95% confidence intervals (95% CI). The model parameters were defined with a significance level (α) of 0.05, ensuring statistical rigor in identifying significant changes in temporal trends. Annual percentage changes (APCs) and their 95% CIs were calculated to describe and quantify trends. When more than one significant inflection was detected during the study period, the average annual percentage change (AAPC) was calculated [23].

Trends were considered significant if APC had p-value < 0.05 and 95% CI did not include zero. A positive significant APC indicates an increasing trend; a negative significant APC, a decreasing trend; and non-significant APC was considered stable despite p-value. The final selected model was the best fit with the fewest inflection points, allowing the best trend representation [23].

Spatial data analysis

Data were made available through a Geographic Information System (GIS)-based data system. GIS links stored data to geographic features, allowing spatial visualization and analysis. Results were presented as thematic maps. Cartographic bases of Brazil and its political-administrative divisions were provided by IBGE. The cartographic projection used was the geographic coordinate system (latitude/longitude), referenced to the SIRGAS 2000 Datum (Geocentric Reference System for the Americas 2000).

Georeferenced data and meshes were imported into the GIS, where spatial statistics inferences were performed and choropleth maps produced. Analyses were conducted using TerraView 4.2.2 and QGIS 3.4 software [24]. Choropleth maps were created to represent the percentage of change by Brazilian states for hospitalization data from 2020 to 2022 and also for mortality data from 2020 to 2023. Classification intervals were defined using an equal-interval statistical method based on the total range of observed percentage change values. Therefore, maps were classified into nine equal-interval categories according to percentage change values (positive or negative): < -75.00%; -74.99 to -50.00%; -49.99 to -25.00%; -24.99 to -0.01%; 0.00%; 0.01 to 25.00%; 25.01 to 50%; 50.01 to 75.00%; and > 75.00%.

Ethical considerations

As this is an ecological study using publicly available secondary data with no variables related to individual identification, the requirement for Free and Informed Consent and submission to the Research Ethics Committee was not mandatory. However, the principles established in the Resolution 466/2012 of the National Health Council and also the Helsinki Declaration were respected.

Results

In Brazil, between 2015 and 2023, there were 1,177,532 hospitalizations due to AMI. The pre-pandemic annual average (2015–2019) was 114,295 cases, while during the pandemic period (2020–2023) the annual average increased to 151,515 hospitalizations. Between 2015 and 2022, there were 750,741 deaths from AMI in Brazil. The pre-pandemic annual average (2015–2019) was 93,289 deaths, while during the pandemic period (2020–2022) the annual average was 94,765.

The study reveals a significant increase in hospitalizations associated with AMI in Brazil over the evaluated period. The results displayed a substantial percentage of change in hospital admissions in 2020 (13.4%), 2021 (21.2%), 2022 (36.9%), and 2023 (30.9%) nationwide (Fig. 1A-D). Similarly, all regions of Brazil recorded an increase in the number of hospitalizations, with the Central-West region showing the highest growth rates. Moreover, nearly all Brazilian states also experienced an increase in the percentage of hospitalizations due to AMI during the pandemic, especially the states of Roraima, Goiás, Amapá, Tocantins, and Paraíba.

Fig. 1.

Percentage of change (P-score) in hospitalizations due to acute myocardial infarction (AMI) in Brazil for the years (A) 2020, (B) 2021, (C) 2022 and (D) 2023

Notably, there was a reduction in the number of deaths due to AMI in Brazil during the first year of the pandemic (2020 = -3.0%). However, an increase in mortality during 2021 (2.2%) and 2022 (4.6%) was identified in Brazil. In 2022, all regions of the country showed an increase in the number of deaths. Furthermore, the North and Central-West regions stood out with the highest growth rates. Additionally, Roraima was the state with the greatest increase in the number of deaths due to AMI (Fig. 2A-C). Hospitalization and mortality rates due to AMI in Brazil and its regions between 2015 and 2023 were also standardized per 100,000 inhabitants (Supplementary material 1 and 2).

Fig. 2.

Percentage of change (P-score) in deaths due to acute myocardial infarction (AMI) in Brazil for the years (A) 2020, (B) 2021, and (C) 2022

The percentages of hospitalizations and deaths by age group were assessed, by comparing the values between the periods before (2015–2019) and during (2020–2023) the COVID-19 pandemic. The highest rates of hospitalizations (2015–2019 = 60.65%; 2020–2023 = 62.71%) and deaths (2015–2019 = 66.91%; 2020–2022 = 76.57%) were observed among the elderly (over 60 years old) (Supplementary material 3).

Table 1 presents the temporal trends in hospitalizations and mortality due to AMI across the regions of Brazil, stratified by sex and age groups, over two distinct periods: the five years preceding the COVID-19 pandemic (2015–2019) and the pandemic period (2020 to 2022 for hospitalizations and 2020 to 2023 for deaths).

Table 1.

Temporal trends of hospitalizations (2015–2023) and deaths (2015–2022) by Acute Myocardial Infarction (AMI) by region, sex and age group in Brazil

Indicator		2015–2019		2015–2022/2023#
	Period	APC (CI95%)	Trend	Period	APC (CI95%)	Trend
Hospitalizations
Brazil	2015–2019	6.1* (4.6 to 7.6)	Increasing	2015–2023	5.7* (4.5 to 6.9)	Increasing
Region
North	2015–2019	6.0* (2.3 to 9.8)	Increasing	2015–2023	6.3* (3.5 to 9.0)	Increasing
Northeast	2015–2019	7.7* (4.2 to 11.5)	Increasing	2015–2023	5.9* (4.4 to 7.5)	Increasing
Southeast	2015–2019	5.7* (3.8 to 7.7)	Increasing	2015–2023	5.4* (4.2 to 6.7)	Increasing
South	2015–2019	2.6 (-0.4 to 5.7)	Stable	2015–2023	4.1* (2.7 to 5.6)	Increasing
Midewst	2015–2019	15.5* (12.4 to 18.7)	Increasing	2015–2023	10.4* (7.7 to 13.2)	Increasing
Sex
Male	2015–2019	6.2* (4.8 to 7.6)	Increasing	2015–2023	5.7* (4.5 to 6.9)	Increasing
Female	2015–2019	6.0* (4.3 to 7.6)	Increasing	2015–2023	5.6* (4.4 to 6.9)	Increasing
Age group
0 to 9	2015–2019	-0.7 (-17.2 to 19.0)	Stable	2015–2023	4.8 (-2.7 to 12.9)	Stable
10 to 19	2015–2019	0.6 (-2.9 to 4.2)	Stable	2015–2023	2.1 (-1.0 to 5.2)	Stable
20 to 39	2015–2019	5.6* (0.2 to 11.2)	Increasing	2015–2023	5.8* (4.5 to 7.2)	Increasing
40 to 59	2015–2019	3.3* (1.8 to 4.8)	Increasing	2015–2023	3.0* (1.9 to 4.0)	Increasing
≥ 60	2015–2019	3.9* (2.5 to 5.2)	Increasing	2015–2023	3.5* (2.1 to 4.8)	Increasing
Deaths
Brazil	2015–2019	0.3 (-1.1 to 1.7)	Stable	2015–2022	0.1 (-0.8 to 1.0)	Stable
Region
North	2015–2019	3.0* (1.5 to 4.6)	Increasing	2015–2022	2.6* (1.5 to 3.6)	Increasing
Northeast	2015–2019	1.2* (0.5 to 1.9)	Increasing	2015–2022	-0.1 (-0.8 to 1.0)	Stable
Southeast	2015–2019	0.3 (-1.9 to 2.6)	Stable	2015–2022	0.2 (-0.8 to 1.3)	Stable
South	2015–2019	-2.9 (-5.8 to 0.2)	Stable	2015–2022	-1.6 (-3.2 to 0.1)	Stable
Midewst	2015–2019	0.7 (-1.4 to 2.7)	Stable	2015–2022	1.6* (0.4 to 2.8)	Increasing
Sex
Male	2015–2019	0.4 (-1.2 to 2.0)	Stable	2015–2022	0.2 (-0.6 to 1.1)	Stable
Female	2015–2019	0.1 (-1.0 to 1.2)	Stable	2015–2022	-0.1 (-1.1 to 0.9)	Stable
Age group
0 to 9	2015–2019	10.6 (-33.1 to 82.9)	Stable	2015–2022	11.7 (-6.2 to 32.9)	Stable
10 to 19	2015–2019	-11.3 (-24.2 to 3.8)	Stable	2015–2022	-1.6 (-8.1 to 5.4)	Stable
20 to 39	2015–2019	-2.5 (-6.4 to 1.4)	Stable	2015–2022	0.3 (-1.7 to 2.3)	Stable
40 to 59	2015–2019	-2.7* (-4.2 to -1.1)	Decreasing	2015–2022	-2.6* (-3.7 to -1.4)	Decreasing
≥ 60	2015–2019	-2.1* (-3.3 to -0.9)	Decreasing	2015–2022	-2.4* (-3.2 to -1.5)	Decreasing

APC, Annual percentage change; AAPC, Average Annual percentage change; CI, Confidence Interval; *p-value <0.05; #The variables analyzed included all cases of hospitalizations due to AMI between 2015 and 2023 and deaths due to AMI from 2015 to 2022

Regarding AMI hospitalizations, an increasing trend was observed in Brazil during the pre-pandemic period (APC = 6.1%; p < 0.05) and in nearly all regions of the country, with the exception of the South region, which showed stable hospitalization rates. With the inclusion of data from 2020 to 2023, hospitalization trends remained upward at the national level (APC = 5.7%; p < 0.05), with increases observed in all Brazilian regions, particularly in the Central-West (APC = 10.4%; p < 0.05) and North (APC = 6.3%; p < 0.05) regions. Additionally, during the pandemic years, increasing trends in AMI hospitalizations were identified for both sexes—males (APC = 5.7%; p < 0.05) and females (APC = 5.6%; p < 0.05)—as well as across all age groups analyzed: 20–39 years (APC = 5.8%; p < 0.05), 40–59 years (APC = 3.0%; p < 0.05), and individuals aged 60 years or older (APC = 3.5%; p < 0.05) (Table 1).

When analyzing deaths due to AMI, mortality remained stable during the pre-pandemic period in Brazil and in most regions. The exceptions were the North (APC = 3.0%; p < 0.05) and Northeast (APC = 1.2%; p < 0.05) regions, which exhibited increasing mortality trends. During the pandemic period, increasing trends in AMI mortality were identified in the North (AAPC = 2.6%; p < 0.05) and Central-West (AAPC = 1.6%; p < 0.05) regions. With respect to sex, AMI mortality rates remained stable for both males and females in the pre-pandemic and pandemic periods. Regarding age groups, most groups showed stable AMI mortality rates during the pandemic. However, individuals aged 40–59 years and those aged 60 years or older exhibited declining mortality trends during this period (Table 1).

The spatial distribution analyses showed an increase of the percentage change in hospitalization rates for AMI in the first year of the pandemic (2020), in almost all of 27 federal units (n = 24). Moreover, the highest percentages were observed in the states of Roraima (60.57%), Goiás (58.84%), and Mato Grosso do Sul (42.61%) (Fig. 3). In 2021, only the state of Piauí (-7.1%) showed a decrease in AMI hospitalizations. In 2022 and 2023, all states in the country recorded increases in hospitalizations, with eight states exhibiting growth rates above 50% during 2022, and in the year 2023 this number rose to nine. Furthermore, most of these states are located in the North (Roraima, Tocantins, Amapá, and Rondônia) and Central-West (Goiás and Mato Grosso do Sul) regions.

Fig. 3.

Spatial distribution of the percentage change (P-score) of hospitalizations due to acute myocardial infarction (AMI) in Brazil, for the years (A) 2020, (B) 2021, (C) 2022, and (D) 2023, compared to the baseline mean calculated from the previous five years for each analyzed year (2015–2019 for 2020; 2016–2020 for 2021; 2017–2021 for 2022; and 2018–2022 for 2023)

Regarding the spatial distribution of deaths due to AMI, 11 states registered a percentage increase in mortality, during 2020, in Brazil. This number rose to 19 states in 2021 and 21 states in 2022. The state of Roraima, stood out with the highest percentage increases (Fig. 4).

Fig. 4.

Spatial distribution of the percentage change (P-score) of deaths due to acute myocardial infarction (AMI) in Brazil, for the years (A) 2020, (B) 2021 and (C) 2022, compared to the baseline mean calculated from the previous five years for each analyzed year (2015–2019 for 2020; 2016–2020 for 2021; 2017–2021 for 2022)

Discussion

To the best of our knowledge, this is the first study to report the variations and inequalities observed in hospitalizations (between 2020 and 2023) and deaths (between 2020 and 2022) due to AMI across all regions of Brazil during the COVID-19 pandemic. The analyses revealed that the total number of hospitalizations for AMI in Brazil increased by 13.4% in 2020, 21.2% in 2021, 36.9% in 2022, and 30.9% in 2023. Additionally, there was a decrease in AMI-related deaths in 2020 (-3.0%), followed by an increase in the following years (2021: 2.2%; 2022: 4.6%). All regions of Brazil recorded an increase in the number of hospitalizations, mostly the Central-West region.

Similarly, an increase in AMI-related deaths was observed in three of the five regions during 2021 and in all regions in 2022, and the Central-West and North regions exhibited the highest rates. Furthermore, temporal trend analyses showed an increase in hospitalizations across all regions of Brazil, in both sexes and among individuals aged over 20 years, as well as a rise in mortality in the North and Central-West regions following the onset of the pandemic. Overall, the findings highlight notable changes in AMI-related hospitalizations and mortality observed during the COVID-19 pandemic period, which may be associated with disruptions in healthcare services and changes in care-seeking behavior during the pandemic.

Interestingly, the increase in hospitalizations for AMI identified herein diverge from previous studies that reported a decrease in hospital admissions for this condition following the onset of the pandemic [25–29]. This discrepancy may be related to the time frame analyzed, as many of those studies focused on the initial months of the pandemic [29–33], when the reduction in hospital admissions was probably a reflection of fear of contamination and concerns about overburdening hospitals [34]. In contrast, the present study covers data from 2020 to 2023, enabling to assess the long-term effects of the COVID-19 pandemic on AMI hospitalization rates in Brazil. In agreement with our results, Rognoni et al. [35] reported an increase in AMI admissions after the lockdown was implemented in Italy. Likewise, Gluckman et al. [36] described a rise in AMI hospitalizations in the end of the pandemic in the United States.

During the pandemic period, countries adopted a series of containment and mitigation measures to reduce the spread of SARS-CoV-2 and prevent the collapse of healthcare systems [8, 9]. The implementation of these emergency actions had negative effects on various health programs and services [13, 14, 37] and the strategies for prevention, diagnosis, and management of risk factors for AMI were severely compromised. A multicenter study analyzing data from 108 countries revealed a significant reduction in cardiovascular diagnostic services after the onset of the pandemic. The greatest reductions in cardiac diagnostic procedures were recorded in the Middle East and Latin America [38]. Furthermore, Dale et al. [39] identified a decline in the dispensing of antihypertensive medications in England, Scotland, and Wales between March 2020 and July 2021.

In Brazil, Normando et al. [40] depicted a reduction in cardiovascular care during the first months of the pandemic, with a decline in diagnostic and surgical procedures such as exercise testing, electrocardiograms, catheterizations, pacemaker implants, and cardiovascular surgeries. In addition, COVID-19 caused significant changes of healthcare services workflows in the country. Individuals with non-communicable chronic diseases, such as hypertension and diabetes—key risk factors for AMI—faced greater barriers to accessing healthcare services [41]. The inadequate management of risk factors, combined with reduced access to early diagnosis, may be associated with the worsening of cardiovascular conditions and a higher risk of AMI episodes [42]. These factors may have contributed to the increase in AMI hospitalizations in Brazil, as observed in the present study.

Moreover, evidence indicates that individuals infected with SARS-CoV-2 are more susceptible to various forms of myocardial injury, including AMI [11]. This predisposition is associated with several factors, such as direct myocardial damage due to viral entry and a systemic inflammatory response [11]. Therefore, it is possible that many of the AMI case records used in our analysis actually correspond to underreported COVID-19 cases that progressed with cardiac involvement, being recorded as AMI after hospital admission. During the early months of the pandemic, factors such as the insufficient number of diagnostic tests significantly contributed to underreporting of the disease in Brazil [43], which may have distorted the recorded data and the actual incidence of other health conditions.

The observed increase in the number of deaths from AMI in Brazil, in the years 2021 and 2022, was consistent with previous studies that also showed increased AMI mortality in other countries such as the United States [44] and England [45]. Additionally, a systematic review with meta-analysis identified a significant increase in AMI mortality rates among the included countries. The highest increases in AMI death rates were observed in Serbia, Italy, Pakistan and France [46].

There are several explanations for the increased mortality related to AMI during the COVID-19 pandemic, such as the fear of contamination and also underestimation of symptoms, leading to delays in seeking medical assistance and initiating treatment, enhancing the risk of severe cases and mechanical complications such as cardiac tamponade and cardiogenic shock [46]. Another possible explanation is the reallocation of healthcare resources to manage the pandemic, which led to the cancellation of elective cardiovascular procedures and outpatient visits, contributing to clinical decompensation and disease progression [47]. Furthermore, the overload of healthcare systems caused by COVID-19 may have contributed to the higher number of individuals being treated outside the therapeutic window [48]. The viral infection effects on the cardiovascular system emerge as a potential contributor to a higher occurrence of adverse outcomes, including myocardial injury, AMI, and death [11].

The highest percentages of hospitalizations and deaths due to AMI were observed in the Central-West and Northern regions of Brazil. Several factors can be related to these findings. It is undeniable that an unequal impact on different populations. Although the pandemic affected society as a whole, certain regions proved to be more vulnerable due to factors related to healthcare services availability [49]. Notably, in the North and Central-West regions of Brazil, many population groups live in remote rural areas and face significant transport challenges, which pose major barriers to accessing healthcare services [50, 51]. This concerning scenario may have been exacerbated during the pandemic, leading to delays in diagnosis and also in clinical management of conditions that increase the risk of AMI, culminating in a greater number of cases and hospitalizations. These factors may have contributed to delays in diagnosis and treatment, potentially leading to more severe cases and higher mortality.

Although the epidemiological situation of COVID-19 has improved, the findings of this study highlight important changes in AMI-related hospitalizations and mortality during the pandemic period in Brazil. These results underscore regional disparities and temporal variations that may be relevant for understanding the broader impact of the pandemic on cardiovascular health. Further studies incorporating healthcare system indicators and patient-level data are needed to better explore the underlying mechanisms and to inform targeted public health strategies.

Furthermore, although not directly derived from the findings of the present study, these results may have broader implications for health system planning. In this context, strengthening investments in diagnostic and treatment services for cardiovascular conditions, improving existing infrastructure, and implementing cross-sectoral strategies to reduce barriers to healthcare access may be important considerations. Such efforts should take into account regional heterogeneity, with particular attention to the most affected areas.

This study has some limitations that warrant caution. First, as an ecological study using aggregate secondary data from the SIM and SIH databases, it lacks the granularity to adjust for individual-level confounders. Factors such as the progressive aging of the Brazilian population, socioeconomic shifts during the pandemic, and the heterogeneity of the vaccination rollout across regions may have influenced AMI trends. Additionally, the use of secondary data presents the possibility of underreporting or overreporting of cases in certain regions. The estimation of true prevalence and mortality may also have been affected by difficulties in case detection and potential inaccuracies in the coding of AMI and COVID-19 cases. Furthermore, using a trailing five-year mean for expected values (P-score) may overstate percentage changes, as AMI hospitalizations already showed a slight upward trend in Brazil prior to 2020.

Finally, mortality data were analyzed up to 2022 and hospitalizations up to 2023 because these represented the most recent periods with fully consolidated and validated records at the time of analysis. More recent data (from 2024 onward) remain subject to reporting delays and reclassifications in several states, which could compromise the completeness and comparability of temporal trend analyses. Despite these limitations, the nationwide scale of this study provides a critical ‘real-world’ perspective on the long-term impact of the pandemic on cardiovascular health in a diverse middle-income country.

Conclusion

Altogether, the analyses performed revealed an increase in the number of hospitalizations and deaths due to AMI in Brazil, particularly in the Central-West and Northern regions of the country, highlighting the persistence of regional inequalities in access to and quality of cardiovascular care. There is an urgent need to strengthen the health system through investments aimed at improving the organization and responsiveness of cardiovascular care networks across regions, along with measures that ensure timely access to diagnosis and treatment. In light of this, it is crucial for policymakers to implement strategic actions aimed at reducing these inequalities and improving cardiovascular health outcomes across the country, especially during public health crises, such as future pandemics. Such interventions include strengthening emergency care networks, improving care coordination within the health system, developing contingency plans for public health crises, training healthcare professionals, and implementing population-level awareness strategies.

Abbreviations

AMI

Acute Myocardial Infarction

SIM

Mortality Information System

SIH

Hospital Information System

WHO

World Health Organization

CVD

Cardiovascular diseases

ICD

10-10th Revision of the International Classification of Diseases

IBGE

Brazilian Institute of Geography and Statistics

APC

Annual Percentage Change

AAPC

Average Annual Percentage Change

CI

Confidence Intervals

GIS

Geographic Information System

UTM

Universal Transverse Mercator

SIRGAS

Geocentric Reference System for the Americas

Authors’ contributions

Thallysson Hebert da Silva: conception, analysis, manuscript writing. Pedro Afonso de Vasconcelos Brandão: conception, analysis, manuscript writing. Lucas Almeida Andrade: data collection, analysis, manuscript writing. Gabriel Arthur Gomes Cavalcante: analysis, manuscript writing. Katiane de Lima Pinheiro: analysis, manuscript writing. Igor Fernando de Melo Cavalcante: analysis, manuscript writing. Wandklebson Silva da Paz: data collection, analysis. Allan Dantas dos Santos: edition and revision of the article. Rodrigo Feliciano do Carmo: edition and revision of the article. Carlos Dornels Freire de Souza: edition and revision of the article. Jussara Almeida de Oliveira Baggio: conception, analysis, edition and revision of the article. Márcio Bezerra-Santos: conception, analysis, edition and revision of the article. All authors read and approved the manuscript prior to submission.

Funding

None.

Data availability

The datasets related to hospitalizations and deaths from AMI used in this study are publicly available through the Hospital Information System (SIH-SUS) and the Mortality Information System (SIM), both accessible via the Department of Informatics of the Brazilian Unified Health System (DATASUS) at [https://datasus.saude.gov.br/](https:/datasus.saude.gov.br) .

Declarations

Ethics approval and consent to participate

This study followed the ethical principles of research involving human beings established by Resolution 466/2012 of the National Health Council and by the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.