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. 2016 Aug;107(2):137–146. doi: 10.5935/abc.20160102

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

Antonio de Padua Mansur 1,✉, Desidério Favarato 1
PMCID: PMC5074067  PMID: 27437866

Abstract

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

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

Introduction

Cardiovascular diseases (CVD) are the major cause of death in men and women in the five Brazilian geoeconomic regions.1 The Southeastern and Southern regions had the highest adjusted coefficients of mortality due to CVD, ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) as compared to the Northern, Northeastern and West-Central regions.1 Mortality due to CVD in the Southeastern and Southern regions has a pattern similar to that observed in more developed countries, where CVD have a greater participation in the population overall mortality, and mortality due to IHD is more frequent than that due to CbVD. 2,3 Mortality due to CVD in the Northern, Northeastern and West-Central regions has a pattern similar to that observed in developing countries, where CVD have a proportionally smaller participation in the population overall mortality, and mortality due to CbVD is more frequent than that due to IHD.1-3 Similarly, the reduction in mortality due to CVD, IHD and CbVD was significantly higher in the Southeastern and Southern regions as compared to that in the Northern and West-Central regions, while the Northeastern region showed an increase in mortality due to those diseases.1,4 Those two studies have shown an approximation of the trends in mortality due to CVD in the five regions. However, Souza et al.1 have assessed the mortality data due to CVD only until 2006, and Baena et al.4 have reported mortality data in the five regions only for IHD until 2010.

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

Methods

This ecological, retrospective study based on temporal series assessed mortality due to DC, IHD and CbVD in a population aged ≥ 30 years in the five Brazilian regions (Northern, Northeastern, West-Central, Southeastern and Southern) from 1980 to 2012. Mortality data were obtained from the Brazilian Ministry of Health web portal, www.datasus.gov.br.5 The population data of the Brazilian Institute of Geography and Statistics (IBGE) were obtained from that same web portal. The deaths from 1990 to 1995 were classified according to the World Health Organization's International Classification of Disease (ICD), Ninth Revision (ICD-9), 1975, and adopted by the 20th World Health Assembly. According to ICD-9, diseases of the circulatory system (DCS) were encoded as 390 - 459, IHD were encoded as 410 - 414, and CbVD were encoded as 430 - 438. Mortality data from the year 1996 onwards were obtained from the Tenth Revision of ICD, and classified as follows: DCS were encoded as I00 - I99; IHD were encoded as I20 - I25; and CbVD were encoded as I60 - I69. For comparison purposes, mortality (per 100,000 inhabitants) was adjusted by using the direct standardization method, using as reference the 2000 world standard population.6 Simple linear regression model was used to analyze and compare mortality trends. The dependent variables were DCS, IHD and CbVD, and the independent variable was year. The significance level adopted for the statistical tests was 5% (p < 0.05). The statistical program used was SAS (SAS Institute Inc., 1989-1996, Cary, NC, USA), 9.2 version.

Results

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

Table 1.

Risk of death* per 100,000 inhabitants due to cardiovascular diseases (CVD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions

CVD total population CVD men CVD women
Year Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West-Central
1980 430 261 863 791 503 464 278 986 891 529 395 245 740 691 478
1981 365 268 832 748 583 386 288 951 847 643 344 248 713 649 523
1982 329 271 789 713 538 355 295 914 827 590 302 248 664 598 485
1983 331 263 792 740 568 355 285 919 854 631 307 240 665 626 504
1984 334 276 785 727 578 362 302 916 840 641 307 250 654 615 515
1985 339 273 779 694 580 368 302 909 796 641 310 244 649 591 520
1986 341 277 749 678 565 364 304 872 790 632 319 250 625 566 497
1987 317 257 727 677 526 337 284 846 778 580 297 230 609 575 472
1988 324 276 756 711 552 349 308 889 814 612 299 244 624 607 493
1989 319 270 721 653 516 346 299 849 752 581 291 240 593 555 451
1990 324 264 700 665 483 351 296 818 767 534 298 232 582 562 431
1991 309 261 646 620 494 340 293 758 716 550 278 228 535 524 438
1992 277 263 632 615 507 310 299 743 713 569 245 227 521 517 445
1993 323 287 678 681 553 355 323 795 785 621 290 251 561 577 485
1994 327 292 663 667 579 357 325 775 766 663 296 259 552 568 495
1995 340 298 644 665 553 371 327 743 756 605 308 269 546 573 500
1996 271 266 601 593 469 296 293 702 676 520 247 239 500 510 418
1997 284 276 584 580 497 310 306 681 663 546 257 246 487 496 447
1998 294 295 576 618 500 321 331 673 714 556 267 259 479 523 444
1999 303 294 574 599 520 338 326 669 688 588 268 261 480 511 452
2000 272 277 494 532 450 308 315 583 620 511 237 240 404 444 389
2001 288 295 487 509 457 323 337 578 592 523 252 254 397 427 391
2002 283 305 483 513 482 323 345 566 596 548 243 265 401 429 415
2003 302 313 491 511 499 339 353 582 599 576 264 272 399 423 423
2004 308 332 502 523 521 355 374 595 607 597 260 291 408 439 446
2005 312 352 474 493 493 354 396 560 573 565 269 309 387 413 420
2006 329 403 492 493 504 378 454 581 572 575 279 352 403 415 433
2007 301 381 398 408 400 344 435 473 473 467 258 327 322 343 333
2008 322 383 399 396 399 369 439 474 462 465 275 327 324 329 333
2009 318 375 386 389 381 366 430 460 455 443 270 320 313 323 319
2010 298 341 387 389 384 353 396 465 456 451 242 285 310 323 316
2011 316 358 387 398 382 367 417 463 468 447 264 298 312 328 318
2012 318 357 382 381 394 369 415 458 450 455 268 299 306 313 333
var (%) -35 27 -126 -108 -28 -26 33 -115 -98 -16 -47 18 -142 -121 -44
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*

adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980).

Table 2.

Risk of death* per 100,000 inhabitants due to ischemic heart diseases (IHD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions

IHD total population IHD men IHD women
Year Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West- Central
1980 91 49 267 225 106 110 60 327 278 122 72 38 207 172 90
1981 75 52 259 221 121 87 64 317 271 149 63 41 201 171 93
1982 75 54 244 205 115 94 66 303 261 141 56 43 185 150 90
1983 76 52 252 225 124 91 65 312 280 152 61 40 192 170 97
1984 71 56 247 226 121 88 70 310 285 148 55 41 185 168 95
1985 76 60 244 226 126 89 75 306 279 156 63 45 182 172 95
1986 77 61 234 212 128 90 76 291 266 158 64 45 176 159 99
1987 71 57 232 219 117 85 71 289 273 143 56 43 175 165 91
1988 73 61 239 228 123 88 76 301 282 151 58 46 177 174 94
1989 69 60 228 204 116 82 74 287 252 139 56 47 170 155 93
1990 77 60 218 206 106 95 74 273 257 132 60 45 162 155 80
1991 74 61 202 198 114 91 76 252 246 137 58 46 151 150 91
1992 64 61 191 194 118 80 75 241 242 147 48 47 141 146 89
1993 74 65 199 211 126 91 80 251 262 157 58 50 148 160 95
1994 73 66 197 209 127 91 81 247 259 158 56 51 148 160 95
1995 79 71 194 210 127 92 85 239 258 150 66 56 149 162 10
1996 66 66 186 194 118 79 79 234 239 142 52 52 138 148 93
1997 68 70 181 188 118 82 84 227 229 142 54 55 135 147 94
1998 68 73 179 202 122 81 89 225 248 150 55 57 133 156 95
1999 74 73 180 201 124 88 87 227 247 155 60 59 134 156 93
2000 65 71 157 180 115 80 87 200 224 143 50 55 113 136 87
2001 67 78 155 171 120 82 96 198 213 150 52 60 113 128 89
2002 66 82 156 173 129 84 100 198 216 159 48 64 114 129 99
2003 72 84 158 169 134 88 103 202 213 168 56 66 114 125 99
2004 78 90 161 173 143 99 109 206 216 179 56 71 116 131 10
2005 75 94 150 163 134 94 115 192 204 169 56 74 108 121 99
2006 81 109 156 162 139 104 133 200 205 172 59 86 111 120 10
2007 78 106 126 135 111 97 130 164 171 142 58 82 89 98 80
2008 82 109 127 129 113 104 134 165 164 145 61 85 89 93 81
2009 86 108 122 126 110 110 133 159 162 142 62 83 85 90 78
2010 81 103 124 125 112 105 128 161 159 147 57 77 86 92 77
2011 85 109 125 128 115 110 137 162 165 148 61 82 87 91 82
2012 84 111 125 121 121 118 137 163 158 157 50 85 86 85 86
var (%) -8 56 -114 -86 12 7 128 -101 -76 22 -44 55 -140 -102 -5
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*

adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980).

Table 3.

Risk of death* per 100,000 inhabitants due to cerebrovascular diseases (CbVD), and total variation, in the total population and in men and women in the period studied (1980-2012) in the five Brazilian regions

CbVD total population CbVD men CbVD women
Year Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West- Central Northern Northeastern Southeastern Southern West- Central
1980 117 82 275 207 110 121 82 303 225 114 113 82 247 188 107
1981 96 88 282 213 146 97 89 312 234 157 95 88 252 193 134
1982 98 87 270 207 137 98 89 302 235 147 99 85 238 178 128
1983 98 83 266 212 148 97 84 300 239 163 99 83 232 185 133
1984 103 89 276 209 151 104 92 312 232 165 102 86 240 186 137
1985 103 86 271 201 148 105 89 309 226 159 101 83 233 176 137
1986 102 89 266 202 148 103 93 303 234 160 100 86 229 170 135
1987 105 86 254 201 138 107 90 289 227 148 103 82 220 174 128
1988 107 93 265 208 146 112 98 304 234 162 103 89 226 182 131
1989 102 91 251 199 144 107 97 289 226 155 97 86 212 172 134
1990 101 89 249 203 135 104 95 288 231 149 97 82 209 176 122
1991 99 87 229 192 132 105 93 266 220 147 92 81 192 164 118
1992 84 90 229 189 136 90 98 266 217 148 79 81 192 160 125
1993 104 97 246 204 158 108 105 286 231 175 101 88 206 176 141
1994 106 97 239 199 168 112 104 276 226 190 100 90 202 172 146
1995 111 97 233 198 148 119 104 268 224 163 103 90 198 173 133
1996 89 81 155 164 121 93 87 179 183 135 84 76 130 144 107
1997 92 85 152 165 131 94 91 177 190 146 89 79 128 140 116
1998 97 89 147 176 133 103 97 171 205 150 90 81 122 146 117
1999 93 88 141 167 141 102 94 165 192 158 85 81 118 142 125
2000 89 82 121 144 113 95 91 142 167 129 83 73 101 120 98
2001 93 91 119 141 114 101 101 142 162 129 84 81 97 119 99
2002 93 92 119 140 119 102 103 139 163 134 83 82 99 118 103
2003 98 94 118 139 121 105 104 140 162 138 92 84 96 116 105
2004 97 97 116 142 124 109 106 137 164 142 85 88 96 121 105
2005 101 103 109 134 114 111 113 127 153 124 90 93 91 114 104
2006 109 120 115 135 119 119 131 134 155 134 98 108 96 115 105
2007 96 109 91 111 89 105 122 107 127 102 87 95 75 95 77
2008 105 108 89 106 92 115 121 105 124 106 95 94 74 88 78
2009 100 103 87 105 85 110 115 103 121 96 91 91 72 90 74
2010 91 94 86 107 89 102 105 103 125 102 80 82 69 88 75
2011 95 97 84 106 84 107 112 100 123 97 82 82 68 88 71
2012 93 97 81 103 86 104 111 96 120 98 82 82 66 86 74
var (%) -26 15 -240 -101 -28 -16 26 -216 -88 -16 -38 0 -274 -119 -45
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*

adjusted by use of the direct method for the 2000 standard world population; var (%): percentage variation (2012/1980).

Table 4.

Simple linear regression model for mortality due to cardiovascular diseases (CVD), ischemic heart diseases (IHD) and cerebrovascular diseases (CbVD) in men and women in the period studied (1980-2012) in the five Brazilian regions

  Total Men Women
  Raj2 β 95%CI P Raj2 β 95%CI P Raj2 β 95%CI P
CVD Northern 0.23 -1.56 -2.53 – -0.59 0.003 0.02 -0.68 -1.78 – 0.42 0.220 0.51 -2.45 -3.30 – -1.60 < 0.0001
CVD Northeastern 0.70 3.72 2.85 – 4.60 < 0.0001 0.76 4.75 3.89 – 5.82 < 0.0001 0.57 2.58 1.78 – 3.39 < 0.0001
CVD Southeastern 0.97 -15.30 -16.18 – -14.43 < 0.0001 0.97 -17.22 -18.23 – -16.20 < 0.0001 0.97 -13.38 -14.17 – -12.60 < 0.0001
CVD Southern 0.93 -12.12 -13.32 – -10.92 < 0.0001 0.93 -13.53 -14.84 – -12.21 < 0.0001 0.92 -10.70 -11.81 – -9.57 < 0.0001
CVD West-Central 0.63 -5.17 -6.59 – -3.76 < 0.0001 0.50 -4.70 -6.37 – -3.03 < 0.0001 0.74 -5.64 -6.86 – -4.44 < 0.0001
IHD Northern 0.14 0.14 -0.10 – 0.38 0.238 0.16 0.45 0.11 – 0.80 0.012 0.07 -0.17 -0.35 – 0.02 0.072
IHD Northeastern 0.90 1.97 1.73 – 2.22 < 0.0001 0.88 2.41 2.10 – 2.73 < 0.0001 0.90 1.54 1.36 – 1.73 < 0.0001
IHD Southeastern 0.97 -4.64 -4.92 – -4.36 < 0.0001 0.97 -5.47 -5.83 – -5.12 < 0.0001 0.97 -3.81 -4.03 – -3.60 < 0.0001
IHD Southern 0.85 -3.27 -3.76 – -2.78 < 0.0001 0.87 -3.92 -4.47 – -3.37 < 0.0001 0.82 -2.62 -3.10 – -2.17 < 0.0001
IHD West-Central 0.48 0.11 -0.21 – 0.44 0.479 0.10 0.43 0.02 – 0.84 0.023 0.06 -0.76 -1.63 – 0.12 0.089
CbVD Northern 0.08 -0.24 -0.49 – 0.01 0.056 0.01 0.11 -0.17 – -0.39 0.440 0.45 -0.60 -0.84 – -0.37 < 0.0001
CbVD Northeastern 0.38 0.56 0.31 – 0.81 < 0.0001 0.62 0.95 0.68 – 1.22 < 0.0001 0.01 0.14 -0.10 – 0.38 0.234
CbVD Southeastern 0.92 -7.51 -8.29 – -6.74 < 0.0001 0.91 -8.27 -9.20 – -7.34 < 0.0001 0.94 -6.74 -7.37 – -6.11 < 0.0001
CbVD Southern 0.90 -3.84 -4.38 – -3.40 < 0.0001 0.88 -4.13 -4.68 – -3.59 < 0.0001 0.92 -3.56 -3.94 – -3.18 < 0.0001
CbVD West-Central 0.56 -1.81 -2.38 – -1.24 < 0.0001 0.45 -1.72 -2.39 – -1.05 < 0.0001 0.67 -1.91 -2.39 – -1.43 < 0.0001
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95% CI: 95% confidence interval.

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

Figure 1.

Figure 1

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

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

Figure 2.

Figure 2

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

Figure 3.

Figure 3

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

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

Figure 4.

Figure 4

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

Figure 5.

Figure 5

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

Discussion

This study showed the highest reductions in mortality due to CVD, IHD and CbVD in the Southeastern and Southern regions, while the Northeastern region had mortality due to those diseases increased. The results varied in the Northern and West-Central regions. Therefore, the Southeastern and Southern regions behaved similarly to the most developed countries, with a persistent trend of reduction in mortality due to CVD.7,8

On the other hand, the mortality trends of the other regions behaved similarly to those of developing countries. The population's more limited access to a more appropriate health care system, in addition to socioeconomic and cultural aspects, might justify those trends. For example, the control of risk factors accounted for at least a 50% reduction in mortality due to CVD in more developed countries.9

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

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

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

In addition to the drug treatment complexity, there is limited availability of the intervention treatment, restricted to large urban centers. Such diagnostic and therapeutic limitations can justify the heterogeneity in the risk of death due to acute myocardial infarction in the different Brazilian regions.11

Similarly, social inequalities and low educational level are additional conditions associated with higher mortality due to CVD.12-14 The Southern and Southeastern regions have the highest urban developing indices, which is assessed by the progress of the regions in three basic dimensions: income, educational level and health.15,16 Half of the mortality due to CVD before the age of 65 years can be attributed to poverty.13 Similarly, the educational level has an inverse relationship with mortality due to CVD. Inadequate feeding, insufficient physical activity, alcohol consumption and smoking are important risk factors for DVC and more prevalent in the least favored social levels.17 Therefore, primary and secondary prevention programs aimed at those population strata can significantly impact morbidity and mortality due to CVD. For example, the "Family Health Strategy" program facilitated actions for health promotion and perfected the process of prevention and early diagnosis of the major risk factors for CVD.18

Another important point observed in our study was the convergence of the trends in mortality due to IHD and CbVD in the Brazilian regions. The convergence of the trends in mortality due to IHD occurred from 2007 onwards, while that due to CbVD occurred 10 years earlier. That behavior reflects in the earlier and steepest drop in mortality due to CbVD, resulting in the epidemiological transition phenomenon, which is predominance of mortality due to IHD over that due to CbVD.19

This study's major limitations relates to the quality of Brazilian mortality data, such as errors related to the diagnosis and accuracy of death certificates, ill-defined causes of deaths and data inputting errors. The number of death certificates with symptoms, signs and ill-defined health conditions reported as cause of death is an indirect indicator of the data quality pattern. Despite the progressive improvement, the number of death certificates with those characteristics in the Northeastern, Northern and West-Central regions is still significant.20,21

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

Conclusion

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

Footnotes

Author contributions

Conception and design of the research, Statistical analysis and Writing of the manuscript: Mansur AP; Acquisition of data: Favarato D; Analysis and interpretation of the data and Critical revision of the manuscript for intellectual content: Mansur AP, Favarato D.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any thesis or dissertation work.

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