About

Brazil is a continental country of extreme diversity regarding climate and environmental conditions, population density, economic development, and racial and cultural features. One of the 10 richest economies of the world, it is also one of the most unequal countries: according to the World Bank, it ranks among the 10 countries with the highest Gini index, a measurement of income distribution inequality, (https://data.worldbank.org/indicator/SI.POV.GINI). Brazil has one of the largest public health systems with universal coverage, the Unified National Health System (SUS – Sistema Único de Saúde), which covers the whole Brazilian population, estimated at 210 million inhabitants in 2019, year in which it was the exclusive health system for 76% of the population (http://www.ans.gov.br). Indeed, SUS co-exists with a private health system that includes health plans, insurance, and private health professionals. Established by the Brazilian Constitution of 1988, the implementation and expansion of SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health services coverage and increase in life expectancy in just three decades (1, 2). The Family Health Program (FHP), launched in 1994, is a leading initiative in the national strategy to reduce CVD mortality based on primary health care, covering almost 123 million individuals (63% of the Brazilian population) in 2015 (3). However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and issues related to access and quality of care (1, 2).

Cardiovascular disease (CVD) has been the leading cause of mortality since the 1960’s and has accounted for a substantial burden of disease in Brazil (2, 4). Considerable data relevant to cardiovascular health are now available from governmental health surveillance and administrative databases and from epidemiological studies (5-10). However, representative and reliable nationwide data on many health behaviors and cardiovascular risk factors, and on morbidity assessed in both the public and the private sectors remain sparse (2). In the last years, the Global Burden of Disease project, led by the Institute of Health Metrics and Evaluation of the University of Washington, begun working with a Brazilian GBD network to release subnational estimates of the burden of disease by  Brazilian federative units, including for cardiovascular causes (11-14). 
 

This report, the Cardiovascular Statistics Brazil document, incorporates official statistics provided by the Brazilian Health Ministry and other government agencies, as well as data generated by other sources and scientific studies on heart disease, stroke, and other cardiovascular diseases, including data from GBD/IHME. The aim of this project is to continuously monitor and evaluate sources of data on heart disease and stroke in Brazil, in order to provide the most current information on the epidemiology of heart diseases and stroke to the Brazilian society, on an annual basis. This initiative is based on the American Heart Association Heart Disease & Stroke Statistics Update (15) methodology, and is being supported by the Brazilian Society of Cardiology (SBC), the GBD Brazil network, and an International Committee. The Cardiovascular Statistics Brazil document is the product of effort by dedicated volunteer clinicians and scientists, committed government professionals, and outstanding SBC members, without whom publication of this valuable resource would be impossible. The document was designed to be a valuable resource for researchers, clinicians, patients, healthcare policy makers, media professionals, the public, and others who seek comprehensive national data available on heart disease and stroke. The first edition was restricted to a limited number of clinical conditions, listed below:

  1. Total Cardiovascular Disease

  2. Cerebrovascular Disease

  3. Coronary Heart Disease, Acute CS, and Angina Pectoris

  4. Cardiomyopathy and Heart Failure

  5. Valvular Diseases including Rheumatic Heart Disease

  6. Atrial Fibrillation

All chapters are standardized in a common structure and included at least the following topics: Prevalence, Incidence, Mortality, Burden of Disease, HealthCare Utilization and Costs, Future Directions. In the following editions, we intend to more comprehensively cover the clinical cardiac conditions, and also cardiovascular risk factors, life habits, quality of care and other aspects that are relevant to the study of cardiovascular diseases.


The emphasis of the document is on updated epidemiological data. It does not focus on physiopathological mechanisms or the merits of specific clinical treatments and does not make treatment recommendations. It is also not a position paper or a comprehensive review but tries to present the newest and best health related metrics of cardiovascular disease statistics for the Brazilian population. Moreover, it is not intended to cover other countries and regions, being restricted to Brazil, its regions, and federative units. 

For the present document, we mostly used 3 sources of data: (a) Data for Brazilian Mortality and Health Systems, provided by the government; (b) GBD 2017 estimates; (c) systematic review of the literature with emphasis of what was published in the last 10 years. Same metrics from different sources were not identical and differences may be related to different time periods, location, age range or other methodological aspects (Malta, 2020, ABC Cardiol, in press). As such, we did not avoid citing discordant metrics, but possible reasons for these differences were generally mentioned or discussed.

 

Since many studies cover a long period of time and life expectancy increased in Brazil in the last decades, we decided to use age-standardized rates, i.e.,  a weighted average of the age-specific rates per 100 000 persons, where the weights are the proportions of persons in the corresponding age groups of a standard population. GBD age-standardization uses a global age pattern, although other sources may have used different reference populations. For most studies, race/skin color was used according to IBGE definition, i.e., white, black, brown, yellow (oriental) or indian (native indian).

References:

  1. Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet. 2019;394(10195):345-56.

  2. Ribeiro AL, Duncan BB, Brant LC, Lotufo PA, Mill JG, Barreto SM. Cardiovascular Health in Brazil: Trends and Perspectives. Circulation. 2016;133(4):422-33.

  3. Andrade MV, Coelho AQ, Xavier Neto M, Carvalho LR, Atun R, Castro MC. Brazil's Family Health Strategy: factors associated with programme uptake and coverage expansion over 15 years (1998-2012). Health Policy Plan. 2018;33(3):368-80.

  4. Nascimento BR, Brant LCC, Oliveira GMM, Malachias MVB, Reis GMA, Teixeira RA, Malta DC, Franca E, Souza MFM, Roth GA, Ribeiro ALP. Cardiovascular Disease Epidemiology in Portuguese-Speaking Countries: data from the Global Burden of Disease, 1990 to 2016. Arq Bras Cardiol. 2018;110(6):500-11.

  5. Malta DC, Stopa SR, Iser BP, Bernal RT, Claro RM, Nardi AC, Dos Reis AA, Monteiro CA. Risk and protective factors for chronic diseases by telephone survey in capitals of Brazil, Vigitel 2014. Rev Bras Epidemiol. 2015;18 Suppl 2:238-55.

  6. Nascimento BR, Brant LC, Lana ML, Lopes EL, Ribeiro AL. Trends in Procedure Type, Morbidity and In-Hospital Outcomes of Patients with Peripheral Artery Disease: Data from the Brazilian Public Health System. Annals of vascular surgery. 2016;31:143-51.

  7. Goncalves RPF, Haikal DS, Freitas MIF, Machado IE, Malta DC. Self-reported medical diagnosis of heart disease and associated risk factors: National Health Survey. Rev Bras Epidemiol. 2019;22Suppl 02(Suppl 02):E190016 SUPL 2.

  8. Schmidt MI, Duncan BB, Mill JG, Lotufo PA, Chor D, Barreto SM, Aquino EM, Passos VM, Matos SM, Molina MD, Carvalho MS, Bensenor IM. Cohort Profile: Longitudinal Study of Adult Health (ELSA-Brasil). IntJ Epidemiol. 2015;44(1):68-75.

  9. Lima-Costa MF, Peixoto SV, Matos DL, Firmo JO, Uchoa E. Predictors of 10-year mortality in a population of community-dwelling Brazilian elderly: the Bambui Cohort Study of Aging. Cadernos de saude publica. 2011;27 Suppl 3:S360-9.

  10. Villela PB, Klein CH, de Oliveira GMM. Socioeconomic factors and mortality due to cerebrovascular and hypertensive disease in Brazil. Rev Port Cardiol. 2019;38(3):205-12.

  11. Lotufo PA, Goulart AC, Passos VMA, Satake FM, Souza MFM, Franca EB, Ribeiro ALP, Bensenor IJM. Cerebrovascular disease in Brazil from 1990 to 2015: Global Burden of Disease 2015. Rev Bras Epidemiol. 2017;20Suppl 01(Suppl 01):129-41.

  12. Brant LCC, Nascimento BR, Passos VMA, Duncan BB, Bensenor IJM, Malta DC, Souza MFM, Ishitani LH, Franca E, Oliveira MS, Mooney M, Naghavi M, Roth G, Ribeiro ALP. Variations and particularities in cardiovascular disease mortality in Brazil and Brazilian states in 1990 and 2015: estimates from the Global Burden of Disease. Rev Bras Epidemiol. 2017;20Suppl 01(Suppl 01):116-28.

  13. Franca EB, Passos VMA, Malta DC, Duncan BB, Ribeiro ALP, Guimaraes MDC, Abreu DMX, Vasconcelos AMN, Carneiro M, Teixeira R, Camargos P, Melo APS, Queiroz BL, Schmidt MI, Ishitani L, Ladeira RM, Morais-Neto OL, Bustamante-Teixeira MT, Guerra MR, Bensenor I, Lotufo P, Mooney M, Naghavi M. Cause-specific mortality for 249 causes in Brazil and states during 1990-2015: a systematic analysis for the global burden of disease study 2015. Popul Health Metr. 2017;15(1):39.

  14. Collaborators GBDB. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10149):760-75.

  15. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW, American Heart Association Council on E, Prevention Statistics C, Stroke Statistics S. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-e596.
     

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