Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC DBcdvZJs8v7JFG95RNnHrjv S0066-782X2020001100308 abc.20200812 10.36660/abc.20200812 Artigo Especial Estatística Cardiovascular – Brasil 2020 0000-0002-6306-1279 Oliveira Gláucia Maria Moraes de 1 2 0000-0002-7317-1367 Brant Luisa Campos Caldeira 3 4 0000-0002-2447-2577 Polanczyk Carisi Anne 5 6 7 0000-0002-8579-4158 Biolo Andreia 5 6 7 0000-0002-5586-774X Nascimento Bruno Ramos 3 4 0000-0002-8214-5734 Malta Deborah Carvalho 8 0000-0003-3287-9163 Souza Maria de Fatima Marinho de 8 9 0000-0002-7058-799X Soares Gabriel Porto 1 10 0000-0001-5190-3523 Xavier Gesner Francisco Junior 11 0000-0003-1840-4372 Machline-Carrion M. Julia 12 0000-0002-3711-1754 Bittencourt Marcio Sommer 13 14 0000-0003-0317-843X Pontes Octavio M. Neto 15 0000-0002-5538-7455 Silvestre Odilson Marcos 16 Teixeira Renato Azeredo 8 0000-0001-6524-9614 Sampaio Roney Orismar 17 18 19 0000-0002-5985-345X Gaziano Thomaz A. 20 21 Roth Gregory A. 22 23 0000-0002-2740-0042 Ribeiro Antonio Luiz Pinho 3 4 Instituto do Coração Edson Saad Universidade Federal do Rio de Janeiro Rio de Janeiro RJ Brasil Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro , RJ – Brasil Departamento de Clínica Médica Faculdade de Medicina Universidade Federal do Rio de Janeiro Rio de Janeiro RJ Brasil Disciplina de Cardiologia, Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro , RJ – Brasil Departamento de Clínica Médica Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte MG Brasil Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte , MG – Brasil Centro de Telessaúde Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte MG Brasil Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte , MG – Brasil Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brasil Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre , RS – Brasil Serviço de Cardiologia Hospital Moinhos de Vento Porto Alegre RS Brasil Serviço de Cardiologia do Hospital Moinhos de Vento , Porto Alegre , RS – Brasil Hospital de Clínicas de Porto Alegre Porto Alegre RS Brasil Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre , RS – Brasil Programa de Pós-Graduação em Saúde Pública Universidade Federal de Minas Gerais Belo Horizonte MG Brasil Programa de Pós-Graduação em Saúde Pública da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte , MG – Brasil Organização Vital Strategies Nova York EUA Organização Vital Strategies , Nova York – EUA Universidade de Vassouras Vassouras RJ Brasil Curso de Medicina da Universidade de Vassouras , Vassouras , RJ – Brasil Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte MG Brasil Biblioteca da Faculdade de Medicina Universidade Federal de Minas Gerais (UFMG), Belo Horizonte , MG – Brasil ePHealth Primary Care Solutions Santo Antônio SC Brasil ePHealth Primary Care Solutions , Santo Antônio , SC – Brasil Divisão de Clínica Médica Hospital Universitário Universidade de São Paulo São Paulo SP Brasil Divisão de Clínica Médica do Hospital Universitário da Universidade de São Paulo , São Paulo , SP – Brasil Faculdade Israelita de Ciências da Saúde Albert Einstein São Paulo SP Brasil Faculdade Israelita de Ciências da Saúde Albert Einstein , São Paulo , SP – Brasil Departamento de Neurociências e Ciências do Comportamento Faculdade de Medicina de Ribeirão Preto Universidade de São Paulo São Paulo SP Brasil Serviço de Neurologia Vascular e Emergências Neurológicas, Divisão de Neurologia, Departamento de Neurociências e Ciências do Comportamento , Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (USP), São Paulo , SP – Brasil Universidade Federal do Acre Rio Branco AC Brasil Universidade Federal do Acre (UFAC), Rio Branco , AC – Brasil Departamento de Cardiopneumologia Faculdade de Medicina Universidade de São Paulo São Paulo SP Brasil Departamento de Cardiopneumologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo , SP – Brasil Programa de Pós-Graduação Faculdade de Medicina Universidade de São Paulo São Paulo SP Brasil Programa de Pós-Graduação da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo , SP – Brasil Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São Paulo SP Brasil Unidade Clínica de Cardiopatias Valvares do Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo , SP – Brasil Brigham and Women’s Hospital Boston EUA Brigham and Women’s Hospital , Boston – EUA Department of Medicine Harvard Medical School Boston EUA Department of Medicine , Cardiovascular, Harvard Medical School , Boston – EUA Global Health and Health Metrics Sciences Institute for Health Metrics and Evaluation Washington EUA Global Health and Health Metrics Sciences at the Institute for Health Metrics and Evaluation (IHME), Washington – EUA Division of Cardiology University of Washington School of Medicine Washington EUA Division of Cardiology at the University of Washington School of Medicine , Washington – EUA Correspondência: Gláucia Maria Moraes de Oliveira e Antonio Luiz Pinho Ribeiro • Universidade Federal do Rio de Janeiro – R. Prof. Rodolpho P. Rocco, 255 – 8°. Andar – Sala 6, UFRJ. CEP: 21941-913, Cidade Universitária, RJ – Brasil E-mail: glauciam@cardiol.br , glauciamoraesoliveira@gmail.com ; tom1963br@yahoo.com.br

Contribuição dos Autores

Concepção e desenho da pesquisa; Obtenção de dados; Análise e interpretação dos dados; Análise estatística; Redação do manuscrito; Revisão crítica do manuscrito quanto ao conteúdo intelectual importante: Oliveira GMM, Brant LCC, Polanczyk CA, Biolo A, Nascimento BR, Malta DC, Souza MFM, Soares GP, Xavier Junior GF, Machline-Carrion MJ, Bittencourt MS, Pontes-neto OM, Silvestre OM, Teixeira RA, Sampaio RO, Gaziano TA, Roth GA, Ribeiro ALP. Supervisão / como investigador principal: Oliveira GMM, Ribeiro ALP.

Potencial Conflito de Interesse

Declaro não haver conflito de interesses pertinentes.

28 09 2020 09 2020 115 3 308 439 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Doenças Cardiovasculares Doença das Coronárias Cardiomiopatias. Insuficiência Cardíaca Doenças das Valvas Cardíacas Fibrilação Atrial Flutter Atrial Estatística Brasil Sobre este Documento

Abreviaturas usadas nesta Introdução
CID Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DCV Doença Cardiovascular
GBD Global Burden of Disease
IBGE Instituto Brasileiro de Geografia e Estatística
IHME Institute for Health Metrics and Evaluation
IPCA Índice de Preços ao Consumidor Amplo
PIB Produto Interno Bruto
PNS Pesquisa Nacional de Saúde
PPC Paridade do Poder de Compra
SBC Sociedade Brasileira de Cardiologia
SIH Sistema de Informações Hospitalares
SIM Sistema de Informações sobre Mortalidade
SUS Sistema Único de Saúde
UF Unidade Federativa
YLDs Anos vividos com incapacidade (do inglês, Years Lived with Disability )
YLLs Anos potenciais de vida perdidos (do inglês, Years of Life Lost )

O Brasil é um país continental de extrema diversidade quanto a clima e condições ambientais, densidade populacional, desenvolvimento econômico e características raciais e culturais. Uma das dez economias mais ricas do mundo, o Brasil é também um dos países mais desiguais: segundo o Banco Mundial, está entre os dez países de maior Índice de Gini, uma medida da desigualdade de distribuição de renda (https://data.worldbank.org/indicator/SI.POV.GINI). O Brasil possui o SUS, um dos maiores sistemas públicos de saúde com cobertura universal, que abrange toda a população brasileira, estimada em 210 milhões de habitantes em 2019 (https://www.ibge.gov.br/estatisticas/sociais/populacao.html), ano em que o SUS foi o único sistema de saúde para 76% daquela população (http://www.ans.gov.br). Na verdade, o SUS coexiste com o sistema privado de saúde, que inclui planos e seguros de saúde, além de profissionais de saúde privados. Estabelecido pela Constituição Brasileira de 1988, a implementação e a expansão do SUS permitiram ao Brasil abordar rapidamente as mudanças nas necessidades de saúde da população, com dramática sofisticação da cobertura dos serviços de saúde e aumento da expectativa de vida em apenas três décadas. 1 , 2 O Programa de Saúde da Família, lançado em 1994, é uma importante iniciativa da estratégia nacional para reduzir a mortalidade por DCV com base na atenção primária à saúde, cobrindo quase 123 milhões de indivíduos (63% da população brasileira) em 2015. 3 Entretanto, a despeito dos sucessos, a análise dos cenários futuros sugere a necessidade urgente de abordar desigualdades geográficas persistentes, financiamento insuficiente, além de questões relacionadas ao acesso ao cuidado e à sua qualidade. 1 , 2

A DCV tem sido a principal causa de mortalidade desde a década de 60, sendo responsável por uma substancial carga de doença no Brasil. 2 , 4 Uma quantidade considerável de dados relevantes para a saúde cardiovascular é disponibilizada tanto pelo governo, através de vigilância em saúde e bancos de dados administrativos, quanto pelos estudos epidemiológicos. 5 - 10 Entretanto, dados nacionais representativos e confiáveis sobre muitos comportamentos relacionados a saúde e fatores de risco cardiovascular, assim como sobre morbidade, avaliados nos setores público e privado permanecem escassos. 2 Nos últimos anos, o Projeto GBD, conduzido pelo IHME da Universidade de Washington, começou a trabalhar com a rede GBD Brasil para fornecer estimativas subnacionais de carga de doença para as UF do Brasil, incluindo as causas cardiovasculares. 11 - 14

Este relatório, Estatística Cardiovascular – Brasil 2020 , incorpora estatísticas oficiais fornecidas pelo Ministério da Saúde brasileiro e outras agências governamentais, além de dados gerados por outras fontes e estudos científicos sobre doença cardíaca, acidente vascular cerebral e outras DCV, inclusive dados do GBD/IHME. Este projeto tem por objetivo monitorar e avaliar continuamente as fontes de dados sobre doença cardíaca e acidente vascular cerebral no Brasil para fornecer a informação mais atualizada sobre a epidemiologia dessas doenças para a sociedade brasileira anualmente. Esta iniciativa é baseada na metodologia Heart Disease & Stroke Statistics Update 15 da American Heart Association , contando com o suporte da SBC, da rede GBD Brasil e de um comitê internacional. O documento Estatística Cardiovascular – Brasil 2020 resulta do esforço de clínicos e cientistas dedicados e voluntários, profissionais do governo comprometidos e excepcionais membros da SBC, sem os quais a publicação desta valiosa fonte não seria possível. Este documento foi projetado para ter grande utilidade para pesquisadores, clínicos, pacientes, formuladores de políticas de saúde, profissionais da mídia, o público em geral e todos aqueles que buscam dados nacionais abrangentes sobre doença cardíaca e acidente vascular cerebral. A primeira edição ficou restrita a um número limitado de condições clínicas, listadas a seguir:

Doença Cardiovascular Total

Doença Cerebrovascular

Doença Arterial Coronariana, Síndrome Coronariana Aguda e Angina Pectoris

Cardiomiopatia e Insuficiência Cardíaca

Doenças Valvares, incluindo Cardiopatia Reumática

Fibrilação Atrial

Todos os capítulos estão padronizados e apresentam uma estrutura em comum, que inclui pelo menos os seguintes tópicos: Prevalência, Incidência, Mortalidade, Carga de Doença, Utilização e Custo da Atenção à Saúde, Pesquisa Futura. Nas próximas edições, pretendemos ampliar a cobertura das condições cardíacas clínicas e ainda dos fatores de risco cardiovascular, dos hábitos de vida, da qualidade do cuidado e de outros aspectos relevantes para o estudo das DCV.

A ênfase do documento está nos dados epidemiológicos atualizados. Não foca nos mecanismos fisiopatológicos nem nos méritos de tratamentos clínicos específicos, sequer faz recomendações terapêuticas. Ademais, não é um position paper nem uma revisão abrangente, mas procura apresentar as melhores e mais novas métricas relacionadas à saúde sobre as estatísticas das DCV para a população brasileira. Importante notar ainda que este documento não tem a pretensão de cobrir outros países e regiões, ficando restrito ao Brasil e às suas regiões e UF.

Para o presente documento, foram utilizadas principalmente três fontes de dados: (a) sistemas de informação de mortalidade e saúde no Brasil, disponibilizados pelo governo; (b) estimativas do GBD 2017; (c) revisão sistemática da literatura com ênfase nas publicações dos últimos dez anos. As métricas das diversas fontes não foram idênticas, podendo as diferenças estar relacionadas a diferentes períodos de tempo, localizações, faixas etárias ou a outros aspectos metodológicos (Malta, 2020, ABC Cardiol, in press ). Por isso não evitamos citar métricas discordantes e, em geral, mencionamos ou discutimos as possíveis razões para tais diferenças. Como muitos estudos cobrem um longo período de tempo e a expectativa de vida no Brasil aumentou nas últimas décadas, decidimos usar taxas padronizadas por idade, i.e., uma média ponderada de taxas específicas para idade por 100 mil pessoas, onde os pesos são as proporções de pessoas nos grupos etários correspondentes de uma população padrão. A padronização por idade do GBD utiliza um padrão global de idade, embora outras fontes possam ter usado diferentes populações de referência. Para a maioria dos estudos, raça/cor da pele foi usada de acordo com a definição do IBGE, i.e., branca, preta, parda, amarela (oriental) ou indígena (nativa).

A seguir, apresentamos um breve resumo das nossas fontes de dados e da metodologia usada para avaliar a utilização do cuidado de saúde.

Sistemas de Informação de Mortalidade e de Saúde no Brasil

Na presente versão da Estatística Cardiovascular – Brasil 2020 , as principais fontes de dados brasileiros são os sistemas de informação de saúde brasileiros, que compreendem o SIM e o SIH, as pesquisas de saúde periódicas, como a PNS, e as estimativas populacionais oficiais, especificados a seguir:

Sistema de Informação sobre Mortalidade: O SIM foi criado em 1975 pelo Ministério da Saúde brasileiro, sendo responsável por coletar, armazenar, gerenciar e divulgar dados nacionais de mortalidade. Esse sistema de informação em saúde representou um grande avanço na vigilância epidemiológica do país, pois sua principal atribuição é registrar todas as mortes ocorridas no território brasileiro. O Ministério da Saúde implementou um modelo de declaração de óbito padrão para coletar informação sobre morte, que utiliza a CID para codificar as causas de morte. Além disso, um fluxo para coletar, processar e distribuir a informação sobre morte foi implementado em todos os 5.570 municípios do país. 16 , 17 A qualidade da estatística sobre causas de morte no Brasil, baixa no início dos anos 2000, em especial em algumas partes do país, melhorou significativamente nas duas últimas décadas. 18 Por conhecer a heterogeneidade desses indicadores no Brasil e buscando uma estimativa da informação mais próxima da situação real, o relatório E statística Cardiovascular – Brasil 2020 tratou os dados, realizando a correção para subnotificação e a redistribuição das causas de morte mal definidas. Mais detalhes podem ser obtidos no artigo de Malta et al. ( in press ).

Sistema de Informação Hospitalar: O objetivo da base de dados do SIH é registrar todas as hospitalizações financiadas pelo SUS. O SIH-SUS armazena dados sobre as hospitalizações em nível municipal através da Autorização de Internação Hospitalar, que contém informação sobre as doenças que levaram a hospitalização (usando a CID-10), o tempo de permanência, os procedimentos e os custos. 19 A informação do SIH-SUS permite o desenvolvimento de metodologias e a definição de indicadores para identificar disparidades geográficas relacionadas aos recursos hospitalares. 20

Pesquisa Nacional de Saúde: Embora não esteja no escopo do documento deste ano descrever a estatística para fatores de risco cardiovascular, alguns capítulos citam a métrica para alguns fatores de risco no contexto da doença especificada. Nesses casos, deu-se preferência à PNS, que é um inquérito de base domiciliar, representativo do Brasil, de suas grandes regiões e UF, regiões metropolitanas, capitais e de outros municípios em cada UF. A amostragem da PNS 2013 foi composta por 64.348 domicílios. A pesquisa foi conduzida pelo IBGE em parceria com o Ministério da Saúde, tendo incluído a maioria dos tópicos de saúde, como doenças não transmissíveis, função renal, idosos, mulheres, crianças, utilização dos serviços de saúde, desigualdades em saúde, características antropométricas, exames laboratoriais, além de aferição de pressão arterial. 21 Os dados da PNS são usados pelo GBD em suas estimativas para o Brasil.

Para as estimativas populacionais, utilizaram-se no denominador as estimativas populacionais mais atualizadas geradas pelo IBGE (www.ibge.gov.br). Para as hospitalizações e análises de custo, utilizou-se a população residente estimada para o Tribunal de Contas da União anualmente, de 2008 a 2018.

GBD 2017

O Estudo GBD (http://www.healthdata.org/gbd) é o mais abrangente estudo epidemiológico observacional de âmbito mundial até o momento. Descreve mortalidade e morbidade decorrentes das principais doenças, injúrias e fatores de risco em níveis global, nacional e regional. O exame das tendências a partir de 1990 até o presente, assim como as comparações entre populações, permitem compreender os desafios em saúde enfrentados pelas pessoas em todo o mundo no século 21. O GBD 2017 é o último conjunto de dados disponibilizado publicamente. 22 - 25 A rede GBD Brasil tem colaborado com o IHME, que lidera o projeto em âmbito mundial, para a identificação e a provisão de conjuntos de dados, a revisão de modelos e estimativas, bem como a validação e a publicação de resultados para o Brasil. 13 , 14 Detalhes de como as estimativas são calculadas podem ser obtidos nas publicações de base do Estudo GBD 22 - 25 e no website do IHME (http://www.healthdata.org/acting-data/what-we-measure-and-why). As principais estimativas usadas neste documento estão resumidas abaixo:

Estimativas de mortes e de causas de morte. A principal fonte de informação é o SIM, uma base de dados do Ministério da Saúde, ajustada para outras fontes nacionais e internacionais. O IHME corrigiu a subnotificação de mortes e as mortes com “código garbage ” através da utilização de metodologia com algoritmos previamente publicada, 26 atualizada nas versões mais recentes do estudo (http://www.healthdata.org/acting-data/determining-causes-death-how-we-reclassify-miscoded-deaths).

Os YLLs são os anos perdidos em razão de mortalidade prematura, sendo calculados subtraindo-se a idade à época da morte da maior expectativa de vida possível para uma pessoa. Por exemplo, se a maior expectativa de vida para um homem em um certo país for de 75 anos, e se um homem morre de câncer aos 65 nesse país, tem-se 10 anos potenciais de vida perdidos para o câncer.

Os YLDs também podem ser descritos como os anos vividos com saúde inferior à ideal. Estão aqui incluídas condições como influenza, que pode durar apenas uns poucos dias, ou epilepsia, que pode durar uma vida inteira. Os YLDs podem ser calculados ao se multiplicar a prevalência da condição pelo peso da incapacidade por ela gerada. Os pesos da incapacidade refletem a gravidade de diferentes condições e são desenvolvidos através de pesquisas com o público em geral.

Os DALYs são uma métrica universal que permite que pesquisadores e formuladores de políticas comparem populações e condições de saúde muito diferentes ao longo do tempo. Os DALYs correspondem à soma dos YLLs e YLDs, sendo 1 DALY igual a 1 ano de vida saudável perdido. Esse índice permite que se estime o número total de anos perdidos devido a causas específicas e fatores de risco em níveis global, nacional e regional.

Revisão Sistemática da Literatura

Os descritores para a elaboração das estratégias de busca foram selecionados no MeSH e no DeCS, os vocabulários controlados da MEDLINE e da LILACS, respectivamente. O plano da Embase foi desenhado com descritores Emtree em associação com MeSH. Além disso, termos livres foram usados, i.e., palavras-chave significativas e seus sinônimos, variações ortográficas e acrônimos essenciais para a busca no domínio pesquisado, mas que não são descritores controlados (ou não estão na lista de sinônimo desses descritores). É importante lembrar que, para manter a uniformidade, os mesmos descritores foram usados em todas as estratégias de busca. Entretanto, as estratégias foram customizadas conforme as especificidades de cada base de dados. Vale ainda lembrar que o grupo de termos relacionados a “Brasil” foi em geral utilizado em todos os campos de pesquisa (assunto, autor, título, afiliação institucional, nome do periódico, etc.).

As bases selecionadas para busca foram a MEDLINE através da PubMed, Embase, LILACS, CINAHL, Cochrane Library Scopus e Web of Science . Os seguintes filtros e limites da pesquisa bibliográfica foram utilizados: período de publicação (2004-2019); línguas: português, inglês e espanhol; tipo de estudo/publicação: Revisão, Meta-Análise, Ensaio Clínico, Ensaio Randomizado Controlado, Estudo Comparativo, Diretriz de Prática, Diretriz, Revisão Sistemática, Estudo de Avaliação, Publicação Governamental e Estudo Multicêntrico. Todas as referências foram organizadas usando-se o EndNote Web . A partir da busca, os artigos foram incluídos se os estudos fossem de base populacional ou comunitária. Deu-se preferência aos estudos de âmbito nacional ou estadual. Os estudos conduzidos em serviços de saúde ou hospitais foram incluídos caso fossem multicêntricos e possuíssem tamanho amostral adequado (> 200 participantes foi o ponto de corte sugerido). Além dos artigos identificados na busca sistemática, os autores puderam incluir outros encontrados nas referências dos artigos buscados ou outros de que tivessem conhecimento em suas áreas de especialidade, caso os estudos atendessem aos critérios acima mencionados. Por fim, a decisão de quais estudos incluir em cada capítulo coube principalmente aos especialistas designados para o tema em questão.

Utilização da Atenção à Saúde

Os estudos sobre o custo da atenção à saúde apresentam grande variabilidade metodológica e precisam ser interpretados com cautela. No presente documento, a maior parte dos dados sobre custo foi obtida das tabelas de reembolso do Sistema Público de Saúde de 2008 a 2018. Durante esse período, o reajuste pela inflação não foi realizado de maneira regular nem homogênea nos grupos e procedimentos de DCV. A taxa de inflação brasileira (baseada no IPCA) de 2008 a 2018 foi 76,3%, enquanto a inflação média para os procedimentos cardiovasculares foi 43,5%. Para alguns códigos de procedimento, o reajuste foi mínimo, como para a implantação de stent coronariano, cujo reajuste foi de 8,7%. Para outros códigos, o reajuste ficou acima da inflação, como para o tratamento de arritmias (83,4%).

Para minimizar o viés na notificação e na interpretação dos dados de custo, aplicou-se uma abordagem sistemática em todos os capítulos. Nas análises de custo geral, foram utilizadas as unidades monetárias originais [ Reais (R$) ou dólares americanos (US$) em um determinado ano] e dólares internacionais. Os dólares internacionais foram convertidos em PPC ajustados para US$ 2018 (Int$ 2018), usando-se o conversor de custo do Centro Campbell and Cochrane Economics Methods Group Evidence for Policy and Practice Information and Coordination (https://eppi.ioe.ac.uk/costconversion/default.aspx ) . Nesse método, aplicou-se uma abordagem em duas etapas. Na primeira, ajustou-se a estimativa original de custo no preço-ano original para o preço-ano alvo, usando-se o índice de deflação do PIB (valores PIBD). Na segunda, houve conversão dessa estimativa ajustada da moeda original para a moeda alvo, usando-se as taxas de conversão baseadas em PPC para o PIB (valores PPC). 27 Para estudos econômicos originais, quando o ano-base da moeda não foi informado ou não pôde ser inferido a partir do manuscrito (p. e., coleta de dados do ano passado), recomendou-se adotar o ano anterior ao da publicação do manuscrito.

1. DOENÇA CARDIOVASCULAR TOTAL CID-9 390 a 459; CID-10 I00 a I99.

Ver Tabelas 1-1 até 1-9 e Figuras 1-1 até 1-16

Abreviaturas usadas no Capítulo 1
AHA American Heart Association
AVC Acidente Vascular Cerebral
CID Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde
CRVM Cirurgia de Revascularização do Miocárdio
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DATASUS Departamento de Informática do Sistema Único de Saúde
DCNT Doenças Crônicas Não Transmissíveis
DCV Doença Cardiovascular
DIC Doença Isquêmica do Coração
ELSA-Brasil Estudo Longitudinal da Saúde do Adulto
ELSI-Brasil Estudo Longitudinal da Saúde dos Idosos Brasileiros
GBD Global Burden of Disease
IAM Infarto Agudo do Miocárdio
IBGE Instituto Brasileiro de Geografia e Estatística
IC Intervalo de Confiança
IDH Índice de Desenvolvimento Humano
IDHm Índice de Desenvolvimento Humano Municipal
II Intervalo de Incerteza
OR Odds Ratio
PIB Produto Interno Bruto
PSF Programa Saúde da Família
RAP Risco Atribuível na População
RR Risco Relativo
SCA Síndrome Coronariana Aguda
SDI Índice Sociodemográfico (do inglês, Sociodemographic Index )
SIDRA Sistema IBGE de Recuperação Automática
SIH Sistema de Informações Hospitalares
SIM Sistema de Informações sobre Mortalidade
SNS Sistema Nacional de Saúde
SUS Sistema Único de Saúde
UF Unidade Federativa

Panorama

As DCNT constituem o principal grupo de causa de morte em todo o mundo, sendo responsáveis por mortes prematuras, perda de qualidade de vida, além de impactos adversos econômicos e sociais. As DCNT são responsáveis por cerca de 70% das mortes globais, equivalendo a mais de 38 milhões de mortes por ano, excedendo significativamente as mortes por causas externas e por doenças infecciosas. 28 - 31 Cerca de 45% de todas as mortes por DCNT no mundo, mais de 17 milhões, são causadas por DCV. O mesmo ocorre no Brasil, onde 72% das mortes resultam de DCNT, sendo 30% devidas a DCV, 16% a neoplasias e 6% a doenças respiratórias. 32 - 34

A definição de DCV pode variar de acordo com o estudo, desde a inclusão de todas as doenças listadas no Capítulo IX da CID-10 até o simples agrupamento das 3 principais causas (DIC, AVC e insuficiência cardíaca). Para o GBD, a definição de DCV total engloba 10 causas: cardiopatia reumática, DIC, doença cerebrovascular, cardiopatia hipertensiva, cardiomiopatia, miocardite, fibrilação e flutter atrial, aneurisma aórtico, doença vascular periférica e endocardite. 35

As DCV eram a principal causa de morte no Brasil em 1990 e 2017 (Figura 1-1). De acordo com as estimativas do Estudo GBD 2017, entre as DCV, a DIC era a causa número 1 de morte no país, seguida por AVC, em 1990 e 2017 (Figura 1-2). Na verdade, em 2017, a DIC foi a principal causa de morte em todas as UF brasileiras, embora, em 1990, o AVC ainda fosse a causa de morte número 1 nos estados de Alagoas e Sergipe (Figuras 1-3 e 1-4).

Prevalência

Gonçalves et al. publicaram em 2019 um estudo transversal que analisou informação da Pesquisa Nacional de Saúde conduzida em 2013 em uma amostra de 60.202 adultos com mais de 18 anos, estratificados por sexo e 6 grupos etários, usando um modelo de regressão logística binário e hierárquico. O diagnóstico autorreferido de doença cardíaca no Brasil foi de 4,2% (IC 95%: 4,0-4,3 ) e associado com as seguintes características: sexo feminino (OR = 1,1; IC 95%: 1,1-1,1), indivíduos de 65 anos ou mais, hipertensão (OR = 2,4; IC 95%: 2,2-2,7), elevação de colesterol (OR = 1,6; IC 95%: 1,5-1,8), sobrepeso (OR = 1,5; IC 95%: 1,4-1,8) ou obesidade (OR = 2,0; IC 95%: 1,7-2,2), sedentarismo (OR = 1,5; IC 95%: 1,02-2,1) e tabagismo (OR = 1,2; IC 95%: 1,03-1,3). 36

No estudo ELSA-Brasil, uma coorte que incluiu 15.105 funcionários públicos de 6 universidades ou institutos de pesquisa (54% mulheres, 35-74 anos, com avaliação basal entre 2008 e 2010), a prevalência autorreferida foi a seguinte: DIC, 4,7% (homens=5,7%, mulheres=4,0%); insuficiência cardíaca, 1,5% (homens=1,9%, mulheres=1,5%); AVC, 1,3% para ambos os sexos; febre reumática, 2,9% (homens=2,2%, mulheres=3,4%); e doença de Chagas, 0,4% para ambos os sexos. 37

A prevalência de DCV aumenta significativamente com a idade. Em um estudo longitudinal com idosos a partir dos 60 anos, do estado de São Paulo, em 2000, 2006 e 2010, a prevalência de DCV foi definida como resposta positiva à pergunta: “Algum médico ou enfermeiro já lhe disse que você teve um ataque cardíaco, doença isquêmica do coração, angina, doença congestiva ou outros problemas cardíacos?” A prevalência de DCV foi de 17,9%, 22,2% e 22,9% em 2000, 2006 e 2010, respectivamente. A presença de DCV foi associada a idade mais avançada, história de tabagismo, presença de diabetes e hipertensão. 38

De acordo com o Estudo GBD 2017, a prevalência padronizada por idade de DCV no Brasil em 1990 foi de 6.290 (II 95%, 6048-6549) por 100 mil habitantes e, em 2017, de 6.025 (II 95%, 5.786-6.275) por 100 mil habitantes, acometendo 6% da população com idade ≥ 20 anos, havendo leve redução de 4,2% (II 95%, -3,2 a -5,1) de 1990 a 2017. Os homens apresentaram maior prevalência padronizada por idade do que as mulheres de 1990 a 2017 (Figuras 1-5 e 1-6), embora a variação percentual tenha sido maior para os homens -5,5 (-4,2; -6,7) do que para as mulheres -2,4 (-1,3; -3,4) no período (Figura 1-6). Considerando-se o número total em 2017, 13.702.303 indivíduos (II 95%, 13.110.682-14.281.540) apresentaram DCV prevalente no Brasil, 6.784.523 homens (II 95%, 6.517.523-7.167.162) e 6.917.779 mulheres (6.616.359-7.220.572) (Tabela 1-1). 39

– Taxa de prevalência de DCV padronizada por idade por 100 mil habitantes, por sexo, no Brasil e suas unidades federativas, 1990 e 2017, e variação percentual
Unidades federativas Ambos os sexos Feminino Masculino
1990 2017 Variação percentual 1990 2017 Variação percentual 1990 2017 Variação percentual
Brasil 6290 (6048.3;6548.9) 6025 (5785.8;6274.8) -4.2 (-3.2;-5.1) 5939.5 (5694.8;6205.5) 5612.9 (5366.3;5856.6) -5.5 (-4.2;-6.7) 6697.3 (6433.7;6961.9) 6536.8 (6282.7;6806.6) -2.4 (-1.3;-3.4)
Acre 6011.6 (5762.4;6272.3) 5814.9 (5568.2;6071.4) -3.3 (-1.4;-5.3) 5595.5 (5340.7;5865.5) 5350.3 (5101.6;5618.9) -4.4 (-1.5;-7.2) 6361.8 (6076.6;6659.2) 6299 (6033;6583.4) -1 (1.8;-3.9)
Alagoas 5960.7 (5700.5;6233.7) 5790.1 (5543.7;6044.7) -2.9 (-0.8;-4.8) 5603.9 (5346;5888.2) 5381 (5123;5659.8) -4 (-1;-6.9) 6360 (6070.2;6651.8) 6307.2 (6024.2;6580.8) -0.8 (2;-3.5)
Amapá 6219.5 (5950.1;6490.2) 6185.3 (5922.8;6478.7) -0.5 (1.5;-2.7) 5945.1 (5646.7;6260.9) 5817.8 (5542.5;6137.7) -2.1 (1.3;-5.4) 6515.4 (6227.7;6811.6) 6587.8 (6304.5;6889.1) 1.1 (3.8;-1.6)
Amazonas 5728.7 (5485.7;5987.5) 5701.6 (5455.9;5955) -0.5 (1.8;-2.6) 5367.7 (5112.8;5643.3) 5244.5 (4984.1;5506.4) -2.3 (0.8;-5.5) 6092 (5823.9;6361.4) 6183.2 (5892.3;6475.4) 1.5 (4.5;-1.3)
Bahia 5760.9 (5521.5;6019.9) 5685.9 (5433.9;5942.7) -1.3 (0.9;-3.4) 5420.2 (5164;5706.9) 5247 (4989.7;5508.9) -3.2 (-0.2;-6) 6147.9 (5863.3;6431.4) 6225 (5936.4;6513.3) 1.3 (4.3;-1.6)
Ceará 5860.4 (5600.4;6118.9) 5943.7 (5668.7;6231.8) 1.4 (3.8;-0.9) 5545.9 (5270.6;5820.4) 5541.3 (5256.3;5850.7) -0.1 (3.2;-3.3) 6211.7 (5923.9;6506.7) 6448.9 (6145.4;6775.2) 3.8 (7.1;0.7)
Distrito Federal 5798.5 (5563.4;6037.2) 5529.8 (5303.6;5752.8) -4.6 (-2.7;-6.5) 5461.1 (5211.3;5732.7) 5144.9 (4908.1;5382.3) -5.8 (-3;-8.7) 6209.3 (5957.1;6458.7) 6061.9 (5797;6321.5) -2.4 (0.3;-4.9)
Espírito Santo 6214.8 (5957;6478.6) 5748.2 (5490.1;5998.6) -7.5 (-5.6;-9.5) 5868.6 (5600.7;6137.1) 5341.6 (5086.6;5596.6) -9 (-6.1;-11.8) 6591.9 (6320.7;6883.9) 6240.1 (5950.8;6518.6) -5.3 (-2.8;-7.8)
Goiás 5642.8 (5395.9;5901.5) 5527.3 (5295.5;5762.8) -2 (0.1;-4.2) 5318.3 (5037.2;5601.6) 5136.8 (4890.8;5398.2) -3.4 (0;-6.6) 5947.9 (5701.8;6217.5) 5969.3 (5701.1;6245.8) 0.4 (3.2;-2.6)
Maranhão 5596.3 (5341.3;5857.4) 5592.5 (5348.5;5844.7) -0.1 (2;-2.1) 5196.3 (4944.4;5463.5) 5174.8 (4941.4;5424) -0.4 (2.6;-3.3) 6026.1 (5740.7;6311.6) 6065.4 (5785.2;6348.3) 0.7 (3.5;-2.2)
Mato Grosso 5995.6 (5727.7;6258.6) 5869.7 (5612.3;6121.4) -2.1 (0.2;-4.1) 5622 (5350.5;5896.6) 5441.8 (5189.2;5704.2) -3.2 (-0.1;-6) 6297.7 (6001.6;6588.6) 6285.3 (5998.3;6582.1) -0.2 (2.8;-3)
Mato Grosso do Sul 6168.4 (5915.1;6427.7) 5964.9 (5727.2;6210.6) -3.3 (-1.3;-5.3) 5730.5 (5467.9;5987.4) 5472.6 (5219.8;5732.1) -4.5 (-1.6;-7.4) 6571.7 (6308.5;6860.6) 6512.2 (6248.7;6790.3) -0.9 (1.8;-3.7)
Minas Gerais 6269 (5985.9;6552.4) 6031.6 (5768.1;6308.7) -3.8 (-1.4;-5.9) 5902 (5602;6201.4) 5614.5 (5333.5;5907.9) -4.9 (-1.8;-7.9) 6699.1 (6401.3;6989.1) 6532.8 (6246.7;6839) -2.5 (0.2;-5)
Pará 5842.4 (5588.6;6111.7) 5751 (5495.1;6017.5) -1.6 (0.6;-3.6) 5511.2 (5245.2;5786.3) 5291.5 (5022.7;5567.5) -4 (-0.7;-7.2) 6191.5 (5918.1;6485.6) 6236.9 (5947.8;6540.6) 0.7 (3.7;-2)
Paraíba 5802.6 (5546.1;6053.4) 5755.9 (5515.6;6004.5) -0.8 (1.4;-3) 5477.7 (5212.5;5728.9) 5371 (5114.4;5651.9) -1.9 (1.3;-5) 6170.5 (5892.1;6456.2) 6253.3 (5978.4;6539.4) 1.3 (4.1;-1.5)
Paraná 6350.3 (6083.3;6621.1) 5998 (5747.6;6250.1) -5.5 (-3.5;-7.6) 5947.5 (5671;6238.5) 5549.2 (5289.1;5808) -6.7 (-3.8;-9.5) 6765.8 (6472.5;7054) 6538.5 (6262.5;6813.3) -3.4 (-0.5;-6)
Pernambuco 5864.3 (5618.3;6114.8) 5642.3 (5399.5;5887.5) -3.8 (-1.7;-5.9) 5544.4 (5296;5814.4) 5239.5 (4986.3;5490.8) -5.5 (-2.5;-8.3) 6252.9 (5972.2;6545.7) 6184.6 (5912.5;6459.7) -1.1 (1.7;-3.9)
Piauí 5511.3 (5276.3;5755.1) 5545.1 (5314.7;5786.3) 0.6 (2.8;-1.4) 5145.2 (4900.4;5394.3) 5131.4 (4894.1;5385.3) -0.3 (2.8;-3.3) 5911.2 (5642.8;6176.5) 6034.4 (5776.8;6317.2) 2.1 (4.8;-0.6)
Rio de Janeiro 6714.2 (6446.8;7008.6) 6230.8 (5980.5;6490.7) -7.2 (-5.3;-9.2) 6350.5 (6067.4;6659.1) 5820 (5546.8;6108.8) -8.4 (-5.6;-11.1) 7208.1 (6917.8;7498.2) 6800.2 (6527.3;7073.1) -5.7 (-3.1;-8.1)
Rio Grande do Norte 5701.2 (5452.1;5951.2) 5672.5 (5438;5939.2) -0.5 (1.6;-2.4) 5393 (5131.9;5659.9) 5280.7 (5029.7;5550.9) -2.1 (0.8;-5) 6041.8 (5780.8;6327.3) 6170.4 (5892.3;6466.5) 2.1 (5.1;-0.6)
Rio Grande do Sul 6600.3 (6315.3;6880.9) 6182.1 (5906.1;6460.9) -6.3 (-4.4;-8.3) 6322.7 (6028.2;6645.2) 5828.4 (5536.3;6116.6) -7.8 (-4.9;-10.6) 6961.6 (6661.6;7269.6) 6639.1 (6336.7;6946.7) -4.6 (-2;-7.3)
Rondônia 5985.6 (5731;6240.1) 5705.1 (5457.5;5949.3) -4.7 (-2.4;-6.8) 5599.4 (5348.2;5868.1) 5285.8 (5041.4;5543.5) -5.6 (-2.6;-8.6) 6276.9 (5998.5;6564.3) 6111.8 (5837.6;6398.4) -2.6 (0.4;-5.3)
Roraima 6064.1 (5818.4;6308.8) 5814.1 (5583.7;6060.7) -4.1 (-2.1;-6) 5617 (5371;5884) 5317.9 (5070;5562.2) -5.3 (-2.4;-8.1) 6407.7 (6148.3;6694.1) 6269.6 (6021.5;6541.3) -2.2 (0.4;-4.9)
Santa Catarina 6679.1 (6397.8;6964.3) 6217 (5941.2;6488.4) -6.9 (-5;-8.8) 6375.3 (6069.7;6674.6) 5844.5 (5564.4;6133.5) -8.3 (-5.4;-11.1) 7026.3 (6731;7339.3) 6667 (6373.5;6959.6) -5.1 (-2.3;-7.8)
São Paulo 6801.7 (6517.3;7096.7) 6423.9 (6151.9;6705.8) -5.6 (-3.4;-7.5) 6406.6 (6114.7;6715.3) 6000.7 (5715;6302.4) -6.3 (-3.1;-9.3) 7284.4 (6975.5;7612.3) 6975.7 (6661.7;7268.7) -4.2 (-1.4;-6.8)
Sergipe 5922.8 (5667.3;6171.5) 5851.4 (5597.1;6110.4) -1.2 (1.2;-3.4) 5582.1 (5328.1;5864.7) 5442.8 (5194.8;5717) -2.5 (0.7;-5.3) 6324.1 (6036.1;6611.2) 6374.1 (6091.1;6662.7) 0.8 (3.9;-1.8)
Tocantins 5849.3 (5606.1;6103.5) 5849.2 (5606.6;6094.9) 0 (2.1;-2.1) 5387.1 (5153.3;5644.6) 5307.1 (5065.3;5571.5) -1.5 (1.5;-4.3) 6261.9 (5993.8;6548.1) 6368.8 (6094;6643.8) 1.7 (4.6;-1)

Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 66

O Estudo GBD 2017 revela que a prevalência padronizada por idade de DCV diminuiu desigualmente nas UF, sendo a redução maior nas regiões Sudeste e Sul, em particular nos estados do Espírito Santo, Rio de Janeiro, Santa Catarina e Rio Grande do Sul (Tabela 1-1), que estão entre os mais desenvolvidos do país.

Incidência

De acordo com o Estudo GBD 2017, a taxa de incidência padronizada por idade de DCV no Brasil em 2017 foi de 687,5 (II 95%, 663,4-712,4) casos por 100 mil habitantes, menor do que em 1990, quando havia 755,6 (II 95%, 731,6-783) casos por 100 mil habitantes (Tabela 1-2). Importante notar que, em toda a série temporal, as taxas de incidência do GBD para DCV total podem estar subestimadas em razão dos critérios de inclusão e exclusão dos modelos para cada doença específica incluída. A incidência de DCV total é o agregado das incidências de todas as doenças contidas no grupo. 39

– Número de casos e incidência padronizada por idade (por 100 mil) de DCV no Brasil e em suas unidades federativas, 1990 e 2017, e variação percentual
Unidades federativas brasileiras 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Brasil 723595.1 (700074.3;750549.6) 755.6 (731.6;783) 1550188.5 (1495647.3;1607115.8) 687.5 (663.4;712.4) -9 (-9.9;-8.2)
Acre 1400.9 (1352.7;1453.7) 701.5 (675.5;730.5) 4219.8 (4070.7;4381.3) 673.9 (648.3;700.9) -3.9 (-5.4;-2.4)
Alagoas 10692.8 (10301.7;11114.3) 715.2 (688;744.7) 21304 (20503.3;22148.2) 675.8 (649.9;702.9) -5.5 (-7;-4)
Amapá 845.7 (817.2;875.8) 697.3 (672.7;723.9) 3589.8 (3464.8;3720.7) 680.8 (655.6;706.2) -2.4 (-3.9;-0.9)
Amazonas 6580.8 (6356.7;6809.1) 683.2 (658.2;709.5) 19228.5 (18527.4;19964.4) 667.3 (643.2;695.3) -2.3 (-3.7;-0.9)
Bahia 53499.5 (51571.2;55573.5) 715.2 (689.1;744.7) 108386.9 (104426.4;112633.4) 686 (660.4;713) -4.1 (-5.6;-2.5)
Ceará 29391.6 (28364.7;30541.6) 668.4 (644.1;695.3) 64457.4 (61963.2;67082.7) 657.3 (631.5;684.4) -1.7 (-3.2;-0.1)
Distrito Federal 5460.4 (5280.9;5656.2) 735.9 (711.2;762.2) 17461 (16845.3;18144.4) 681 (657.1;706.6) -7.5 (-8.8;-6.1)
Espírito Santo 12056.9 (11646.4;12504.3) 761.1 (733.7;789.4) 28206.7 (27136.4;29299.3) 669.3 (644.8;695.5) -12.1 (-13.6;-10.6)
Goiás 16069.6 (15492.1;16700.6) 721.2 (695.6;749.2) 44756.7 (43051.4;46526.6) 667.8 (643.2;694.3) -7.4 (-8.8;-6.1)
Maranhão 19179.5 (18453.2;19975.2) 668.8 (642.1;698.5) 42991.2 (41329.7;44766) 660.5 (634.6;689.6) -1.3 (-2.8;0.3)
Mato Grosso 6719.6 (6494.8;6965.5) 704 (679.9;731.2) 21357.5 (20543;22189.1) 675.9 (649.6;702.9) -4 (-5.4;-2.4)
Mato Grosso do Sul 7537.2 (7281.1;7807.5) 744.2 (717.8;772.7) 19409.2 (18668.4;20188) 693.7 (667.6;721.3) -6.8 (-8.1;-5.4)
Minas Gerais 80523.3 (77820.9;83428.5) 768.2 (742;795.2) 171252.6 (164841.8;177705.6) 685.1 (660.4;709.9) -10.8 (-12.3;-9.4)
Pará 17011.1 (16426.2;17625.4) 688.6 (662.5;716.5) 45519.2 (43870.8;47258) 661.7 (637.2;688.8) -3.9 (-5.4;-2.5)
Paraíba 16176.5 (15565.7;16826.5) 667.2 (642.6;693.4) 29872.4 (28740.8;31073.8) 657.2 (632.5;684.2) -1.5 (-3;0)
Paraná 41419.6 (40008.6;42968.7) 800.3 (773;830.5) 87883.8 (84611.7;91450.2) 695.9 (670.7;722.7) -13 (-14.5;-11.6)
Pernambuco 35110.1 (33804.7;36547.8) 732.2 (705.7;761.9) 66763.4 (64155.4;69477.8) 675.2 (649.1;703) -7.8 (-9.3;-6.2)
Piauí 10631.7 (10240.3;11034.3) 670.2 (644.4;697.2) 23550.9 (22654.2;24486.5) 655.2 (629.6;681.5) -2.2 (-3.7;-0.7)
Rio de Janeiro 81868.9 (78983.8;85145.6) 821.9 (793.4;852.5) 150842.8 (145276.6;156396.1) 709 (683.9;734.5) -13.7 (-15.1;-12.3)
Rio Grande do Norte 11276.8 (10853;11708.8) 654.7 (629.9;680.7) 24101.3 (23205;25082.8) 646.6 (621.9;674.4) -1.2 (-2.6;0.3)
Rio Grande do Sul 53751.8 (51853.1;55798.7) 788.9 (761.7;817.8) 101785.9 (97835;105973.3) 695.5 (669.9;722.4) -11.8 (-13.3;-10.3)
Rondônia 3371.8 (3252.6;3505) 720.6 (695.4;749.2) 9991.1 (9629.9;10396.4) 668.7 (643.9;697) -7.2 (-8.7;-5.7)
Roraima 568.1 (548.3;589.3) 720.4 (694.8;748.1) 2537.1 (2444.2;2635) 677 (651.8;703.1) -6 (-7.4;-4.7)
Santa Catarina 21007.9 (20283;21746.3) 763.1 (736.1;790.2) 52679.6 (50763.8;54847.6) 685.8 (661.2;712.9) -10.1 (-11.6;-8.7)
São Paulo 171665.5 (165924.5;178117.1) 803.6 (775.3;833.8) 364049.8 (350776.2;377905.8) 707.2 (681.6;733.4) -12 (-13.4;-10.6)
Sergipe 6408.5 (6185.3;6643.9) 693.3 (667.4;720.5) 14467 (13942.5;15036.2) 667.5 (642.1;694.7) -3.7 (-5.2;-2.2)
Tocantins 3369.1 (3254.2;3500) 711.8 (686.8;739.6) 9522.9 (9187.6;9895.5) 676.5 (652.2;704) -5 (-6.5;-3.5)

II: intervalo de incerteza; Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 66

A UF com a maior taxa de incidência em 2017 foi o estado do Rio de Janeiro, com 709 (II 95%, 683,9-734,5) casos por 100 mil habitantes, e a de menor taxa de incidência em 2017 foi o estado do Rio Grande do Sul, com 646,6 (II 95%, 621,9-674,4) casos por 100 mil habitantes (Tabela 1-2).

Mortalidade

No Brasil, Mansur e Favarato relataram que a taxa de mortalidade por DCV padronizada por idade diminuiu significativamente nas últimas décadas. Um estudo de 2016 analisou as taxas de mortalidade por DCV a partir dos 30 anos de idade, por sexo, por 100 mil habitantes. As variações anuais na mortalidade cardiovascular para os períodos 1980-2006 e 2007-2012 foram, respectivamente, para ambos os sexos: -1,5% e -0,8%; para homens: -1,4% e -0,6%; para mulheres: -1,7% e -1,0%. 40

Baptista et al. investigaram como a composição etária e as taxas de mortalidade específicas por idade se relacionam à diferença observada nas mortes por DCV na população adulta, por sexo, nas microrregiões brasileiras de 1996 a 2015. Aqueles autores sugeriram, após correção para subnotificação das mortes, que haja uma redução nas taxas de morte por DCV no período estudado. Entretanto, o principal motivo da mudança nas taxas de mortalidade foi heterogêneo nas microrregiões brasileiras. Em geral, nas áreas mais desenvolvidas socioeconomicamente, a estrutura etária relacionou-se de maneira mais importante às taxas de mortalidade, com as populações mais idosas morrendo por DCV. É interessante notar que os principais motivos da mudança nas taxas de mortalidade por DCV diferiram ainda entre as UF brasileiras. 41

Dados do Estudo GBD 2017 revelam que, embora as taxas de mortalidade por DCV no Brasil tenham diminuído significativamente nos últimos anos, o número total de mortes por DCV aumentou, provavelmente como resultado do crescimento e envelhecimento da população. Houve 266.958 (II 95%, 264.385-269.671) e 388.268 (II 95%, 383.815-392.698) mortes por DCV no país em 1990 e 2017, respectivamente. A taxa de mortalidade padronizada por idade por 100 mil habitantes foi 341,8 (II 95%, 338,7-345,2) em 1990 e 178,0 (II 95%, 175,9-180) em 2017, diminuindo -47,9 (II 95%, -48,5 a -47,2) no período (Figura 1-7). Embora as taxas de mortalidade padronizadas por idade fossem maiores nos homens em todo o período, a redução percentual foi similar para ambos os sexos, e a mortalidade proporcional por DCV foi maior nas mulheres, excedendo 30% em todo o período, enquanto para os homens permaneceu sempre ligeiramente superior a 25% (Figura 1-8).

A Tabela 1-3 mostra o número de mortes, a taxa de mortalidade padronizada por idade por 100 mil habitantes e a variação percentual por DCV, por UF e no Brasil, em 1990-2017. As UF com as maiores porcentagens de redução observadas entre 1990 e 2017 foram os estados do Espírito Santo, Paraná, Minas Gerais, Santa Catarina, Rio de Janeiro, São Paulo, e Rio Grande do Sul, nessa ordem.

– Número de mortes e taxa de mortalidade padronizada por idade (por 100 mil) por DCV, no Brasil e em suas unidades federativas, 1990 e 2017, e variação percentual
1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Brasil 266957.7 (264384.5;269670.5) 341.8 (338.7;345.2) 388268.1 (383814.8;392697.7) 178 (175.9;180) -47.9 (-48.5;-47.2)
Acre 398.2 (388.1;407.4) 276.3 (269.5;282.7) 860.3 (827.9;893.3) 158.5 (152.2;164.7) -42.6 (-45.5;-39.5)
Alagoas 4053.8 (3962.9;4148.6) 312.4 (306.1;318.9) 6330.3 (6126.2;6536.9) 211.9 (204.9;218.9) -32.2 (-34.8;-29.5)
Amapá 204.7 (199.9;209.6) 252.5 (246.8;258.8) 668.5 (646.7;691.1) 157.2 (152.2;162.6) -37.8 (-40.2;-35.1)
Amazonas 1671.4 (1607.3;1730) 248.9 (239.5;257.4) 3566.2 (3452.4;3679.5) 147 (142.3;151.9) -40.9 (-43.7;-37.8)
Bahia 16748.2 (15951.3;17572.4) 252.2 (240.6;264.6) 25924.4 (25261.1;26649.5) 162.9 (158.6;167.6) -35.4 (-38.8;-31.7)
Ceará 8157.7 (7634.1;8698.6) 200.3 (187.1;213.5) 15199.6 (14788.3;15643.8) 152.4 (148.2;156.9) -24 (-28.8;-18.3)
Distrito Federal 1564 (1530.6;1593.1) 347.4 (340.8;353.3) 3196.5 (3061;3340.7) 175.4 (168;183.2) -49.5 (-51.8;-47)
Espírito Santo 4547.7 (4479.3;4621.1) 409.1 (403.1;415.6) 6692 (6473.6;6899.1) 165.8 (160.3;171) -59.5 (-60.9;-58.1)
Goiás 5034.5 (4904.9;5160.8) 326.3 (317.6;334.9) 10071.3 (9753.2;10423.5) 163.9 (158.7;169.5) -49.8 (-51.4;-48)
Maranhão 6355.1 (5965.1;6814.3) 250.6 (234.1;269) 11471.5 (11001.2;11997) 184.6 (177;193.1) -26.3 (-30.8;-22)
Mato Grosso 1969.9 (1862.5;2089.6) 288.6 (274.1;305) 4470.8 (4292.6;4648.3) 162.8 (156.5;169.3) -43.6 (-47.1;-39.8)
Mato Grosso do Sul 2619.6 (2546.5;2676.5) 351.7 (344.2;358.2) 5149.6 (4987.1;5336) 198.6 (192.5;205.5) -43.5 (-45.6;-41.2)
Minas Gerais 29369 (28899.2;29849.4) 357.1 (351.8;362.5) 38721.8 (37782;39823.5) 154.5 (150.8;159) -56.7 (-58;-55.3)
Pará 5266.9 (5055.8;5475) 280 (269.1;290.5) 10353.6 (9971.8;10725.7) 168.6 (162.5;174.7) -39.8 (-43.2;-36.4)
Paraíba 5718.5 (5474.8;5964.4) 254.9 (244.2;265.8) 8984.7 (8426.7;9582.7) 190.9 (179;203.9) -25.1 (-30.9;-18.6)
Paraná 16504.7 (16270.4;16731.9) 445.3 (438.8;451.5) 22160.3 (21559.6;22775.3) 188.3 (183.3;193.6) -57.7 (-59.1;-56.4)
Pernambuco 14360.8 (14092.9;14607.3) 364.9 (358.4;371) 20620.7 (20029;21264.3) 214.6 (208.3;221.3) -41.2 (-43;-39.3)
Piauí 3514.8 (3300.4;3730.5) 262.9 (247.1;279.1) 6327.5 (6132.3;6535.5) 175.1 (169.7;181) -33.4 (-37.3;-28.8)
Rio de Janeiro 37561.8 (37050.8;38028.3) 456.7 (450.5;462.1) 43858 (42710.9;45057.9) 207.7 (202.4;213.3) -54.5 (-55.8;-53.2)
Rio Grande do Norte 3386.4 (3206.1;3566.2) 213.3 (202;224.8) 6068 (5855.2;6289.3) 159.2 (153.6;165.1) -25.4 (-30;-19.9)
Rio Grande do Sul 20393.7 (20091.6;20681.9) 378.1 (372.6;383.2) 25992.2 (25243.6;26731.3) 177.2 (172.1;182.3) -53.1 (-54.6;-51.6)
Rondônia 1006.4 (941.1;1071.3) 368.1 (347.8;387.7) 2351.5 (2146.6;2592.9) 184.8 (169.6;202.6) -49.8 (-54.8;-44.5)
Roraima 146.8 (135.1;159.4) 373.6 (349.4;399.7) 495.4 (447.4;549.9) 196.3 (178.6;216) -47.5 (-53.5;-41.2)
Santa Catarina 7674.7 (7557;7795.4) 389.1 (383.2;395.1) 11764.8 (11388.8;12125) 170.2 (164.9;175.2) -56.3 (-57.8;-54.7)
São Paulo 65661.8 (64717.7;66544.9) 401.2 (395.5;406.2) 91136 (88785.8;93412.4) 185.6 (180.7;190.2) -53.8 (-55;-52.5)
Sergipe 2100.9 (2048.7;2155) 252.8 (246.6;259.1) 3529.6 (3404.6;3655.8) 171.6 (165.6;177.7) -32.1 (-35;-29.2)
Tocantins 965.7 (864.4;1053.9) 329.1 (304.8;353.4) 2302.8 (2183.2;2429) 173.9 (165.1;183.1) -47.2 (-51.4;-42.2)

II: intervalo de incerteza; Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 66

A Figura 1-9 mostra a distribuição geográfica das taxas de mortalidade por 100 mil habitantes, padronizadas por idade nas UF brasileiras, para ambos os sexos, em 2000 e 2017, de acordo com dados do SIM e utilizando a população do IBGE, a redistribuição de causas mal definidas e a correção para subnotificação de acordo com os coeficientes do GBD 2017. Houve diminuição nas taxas de mortalidade padronizadas em ambos os sexos, exceto para os homens do Maranhão e de Roraima. Malta et al. compararam uma série histórica de taxa de mortalidade por DCV no Brasil, usando a base de dados do SIM com e sem correção (dados brutos) e as estimativas do GBD 2017 entre 2000 e 2017. Os autores indicaram que o aumento na taxa de mortalidade bruta por DCV padronizada por idade, a partir do SIM, observado em 2017 em comparação a 2010 na maioria das UF do Norte e Nordeste resultou, na verdade, das melhorias nos registros de morte e na definição das causas básicas de morte nos últimos anos. Quando foram utilizados dados corrigidos do SIM ou as estimativas do GBD 2017, as tendências de 2010 a 2017 foram similares em todas as UF brasileiras. 42

Ao analisarem dados do GBD 2015, Brant et al. observaram uma redução na taxa de mortalidade por DCV padronizada por idade de 429,5 (1990) para 256,0 (2015) por 100 mil habitantes (40,4%), com acentuadas diferenças entre as UF. Essa redução foi mais pronunciada nas UF do Sudeste e Sul e no Distrito Federal, regiões que concentram as maiores populações e renda, sendo mais modesta na maioria dos estados do Norte e Nordeste. Importante salientar ainda que Brant et al. enfatizaram que a redução anual nas taxas de mortalidade por DCV no Brasil foi menor nos últimos anos da série analisada (1990-2015). Ao se considerar o período de 1990-2017, as estimativas do GBD 2017 confirmam a mesma tendência para homens e mulheres. As Figuras 1-10 e 1-11 mostram o declínio na taxa de mortalidade por DCV padronizada por idade de 1990 a 2017, revelando uma redução no declínio nos últimos 5 anos da série, quando as taxas alcançaram um platô ou até aumentaram em algumas regiões. 35

Quanto à tendência por grupo etário, as maiores reduções nas taxas de mortalidade por DCV por 100 mil, entre 1990 e 2017, foram observadas no grupo ‘abaixo de 5’ [-65,4 (-71,2; -60)], seguido pelos grupos etários ‘5-14 anos’ [-48,3 (-52,5; -42,1)], ‘50-69 anos’ [-46,5 (-47,4; -45,6)] e finalmente ‘>70 anos’, revelando um deslocamento na mortalidade por DCV para os indivíduos mais idosos.

A cobertura do PSF foi associada com redução nas hospitalizações e na mortalidade por DCV que foram incluídas na Lista de Condições Sensíveis à Atenção Primária no Brasil, tendo seu efeito aumentado de acordo com a duração da implementação do PSF no município. Rasella et al. relataram reduções nas mortalidades por doença cerebrovascular e por doença cardíca de 0,82 (IC 95%: 0,79-0,86) e 0,79 (IC 95%: 0,75-0,80), respectivamente, chegando a 0,69 (IC 95%: 0,66-0,73) e 0,64 (IC 95%: 0.59-0.68), respectivamente, quando a cobertura do PSF foi consolidada no total dos 8 anos estudados. 43

De acordo com o banco de dados do SIM, em 2017, as DCV corresponderam a 27,3% do total de mortes, com a maior proporção na região Sudeste e a menor na região Norte. A DIC foi responsável por 32,1% do total de mortes por DCV no Brasil e o AVC, por 28,2%. A maior proporção de mortalidade por DIC ocorreu nos estados de Mato Grosso do Sul, Pernambuco e Espírito Santo, enquanto a maior proporção de mortes por AVC ocorreu nos estados de Amazonas e Pará e no Distrito Federal (Tabela 1-4).

– Mortalidade proporcional por doença cardiovascular, doença isquêmica do coração e acidente vascular cerebral, por região brasileira, unidade federativa e no Brasil, 2017
Região Unidade federativa DCV/Total % DIC/DCV % AVC/DCV %
Norte 22,9 30,6 33,4
Rondônia 24,2 33,0 27,7
Acre 22,3 27,6 32,4
Amazonas 18,1 27,7 36,9
Roraima 21,3 24,8 30,3
Pará 23,4 31,4 35,1
Amapá 19,6 32,3 34,2
Tocantins 30,8 31,0 27,7
Nordeste 27,2 32,2 30,3
Maranhão 30,8 33,0 33,2
Piauí 32,5 30,0 33,1
Ceará 26,3 31,4 31,7
Rio Grande do Norte 25,8 38,9 24,0
Paraíba 29,2 35,4 26,1
Pernambuco 28,1 37,8 28,2
Alagoas 30,2 29,6 30,2
Sergipe 23,5 29,5 31,5
Bahia 24,0 26,4 31,8
Sudeste 28,3 32,4 25,7
Minas Gerais 25,4 24,4 28,4
Espírito Santo 28,8 36,8 28,0
Rio de Janeiro 27,9 32,9 25,1
São Paulo 29,8 34,9 24,8
Sul 27,2 31,1 30,2
Paraná 28,3 29,4 29,5
Santa Catarina 27,4 32,4 25,7
Rio Grande do Sul 26,2 32,1 32,9
Centro-Oeste 26,4 33,0 28,4
Mato Grosso do Sul 28,6 37,9 29,3
Mato Grosso 24,3 31,2 27,6
Goiás 26,2 31,8 26,3
Distrito Federal 26,7 32,2 35,1
BRASIL 27,3 32,1 28,2
Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 56

A proporção de mortes por DCV diminuiu entre homens (de 30,1% para 27,6%) e mulheres (31,1% para 29,9%) de 2000-2002 a 2015-2017. Além disso, Lotufo notou um constante excesso de mortes prematuras por DCV entre os homens naquele período, com uma razão homem:mulher de 2:1. 44

O SDI é uma estimativa do nível socioeconômico e pode ser usado para avaliar a associação desse nível com a carga de DCV. A Figura 1-12 mostra a correlação entre a variação percentual da taxa de mortalidade padronizada por idade 2017/1990 e o SDI de 2017. Revela uma correlação entre a maior redução na variação percentual das taxas de mortalidade por DCV padronizadas por idade, entre 1990 e 2017, e o maior SDI de 2017, sugerindo que a diminuição da mortalidade por DCV seguiu-se a uma melhora nas condições socioeconômicas locais, como observado em outros estudos. 32 , 45 - 47

Lotufo et al. compararam 3 diferentes níveis de renda por domicílio (alto, médio e baixo) com taxas de mortalidade por DCV, na cidade de São Paulo, de 1996 a 2010. As variações percentuais anuais e os IC 95% para homens residentes em áreas de renda alta, média e baixa foram -4,1 (IC 95%: -4,5 a -3,8), -3,0 (IC 95%: -3,5 a -2,6) e -2,5 (IC 95%: -2,8 a -2,1), respectivamente. As tendências para as taxas de mulheres residentes em áreas de renda alta foram -4,4 (IC 95%: -4,8 a -3,9) em 1996-2005 e -2,6 (IC 95%: -3,8 a -1,4) em 2005-2010. A redução nas mortes por DCV foi mais significativa para homens e mulheres residentes em áreas mais abastadas, com um gradiente decrescente para risco de morte, maior para os residentes de áreas mais abastadas em comparação àqueles de áreas mais carentes. 48

Observou-se associação inversa do IDHm e da cobertura de saúde suplementar com a mortalidade por DCV, sugerindo uma relação entre fatores socioeconômicos e DCV. 45 O IDHm aumentou entre 2000 e 2010 em todas as UF, sendo 0,7 ou maior na metade das UF. A cobertura de saúde suplementar aumentou no país durante o período estudado e associou-se inversamente com mortalidade por DCV entre 2004 e 2013. 45

Soares et al. observaram uma diminuição na mortalidade por DCV nos estados do Rio de Janeiro, São Paulo e Rio Grande do Sul que precedeu a melhoria no índice socioeconômico. A evolução do PIB per capita, o declínio da mortalidade infantil, o maior nível educacional (representado pela escolaridade, em anos, dos indivíduos com idade superior a 25 anos) e o IDHm mostraram uma grande correlação com a redução na taxa de mortalidade por DCV. A redução nas taxas de mortalidade por DCV, AVC e DIC no estado do Rio de Janeiro nas últimas décadas foi precedido por um aumento no IDH, com números significativos, pois um aumento de 0,1 no IDH correlacionou-se com as seguintes reduções no número de mortes por 100 mil habitantes: 53,5 por DCV; 30,2 por AVC; e 10,0 por DIC. 46 , 47

Baptista e Queiroz investigaram a relação entre a taxa de mortalidade bruta por DCV e o desenvolvimento econômico no tempo e no espaço, medido pelo PIB per capita, nas microrregiões brasileiras, de 2001 a 2015. Os autores, usando as bases de dados SIM-DATASUS e SIDRA do IBGE, observaram um rápido declínio nas taxas brutas de mortalidade por DCV em microrregiões do Sul e Sudeste, assim como um declínio mais lento na região Centro-Oeste. Por outro lado, as regiões Norte e Nordeste apresentaram um aumento nas taxas brutas de mortalidade por DCV ao longo do tempo, refletindo o envelhecimento mais tardio da população nessas regiões brasileiras e talvez menor acesso ao cuidado em saúde e outros fatores socioeconômicos. 49

Silveira et al. , estudando o efeito da temperatura ambiente na mortalidade cardiovascular em 27 cidades brasileiras, observaram maior número de mortes cardiovasculares associado com temperaturas baixas e altas na maioria das cidades brasileiras e nas regiões Centro-Oeste, Norte, Sul e Sudeste. O RR geral para o Brasil foi 1,26 (IC 95%: 1,17-1,35) para o percentil 1 de temperatura e 1,07 (IC 95%: 1,01-1,13) para o percentil 99 de temperatura em comparação ao percentil 79 (27,7 °C), cujo RR foi o menor. 50

Carga de Doença

As taxas de DALYs padronizadas por idade no Brasil foram 6.907 (II 95%, 6.783-7.039) por 100 mil habitantes em 1990, caindo para 3.735 (II 95%, 3.621-3.849) por 100 mil habitantes em 2017. A região Sudeste apresentou as mais altas taxas de DALYs, enquanto as regiões Norte e Nordeste, as mais baixas (Figura 1-13). A tendência das taxas de DALYs entre 1990 e 2017 no Brasil foi similar à relatada para a taxa de mortalidade padronizada por idade: houve redução heterogênea em todas as UF, mais acentuada naquelas com melhor SDI ( Figura 1-14 e Tabela 1-5 ).

–Ranking das causas de morte no Brasil, 1990 e 2017, de acordo com as taxas de mortalidade padronizadas por idade por 100 mil habitantes, ambos os sexos, 1990 e 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

– Ranking das causas de morte cardiovascular por unidade federativa brasileira em 1990, de acordo com as taxas de mortalidade padronizadas por idade por 100 mil habitantes, ambos os sexos. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017).66

- Ranking das causas de morte cardiovascular por unidade federativa brasileira em 2017, de acordo com as taxas de mortalidade padronizadas por idade por 100 mil habitantes, ambos os sexos. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Prevalência percentual de doença cardiovascular, por sexo, no Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

-Taxa de prevalência de doença cardiovascular padronizada por idade, por 100 mil habitantes, por sexo, Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

-Taxa de mortalidade padronizada por idade por doença cardiovascular, por 100 mil habitantes, por sexo, Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

-Mortalidade proporcional por doença cardiovascular, por sexo, Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Distribuição geográfica das taxas de mortalidade padronizadas por idade, por 100 mil habitantes, nas unidades federativas do Brasil, de acordo com sexo, 2000 e 2017. Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS, com redistribuição de causas mal definidas e correção para subnotificação (de acordo com os coeficientes do GBD 2017), e população IBGE. 56

Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Taxa de mortalidade padronizada por idade por doença cardiovascular, por 100 mil habitantes, por regiões brasileiras, para homens, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Correlação entre variação percentual da taxa de mortalidade padronizada por idade 2017/1990 e o índice sociodemográfico 2017 (SDI 2017). Dados derivados do DATASUS. 56

- Taxas de DALYs padronizadas por idade para doença cardiovascular, por 100 mil habitantes, 1990-2017, Brasil e suas regiões. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Correlação entre a variação percentual das taxas de DALYs padronizadas por idade 2017/1990 e o índice sociodemográfico 2017 (SDI 2017). Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 66

- Custos das hospitalizações clínicas referentes aos códigos dos procedimentos das mais relevantes doenças cardiovasculares de 2008 a 2018, Brasil. Dados derivados do DATASUS. 56

- Custos das hospitalizações cirúrgicas referentes aos códigos dos procedimentos das mais relevantes doenças cardiovasculares de 2008 a 2018, Brasil. Dados derivados do DATASUS. 56

– Códigos dos procedimentos incluídos em cada grupo de condições para análise de custo
Tipo Grupo de Doença Código Descrição do Código
Cirúrgico Ablação de fibrilação atrial 0406050074 Estudo Eletrofisiológico Terapêutico II (Ablação de Fibrilação atrial)
Cirúrgico Angioplastia coronariana 0406030073 Angioplastia em Enxerto Coronariano (c/ Implante de Stent)
Cirúrgico Angioplastia coronariana 0406030014 Angioplastia Coronariana
Cirúrgico Angioplastia coronariana 0406030065 Angioplastia em Enxerto Coronariano
Cirúrgico Angioplastia coronariana 0406030022 Angioplastia Coronariana c/ Implante de dois Stents
Cirúrgico Angioplastia coronariana 0406030030 Angioplastia Coronariana c/ Implante de Stent
Cirúrgico Cirurgia de Revascularização do Miocárdio 0406010927 Revascularização Miocárdica c/ uso de Extracorpórea
Cirúrgico Cirurgia de Revascularização do Miocárdio 0406010935 Revascularização Miocárdica c/ uso de Extracorpórea (c/ 2 ou mais enxertos)
Cirúrgico Cirurgia de Revascularização do Miocárdio 0406010943 Revascularização Miocárdica s/ uso de Extracorpórea
Cirúrgico Cirurgia de Revascularização do Miocárdio 0406010951 Revascularização Miocárdica s/ uso de Extracorpórea (c/ 2 ou mais enxertos)
Cirúrgico Cirurgia valvar 0406010811 Plástica valvar c/ Revascularização Miocárdica
Cirúrgico Cirurgia valvar 0406010340 Correção de Insuficiência da Válvula Tricúspide
Cirúrgico Cirurgia valvar 0406010692 Implante de Prótese Valvar
Cirúrgico Cirurgia valvar 0406010021 Abertura de estenose Aórtica Valvar
Cirúrgico Cirurgia valvar 0406010803 Plástica Valvar
Cirúrgico Cirurgia valvar 0406010030 Abertura de Estenose Pulmonar Valvar
Cirúrgico Cardiomiopatias 0406011397 Correção de Hipertrofia Septal Assimétrica (criança e adolescente)
Cirúrgico Cirurgia valvar 0406011206 Troca valvar c/ Revascularização Miocárdica
Cirúrgico Angioplastia primária 0406030049 Angioplastia Coronariana Primária
Cirúrgico Cardiomiopatias 0406011397 Correção de Hipertrofia Septal Assimétrica (criança e adolescente)
Cirúrgico Outras valvuloplastias 0406030146 Valvuloplastia Tricúspide Percutânea
Cirúrgico Outras valvuloplastias 0406030138 Valvuloplastia Pulmonar Percutânea
Cirúrgico Outras valvuloplastias 0406030111 Valvuloplastia Aórtica Percutânea
Cirúrgico Valvuloplastias mitrais 0406030120 Valvuloplastia Mitral Percutânea
Clínico Doença isquêmica do coração crônica 0303060042 Tratamento de Cardiopatia Isquêmica Crônica
Clínico Acidente vascular cerebral 0303040149 Tratamento de Acidente Vascular Cerebral - AVC (isquêmico ou hemorrágico agudo)
Clínico Acidente vascular cerebral 0303040076 Tratamento Conservador da Hemorragia Cerebral
Clínico Acidente vascular cerebral 0303040300 Tratamento do Acidente Vascular Cerebral Isquêmico Agudo com uso de Trombolítico
Clínico Doenças valvares 0303060123 Tratamento de Doença Reumática s/ Cardite
Clínico Doenças valvares 0303060115 Tratamento de Doença Reumática c/ Comprometimento Cardíaco
Clínico Fibrilação atrial 0303060026 Tratamento de Arritmias*
Clínico Infarto do miocárdio – Tratamento clínico 0303060190 Tratamento de Infarto Agudo do Miocárdio
Clínico Insuficiência cardíaca 0303060131 Tratamento de Edema Agudo de Pulmão
Clínico Insuficiência cardíaca 0303060212 Tratamento de Insuficiência Cardíaca
Clínico Cardiomiopatias 0303060239 Tratamento de Miocardiopatias
Clínico Cardiomiopatias 0303060034 Tratamento de Cardiopatia Hipertrófica
Clínico Síndromes coronarianas agudas 0303060280 Tratamento de Síndrome Coronariana Aguda

*If CID 10 I48

Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 56

Utilização e Custo da Atenção à Saúde (Ver Tabelas 1-6 a 1-9)

No Brasil, as DCV foram responsáveis pelos gastos diretos mais substanciais com hospitalização e pelos custos indiretos por redução da produtividade devida a ausência do trabalho. 51 - 53 As DCV e suas complicações resultaram em um gasto de US$ 4,18 bilhões na economia brasileira entre 2006 e 2015. 54 , 55

A partir da base de dados SIH/SUS, avaliamos o número de hospitalizações de 2008 a 2018 e seus custos com base nos códigos dos procedimentos relacionados aos tópicos do presente documento: AVC; doença arterial coronariana aguda e crônica; cardiomiopatias (incluindo doença de Chagas) e insuficiência cardíaca; doenças valvares; e fibrilação atrial ( Tabela 1-6 ). Procedimentos relacionados a cardiopatia congênita, doença arterial periférica, endocardite, e arritmias, exceto fibrilação atrial, não foram incluídos.

– Procedimentos pagos pelo SUS de 2008 a 2018, por grupo de procedimentos.
Grupo de Procedimentos Número de procedimentos pagos pelo SUS
Cardiomiopatias e Insuficiência Cardíaca
Insuficiência cardíaca 2.862.739
Cardiomiopatias 24.964
Doença Isquêmica do Coração
Crônica, Tx clínico 87.894
Infarto do miocárdio, Tx clínico 676.467
Angioplastia primária 85.664
Síndrome coronariana aguda, Tx clínico 784.921
Angioplastia coronariana 669.893
CRVM 244.105
Acidente Vascular Cerebral 2 042.195
Doença Valvar
Tx clínico 32.795
Cirurgias 139.131
Valvuloplastia mitral 4.204
Outras valvuloplastias 5.087
Fibrilação Atrial 321.866
Ablação de fibrilação atrial 1.250

CRVM: Cirurgia de Revascularização do Miocárdio; Tx: Tratamento.

Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 56

Quanto às hospitalizações clínicas, a insuficiência cardíaca liderou as admissões por DCV, com 2.862.739 hospitalizações (131 por 100 mil habitantes), sendo seguida por doenças cerebrovasculares com 2.042.195 hospitalizações (93 por 100 mil habitantes), IAM e SCA com 1.461.388 hospitalizações (76 por 100 mil habitantes), e fibrilação atrial com 321.866 hospitalizações (14,7 por 100 mil habitantes) ( Tabela 1-7 ). 54 As taxas (por 100 mil habitantes) de admissões clínicas relacionadas aos códigos dos procedimentos avaliados (324 a 293) mostraram uma diminuição de 10% de 2008 a 2018, embora o número absoluto tenha apresentado apenas discreta redução, de 615.433 em 2008 para 610.273 em 2018.

– Número absoluto e taxas de procedimentos anuais pagos pelo SUS, de 2008 a 2018, por grupo de doença*
Procedimento code 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil N por 100 mil
Cardiomiopatias e Insuficiência Cardíaca
Insuficiência cardíaca 298,474 157.41 297,763 155.48 289,11 151.58 284,844 148.06 264,469 136.34 254,285 126.47 243,913 120.27 240,832 117.78 236,358 114.67 230,297 110.90 222,394 106.67
Cardiomiopatias 2,092 1.10 2,363 1.23 2,459 1.29 2,302 1.20 2,357 1.22 2,293 1.14 2,370 1.17 2,230 1.09 2,250 1.09 1,997 0.96 2,251 1.08
Doença Isquêmica do Coração
Crônica, Tx clínico 12,393 6.54 9,743 5.09 9,300 4.88 8,497 4.42 8 4.12 7,197 3.58 7,581 3.74 6,403 3.13 6,317 3.06 6,171 2.97 6,292 3.02
Infarto do miocárdio, Tx clínico 47,358 24.98 50,987 26.62 55,513 29.11 58,194 30.25 59,562 30.71 58,552 29.12 62,809 30.97 66,647 32.59 70,441 34.18 71,835 34.59 74,569 35.77
Angioplastia primária 7,648 4.03 6,362 3.32 6,262 3.28 6,033 3.14 5,865 3.02 6,055 3.01 7,135 3.52 8,524 4.17 10,195 4.95 10,774 5.19 10,811 5.19
Síndrome coronariana aguda, Tx clínico 63,300 33.38 68,833 35.94 72,912 38.23 71,523 37.18 75,734 39.04 73,432 36.52 76,945 37.94 72,686 35.55 70,430 34.17 70,713 34.05 68,413 32.81
Angioplastia coronariana 38,635 20.38 45,648 23.84 49,492 25.95 55,931 29.07 60,959 31.43 63,838 31.75 66,492 32.79 66,55 32.55 69,802 33.87 73,971 35.62 78,575 37.69
CRVM 20,515 10.82 22,077 11.53 21,225 11.13 23,187 12.05 23,9 12.32 23,249 11.56 22,997 11.34 22,559 11.03 22,248 10.79 21,474 10.34 20,674 9.92
AVC 159,545 84.14 176,047 91.93 181,035 94.92 184,751 96.03 182,065 93.86 183,043 91.04 187,110 92.26 191,678 93.74 195,787 94.99 198,068 95.38 203,066 97.40
Doenças Valvares
Tx clínico 3,237 1.71 4,156 2.17 3,526 1.85 3,637 1.89 3,285 1.69 2,996 1.49 2,753 1.36 2,400 1.17 2,244 1.09 2,231 1.07 2,330 1.12
Cirurgias 12,201 6.43 12,664 6.61 12,169 6.38 13,181 6.85 13,435 6.93 13,067 6.50 12,993 6.41 12,624 6.17 12,432 6.03 12,277 5.91 12,088 5.80
Valvuloplastia mitral 477 0.25 551 0.29 478 0.25 473 0.25 403 0.21 431 0.21 408 0.20 341 0.17 206 0.10 236 0.11 200 0.10
Outras valvuloplastias 451 0.24 477 0.25 445 0.23 486 0.25 456 0.24 527 0.26 515 0.25 513 0.25 399 0.19 427 0.21 391 0.19
Fibrilação Atrial
FA 29,034 15.31 28,174 14.71 28,382 14.88 28,583 14.86 28,760 14.83 28,268 14.06 29,799 14.69 29,754 14.55 29,889 14.50 30,265 14.57 30,958 14.85
Ablação de FA 68 0.04 72 0.04 90 0.05 85 0.04 123 0.06 139 0.07 143 0.07 161 0.08 124 0.06 120 0.06 125 0.06

* Grupos de doença de acordo com os códigos de procedimentos da Tabela 1-5.

AVC: Acidente Vascular Cerebral, CRVM: Cirurgia de Revascularização do Miocárdio, FA: fibrilação atrial, Tx: tratamento.

Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 56

Dos 1.149.602 procedimentos cardiovasculares cirúrgicos/intervencionistas realizados sob os códigos de procedimento selecionados ( Tabela 1-6 ), a angioplastia coronariana correspondeu a 66% (755.557), sendo seguida por CRVM (21%, 244.105) e cirurgia valvar cardíaca (8%, 88.280). A relação angioplastia/CRVM em 2008 foi 2,2, aumentando para 4,3 em 2018. Durante o período, houve aumento no número de procedimentos relacionados a infarto do miocárdio e SCA (70%). A taxa de hospitalização cirúrgica por 100 mil habitantes relacionada aos códigos dos procedimentos avaliados de 2008 a 2018 (42 a 59) mostrou aumento de 29%, enquanto o número absoluto cresceu de 80.010 em 2008 para 122.890 em 2018 ( Tabela 1-7 ).

O estudo ELSI-Brasil, conduzido em 2015-2016 com uma amostra nacionalmente representativa da população brasileira com idade a partir de 50 anos, avaliou as hospitalizações de 9.389 participantes (idade média, 63 anos; 54% mulheres) e descobriu que 10,2% deles haviam sido hospitalizados nos 12 meses anteriores. A análise do RAP para hospitalização revelou importantes contribuições de AVC (RAP = 10,7%), DCV (RAP = 10,0%) e câncer (RAP = 8,9%). 56 , 57

Cerca de metade dos custos em saúde no Brasil é financiada pelo governo. 54 As DCV são responsáveis pelos maiores gastos com hospitalização no SUS e criam o principal número de pensões por incapacidade e maior carga de morbidade para os pacientes. 58 - 61 Em 2015, o gasto estimado direto do setor público com hospitalizações e consultas para DCV no Brasil excedeu R$ 5 bilhões. Estima-se que o custo com licença temporária ou permanente por DCV tenha excedido R$ 380 milhões. 62

A AHA 62 projetou que, para o período 2012-2030, 61% dos gastos diretos com saúde para DCV nos Estados Unidos serão atribuídos a custos hospitalares. No Brasil, em 2012, o SUS gastou US$ 608,9 milhões com procedimentos terapêuticos altamente complexos realizados durante hospitalizações por DCV, 34% dos quais foram associados com angioplastia coronariana e 25%, com CRVM. 58 , 63 As Tabelas 1-8 e 1-9 mostram o valor pago pelos procedimentos clínicos e cirúrgicos, respectivamente, no Brasil de 2008 a 2018 pelo sistema público de saúde. O AVC e a insuficiência cardíaca foram responsáveis pelos mais altos valores cumulativos reembolsados para procedimentos clínicos, totalizando R$ 8,4 bilhões. O total pago pelos procedimentos cirúrgicos foi R$ 9,5 bilhões, tendo angioplastia coronariana e CRVM correspondido aos maiores valores.

De 2008 a 2018, a taxa de inflação no Brasil foi 88% (variando de 76% a 96%) e os valores não ajustados gastos pelo SUS cresceram em uma proporção similar para a maioria das condições clínicas, com duplicação no período, exceto para hospitalizações por insuficiência cardíaca, cujos valores totais reembolsados aumentaram apenas 28%, e por DIC crônica, cujos custos apresentaram uma redução de 27%. Nas admissões cirúrgicas, todos os grupos relacionados apresentaram elevação dos valores gastos – a maioria quase dobrou os valores, exceto a valvuloplastia mitral, que mostrou diminuição de 53% no valor pago pelo SUS na década ( Tabelas 1-8 e 1-9). Entretanto, ao se calcularem os valores pagos pelo SUS em dólares internacionais, os custos para a maior parte dos grupos de hospitalização clínica variaram menos do que 10%, exceto para insuficiência cardíaca, cujas despesas caíram 35%, e para infarto do miocárdio e cardiomiopatias, cujas despesas subiram 13% e 23%, respectivamente. Quanto aos procedimentos cirúrgicos/intervencionistas, houve redução nos custos em todos os grupos relatados, exceto para angioplastia coronariana, cujos custos aumentaram 20%, e cardiomiopatias, cujos custos aumentaram 30% ( Tabelas 1-8 e 1-9 ).

Pesquisa Futura

O SIM, implementado em 1975, é uma ferramenta essencial para monitorar as estatísticas de mortalidade no Brasil, pois o registro de todas as mortes é obrigatório nas UF, sendo que, em 2017, a cobertura do território nacional foi de 98%, menor na região Norte do que na Sul. A região Nordeste apresenta a menor cobertura, ainda inferior a 95%. 57 Embora o SIM tenha melhorado através de projetos específicos do Ministério da Saúde, 65 , 66 ainda persistem problemas, como as causas mal definidas (cerca de 6%), ‘códigos garbage ’ e subnotificação de mortes, que geram vieses que podem comprometer a métrica apresentada. Portanto, pesquisa adicional é necessária para promover ajustes metodológicos para cobertura e redistribuição de causas mal definidas, especialmente nos primeiros anos da série histórica. Por outro lado, as estimativas do Estudo GBD requerem mais pesquisa para a implementação de modelos com melhor distribuição de ‘códigos garbage ’ adaptados às realidades locais.

Vale mencionar que, devido à falta de dados de incidência primária (coortes) no Brasil, há necessidade de pesquisa que permita compreender como enfrentar a DCV nos estados e nas populações com baixos índices socioeconômicos.

Devido à redução da tendência de declínio da mortalidade por DCV padronizada por idade nos últimos 5 anos, novas estratégias para combater tal mortalidade devem ser estudadas. É fundamental que se compreendam os motivos para tal redução para que se implementem políticas efetivas, em particular em face ao envelhecimento da população, que vai aumentar o número de indivíduos com DCV no país.

A maior parte dos dados sobre custo foi obtida a partir das tabelas de reembolso do Sistema Público de Saúde de 2008 a 2018, não capturando o verdadeiro custo relacionado àquelas condições. Informação confiável e abrangente do custo da prestação do cuidado nas condições cardiovasculares é extremamente importante para melhor entender o impacto financeiro dessas doenças e melhor reavaliar estratégias de prevenção e tratamento. Além disso, os dados de custo do sistema suplementar de saúde, assim como do cuidado ambulatorial, e custos indiretos são fundamentais para uma avaliação econômica abrangente das DCV no Brasil.

2. ACIDENTE VASCULAR CEREBRAL (DOENÇAS CEREBROVASCULARES) CID-9 430 a 438; CID-10 I60 a I69

Ver Tabelas 2-1 a 2-10 e Figuras 2-1 a 2-4

Abreviaturas usadas no Capítulo 2
AIT Ataque Isquêmico Transitório
AVCH Acidente Vascular Cerebral Hemorrágico
CID Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde
CID-9 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 9a Revisão
CID-10 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10a Revisão
CIF Classificação Internacional de Funcionalidade, Incapacidade e Saúde
DAC Doença Arterial Coronariana
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DCV Doença Cardiovascular
DP Desvio-Padrão
GBD Global Burden of Disease
GWTG-S Programa ‘ Get With The Guidelines-Stroke ’
HR Hazard Ratio
HSA Hemorragia Subaracnóidea
IBGE Instituto Brasileiro de Geografia e Estatística
IC Intervalo de Confiança
IECA/BRA Inibidor da Enzima de Conversão da Angiotensina/ Bloqueador do Receptor de Angiotensina
II Intervalo de Incerteza
JCI Joint Commission International
LDL Colesterol de baixa densidade (do inglês, Low-Density Lipoprotein )
NCEP National Cholesterol Education Program Adult Treatment Panel
NIHSS Escala do National Institutes of Health para avaliar AVC (do inglês, National Institutes of Health Stroke Scale )
OMS Organização Mundial da Saúde
OR Odds Ratio
PNS Pesquisa Nacional de Saúde
PSF Programa Saúde da Família
QALY Quality-Adjusted Life-Year
rtPA Ativador do Plasminogênio Tecidual Recombinante
SIH Sistema de Informações Hospitalares
SIM Sistema de Informações sobre Mortalidade
SSQOL Escala Específica de Qualidade de Vida no AVC (em inglês, Stroke Specific Quality of Life Scale )
SUS Sistema Único de Saúde

Prevalência

As estimativas de prevalência de AVC podem diferir levemente entre os estudos, pois cada um seleciona e recruta uma amostra de participantes para representar sua população-alvo (estado, região ou país).

Em um estudo de base comunitária no Brasil, que aplicou um questionário para 4.496 indivíduos com idade superior a 35 anos, residentes de uma área carente da cidade de São Paulo em 2011, Abe et al . identificaram, em uma triagem inicial, 243 indivíduos positivos para AVC. A taxa de prevalência padronizada por idade para homens foi 4,6% (IC 95%, 3,5 - 5,7) e, para mulheres, 6,5% (IC 95%, 5,5 - 7,5). 67

Em um estudo transversal de base populacional que incluiu 3.391 indivíduos com idade igual ou superior a 20 anos, realizado em Porto Alegre, sul do Brasil, de julho a dezembro de 2009, com amostragem sistemática, Copstein et al . encontraram 285 indivíduos que relatavam diagnóstico ou sintomas consistentes com AVC prévio (8,4% da amostra). 68

Usando uma ferramenta de rastreio, um questionário de sintomas de AVC, Fernandes et al . estudaram a prevalência de AVC na cidade de Coari, na Bacia Amazônica Brasileira, e compararam essa prevalência entre ribeirinhos e a população urbana do mesmo município. Em 4.897 respondentes da área urbana e 1.028 da rural, os autores encontraram uma prevalência bruta de AVC de 6,3% na área rural e de 3,7% na urbana, com diferenças mantidas após ajuste para sexo e idade. 69

Pereira et al . conduziram um estudo para estimar a prevalência de AVC entre idosos na cidade de Vassouras, no Rio de Janeiro, em 2007, usando dados do Sistema de Informação da Atenção Básica, do censo populacional conduzido pelo IBGE e da ficha de atendimento padronizada pelo PSF do Ministério da Saúde. A qualidade dos diagnósticos de AVC do PSF foi analisada. De 4.154 idosos rastreados, o estudo detectou 122 com diagnóstico de AVC (prevalência, 2,9%; homens, 3,2%; mulheres, 2,7%) e aumento progressivo com o avançar da idade. A taxa de prevalência foi a mesma nas áreas rural e urbana do município (2,9%). 70

Utilizando o Stepwise Approach to Stroke Surveillance da OMS, Goulart et al . realizaram um estudo para verificar as taxas de mortalidade e morbidade por AVC em uma área de São Paulo. O questionário para determinar a prevalência de AVC foi aplicado de porta em porta em uma vizinhança do PSF (etapa 3). Dos 3.577 indivíduos com mais de 35 anos avaliados em casa, foram identificados 244 (6,8%) sobreviventes de AVC através do questionário validado por um neurologista certificado. 71

Benseñor et al ., analisando um inquérito epidemiológico de base domiciliar (PNS - 2013) com uma amostra representativa nacional, avaliaram o número absoluto de indivíduos com AVC e com incapacidade por AVC, com as respectivas prevalências. Foram estimados 2.231.000 indivíduos com AVC e 568.000 com incapacidade grave por AVC. As prevalências pontuais de AVC foram 1,6% e 1,4% para homens e mulheres, respectivamente. 72

De acordo com o Estudo GBD 2017, a prevalência de AVC padronizada por idade diminuiu 44,2% (II 95%, -41,7 a -46,9) no Brasil, passando de 1.810,9 (II 95%, 1.530,9 - 2.131,5) em 1990 para 1.010,6 (II 95%, 843,2 - 1.197,8) em 2017. 7 A prevalência padronizada por idade diminuiu similarmente entre homens e mulheres, mas foi maior entre os homens em todo o período ( Tabela 2-1 ). A Tabela 2-1 também mostra as taxas de prevalência padronizada por idade de AVC no Brasil e em suas unidades federativas.

– Taxa de prevalência de AVC padronizada por idade (por 100 mil) para ambos os sexos, para homens e para mulheres, no Brasil e unidades federativas, 1990 e 2017, e variação percentual das taxas
Ambos os sexos Mulheres Homens
1990 2017 Variação percentual 1990 2017 Variação percentual 1990 2017 Variação percentual
Brasil 6290 (6048.3;6548.9) 6025 (5785.8;6274.8) -4.2 (-3.2;-5.1) 5939.5 (5694.8;6205.5) 5612.9 (5366.3;5856.6) -5.5 (-4.2;-6.7) 6697.3 (6433.7;6961.9) 6536.8 (6282.7;6806.6) -2.4 (-1.3;-3.4)
Acre 6011.6 (5762.4;6272.3) 5814.9 (5568.2;6071.4) -3.3 (-1.4;-5.3) 5595.5 (5340.7;5865.5) 5350.3 (5101.6;5618.9) -4.4 (-1.5;-7.2) 6361.8 (6076.6;6659.2) 6299 (6033;6583.4) -1 (1.8;-3.9)
Alagoas 5960.7 (5700.5;6233.7) 5790.1 (5543.7;6044.7) -2.9 (-0.8;-4.8) 5603.9 (5346;5888.2) 5381 (5123;5659.8) -4 (-1;-6.9) 6360 (6070.2;6651.8) 6307.2 (6024.2;6580.8) -0.8 (2;-3.5)
Amapá 6219.5 (5950.1;6490.2) 6185.3 (5922.8;6478.7) -0.5 (1.5;-2.7) 5945.1 (5646.7;6260.9) 5817.8 (5542.5;6137.7) -2.1 (1.3;-5.4) 6515.4 (6227.7;6811.6) 6587.8 (6304.5;6889.1) 1.1 (3.8;-1.6)
Amazonas 5728.7 (5485.7;5987.5) 5701.6 (5455.9;5955) -0.5 (1.8;-2.6) 5367.7 (5112.8;5643.3) 5244.5 (4984.1;5506.4) -2.3 (0.8;-5.5) 6092 (5823.9;6361.4) 6183.2 (5892.3;6475.4) 1.5 (4.5;-1.3)
Bahia 5760.9 (5521.5;6019.9) 5685.9 (5433.9;5942.7) -1.3 (0.9;-3.4) 5420.2 (5164;5706.9) 5247 (4989.7;5508.9) -3.2 (-0.2;-6) 6147.9 (5863.3;6431.4) 6225 (5936.4;6513.3) 1.3 (4.3;-1.6)
Ceará 5860.4 (5600.4;6118.9) 5943.7 (5668.7;6231.8) 1.4 (3.8;-0.9) 5545.9 (5270.6;5820.4) 5541.3 (5256.3;5850.7) -0.1 (3.2;-3.3) 6211.7 (5923.9;6506.7) 6448.9 (6145.4;6775.2) 3.8 (7.1;0.7)
Distrito Federal 5798.5 (5563.4;6037.2) 5529.8 (5303.6;5752.8) -4.6 (-2.7;-6.5) 5461.1 (5211.3;5732.7) 5144.9 (4908.1;5382.3) -5.8 (-3;-8.7) 6209.3 (5957.1;6458.7) 6061.9 (5797;6321.5) -2.4 (0.3;-4.9)
Espírito Santo 6214.8 (5957;6478.6) 5748.2 (5490.1;5998.6) -7.5 (-5.6;-9.5) 5868.6 (5600.7;6137.1) 5341.6 (5086.6;5596.6) -9 (-6.1;-11.8) 6591.9 (6320.7;6883.9) 6240.1 (5950.8;6518.6) -5.3 (-2.8;-7.8)
Goiás 5642.8 (5395.9;5901.5) 5527.3 (5295.5;5762.8) -2 (0.1;-4.2) 5318.3 (5037.2;5601.6) 5136.8 (4890.8;5398.2) -3.4 (0;-6.6) 5947.9 (5701.8;6217.5) 5969.3 (5701.1;6245.8) 0.4 (3.2;-2.6)
Maranhão 5596.3 (5341.3;5857.4) 5592.5 (5348.5;5844.7) -0.1 (2;-2.1) 5196.3 (4944.4;5463.5) 5174.8 (4941.4;5424) -0.4 (2.6;-3.3) 6026.1 (5740.7;6311.6) 6065.4 (5785.2;6348.3) 0.7 (3.5;-2.2)
Mato Grosso 5995.6 (5727.7;6258.6) 5869.7 (5612.3;6121.4) -2.1 (0.2;-4.1) 5622 (5350.5;5896.6) 5441.8 (5189.2;5704.2) -3.2 (-0.1;-6) 6297.7 (6001.6;6588.6) 6285.3 (5998.3;6582.1) -0.2 (2.8;-3)
Mato Grosso do Sul 6168.4 (5915.1;6427.7) 5964.9 (5727.2;6210.6) -3.3 (-1.3;-5.3) 5730.5 (5467.9;5987.4) 5472.6 (5219.8;5732.1) -4.5 (-1.6;-7.4) 6571.7 (6308.5;6860.6) 6512.2 (6248.7;6790.3) -0.9 (1.8;-3.7)
Minas Gerais 6269 (5985.9;6552.4) 6031.6 (5768.1;6308.7) -3.8 (-1.4;-5.9) 5902 (5602;6201.4) 5614.5 (5333.5;5907.9) -4.9 (-1.8;-7.9) 6699.1 (6401.3;6989.1) 6532.8 (6246.7;6839) -2.5 (0.2;-5)
Pará 5842.4 (5588.6;6111.7) 5751 (5495.1;6017.5) -1.6 (0.6;-3.6) 5511.2 (5245.2;5786.3) 5291.5 (5022.7;5567.5) -4 (-0.7;-7.2) 6191.5 (5918.1;6485.6) 6236.9 (5947.8;6540.6) 0.7 (3.7;-2)
Paraíba 5802.6 (5546.1;6053.4) 5755.9 (5515.6;6004.5) -0.8 (1.4;-3) 5477.7 (5212.5;5728.9) 5371 (5114.4;5651.9) -1.9 (1.3;-5) 6170.5 (5892.1;6456.2) 6253.3 (5978.4;6539.4) 1.3 (4.1;-1.5)
Paraná 6350.3 (6083.3;6621.1) 5998 (5747.6;6250.1) -5.5 (-3.5;-7.6) 5947.5 (5671;6238.5) 5549.2 (5289.1;5808) -6.7 (-3.8;-9.5) 6765.8 (6472.5;7054) 6538.5 (6262.5;6813.3) -3.4 (-0.5;-6)
Pernambuco 5864.3 (5618.3;6114.8) 5642.3 (5399.5;5887.5) -3.8 (-1.7;-5.9) 5544.4 (5296;5814.4) 5239.5 (4986.3;5490.8) -5.5 (-2.5;-8.3) 6252.9 (5972.2;6545.7) 6184.6 (5912.5;6459.7) -1.1 (1.7;-3.9)
Piauí 5511.3 (5276.3;5755.1) 5545.1 (5314.7;5786.3) 0.6 (2.8;-1.4) 5145.2 (4900.4;5394.3) 5131.4 (4894.1;5385.3) -0.3 (2.8;-3.3) 5911.2 (5642.8;6176.5) 6034.4 (5776.8;6317.2) 2.1 (4.8;-0.6)
Rio de Janeiro 6714.2 (6446.8;7008.6) 6230.8 (5980.5;6490.7) -7.2 (-5.3;-9.2) 6350.5 (6067.4;6659.1) 5820 (5546.8;6108.8) -8.4 (-5.6;-11.1) 7208.1 (6917.8;7498.2) 6800.2 (6527.3;7073.1) -5.7 (-3.1;-8.1)
Rio Grande do Norte 5701.2 (5452.1;5951.2) 5672.5 (5438;5939.2) -0.5 (1.6;-2.4) 5393 (5131.9;5659.9) 5280.7 (5029.7;5550.9) -2.1 (0.8;-5) 6041.8 (5780.8;6327.3) 6170.4 (5892.3;6466.5) 2.1 (5.1;-0.6)
Rio Grande do Sul 6600.3 (6315.3;6880.9) 6182.1 (5906.1;6460.9) -6.3 (-4.4;-8.3) 6322.7 (6028.2;6645.2) 5828.4 (5536.3;6116.6) -7.8 (-4.9;-10.6) 6961.6 (6661.6;7269.6) 6639.1 (6336.7;6946.7) -4.6 (-2;-7.3)
Rondônia 5985.6 (5731;6240.1) 5705.1 (5457.5;5949.3) -4.7 (-2.4;-6.8) 5599.4 (5348.2;5868.1) 5285.8 (5041.4;5543.5) -5.6 (-2.6;-8.6) 6276.9 (5998.5;6564.3) 6111.8 (5837.6;6398.4) -2.6 (0.4;-5.3)
Roraima 6064.1 (5818.4;6308.8) 5814.1 (5583.7;6060.7) -4.1 (-2.1;-6) 5617 (5371;5884) 5317.9 (5070;5562.2) -5.3 (-2.4;-8.1) 6407.7 (6148.3;6694.1) 6269.6 (6021.5;6541.3) -2.2 (0.4;-4.9)
Santa Catarina 6679.1 (6397.8;6964.3) 6217 (5941.2;6488.4) -6.9 (-5;-8.8) 6375.3 (6069.7;6674.6) 5844.5 (5564.4;6133.5) -8.3 (-5.4;-11.1) 7026.3 (6731;7339.3) 6667 (6373.5;6959.6) -5.1 (-2.3;-7.8)
São Paulo 6801.7 (6517.3;7096.7) 6423.9 (6151.9;6705.8) -5.6 (-3.4;-7.5) 6406.6 (6114.7;6715.3) 6000.7 (5715;6302.4) -6.3 (-3.1;-9.3) 7284.4 (6975.5;7612.3) 6975.7 (6661.7;7268.7) -4.2 (-1.4;-6.8)
Sergipe 5922.8 (5667.3;6171.5) 5851.4 (5597.1;6110.4) -1.2 (1.2;-3.4) 5582.1 (5328.1;5864.7) 5442.8 (5194.8;5717) -2.5 (0.7;-5.3) 6324.1 (6036.1;6611.2) 6374.1 (6091.1;6662.7) 0.8 (3.9;-1.8)
Tocantins 5849.3 (5606.1;6103.5) 5849.2 (5606.6;6094.9) 0 (2.1;-2.1) 5387.1 (5153.3;5644.6) 5307.1 (5065.3;5571.5) -1.5 (1.5;-4.3) 6261.9 (5993.8;6548.1) 6368.8 (6094;6643.8) 1.7 (4.6;-1)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

Dados do estudo ELSA-Brasil, uma coorte de seis centros com funcionários públicos e incluindo 15.105 adultos (45,8% homens; idade variando de 35 a 74 anos), mostraram prevalência de AVC de 1,3% para homens e mulheres. 73

Incidência Subtipos de AVC

Em um estudo de base hospitalar realizado na região de Fortaleza, no nordeste do Brasil, AVC isquêmico foi o subtipo mais frequente (72,9%), seguido por hemorragia intracerebral (15,2%), HSA (6,0%), AIT (3,0%) e AVC indeterminado (2,9%). 74 A distribuição é similar àquela do estudo de base comunitária conduzido de 2005 a 2006 na cidade de Joinville, no sul do Brasil, onde, dos 759 primeiros episódios de AVC, 610 (80,3%) foram isquêmicos, 94 (12,3%) foram hemorrágicos e 55 (7,2%) foram HSA. No estudo de Joinville, a incidência anual por 100 mil pessoas-ano foi 61,8 (IC 95%, 57,0 - 66,9) para AVC isquêmico, 9,5 (5% CI, 7,7 - 11,6) para AVCH e 5,6 (IC 95%, 4,2 - 7,3) para HSA. A incidência de AVC ajustada para a população mundial por 1.000 habitantes com idade acima de 55 anos foi 5,8 (IC 95%, 5,4 - 6,2). A incidência de infarto foi 4,7 (IC 95%, 4,3 - 5,1), de hemorragia intracerebral, 0,6 (IC 95%, 0,5 - 0,8), e de HSA, 0,3 (IC 95%, 0,2 - 0,4). 75

Em estudo de base populacional conduzido em Matão, no sudeste do Brasil, de 2003 a 2004, a incidência anual bruta por 100 mil por ano foi 108 (IC 95%, 85,7 - 134,1) e a taxa ajustada por idade e sexo, usando a População Padrão de Segi, foi 137 (IC 95%, 112,0 - 166,4) por 100 mil habitantes por ano. Acidente vascular cerebral isquêmico ocorreu em 69 (85,2%) indivíduos, hemorragia intracerebral, em 11 (13,6%) e HSA, em 1 (1,2%). 76

Dados do estudo de base comunitária de Joinville mostraram que, ao comparar diferentes períodos (1995, 2005-2006, 2010-2011 e 2012-2013), a incidência de AVC diminuiu. Nos últimos 18 anos, a incidência de AVC geral (todos os tipos principais de AVC) em Joinville diminuiu em 37% (IC 95%, 32 - 42). 75 A incidência de primeiro episódio de AVC ajustada para a população brasileira foi 86,6 por 100 mil (IC 95%, 80,5 - 93,0) em 2005-2006 e 113,46 por 100 mil (IC 95%, 101,5 - 126,8) em 1995. 77 A incidência geral ajustada por idade e para a população mundial por 100 mil pessoas-ano foi 143,7 (IC 95%, 128,4 - 160,3) em 1995, caindo para 105,4 (IC 95%, 98,0 - 113,2) em 2005-2006 e para 90,9 (IC 95%, 85,1 - 96,9) em 2012-2013. A incidência padronizada por idade de primeiro episódio de AVC estratificada por gênero e idade também caiu significativamente ao longo do tempo. A redução foi 11% maior nos homens (42%; IC 95%, 35 - 49) do que nas mulheres (31%; IC 95%, 23 - 39), e 16% maior nos jovens (≤ 44 anos: 54%; IC 95%, 41 – 66; > 44 anos: 38%; IC 95%, 33 - 43). De 1995 a 2013, a proporção de AVC isquêmico aumentou 12%, enquanto a de AVCH diminuiu 16%. Entretanto, a proporção de HSA permaneceu relativamente estável, variando de 7,5% em 1995 a 6% em 2012-2013. O peso da diminuição na incidência de AVC padronizada por idade foi proporcionalmente maior para AVCH do que para AVC isquêmico, enquanto o de HSA permaneceu estável. Nos últimos 8 anos, as incidências de AVC isquêmico e de AVCH apresentaram reduções absolutas significativas de 15% (IC 95%, 1,00 - 28,00) e de 60% (IC 95%, 13,00 - 86,00), respectivamente. Entretanto, a incidência de HSA apresentou redução absoluta não significativa de 29% (IC 95%, 15,00 - 92,00). 78

Um estudo incluindo 213 pacientes consecutivos com cardiomiopatia chagásica no Brasil explorou o risco cumulativo de AVC e AIT de longo prazo e suas relações com disfunção ventricular esquerda naqueles pacientes de junho de 1999 a janeiro de 2007. Após um seguimento médio de 36 meses, a incidência geral de AVC isquêmico foi 2,67 eventos por 100 pacientes/ano. Os fatores de risco independentes para AVC e AIT incluíram fração de ejeção de ventrículo esquerdo (HR 0,95; IC 95%, 0,91 - 0,99, p=0,009) e volume atrial esquerdo corrigido para área de superfície corporal (HR 1,04; IC 95%, 1,01 - 1,07, p=0,007), que persistiram após ajuste para uso de anticoagulação. 79

Mortalidade

Dados do Registro de AVC de Joinville (n=759 casos de primeiro AVC) mostraram que a taxa de mortalidade ajustada para a população brasileira no período 2005-2006 foi de 20,5 por 100 mil (IC 95%, 17,5 - 23,8) e, quando ajustada para a população mundial, 23,9 por 100 mil (IC 95%, 20,4 - 27,8), revelando uma tendência decrescente a partir de 1995. Houve ainda uma redução na mortalidade ajustada por idade, embora muito mais acentuada nos homens (48%) do que nas mulheres (3%). A taxa de letalidade foi 19,1% (145/759) no período 2005-2006, que é também menor do que a de 1995 [26,6% (84/320)]. Portanto, em aproximadamente 10 anos, a mortalidade caiu 37%. A taxa de letalidade de 30 dias diminuiu 28,2% no período (de 26,6% para 7,5%). 77 , 80

Em um estudo de base populacional realizado em Matão, na região sudeste (n=141), a taxa de letalidade geral de 30 dias foi 18,5% (IC 95%, 10,7 - 28,7%). Quanto aos subtipos de AVC, as taxas de letalidade de 30 dias foram 13% (IC 95%, 6,1 - 23,3%) para AVC isquêmico e 45,4% (IC 95%, 16,7 - 76,2%; p=0,02) para AVCH. A taxa de letalidade geral de 1 ano foi 30,9% (IC 95%, 21,1 - 42,1%). Quanto aos subtipos de AVC, as taxas de letalidade de 1 ano foram 24,6% (IC 95%, 23,7 - 47,2%) para AVC isquêmico e 63,6% (IC 95%, 30,7 - 89,0%; p=0,01) para AVCH. 76

Dados do Estudo GBD 2017 mostraram taxas de mortalidade por AVC padronizadas por idade por 100 mil de 122,9 (II 95%, 120,6 - 125) em 1990 e de 56,6 (II 95%, 55,2 - 57,8) em 2017, sendo a variação percentual de -54 (II 95%, -55,1 a -53) ( Figura 2-1 e Tabela 2-4 ). A maior variação percentual ocorreu no Espírito Santo, -68,3 (II 95%, -69,9 a -66,5), e a menor, no Maranhão, -31,7 (II 95%, -36,6 a -26,6) ( Tabela 2-2 ). Para os adultos, a maior variação percentual foi observada no grupo etário 50-69 anos, -56 (II 95%, -57,5 a -54,5) ( Tabela 2-4 ).

- Taxa de mortalidade padronizada por idade por AVC (100 mil habitantes), 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 109

– Taxa de mortalidade padronizada por idade (por 100 mil) por todos os tipos de AVC, AVC isquêmico, hemorragias intracerebral e subaracnóidea, no Brasil, 1990 e 2017, e variação percentual das taxas
Causa de morte e grupo etário 1990 2017 Variação percentual (II 95%)
B.2.3 - AVC
15-49 anos 17,8 (17,3;18,3) 8,3 (8,1;8,6) -53,4 (-55,2;-51,6)
50-69 anos 215,8 (210,8;220,9) 95 (92,4;97,6) -56 (-57,5;-54,5)
5-14 anos 0,9 (0,8;1) 0,4 (0,3;0,4) -57,4 (-61,8;-51,7)
70+ anos 1145,5 (1119,4;1166) 639,5 (622,2;655,6) -44,2 (-45,6;-42,7)
Padronizada por idade 122,9 (120,6;125) 56,6 (55,2;57,8) -54 (-55,1;-53)
Todas as idades 65 (63,8;66,1) 58 (56,6;59,2) -10,8 (-13;-8,8)
Abaixo de 5 4,3 (3,5;5,4) 0,7 (0,6;0,8) -84,1 (-88,7;-78)
B.2.3.1 - AVC Isquêmico
15-49 anos 2,2 (2,1;2,4) 0,9 (0,8;0,9) -59,7 (-64,2;-56,7)
50-69 anos 58 (56;60,2) 21,1 (20,1;21,9) -63,7 (-65,8;-61,6)
5-14 anos 0,1 (0;0,1) 0 (0;0) -71,6 (-76,9;-65,9)
70+ anos 618,1 (603,3;632,5) 319,7 (309,7;328,7) -48,3 (-49,9;-46,5)
Padronizada por idade 54,8 (53,6;55,9) 22,6 (21,9;23,2) -58,7 (-60;-57,4)
Todas as idades 24,8 (24,2;25,4) 22,4 (21,7;23) -9,6 (-12,6;-6,8)
Abaixo de 5 0,2 (0,2;0,3) 0 (0;0) -89,7 (-94,3;-82,2)
B.2.3.2 - Hemorragia Intracerebral
15-49 anos 11,2 (10,9;11,9) 4,8 (4,5;5) -57,6 (-60,9;-55,4)
50-69 anos 133,4 (129,6;137,1) 58,3 (56,4;60,3) -56,3 (-58;-54,5)
5-14 anos 0,3 (0,2;0,3) 0,1 (0,1;0,1) -59,6 (-66,9;-51,7)
70+ anos 482,2 (468,2;494,2) 281 (272,2;289,9) -41,7 (-43,8;-39,6)
Padronizada por idade 58,6 (57,3;59,9) 27,9 (27,1;28,7) -52,4 (-53,8;-51,1)
Todas as idades 33,6 (32,9;34,4) 29 (28,3;29,9) -13,6 (-16,2;-11,1)
Abaixo de 5 1 (0,6;1,6) 0,1 (0,1;0,1) -89 (-94,1;-79,7)
B.2.3.3 - Hemorragia Subaracnóidea
15-49 anos 4,4 (3,8;4,5) 2,6 (2,5;2,9) -39,4 (-43,6;-29,4)
50-69 anos 24,4 (22;25,6) 15,6 (14,8;16,6) -36 (-40,2;-29,6)
5-14 anos 0,6 (0,5;0,6) 0,3 (0,2;0,3) -54,9 (-59,2;-47,8)
70+ anos 45,3 (43,2;49,1) 38,8 (35,8;41) -14,2 (-22,7;-8,1)
Padronizada por idade 9,6 (8,8;9,9) 6,1 (5,8;6,4) -36,5 (-39,8;-32,2)
Todas as idades 6,6 (6;6,8) 6,5 (6,2;6,9) -0,7 (-6;7,4)
Abaixo de 5 3 (2,4;3,6) 0,5 (0,5;0,6) -82 (-86,4;-74,1)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Número de mortes e taxa de mortalidade padronizada por idade (por 100 mil) por AVC e AVC isquêmico no Brasil e suas unidades federativas, 1990 e 2017, e variação percentual das taxas
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.3 - AVC
Acre 146 (140;152) 101 (96,3;104,9) 318 (297;337) 59,3 (55,4;63,1) -41,3 (-45,4;-36,8)
Alagoas 1767 (1697;1843) 138,2 (133;143,6) 2341 (2227;2457) 79,4 (75,4;83,5) -42,6 (-45,8;-39,3)
Amapá 74 (70;77) 90,1 (85;93,9) 242 (226;256) 57,7 (54;61,3) -35,9 (-40;-31,5)
Amazonas 679 (636;714) 99 (92,7;103,9) 1407 (1332;1476) 58,7 (55,7;61,7) -40,7 (-44,4;-36,6)
Bahia 6405 (6059;6787) 96 (90,8;101,7) 9239 (8841;9681) 58,3 (55,7;61,4) -39,3 (-43,1;-35)
Brasil 97101 (95272;98780) 122,9 (120,6;125) 122783 (119899;125348) 56,6 (55,2;57,8) -54 (-55,1;-53)
Ceará 3266 (3038;3496) 80,7 (74,7;86,7) 5444 (5193;5691) 54,8 (52,2;57,2) -32,2 (-37,5;-26,3)
Distrito Federal 536 (516;556) 117,2 (113;121,2) 961 (902;1028) 53,5 (49,9;57,1) -54,4 (-57,5;-51)
Espírito Santo 1972 (1914;2030) 172,1 (166,9;177,1) 2188 (2079;2303) 54,6 (51,9;57,4) -68,3 (-69,9;-66,5)
Goiás 1920 (1845;2004) 121,4 (116,7;126,6) 2925 (2779;3091) 48,2 (45,8;50,9) -60,3 (-62,4;-58)
Maranhão 2563 (2374;2779) 101 (93,1;110,6) 4261 (4020;4592) 68,9 (65;74,3) -31,7 (-36,6;-26,6)
Mato Grosso 637 (596;683) 93,3 (87,3;99,6) 1407 (1328;1491) 51,9 (48,9;55) -44,4 (-48,8;-38,9)
Mato Grosso do Sul 937 (904;973) 121,6 (117,6;126,2) 1554 (1477;1642) 60,4 (57,4;63,8) -50,3 (-53,4;-47,3)
Minas Gerais 10859 (10542;11270) 127 (123,3;131,2) 12638 (12067;13238) 50,5 (48,2;53) -60,2 (-62,2;-58,1)
Pará 2210 (2066;2326) 117,3 (109,8;123,5) 3993 (3776;4201) 66 (62,3;69,5) -43,8 (-47,6;-39,4)
Paraíba 2070 (1958;2194) 92,5 (87,4;98,1) 2856 (2642;3073) 60,8 (56,2;65,4) -34,3 (-40,6;-27,8)
Paraná 6603 (6394;6801) 174,4 (169;179,4) 7455 (7111;7818) 63,8 (60,9;66,8) -63,4 (-65,2;-61,5)
Pernambuco 5744 (5538;5948) 145,5 (140,2;150,6) 6553 (6236;6877) 68,7 (65,3;72,2) -52,8 (-55,1;-50)
Piaui 1422 (1322;1536) 106,4 (98,8;115,1) 2294 (2169;2512) 63,7 (60,2;69,6) -40,1 (-44,6;-35,2)
Rio de Janeiro 13533 (13076;13920) 160,9 (155,4;165,5) 12650 (12074;13184) 60 (57,3;62,5) -62,7 (-64,6;-60,8)
Rio Grande do Norte 1180 (1106;1257) 74,2 (69,7;79,2) 1704 (1604;1806) 45 (42,3;47,7) -39,4 (-44,7;-33,7)
Rio Grande do Sul 7282 (6967;7528) 135,4 (129,5;139,9) 8818 (8373;9257) 60,3 (57,2;63,3) -55,5 (-57,9;-53)
Rondônia 384 (357;413) 140,1 (131,2;149,5) 764 (691;849) 60,9 (55,2;67,3) -56,5 (-61,2;-51,4)
Roraima 50 (45;54) 126,6 (117,3;136,8) 152 (135;171) 61,3 (54,7;68,5) -51,6 (-58;-44,9)
São Paulo 20625 (19917;21335) 121,8 (117,5;126,1) 24963 (23878;26094) 51 (48,7;53,3) -58,1 (-60,4;-55,8)
Santa Catarina 2947 (2832;3048) 148,9 (142,8;153,8) 3539 (3358;3729) 51,9 (49,3;54,6) -65,1 (-66,9;-63)
Sergipe 919 (877;957) 110,6 (105,7;115,2) 1328 (1269;1392) 65,5 (62,5;68,7) -40,8 (-44,4;-37,2)
Tocantins 373 (330;409) 121,4 (110,6;132,1) 790 (741;853) 60,1 (56,3;64,9) -50,5 (-55,4;-44,6)
B.2.3.1 - AVC Isquêmico
Acre 51 (48;54) 43,7 (41,2;45,9) 110 (102;120) 22,5 (20,6;24,4) -48,5 (-53,1;-43,4)
Alagoas 708 (669;750) 61,4 (58,2;64,9) 906 (851;964) 31,9 (29,9;34,1) -48 (-52,3;-43,7)
Amapá 29 (27;31) 43,2 (40,2;45,5) 83 (76;89) 22,9 (21;24,6) -46,9 (-51,3;-42,1)
Amazonas 247 (228;263) 43,4 (40;46,1) 492 (461;525) 22,6 (21,1;24,2) -47,8 (-52;-42,6)
Bahia 2466 (2310;2638) 40,2 (37,7;42,9) 3488 (3281;3697) 21,9 (20,6;23,3) -45,4 (-50;-40,4)
Brasil 37045 (36222;37909) 54,8 (53,6;55,9) 47453 (45939;48713) 22,6 (21,9;23,2) -58,7 (-60;-57,4)
Ceará 1279 (1165;1399) 33,5 (30,5;36,6) 2266 (2119;2411) 22,5 (21,1;24) -32,7 (-39,9;-24,2)
Distrito Federal 153 (144;162) 50,9 (48,2;53,5) 325 (299;353) 22,4 (20,6;24,3) -56,1 (-60,1;-51,7)
Espírito Santo 746 (712;782) 80,9 (77,5;84,4) 810 (759;869) 21,1 (19,7;22,6) -74 (-75,8;-71,9)
Goiás 623 (589;658) 52,2 (49,4;55,1) 1005 (940;1081) 18,1 (16,9;19,5) -65,3 (-67,9;-62,5)
Maranhão 812 (712;937) 37,2 (32,6;43) 1582 (1457;1733) 26,3 (24,3;28,9) -29,2 (-36,4;-21,1)
Mato Grosso 226 (209;245) 42 (39;45,2) 492 (459;529) 20,5 (19,1;22) -51,2 (-55,9;-46)
Mato Grosso do Sul 317 (300;334) 51,3 (48,8;54) 543 (508;584) 22,7 (21,2;24,4) -55,8 (-59,7;-51,7)
Minas Gerais 3976 (3792;4182) 56,4 (53,8;59) 4748 (4435;5040) 19,2 (17,9;20,4) -65,9 (-68,5;-63,4)
Pará 959 (890;1015) 58 (53,8;61,2) 1551 (1442;1657) 27,5 (25,5;29,3) -52,6 (-56,7;-48,4)
Paraíba 853 (787;928) 40 (37;43,3) 1163 (1065;1266) 24,2 (22,1;26,5) -39,4 (-46,7;-31,4)
Paraná 2537 (2416;2649) 82,5 (78,8;86,1) 3107 (2930;3296) 28,1 (26,5;29,8) -65,9 (-68,2;-63,6)
Pernambuco 2296 (2183;2413) 65,8 (62,7;69) 2429 (2266;2589) 26,3 (24,4;28,1) -60,1 (-63,1;-56,7)
Piaui 523 (472;587) 43,8 (39,6;49,1) 922 (859;1023) 25,6 (23,8;28,4) -41,7 (-47,5;-35,4)
Rio de Janeiro 4769 (4552;4985) 68,3 (65,2;71,3) 4520 (4224;4807) 22 (20,6;23,4) -67,8 (-70,1;-65,2)
Rio Grande do Norte 565 (523;611) 36,9 (34,2;39,8) 699 (648;751) 18,2 (16,8;19,6) -50,7 (-56,3;-44,9)
Rio Grande do Sul 3219 (3048;3377) 70,1 (66,5;73,2) 3691 (3446;3933) 25,6 (23,9;27,4) -63,4 (-66,1;-60,6)
Rondônia 110 (101;120) 61,3 (57;65,7) 282 (253;314) 25,1 (22,7;28) -59 (-63,6;-53,7)
Roraima 15 (13;16) 59,1 (54,5;64,2) 52 (46;58) 26,2 (23,2;29,3) -55,7 (-62,1;-48,8)
São Paulo 7894 (7483;8299) 56,8 (53,9;59,6) 9945 (9357;10577) 21,3 (20;22,7) -62,5 (-65,3;-59,5)
Santa Catarina 1164 (1104;1224) 71,1 (67,5;74,5) 1419 (1328;1513) 22,4 (20,9;23,8) -68,6 (-70,8;-66,1)
Sergipe 389 (367;411) 49,1 (46,2;51,8) 526 (494;559) 26,9 (25,2;28,6) -45,3 (-49,7;-40,5)
Tocantins 119 (107;132) 53,8 (48,5;59,7) 297 (275;320) 23,6 (21,9;25,5) -56 (-60,9;-49,9)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

Quanto aos subtipos de AVC, dados do Estudo GBD 2017 revelaram taxas de mortalidade por AVC isquêmico padronizadas por idade por 100 mil de 54,8 (II 95%, 53,6 - 55,9) em 1990 e de 22,6 (II 95%, 21,9 - 23,2) em 2017, representando uma variação percentual de -58,7 (II 95%, -60 a -57,4) ( Figura 2-2 e Tabela 2-2 ). Para os adultos, a maior variação percentual foi observada no grupo etário 50-69 anos, -63,7 (II 95%, -65,8 a -61,6) ( Tabela 2-4 ).

- Taxa de mortalidade padronizada por idade por AVC isquêmico (100 mil habitantes), 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 109

Segundo o Estudo GBD 2017, para hemorragia intracerebral, as taxas de mortalidade padronizadas por idade por 100 mil foram 58,6 (II 95%, 57,3 - 59,9) e 27,9 (II 95%, 27,1 - 28,7) em 1990 e 2017, respectivamente, representando uma variação percentual de -52,4 (II 95%, -53,8 a -51,1) ( Figura 2-3 e Tabela 2-4 ). Para os adultos, a maior variação percentual foi observada no grupo etário 15-49 anos, -57,6 (II 95%, -60,9 a -55,4) ( Tabela 2-4 ).

- Taxa de mortalidade padronizada por idade por hemorragia intracerebral (100 mil habitantes), 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 109

Segundo o Estudo GBD 2017, para HSA, as taxas de mortalidade padronizadas por idade por 100 mil foram 9,6 (II 95%, 8,8 - 9,9) e 6,1 (II 95%, 5,0 - 6,7) em 1990 e 2017, respectivamente, representando uma variação percentual de -36,5 (II 95%, -39,8 a -32,2) ( Figura 2-4 e Tabela 2-4 ). Para os adultos, a maior variação percentual foi observada no grupo etário 15-49 anos, -39,4 (II 95%, -43,6 a -29,4) ( Tabela 2-4 ).

- Taxa de mortalidade padronizada por idade por hemorragia subaracnóidea (100 mil habitantes), 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 109

- Prevalência de doença isquêmica do coração no Brasil, por sexo, porcentagem (1990-2017). Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 151

- Taxa de prevalência de doença isquêmica do coração padronizada por idade por 100 mil habitantes no Brasil por sexo (1990-2017). Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 151

Analisando as estimativas do GBD 2015 em 27 unidades federativas brasileiras entre 1990 e 2015, Lotufo et al. mostraram que, apesar do aumento no número absoluto de mortes por doença cerebrovascular, a proporção de mortes antes dos 70 anos de idade foi reduzida à metade entre 1990 e 2015. Nesse período, o risco de morte atribuível a AVC decresceu tanto para homens (-2,41% por ano) quanto para mulheres (-2,51% por ano). No entanto, a redução anual nas taxas de mortalidade ajustadas para idade, para ambos os sexos, desacelerou entre 2005 e 2015 quando comparada ao período de 1990-2005. Estados com índice de desenvolvimento social no tercil inferior apresentaram reduções anuais menos significativas para homens e mulheres (-1,23% e -1,84%, respectivamente) quando comparados àqueles com índice no tercil médio (-1,94 e -2,22%, respectivamente) e àqueles com índice no tercil superior (-2,85 e -2,82%, respectivamente). Além disso, houve diminuição nos anos vividos com incapacidade nos estados, mas de maneira menos expressiva. 81

André et al. , usando dados do SIM corrigido para mortes por causas mal definidas, mostram que as taxas de mortalidade por AVC padronizadas por idade decresceram consistentemente entre 1980-1982 e 2000-2002, passando de 68,2 para 40,9 por 100 mil habitantes. Durante o mesmo período, as taxas de mortalidade cardiovascular total também diminuíram significativamente, passando de 208,2 para 126,1 por 100 mil habitantes. O declínio na taxa de mortalidade por AVC padronizada por idade foi evidente nas duas décadas, sendo maior entre 1990-1992 e 2000-2002. Tomando as taxas de 1980 como referência, houve uma redução de risco de 30% (IC 95%, 30% - 31%) em 1990 e de 55% (IC 95%, 55% - 56%) em 2000 (P<0,001 para ambas as medidas). A redução proporcional na mortalidade por AVC foi evidente para homens e mulheres, ainda que mais acentuada para os homens. Além disso, a diminuição foi observada em todas as faixas etárias. Detectou-se uma interação entre sexo e idade, com declínio mais acentuado nas taxas de mortalidade padronizadas por idade na população masculina jovem (até 45 anos) e declínio mais abrupto para as mulheres de todas as faixas etárias (P<0,001 para todos os achados). A redução nas taxas de mortalidade por AVC padronizadas por idade ocorreu em todas as regiões geopolíticas. Detectou-se uma interação entre a região estudada e a magnitude da redução. As regiões mais ricas (Sul e Sudeste) exibiram taxas iniciais mais altas e reduções mais marcadas durante o período do estudo. Esses achados foram confirmados pelo modelo de regressão de Poisson, no qual a redução menos marcante na taxa de mortalidade por AVC padronizada foi observada na região Nordeste, 41% (IC 95%, 40% - 42%). Os valores correspondentes para as outras regiões foram: Norte, 52% (IC 95%, 51% - 52%); Centro-Oeste, 53% (IC 95%, 53% - 54%); Sul, 57% (IC 95%, 56% - 57%); e Sudeste, 59% (IC 95%, 58% - 59%). O número total de mortes relacionadas a AVC no Brasil, no entanto, vem aumentando consistentemente nas últimas 3 décadas. O número anual médio de mortes atribuíveis a AVC aumentou de 79.862, em 1980-1982, para 101.625, em 2000-2002. Tendência semelhante foi evidenciada na mortalidade cardiovascular total: 239.876 mortes em 1980-1982 e 311.138 em 2000-2002. Esse aumento reflete principalmente o envelhecimento progressivo da população brasileira. 82

Em outra avaliação das tendências da mortalidade por AVC no Brasil de 1979 a 2009, após a exclusão das mortes devidas às sequelas de AVC, para os homens, as variações percentuais anuais (IC 95%) foram: 1979-1984, 0,7 (-0,8 a 2,1); 1984-1994, -1,8 (-2,4 a -1,2); 1994-2007, -5,0 (-5,4 a -4,7); e 2007-2009, -0,8 (-7,0 a 5,8). Para as mulheres, as variações percentuais anuais (IC 95%) foram: 1979-1994, -1,9 (-2,2 a -1,6); 1994-1997, -7,5 (-14,0 a -0,6); 1997-2007, -4,0 (-4,6 a -3,3); e 2007-2009, 1,6 (-5,5 a 9,2). No período 2006-2009, a média da variação percentual anual (IC 95%) para todos os AVC foi -3,1 (-3,3 a -2,9) para os homens e -2,9 (-3,1 a -2,8) para as mulheres. No mesmo período, a média da variação percentual anual das taxas de morte pelos subtipos de AVC foram, para homens e mulheres, respectivamente: hemorragia intracerebral, -4,0 (-4,9 a -3,1) e -2,9 (-3,4 a -2,3); e AVC isquêmico, -3,2 (-3,3 a -3,0) e -1,4 (-2,0 a -0,9). 83

Uma avaliação considerando a realocação dos óbitos sem registro de sexo ou idade, a redistribuição de ‘códigos garbage ’ e a correção de subnotificação mostrou as seguintes taxas de mortalidade por AVC para 1996 e 2011, ajustadas por idade, antes e depois de correção, respectivamente: 1) para homens: em 1996, 82,9 e 113,6; e, em 2011, 49,6 e 60,9; e 2) para mulheres: em 1996, 58,2 e 84,4; e, em 2011, 34,7 e 42,3. 84

Um estudo avaliando diferenças regionais na transição de mortalidade e utilizando dados do SIM de 1990 a 2012 mostrou uma variação de -48,05% no coeficiente de mortalidade por AVC. A maioria das regiões apresentou redução nas taxas de mortalidade padronizadas por idade: -62% no Sudeste; -55,5% no Sul; -26,91% no Centro-Oeste; e -20,8% no Norte. Apenas no Nordeste ocorreu aumento (13,77%). 85

Na cidade de São Paulo, de 1996 a 2011, 77.848 óbitos por AVC foram confirmados, 51,4% dos quais entre indivíduos com 35-74 anos de idade. Naquele período, taxas de mortalidade ajustadas por idade por doenças cerebrovasculares diminuíram 46,6% nos homens e 47,8% nas mulheres. Para os homens nas áreas de maior renda, a tendência decrescente foi constante; na área de renda média, houve um declínio marcado de 1996 a 2000, seguido por um de menor velocidade entre 2000 e 2011. Nas áreas de renda mais baixa, a variação percentual anual foi maior entre 1996 e 2002, com discreto declínio entre 2002 e 2011. Para as mulheres nas áreas de alta renda, houve um declínio marcado de 1996 a 2003, que foi menor na segunda metade do período; nas áreas de renda baixa e média, o declínio foi constante em todos os períodos. Para todo o período, ambos os sexos e grupo etário de 35-74 anos, a diminuição nas taxas ajustadas por idade foi mais pronunciado entre os residentes da área de maior renda em comparação àqueles da área de menor renda. Esse mesmo padrão, mas com diferente magnitude de declínio, foi observado nos indivíduos com idade ≥75 anos em todas as áreas ao se comparar aos outros grupos etários, para os dois sexos. Além disso, a evolução temporal das razões entre as taxas ajustadas por idade de indivíduos de 35-74 anos vivendo em áreas de renda baixa e alta foi: para homens, de 1996 a 1998, a razão das taxas foi 2,03, e, de 2009 a 2011, 2,34. Para as mulheres, de 1996 a 1998, a razão das taxas foi 2,09, e, de 2009 a 2011, 2,58. A tendência das razões entre as taxas ajustadas por idade dessas áreas mostrou um crescimento da variação percentual anual de 1,4 (0,5 - 2,4) para os homens e de 1,1 (0,1 - 2,0) para as mulheres. 86

Em estudo de base hospitalar realizado nas regiões Nordeste e Sudeste (n=962), as taxas de letalidade geral para 10 dias e 28 dias foram 7,9 (IC 95%, 6,2 - 9,7) e 12,5 (IC 95%, 10,4 - 14,5), respectivamente. As taxas de morte por AVCH foram maiores do que aquelas por AVC isquêmico tanto para 10 dias (12,3[IC 95%, 7,2 - 14,4] vs. 7,0[IC 95%, 5,3 - 8,8]) quanto para 28 dias (19.8[IC 95%, 13,6 - 26,0] vs. 11,1[IC 95%, 8,9 - 13,3]). Além de idade avançada, os fatores de risco para letalidade por AVC isquêmico aos 28 dias foram diabetes (OR=1,69; IC 95%, 1,06 - 2,68) e doença cardíaca prévia (OR=1,86; IC 95%, 1,17 - 2,96) após ajuste por idade. 87

Carga de Doença

Dados do Estudo GBD 2017 mostraram que as taxas de DALYs por AVC padronizadas por idade por 100 mil foram, em 1990, 2.511,9 (II 95%, 2.457,3 - 2.567,6) e, em 2017, 1.145,3 (1.107,8 - 1.185,3), representando uma variação percentual de -54,4 (II 95%, -55,5 a -53,2) ( Tabela 2-6 ). Para homens, a variação percentual foi -54 (II 95%, -55,4 a -52,5) e, para mulheres, -54,2 (II 95%, -55,9 a -52,7) ( Tabelas 2-9 e 2-10 ). A maior variação percentual ocorreu no Espírito Santo, -64,7 (II 95%, -66,5 a -62,8), e a menor, no Amapá, -29,5 (-33,8 a -25,2) ( Tabela 2-5 ).

– Taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, no Brasil, 1990 e 2017, e variação percentual das taxa
Causa de morte e grupo etário 1990 2017 Variação percentual (II 95%)
B.2.3- AVC
15-49 anos 900,8 (875,2;928) 427,2 (412;442,6) -52,6 (-54,4;-50,8)
50-69 anos 6472,1 (6299,3;6661,2) 2930,7 (2823,1;3041,8) -54,7 (-56,2;-53,1)
5-14 anos 76,6 (65,6;82,7) 34,2 (31;37,5) -55,3 (-59,6;-49,8)
70+ anos 15340,3 (14965,2;15714,6) 8044,9 (7764,8;8361) -47,6 (-49;-46,2)
Padronizadas por idade 2511,9 (2457,3;2567,6) 1145,3 (1107,8;1185,3) -54,4 (-55,5;-53,2)
Todas as idades 1638,6 (1601,9;1675,6) 1225 (1185,3;1267,6) -25,2 (-27,2;-23,1)
Abaixo de 5 374,3 (302,2;473,7) 60,2 (51,7;70,9) -83,9 (-88,5;-77,8)
B.2.3.1- AVC Isquêmico
15-49 anos 125,4 (118,1;134) 60,6 (54,5;67,2) -51,6 (-56,6;-48,1)
50-69 anos 1815 (1728,7;1901,4) 750,4 (693,5;808,9) -58,7 (-60,9;-56,4)
5-14 anos 9,2 (7,6;11,3) 4,2 (3,3;5,5) -53,9 (-59,4;-48,5)
70+ anos 8120,6 (7833,9;8406,8) 4071,1 (3858,5;4306,3) -49,9 (-51,8;-47,8)
Padronizadas por idade 871,4 (841,1;902,4) 387,3 (363,8;411,5) -55,6 (-57,3;-53,8)
Todas as idades 489,8 (471,5;508,9) 399,7 (375,2;425,1) -18,4 (-21,8;-15,1)
Abaixo de 5 21,6 (15,5;30,9) 2,7 (2,2;3,4) -87,4 (-92,3;-79,9)
B.2.3.2- Hemorragia Intracerebral
15-49 anos 551,1 (532,8;582,6) 231,9 (219,7;241,4) -57,9 (-61,3;-55,8)
50-69 anos 3889,2 (3785,6;4001,8) 1681,4 (1626,7;1736,2) -56,8 (-58,4;-55,1)
5-14 anos 22,7 (19;25,3) 9,7 (8,4;11) -57,2 (-64,5;-49,3)
70+ anos 6557,5 (6353,6;6729,9) 3451,2 (3343,6;3564,8) -47,4 (-49,2;-45,5)
Padronizadas por idade 1322,1 (1291,8;1358,2) 576,9 (560,7;594,9) -56,4 (-57,8;-55,1)
Todas as idades 893 (872,1;919,4) 626,5 (608,5;645,9) -29,9 (-32,3;-27,7)
Abaixo de 5 89,5 (56,4;137,1) 10 (7,9;12,6) -88,8 (-93,9;-79,4)
B.2.3.3- Hemorragia Subaracnóidea
15-49 anos 224,3 (198,4;234,1) 134,6 (127,8;146,1) -40 (-43,9;-30,9)
50-69 anos 767,9 (694,1;806,4) 499 (472,4;530,5) -35 (-39,1;-28,4)
5-14 anos 44,7 (38;48,3) 20,3 (18,3;22,3) -54,7 (-58,9;-47,7)
70+ anos 662,2 (627,5;712,9) 522,6 (484,9;553) -21,1 (-27,7;-15,6)
Padronizadas por idade 318,4 (287;332,2) 181 (173,1;191) -43,1 (-46,3;-37,2)
Todas as idades 255,7 (228,7;267,6) 198,8 (189,9;210,2) -22,2 (-26,8;-13,2)
Abaixo de 5 263,3 (204;315,7) 47,5 (40,8;56,2) -82 (-86,4;-74)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Número de DALYs, taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, no Brasil e unidades federativas, 1990 e 2017, e variação percentual das taxas
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.3- AVC
Acre 3953.6 (3783.3;4122.2) 1979.4 (1889.4;2059) 7266.7 (6834.2;7705) 1186.3 (1115.8;1257.3) -40.1 (-43.8;-36.1)
Alagoas 43233.8 (40973.6;45710.8) 2817.5 (2696.9;2939.7) 50039.4 (47688.1;52560.1) 1603.7 (1528;1685.4) -43.1 (-46.4;-39.8)
Amapá 1920.5 (1817.3;2003.4) 1670.5 (1572;1744.3) 6037.8 (5631.2;6387.6) 1177.4 (1098.1;1246.7) -29.5 (-33.8;-25.2)
Amazonas 17676.9 (16548.2;18641.9) 1941.3 (1817.2;2042.1) 31700.8 (29773.6;33426.1) 1140 (1076.7;1203.3) -41.3 (-44.6;-37.3)
Bahia 156852.9 (148273.2;166581.9) 2060 (1952.1;2187.7) 195170.9 (186401.1;204704.4) 1235.6 (1179.1;1295.2) -40 (-43.7;-36.1)
Brasil 2448379.5 (2393632.7;2503724.8) 2511.9 (2457.3;2567.6) 2594661.6 (2510573.1;2684848.2) 1145.3 (1107.8;1185.3) -54.4 (-55.5;-53.2)
Ceará 77492.6 (71681.9;83089.4) 1703.7 (1591.4;1819.1) 103566.8 (98110.9;108379.4) 1057.1 (1000.6;1107) -38 (-42.2;-33.4)
Distrito Federal 16605 (15926.8;17311.1) 2251.3 (2165.6;2333.6) 22403.1 (21031.9;23843.1) 920.1 (864.6;978.9) -59.1 (-61.8;-56.6)
Espírito Santo 48506.9 (47021.8;49978.7) 3107.9 (3018.3;3201) 46467.9 (44131.5;48868.8) 1096.7 (1041.8;1153.2) -64.7 (-66.5;-62.8)
Goiás 53132.8 (51019.6;55603.8) 2378.7 (2290.8;2484.2) 67110 (63427;71058) 992.6 (937.7;1051.6) -58.3 (-60.4;-56.1)
Maranhão 75263.4 (68906.4;82104.3) 2388.4 (2215.7;2565.2) 91064 (85853.5;96952.9) 1402.6 (1322.8;1493.3) -41.3 (-46;-36.2)
Mato Grosso 18394.3 (17193.1;19706.7) 1921.2 (1795;2051.7) 33309.4 (31413.2;35286.5) 1053.1 (994.2;1114.2) -45.2 (-49.3;-40.3)
Mato Grosso do Sul 24999.9 (23740.6;26097.7) 2462.2 (2369.6;2564.2) 34030.3 (32246.1;35981.7) 1208.7 (1146.7;1277.8) -50.9 (-53.7;-48)
Minas Gerais 285548.6 (275818.9;297328.5) 2638.6 (2555.4;2738.7) 271355.2 (257504.2;284521) 1075.3 (1020.5;1128.8) -59.2 (-61.3;-57)
Pará 53548.4 (50133.8;56655) 2253.4 (2113.7;2377) 88611.2 (83452.1;93804) 1314.4 (1238.6;1389.9) -41.7 (-45.7;-37.3)
Paraíba 45144.4 (42515.4;47988.9) 1858.6 (1751.2;1976.6) 54910.4 (50876.5;59063.6) 1206.4 (1118.5;1299.4) -35.1 (-40.9;-29.1)
Paraná 161625.7 (156492.6;166651.6) 3179.7 (3077;3274.8) 151291.7 (143947.2;158892.6) 1197.3 (1140.6;1255.3) -62.3 (-64.2;-60.3)
Pernambuco 130872.4 (125974.8;135596) 2751.6 (2651.9;2849.7) 136137.9 (129804.7;142784.5) 1375 (1311.6;1441) -50 (-52.3;-47.6)
Piauí 34432.1 (31750.1;37132.4) 2154.9 (1999.1;2316.3) 44933.5 (42457;48250.5) 1250.2 (1181.4;1343.6) -42 (-46.3;-37.4)
Rio de Janeiro 347453.9 (334592.7;357975.7) 3346.4 (3230.9;3445.4) 273760.5 (261736;286898.1) 1271.2 (1214.1;1331.4) -62 (-63.9;-60.1)
Rio Grande do Norte 25680.8 (24130.7;27242.4) 1487.2 (1395.3;1582.5) 34501.8 (32491.3;36566.5) 927.5 (872.6;983.7) -37.6 (-42.5;-32.5)
Rio Grande do Sul 172339.3 (165146.5;178677.8) 2524.5 (2421.8;2615.5) 170330.5 (160060.7;179998.5) 1150.9 (1082.3;1214.1) -54.4 (-56.8;-52)
Rondônia 12073.7 (11218.4;12924.2) 2741.2 (2563.3;2929.9) 17322.9 (15670.4;19262) 1178.2 (1069.9;1308.7) -57 (-61.6;-51.8)
Roraima 1569.1 (1426.3;1728.5) 2172.9 (2005;2364.6) 3644.2 (3249.6;4101.8) 1057.5 (946.3;1182.6) -51.3 (-57.5;-44.5)
Santa Catarina 69910.9 (67055.5;72514.6) 2666.7 (2559.3;2763.6) 71975.6 (67852.1;76213.3) 950.5 (898.1;1006.1) -64.4 (-66.2;-62.4)
São Paulo 539524.3 (519316.5;557948.6) 2449 (2360.9;2532.4) 542703.5 (515509.8;569546.5) 1043.5 (993.5;1094.6) -57.4 (-59.5;-55.2)
Sergipe 20033.1 (19174.8;20849.7) 2166.3 (2075.3;2253.8) 27552 (26196.3;28951.2) 1282.7 (1220.2;1347.5) -40.8 (-44;-37.2)
Tocantins 10590 (8966.2;11793.5) 2245 (1990.4;2461.4) 17463.5 (16283.5;18745.7) 1235.7 (1153.4;1326.5) -45 (-50.5;-37.6)
B.2.3.1- AVC Isquêmico
Acre 1063.5 (996.8;1132.3) 667.8 (626.7;707.7) 2076 (1893.9;2264.6) 383.1 (351;417.7) -42.6 (-47.4;-37.9)
Alagoas 13197.8 (12462.3;14030.4) 985.2 (929.6;1045.1) 15974 (14833.8;17114.8) 542.2 (503.3;580.4) -45 (-48.8;-40.7)
Amapá 587.7 (545;627.3) 640.8 (595.3;680.4) 1748.6 (1589.7;1898.5) 402.8 (368.8;435.9) -37.1 (-41.9;-32.4)
Amazonas 5084.6 (4695.8;5429.5) 688.6 (637.7;735) 9130.4 (8393.2;9894.1) 375.1 (345.4;405.2) -45.5 (-49.4;-41)
Bahia 46074.5 (43055.7;49389.4) 671.6 (627.8;719.8) 60202.2 (56130.2;64836.4) 388.2 (361.5;418.2) -42.2 (-46.8;-37.5)
Brasil 731917.9 (704484.3;760431.9) 871.4 (841.1;902.4) 846622.4 (794644.5;900331.8) 387.3 (363.8;411.5) -55.6 (-57.3;-53.8)
Ceará 22421 (20485.5;24419.3) 546.3 (497.9;596.2) 35205.6 (32642.9;37754.2) 361.7 (335.2;388.2) -33.8 (-40.2;-27.1)
Distrito Federal 3906.4 (3644.7;4163.9) 766.5 (721.7;813) 6593.1 (5992;7230) 325.9 (298.5;356.9) -57.5 (-61.1;-53.7)
Espírito Santo 14282 (13533.3;15095.1) 1098.2 (1045.3;1153.6) 14731.1 (13585.4;15935.6) 363.2 (335.4;393.2) -66.9 (-69.2;-64.5)
Goiás 13916.2 (12991.6;14820.9) 800.2 (752;844.9) 19898.4 (18199.2;21777) 320.9 (293.9;350) -59.9 (-62.8;-56.7)
Maranhão 17377 (15585.8;19607.3) 660 (586.2;752.6) 27215.8 (24986.8;29637.2) 439.9 (404.1;479) -33.3 (-40;-26)
Mato Grosso 5212.7 (4803.6;5633.7) 705.7 (650.9;759.9) 10002 (9113.3;10867.5) 356.6 (326.3;386.9) -49.5 (-54.1;-44.5)
Mato Grosso do Sul 6723.6 (6322.8;7131.6) 813.8 (767.3;859.5) 10101.1 (9292.6;10911.3) 384.6 (354.4;414.8) -52.7 (-56.5;-48.9)
Minas Gerais 81390.3 (76723.4;86023.9) 881.5 (836.4;927.8) 86497.3 (79441.7;93590) 346.9 (318.9;375.4) -60.6 (-63.5;-57.6)
Pará 18296.6 (16994.5;19445.1) 906.6 (843.3;962.1) 28488.5 (26185.1;30787) 465.3 (428.2;501.5) -48.7 (-53;-44.3)
Paraíba 14128.8 (12998.2;15518.4) 609.2 (560.5;666.9) 18006.3 (16468.6;19631.7) 392.4 (358.4;427.9) -35.6 (-42.9;-27.8)
Paraná 51172.4 (48539.5;53822.5) 1204 (1146.1;1259.9) 55096.3 (51203.8;59213.8) 455.8 (424.5;489.8) -62.1 (-64.8;-59.4)
Pernambuco 41435.4 (39396.4;43702.5) 970.5 (925.1;1020.6) 41014.9 (38043.8;44085.7) 431.5 (400.1;463.9) -55.5 (-58.6;-52.1)
Piauí 9568.2 (8668;10635.1) 687.6 (623.1;765.2) 14673.1 (13540.8;15959.7) 411.7 (379.6;448) -40.1 (-45.6;-34)
Rio de Janeiro 95808.8 (90420.4;100946.9) 1069 (1012.6;1122.6) 83858 (77688.3;90710.3) 394.7 (366.4;426.8) -63.1 (-65.9;-60.3)
Rio Grande do Norte 9503.9 (8745.6;10253.4) 584.6 (538.8;631.1) 11733.2 (10776.4;12756) 319.1 (292.9;346.8) -45.4 (-50.7;-39.9)
Rio Grande do Sul 60826.8 (57517.2;64097.9) 1027.2 (972.9;1078) 61657.7 (56558.6;66642) 417.5 (382.7;451.1) -59.4 (-62.2;-56.3)
Rondônia 3034.7 (2783.7;3293.1) 970.7 (899.5;1042.4) 5412.4 (4855.6;6020.7) 415.3 (373.7;461) -57.2 (-61.8;-51.9)
Roraima 372.6 (336.5;412.4) 795.4 (729;867.3) 1055.5 (934.1;1183.6) 379.8 (337.7;421.7) -52.2 (-58.4;-45.5)
Santa Catarina 22415.1 (21207.6;23730.7) 1029.7 (974;1083.9) 25161.9 (23015.1;27290.2) 354.4 (325.4;383.2) -65.6 (-68;-62.8)
São Paulo 164767.5 (155579.3;173984.4) 890.4 (843.4;938) 186699.6 (171816.4;201713.6) 372 (342.1;401.3) -58.2 (-61;-55.2)
Sergipe 6658.2 (6265.3;7056.5) 781.8 (736.7;828.1) 8987.9 (8329;9671) 443.8 (411.4;476.9) -43.2 (-47.3;-38.6)
Tocantins 2692 (2368.4;3009.9) 750 (674.7;828.6) 5401.9 (4954.1;5885.6) 408.6 (374.8;444.9) -45.5 (-51.5;-38.7)
B.2.3.2- Hemorragia Intracerebral
Acre 2042.4 (1946.7;2151.3) 1021.1 (972.1;1070.2) 3907 (3628.3;4180.9) 625.6 (581;667.5) -38.7 (-43.7;-33.5)
Alagoas 22644.7 (21077;24235.6) 1476.9 (1388.9;1567.2) 27097.9 (25636;28599.9) 855.7 (809.8;904.3) -42.1 (-46.4;-37.8)
Amapá 1000.2 (936.5;1047.5) 829.7 (774.6;869.6) 3256.8 (2973.7;3497.4) 613.2 (561;657.1) -26.1 (-31.8;-19.8)
Amazonas 9657.5 (8944.9;10226.1) 1033.8 (957;1093.8) 17298.4 (16028.8;18370.1) 607.4 (564.8;644.9) -41.2 (-45.5;-36.3)
Bahia 84377.2 (79355.7;90141) 1108.1 (1040.1;1183.5) 104105.8 (98385.8;110053.4) 656.6 (620.6;694) -40.7 (-45.3;-35.8)
Brasil 1334369 (1303152.8;1373801.4) 1322.1 (1291.8;1358.2) 1326910.8 (1288958.3;1368112.2) 576.9 (560.7;594.9) -56.4 (-57.8;-55.1)
Ceará 40070.2 (36879.4;43154.2) 893.2 (817;960.7) 52333.9 (49236;55146.4) 533.9 (501.6;562.5) -40.2 (-45.3;-34.6)
Distrito Federal 9370.1 (8908.1;10046.1) 1179 (1125.2;1252.5) 11358.7 (10528;12284.1) 443.7 (413.3;477.7) -62.4 (-65;-59.3)
Espírito Santo 27092.1 (26043.2;28443.7) 1651.2 (1587.7;1725.3) 23985.1 (22605.5;25435.7) 557 (525.7;591.2) -66.3 (-68.3;-64.1)
Goiás 30618.2 (29152.7;32584.3) 1291.1 (1232.1;1366.3) 35332.4 (33203.1;37574) 509.5 (478.7;541.7) -60.5 (-63;-57.8)
Maranhão 40946.2 (36530.2;45483) 1334.4 (1213.3;1456.3) 48119.1 (44681.6;52607.1) 738.8 (686.2;810.1) -44.6 (-50.9;-37.9)
Mato Grosso 9481.7 (8758.9;10235.2) 952.6 (879.1;1027.3) 17317.5 (16178.9;18505.5) 529.8 (495.5;566.5) -44.4 (-49.2;-38.3)
Mato Grosso do Sul 14326.7 (13580.5;15036) 1346.6 (1285.1;1408.5) 18396.2 (17315.1;19515.4) 639.5 (601.6;678.8) -52.5 (-55.9;-49.1)
Minas Gerais 160746.7 (153946.9;171975.7) 1422.7 (1364.4;1509) 139119.5 (131593;146724) 546.2 (516.9;575.9) -61.6 (-64.2;-58.9)
Pará 27317.6 (25130.3;29082.4) 1111.4 (1017.5;1182.7) 46066.2 (42810.4;49272.9) 668.3 (622.2;712.9) -39.9 (-45;-34.3)
Paraíba 23051.3 (21538.9;24766) 954 (892.6;1024.9) 28591.1 (26253.3;30997.8) 629.8 (578.8;682.3) -34 (-40.8;-26.8)
Paraná 88216.4 (84443;91983) 1633.9 (1570.7;1702) 72564.6 (68483;76843.2) 561.1 (530.1;593.1) -65.7 (-67.9;-63.3)
Pernambuco 73380.8 (69895.3;76702.7) 1499.7 (1430.9;1568.9) 74615.6 (70543.1;78768.3) 744.4 (703.9;786.5) -50.4 (-53.4;-47.5)
Piauí 18501.1 (16948.8;20251.5) 1160.3 (1060.5;1264) 23443.1 (22029.8;25610) 651 (611.5;710.8) -43.9 (-48.8;-38.6)
Rio de Janeiro 201658.8 (193417.1;211873.7) 1858 (1782.2;1943.7) 147613.4 (140085.6;156033.4) 676.3 (641.5;713.3) -63.6 (-66;-61.1)
Rio Grande do Norte 12099.4 (11196.2;12951.9) 706.5 (651.7;757.1) 17465.8 (16141.3;18793.4) 468.6 (433.9;504.3) -33.7 (-39.7;-26.6)
Rio Grande do Sul 90116 (85634.7;94313.2) 1235.2 (1173.1;1292.4) 85329.9 (79196.9;90723.5) 570.3 (529.1;605.5) -53.8 (-56.9;-50.3)
Rondônia 6920.4 (6371.4;7465.9) 1469.9 (1361.9;1583.8) 8998.9 (8019.1;10137.8) 592.7 (529.6;666.4) -59.7 (-64.6;-53.9)
Roraima 868.7 (786;962.9) 1116.5 (1020.8;1223.5) 1914.8 (1686.6;2190.9) 527.6 (464.5;599.3) -52.7 (-59.7;-45.1)
Santa Catarina 37531.6 (35812;39073.7) 1347.1 (1285.7;1402.4) 35160.6 (32444.1;37333.3) 451.6 (418.2;478.8) -66.5 (-68.8;-64.1)
São Paulo 286216.8 (273648.3;299941.9) 1235.3 (1182.4;1289) 259904.1 (245650.4;275069.5) 490.6 (464.5;518.7) -60.3 (-62.8;-57.4)
Sergipe 10290.6 (9777.3;10791) 1120.9 (1062.3;1176.2) 14532.9 (13755.7;15333.1) 666.3 (631.3;703.4) -40.6 (-44.7;-35.7)
Tocantins 5825.5 (4890.2;6575) 1189.3 (1037.1;1325.3) 9081.5 (8410.7;9866.8) 633.5 (587.1;688.8) -46.7 (-52.9;-38.2)
B.2.3.3- Hemorragia Subaracnóidea
Acre 847.7 (773.2;919.3) 290.6 (269.9;311.1) 1283.8 (1183.9;1391) 177.6 (164.1;193.1) -38.9 (-44.9;-32.4)
Alagoas 7391.3 (6373.7;8529.4) 355.3 (311.7;397.2) 6967.4 (6414.6;7757.1) 205.9 (189.4;228.9) -42.1 (-50.3;-29.8)
Amapá 332.7 (309.9;365) 200.1 (186;223.5) 1032.5 (948.2;1149) 161.5 (148.4;179.7) -19.3 (-26.7;-10.9)
Amazonas 2934.8 (2699.5;3205.7) 218.9 (203.2;238.9) 5271.9 (4852.8;5795.8) 157.6 (145.2;173.4) -28 (-34.4;-20.6)
Bahia 26401.2 (23947.3;28838.7) 280.2 (256.7;306.5) 30862.9 (28723;33700.7) 190.8 (177.6;208.7) -31.9 (-38.9;-24.6)
Brasil 382092.5 (341738.8;399795.1) 318.4 (287;332.2) 421128.4 (402202.4;445263.2) 181 (173.1;191) -43.1 (-46.3;-37.2)
Ceará 15001.4 (12391.2;18119.3) 264.2 (225.1;311.9) 16027.3 (14761.6;17474.1) 161.5 (148.7;176) -38.9 (-49.2;-28.2)
Distrito Federal 3328.5 (2921.2;3564.8) 305.8 (267.9;326.7) 4451.2 (3996.2;4855.6) 150.5 (134.4;164.3) -50.8 (-55.3;-45.2)
Espírito Santo 7132.8 (5899.9;7604.3) 358.5 (294.5;382.4) 7751.8 (7128.6;8367.7) 176.5 (162.5;190) -50.8 (-55.4;-39.5)
Goiás 8598.4 (7989.3;9184.5) 287.4 (265.6;307) 11879.3 (10974.1;13114.1) 162.2 (150.1;178.6) -43.6 (-48.6;-36.8)
Maranhão 16940.2 (13560.2;20200.9) 394 (321;459.7) 15729.1 (14113.5;17089.8) 223.9 (199;243.2) -43.2 (-50.9;-32.3)
Mato Grosso 3699.9 (3386.4;4012) 262.9 (241.4;287.3) 5989.9 (5522;6551.1) 166.7 (154.3;182) -36.6 (-43.1;-29.6)
Mato Grosso do Sul 3949.6 (3524;4259.3) 301.8 (272.8;324.2) 5533 (5124.3;6033) 184.7 (171.2;201.1) -38.8 (-45.1;-31.2)
Minas Gerais 43411.7 (36926.5;46441.3) 334.4 (286;356.7) 45738.5 (42358.9;49050.9) 182.2 (169;195.2) -45.5 (-50.4;-37.9)
Pará 7934.2 (7204.8;8740.1) 235.4 (216.8;259.9) 14056.5 (12883.9;15453.7) 180.9 (166.2;198.4) -23.2 (-30.1;-15.8)
Paraíba 7964.3 (6876.5;9209) 295.5 (255.4;339.2) 8313 (7521.9;9221.7) 184.2 (166.7;204.3) -37.7 (-48.2;-25.5)
Paraná 22236.9 (18814.4;23684.3) 341.8 (287.1;364.5) 23630.8 (21760.6;25484.3) 180.4 (166.5;194) -47.2 (-52.1;-39.6)
Pernambuco 16056.3 (14930.2;17673.3) 281.4 (262.2;311.8) 20507.5 (19042.9;22982.6) 199.2 (185;222.9) -29.2 (-35.8;-22.5)
Piauí 6362.7 (5250.5;7430) 307 (258.7;356.2) 6817.4 (6299.7;7358.7) 187.4 (173.4;202.5) -39 (-47.3;-28.2)
Rio de Janeiro 49986.3 (39896.5;53598.5) 419.4 (335.1;449.1) 42289.2 (38909;45633.2) 200.1 (184.6;215.2) -52.3 (-56.7;-41.4)
Rio Grande do Norte 4077.6 (3612.7;4762.8) 196.1 (174.2;236.3) 5302.8 (4835.1;6667.4) 139.8 (127.7;175.3) -28.7 (-37.7;-18.9)
Rio Grande do Sul 21396.6 (19895.4;23508.5) 262.1 (244.7;290.7) 23342.9 (21439;25660.3) 163.1 (150.5;178.8) -37.8 (-43.1;-31.4)
Rondônia 2118.6 (1933.7;2303) 300.6 (275.8;327.4) 2911.6 (2578.8;3318.4) 170.2 (151;193.1) -43.4 (-51;-34.1)
Roraima 327.8 (294;368.6) 261.1 (234.8;298.9) 673.8 (592.6;805.6) 150.1 (132.2;178.6) -42.5 (-50.8;-32.5)
Santa Catarina 9964.3 (9246.9;10542.8) 289.9 (267.1;306.6) 11653.1 (10732.6;13019.9) 144.5 (133.5;160.9) -50.2 (-54.8;-43)
São Paulo 88540 (77303.1;94399.5) 323.3 (286.2;343.1) 96099.9 (89106.8;103155.3) 181 (168.3;194.1) -44 (-49.1;-36.7)
Sergipe 3084.4 (2757.9;3439.9) 263.6 (241.5;290.9) 4031.2 (3725.2;4445.7) 172.6 (159.7;190.2) -34.5 (-42.1;-26.6)
Tocantins 2072.4 (1546;2522.9) 305.7 (242.4;363.9) 2980.1 (2699;3279) 193.6 (175.8;212.5) -36.7 (-47.4;-21.4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

As taxas de DALYs por AVC isquêmico padronizadas por idade por 100 mil foram 871,4 (II 95%, 841,1 - 902,3) e 387,3 (II 95%, 363,9 - 411,5) em 1990 e 2017, respectivamente, representando variação percentual de -55,6 (II 95%, 55,5 a -53,2) ( Tabela 2-6 ). Para adultos, a maior variação percentual foi observada entre indivíduos de 50-69 anos, -58,7 (II 95%, -60,9 a -56,4) ( Tabela 2-6 ), sendo -58,3 (II 95%, -61,1 a -55,6) para homens e -58,7 (II 95%, -61,7 a -55,6) para mulheres ( Tabelas 2-9 e 2-10 ).

As taxas de DALYs por hemorragia intracerebral padronizadas por idade por 100 mil foram 1.322,1 (II 95%, 1.291,8 - 1.358,2) em 1990 e 576,9 (II 95%, 560,7 - 594,9) em 2017, representando variação percentual de -56,4 (II 95%, -57,8 a -55,1) ( Tabela 2-6 ). Para adultos, a maior variação percentual foi observada em indivíduos de 15-49 anos, -57,9 (II 95%, -61,3 a -55,8) ( Tabela 2-6 ), sendo -60,1 (II 95%, -64,4 a -57,1) para homens e -57,1 (II 95%, -59,8 a -54,7) para mulheres ( Tabelas 2-9 e 2-10 ).

As taxas de DALYs por HSA padronizadas por idade por 100 mil foram 318,4 (II 95%, 287 - 332,2) em 1990 e 181,0 (II 95%, 173,1 - 191,0) em 2017, representando variação percentual de -43,1 (II 95%, -46,3 a -37,2) ( Tabela 2-6 ). Para adultos, a maior variação percentual foi observada entre indivíduos de 15-49 anos, -40 (II 95%, -43,9 a -30,9), sendo -44,2 (II 95%, -49,5 a -22,9) para homens e -36,8 (II 95%, -41,6 a -31,8) para mulheres ( Tabelas 2-9 e 2-10 ).

Complicações

Benseñor et al . analisaram um inquérito epidemiológico de base domiciliar (PNS - 2013), com uma amostra representativa nacional, para avaliar o número absoluto e as taxas de prevalência de AVC e de incapacidade por AVC. Foram estimados 2.231.000 indivíduos com AVC e 568.000 com incapacidade grave por AVC. As prevalências pontuais de AVC foram 1,6% e 1,4% para homens e mulheres, respectivamente. A prevalência de incapacidade por AVC foi 29,5% para homens e 21,5% para mulheres. As taxas de prevalência de AVC aumentaram com a idade, o baixo nível educacional e nos residentes de áreas urbanas, mas não apresentaram diferença de acordo com a raça autorreferida. O grau de incapacidade por AVC não diferiu estatisticamente de acordo com sexo, raça, nível educacional ou local de residência. 72

Carvalho-Pinto et al. , conduzindo estudo observacional retrospectivo, coletaram dados dos prontuários médicos e de visitas domiciliares após AVC de pacientes seguidos em uma unidade de atenção primária em Belo Horizonte, entre maio de 2013 e maio de 2014. Os dados incluíram condição de saúde, assistência recebida após AVC, fatores pessoais e ambientais, funcionalidade e incapacidade organizados de acordo com a estrutura conceitual da CIF. A maioria dos participantes apresentou boa percepção da própria habilidade manual (2,39 [DP, 2,29] logits) e limitada habilidade para caminhar (88%), sendo capaz de melhorar a velocidade da marcha natural, apresentou mudança de equilíbrio (51,43%) e mobilidade funcional (54,16%) com risco de queda, e teve percepção negativa da própria qualidade de vida (escore médio de 164,21 [DP, 35,16] pontos na SSQOL-Brasil). 88

De acordo com o Estudo GBD 2016, a maior porcentagem de óbitos por AVC em geral ocorreu em indivíduos com 70 anos ou mais (60,2%; II 95%, 59,9-60,5%) e em homens (52,9%; II 95%, 52,6-53,2%). O AVC isquêmico foi o tipo mais comum, sendo responsável por 61,8% (II 95%, 61,5-62,1%) dos óbitos por AVC em 2016. A maioria dos indicadores epidemiológicos de AVC em geral ou de um subtipo de AVC (incidência, prevalência, razão mortalidade/incidência, mortalidade, DALYs, anos perdidos por incapacidade e anos de vida perdidos) foi maior nos homens e nos indivíduos com 70 anos ou mais. 89

Utilização e Custo da Atenção à Saúde (Tabelas 1-6 a 1-9 e Figuras 1-15 a 1-16) Admissões Hospitalares

Lopes et al . conduziram um estudo ecológico desenhado com abordagem analítica e coleta de dados do SIH sobre episódios de AVC no período de 1998-2012. Todos os dados foram estratificados por sexo e idade, criando um indicador para internação hospitalar relacionada a AVC. Os autores observaram redução de 73,64% nas internações hospitalares relacionadas a AVC, que passaram de 37,56/105 habitantes em 1998-2001 para 10,33/105 habitantes em 2002-2005. Essa redução ocorreu nos dois sexos e em todos os grupos etários. 90

Em uma análise de série temporal, Katz et al . avaliaram a relação entre taxa de desemprego relacionada a AVC e internação hospitalar no Brasil em um período recente de 11 anos. Dados sobre hospitalizações mensais por AVC de março de 2002 a dezembro de 2013 foram extraídos da base de dados do Sistema Público de Saúde Brasileiro, revelando 1.581.675 internações por AVC no período. A taxa de desemprego diminuiu de 12,9% em 2002 para 4,3% em 2013, enquanto as internações por AVC aumentaram. Entretanto, o modelo ajustado não mostrou associação positiva entre taxa de desemprego e internação por AVC (coeficiente estimado = 2,40 ± 4,34; p=0,58). 91

Utilizando dados do SIH, do SIM e do IBGE, Adami et al . analisaram taxas de mortalidade e incidência de hospitalizações relacionadas a AVC em brasileiros com 15-49 anos, por região e grupo etário, entre 2008 e 2012. Definiu-se AVC de acordo com a CID-10 (I60-I64). Mortalidade bruta e padronizada (OMS) e incidência de hospitalizações por 100 mil habitantes, estratificadas por região e grupo etário, foram estimadas. Os autores relataram 131.344 internações por AVC em brasileiros com 15-49 anos entre 2008 e 2012. No mesmo período, a taxa de hospitalizações estabilizou: 24,67 (IC 95%, 24,66 - 24,67) em 2008 e 25,11 (IC 95%, 25,10 - 25,11) em 2012 (β = 0,09, p = 0,692, r2 = 0,05). 92

Dantas et al . realizaram um estudo para avaliar hospitalizações públicas por AVC no Brasil de 2009 a 2016. Aqueles autores selecionaram registros de hospitalização de acordo com os códigos de diagnóstico de AVC da CID-10. De 2009 a 2016, o número de internações subiu de 131.122 para 146.950, tendo o número absoluto de mortes hospitalares aumentado de 28.731 para 31.937. Idade mais jovem e sexo masculino mostraram associação significativa com a sobrevida do paciente. As taxas anuais de hospitalização e de mortalidade hospitalar ajustadas por idade caíram 11,8% e 12,6%, respectivamente, mas a taxa de letalidade aumentou para pacientes acima de 70 anos. 93

Utilização da Atenção à Saúde

Uma análise da tendência de expansão da cobertura do PSF e internação por condições sensíveis à atenção primária no Rio de Janeiro, entre 1998 e 2015, mostrou uma queda de 7,6% nas hospitalizações por doenças cerebrovasculares. 94

Um estudo realizado em Joinville avaliou o impacto de uma unidade dedicada a AVC, a primeira estabelecida no Brasil, na fase aguda do manejo de AVC em comparação ao tratamento convencional em enfermaria geral. O estudo avaliou 35 e 39 pacientes alocados em unidade de AVC e em enfermaria geral, respectivamente, em 2000, mostrando mortalidade em 10 dias de 8,5% e 12,8%, respectivamente (p=0,41). Para os tratamentos em unidade de AVC e em enfermaria geral, as taxas de mortalidade foram, respectivamente: no dia 30, 14,2% e 28,2% (p=0,24); no terceiro mês, 17,4% e 28,7% (p=0,39); e no sexto mês, 25,7% e 30,7% (p=0,41). A curva de sobrevida de 30 dias mostrou tendência não significativa de menor letalidade na unidade de AVC. Para evitar uma morte em 6 meses na unidade de AVC, o número necessário para tratar foi 20; para se mandar para casa mais um paciente independente, o número necessário para tratar foi 15. 95

Um estudo descreveu as características e os cuidados prestados a 148 pacientes admitidos com AVC isquêmico na emergência neurológica e na enfermaria da neurologia de um grande hospital público acadêmico de São Paulo. O estudo mostrou que o AVC isquêmico foi diagnosticado em 79,6% dos pacientes com DCV admitidos na emergência neurológica, sendo trombólise oferecida a 2,7%. A extensão da investigação e o manejo do AVC isquêmico diferiram significativamente entre a emergência neurológica e a enfermaria da neurologia. 96

Um estudo de base hospitalar, avaliando 2.407 pacientes consecutivos (idade média, 67,7 ± 14,4 anos; 51,8% mulheres) admitidos em 19 hospitais de Fortaleza com diagnóstico de AVC ou AIT, mostrou que AVC isquêmico foi o subtipo mais frequente (72,9%), sendo seguido por hemorragia intraparenquimatosa (15,2%), HSA (6,0%), AIT (3%) e AVC indeterminado (2,9%). O tempo médio entre o aparecimento dos sintomas e a internação foi de 12,9 (3,8 - 32,5) horas. Hipertensão foi o fator de risco mais comum. Apenas 1,1% dos pacientes com AVC isquêmico receberam trombólise. O tempo médio entre a internação e a obtenção de neuroimagem foi de 3,4 (1,2 - 26,5) horas. 74

Um estudo comparou os indicadores de qualidade para manejo de AVC de um hospital privado terciário, certificado pela JCI como Centro Primário de AVC, com aqueles do programa GWTG-Stroke da American Heart Association/American Stroke Association : (1) uso do ativador do plasminogênio tecidual em pacientes que chegam até 2 horas após o início dos sintomas; (2) uso de medicação antitrombótica nas primeiras 48 horas de internação; (3) profilaxia de trombose venosa profunda nas primeiras 48 horas de internação para pacientes com contraindicação ou impossibilidade de deambulação; (4) uso de antitrombóticos na alta hospitalar; (5) uso de anticoagulação para fibrilação atrial na alta hospitalar; (6) medida de LDL e tratamento para LDL > 100 mg/dL para pacientes que atendam às recomendações do NCEP III; e (7) aconselhamento para cessação de tabagismo. O estudo avaliou 343 pacientes consecutivos com AVC isquêmico agudo (70,8%) ou AIT (29,2%) de agosto de 2008 a dezembro de 2010. Medicação antitrombótica foi administrada nas primeiras 48 horas em 98,5% dos pacientes elegíveis e profilaxia de trombose venosa profunda foi realizada em 100%. Do total, 123 pacientes chegaram em até 2 horas após o início dos sintomas, 23 eram elegíveis para trombólise intravenosa e 16 foram tratados (69,5%). Todos os pacientes elegíveis receberam alta em uso de medicação antitrombótica e 86,9% dos elegíveis que apresentavam fibrilação atrial receberam anticoagulação. Apenas 56,1% dos pacientes elegíveis foram tratados de acordo com as recomendações do NCEP III. Realizou-se aconselhamento para cessação de tabagismo em 63,6% dos pacientes elegíveis. 97

Um estudo analisou os fatores que influenciam as tendências temporais dos indicadores de qualidade para AVC isquêmico em um Centro Primário de AVC certificado pela JCI. Para tal, 551 pacientes com AVC isquêmico, que receberam alta de hospital terciário de janeiro de 2009 a dezembro de 2013, foram avaliados. A mediana da idade foi 77,0 anos (intervalo interquartil, 64,0-84,0), sendo 58,4% homens. Dez indicadores de desempenho predefinidos, selecionados do programa GWTG-Stroke, foram avaliados. Os indicadores de qualidade que melhoraram com o tempo foram o uso de terapia hipolipemiante (P = 0,02) e orientação sobre AVC (P = 0,04). A mediana do desfecho composto cuidado ideal não melhorou consistentemente no período (P = 0,13). Após ajuste multivariável, apenas tratamento trombolítico (OR 2,06; P < 0,01), dislipidemia (OR 2,03; P < 0,01) e alta em um ano de visita da JCI (OR 1,8; P < 0,01) permaneceram como preditores de um índice de cuidado ideal igual ou superior a 85%. Os indicadores de qualidade com pior desempenho (anticoagulação para fibrilação atrial e redução de colesterol) foram semelhantes nos hospitais comunitários terciários e secundários. A medida geral de cuidado ideal não melhorou e foi influenciada por: receber alta em ano de visita da JCI, ter dislipidemia e ter recebido tratamento trombolítico. 98

Outro estudo avaliou indicadores-chave de desempenho do Ministério da Saúde para AVC nas unidades para AVC de dois centros, incluindo a porcentagem de pacientes admitidos nessas unidades, profilaxia de tromboembolismo venoso nas primeiras 48 horas de internação, pneumonia e mortalidade hospitalar por AVC e alta hospitalar em uso de antitrombóticos para pacientes sem mecanismo cardioembólico. A análise revelou que os dois centros internaram mais de 80% dos pacientes em suas unidades para AVC. A incidência de profilaxia de tromboembolismo venoso foi superior a 85% e a de pneumonia hospitalar foi inferior a 13%. A taxa de mortalidade hospitalar por AVC foi inferior a 15% e a de alta hospitalar em uso de antitrombóticos foi superior a 70%. 99

Um estudo avaliou as taxas de mortalidade antes e depois da implementação de uma unidade cardiovascular dedicada a AVC no setor de emergência de um hospital público terciário em Porto Alegre. No período anterior à implementação da unidade vascular (2002 a 2005), foram incluídos 4.164 pacientes e, no período posterior à implementação (2007 a 2010), foram incluídos 6.280 pacientes. A taxa de letalidade geral por condições vasculares agudas diminuiu de 9% para 7,3% com a implementação (p = 0,002). Entretanto, a taxa de letalidade por AVC não diminuiu a despeito das melhorias nos indicadores de qualidade de cuidado para AVC. 100

Um ensaio clínico randomizado por cluster avaliou o efeito de uma intervenção multifacetada de melhoria da qualidade da adesão às terapias baseadas em evidência para o cuidado de pacientes com AVC isquêmico agudo e AIT (incluindo manejo de caso, lembretes, roadmap e checklist para o plano terapêutico, materiais educativos, auditorias periódicas e relatórios de feedback para cada cluster da intervenção). O estudo avaliou 1.624 pacientes de 36 hospitais, cobrindo todas as regiões brasileiras. O desfecho primário foi um desfecho composto de adesão ao escore para AVC isquêmico agudo e às medidas de desempenho para AIT, e os desfechos secundários incluíram um desfecho composto ‘tudo-ou-nada’ de adesão às medidas de desempenho. A idade média geral (DP) dos pacientes arrolados no estudo foi 69,4 (13,5) anos, e 913 (56,2%) eram homens. As médias (DP) do desfecho composto de adesão ao escore e às 10 medidas de desempenho dos hospitais do grupo ‘intervenção’ e do grupo controle foram 85,3% (20,1%) e 77,8% (18,4%), respectivamente, com diferença média de 4,2% (IC 95%, -3,8% a 12,2%). Como desfecho secundário, 402 de 817 pacientes (49,2%) dos hospitais do grupo ‘intervenção’ receberam todas as terapias para as quais eram elegíveis, enquanto que, nos do grupo controle, 203 de 807 (25,2%) receberam aquelas terapias (OR, 2,59; IC 95%, 1,22 - 5,53; P = 0,01). A intervenção não resultou em significativo aumento de adesão às terapias baseadas em evidência em pacientes com AVC isquêmico agudo ou AIT. Entretanto, ao usar a abordagem ‘tudo-ou-nada’, a intervenção resultou em melhoria da adesão às terapias baseadas em evidência e melhores taxas de trombólise. 101

Custo (Ver Tabelas 1-6 a 1-9 e Figuras 1-15 e 1-16)

De acordo com a base de dados administrativos do SUS, o total de gastos atribuídos a doenças cerebrovasculares aumentou de 2008 a 2018, considerando os procedimentos clínicos relacionados a internações hospitalares. Em 2008 e 2018, houve 159.545 e 203.066 hospitalizações por doenças cerebrovasculares, respectivamente, de um total de 2.042.195 internações no período, representando um total de custos de R$ 142.061.641 (2018 Int$ 136.975.201) em 2008 e de R$ 286.293.302 (2018 Int$ 141.170.268) em 2018, com acumulado de R$ 2.498.850.166 no referido período. Houve um real aumento no total de custos atribuídos a doenças cerebrovasculares na última década após ajuste para inflação, provavelmente em razão do aumento na complexidade do tratamento oferecido para aquelas condições.

Um estudo de custo-efetividade avaliando os trombolíticos no Brasil relatou que, para homens e em 1 ano, o custo do tratamento com rtPA foi maior do que o custo do tratamento conservador, com ganho de QALY de 0,06 para ambos os sexos. Esse resultado deve-se principalmente ao custo da medicação. Parte desse custo adicional é compensado pelo menor custo da reabilitação e menor perda de produtividade nos primeiros 2 anos, pois os pacientes tratados com rtPA apresentaram menos sequelas do que aqueles que receberam tratamento conservador. Depois do segundo ano que se segue a um AVC, para os dois sexos, o tratamento com rtPA (alteplase), considerando-se os custos diretos e indiretos, começou a ter menor custo em comparação ao conservador. Daí para a frente, o custo adicional da medicação começa a ser mais do que compensado pela menor perda de produtividade e menores custos com seguridade social e reabilitação do paciente. 102

Prevenção

O Estudo PURE ( Prospective Urban Rural Epidemiological) examinou as taxas e preditores do uso de medicação de prevenção secundária baseada em evidência (IECA/BRA, antiagregantes plaquetários, estatinas e betabloqueadores) em pacientes com DCV, incluindo DAC e AVC, em países da América do Sul, entre os quais o Brasil. O estudo mostrou que um menor número de pacientes com AVC recebeu antiagregantes plaquetários (24,3%), IECA/BRA (37,6%) e estatinas (9,8%) em comparação àqueles com DAC (30,1%, 36,0% e 18,0%, respectivamente). Essa subutilização de terapias em pacientes com AVC variou substancialmente entre os países, tendo a Colômbia o menor uso (sem prescrição de estatinas). Quando pacientes com DAC e AVC foram combinados, a proporção de uso de antiagregantes plaquetários foi mais alta no Chile (38,1%) e mais baixa na Argentina (23,0%). O uso de IECA/BRA e estatinas foi maior no Brasil (46,4% e 26,4%, respectivamente) e menor na Colômbia (26,4% e 1,4%, respectivamente). Entre os participantes com DAC e AVC, o uso foi maior naqueles com maior nível educacional se comparados àqueles sem nenhuma educação, educação primária ou desconhecida [35,6% vs. 23,6%, respectivamente, para antiagregantes plaquetários (p = 0,002); 20,6% vs. 10,9%, respectivamente, para estatinas (p = 0,0007)]. Ex-fumantes com DAC ou AVC tiveram maior probabilidade de receber terapias comprovadas do que fumantes atuais ou aqueles que nunca fumaram [35,2% vs. 26,6% e 27,7%, respectivamente, para antiagregantes plaquetários (p = 0,039); 19,9% vs. 10,6% e 13,0%, respectivamente, para estatinas (p = 0,004)]. Apenas 4,1% dos pacientes receberam todas as 4 terapias (IECA/BRA, antiagregantes plaquetários, estatinas e betabloqueadores), sendo a maior taxa do Brasil (5,5%) e a menor, da Colômbia (0,5%) (p = 0,02). Além disso, observou-se que 30% dos brasileiros com AVC não usam qualquer medicação. 103

Conscientização, Tratamento e Controle

Vários estudos mostraram alarmante falta de conhecimento sobre os fatores de risco para AVC, seu tratamento e reconhecimento dos sintomas de AVC como uma emergência médica. Em um estudo de base comunitária, Pontes-Neto et al . entrevistaram indivíduos em locais públicos de 4 importantes cidades no Brasil entre julho de 2004 e dezembro de 2005, usando um questionário estruturado aberto em português, baseado na apresentação de um caso típico de AVC agudo domiciliar. Os autores identificaram 28 termos diferentes em português para denominar AVC. Quanto aos entrevistados, 22% deles não reconheceram qualquer sinal de alarme de AVC. Apenas 34,6% dos entrevistados responderam corretamente quando perguntados sobre o número de telefone de emergência no Brasil (#192). Apenas 51,4% dos entrevistados relataram que chamariam uma ambulância para um familiar com sintomas de AVC. 104

Falavigna et al . usaram um questionário fechado e autoadministrado para avaliar o conhecimento sobre AVC entre 952 residentes da cidade de Caxias do Sul. Baixa renda e baixo nível educacional foram preditores independentes da incapacidade de reconhecer que o AVC afeta o cérebro. Renda mais baixa e idade < 50 anos foram preditores independentes da falta de conhecimento sobre os fatores de risco para AVC. 105

Panicio et al . entrevistaram 104 pacientes consecutivos com AVC agudo admitidos em um hospital público terciário de São Paulo, de março a dezembro de 2012, para avaliar o conhecimento sobre AVC e o impacto da falta de conscientização sobre a demora em se chegar ao hospital em caso de AVC. Embora 66,2% dos pacientes conhecessem os sinais de alerta de AVC, apenas 7,8% mostraram saber da limitada janela de tempo para a terapia de reperfusão. A gravidade do AVC medida pela escala NIHSS foi o único preditor independente de chegada precoce ao hospital. 106

Em estudo transversal de base comunitária, Pitton Rissardo et al . aplicaram um inquérito de conhecimento sobre AVC em uma amostra de conveniência composta por 633 passantes de uma praça pública na cidade de Santa Maria, Rio Grande do Sul, de dezembro de 2015 a outubro de 2016. Dos respondentes, 33% informaram corretamente o significado do acrônimo ‘AVC’, o termo mais recomendado para designar ‘acidente vascular cerebral’ pela Sociedade Brasileira de Doenças Cerebrovasculares. Cerca de 30% dos respondentes localizaram incorretamente o AVC no coração. Apenas 50% dos respondentes identificaram corretamente um sinal de alarme de AVC. Indivíduos de nível educacional mais alto apresentaram maior probabilidade de chamar uma ambulância para um familiar com sintomas de AVC. 107

Recentemente, tem havido várias iniciativas para promover a conscientização do público sobre AVC no Brasil, em especial através de campanhas anuais por ocasião do Dia Mundial do AVC (29 de outubro), conduzidas pela Organização Mundial do AVC. A despeito desses esforços, apenas 30-40% dos pacientes com AVC são hospitalizados nas primeiras 4 horas após início dos sintomas. 108

Pesquisa Futura

O portfólio de pesquisa brasileira em neurologia vascular evoluiu muito nos últimos anos. No entanto, ainda há inúmeras oportunidades para melhoria. Os estudos comunitários mais expressivos sobre prevalência e incidência de AVC são provenientes principalmente de 2 cidades. Embora representem uma importante realização para a epidemiologia do AVC, avaliação mais abrangente se faz necessária, compreendendo a representação de todas as regiões geográficas, das diversas culturas, dos níveis de renda e das etnias.

Além disso, há limitações para os estudos relacionadas à identificação do AVC usando os códigos da CID. Não é incomum que os usuários utilizem um código mais amplo na admissão, que, por não ser ajustado durante a hospitalização, não representa o verdadeiro subtipo de AVC (e.g., um AVC isquêmico pode ser codificado como AVC não específico ou até AIT). Com o advento das tecnologias big data (e.g., mineração de dados textuais), informação clínica adicional proveniente dos registros de admissão ou alta pode ser uma fonte confiável de contrarreferência, confirmando ou corrigindo um dado código.

Como desafio mundial, não restrito ao Brasil, estudos dos serviços de saúde utilizando metodologia robusta, avaliando não apenas a realidade da prestação do cuidado em saúde, mas também a efetividade das políticas em saúde através de ensaios clínicos randomizados, precisam se tornar a base dos programas de melhoria da qualidade nos níveis comunitário e populacional.

3. DOENÇA ARTERIAL CORONARIANA AGUDA E CRÔNICA CID-9-CM 410 a 414; CID-10 I10 a I25

Ver Tabelas 3-1 até 3-3 e Figuras 3-1 até 3-6

Abreviaturas usadas no Capítulo 3
ACCEPT/SBC Registro Brasileiro da Prática Clínica nas Síndromes Coronarianas Agudas da Sociedade Brasileira de Cardiologia
BRACE Brazilian Registry on Acute Coronary Syndrome
BYPASS Registro Brasileiro de Pacientes Adultos Submetidos a Cirurgia Cardiovascular
CRVM Cirurgia de Revascularização do Miocárdio
DAC Doença Arterial Coronariana
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DATASUS Departamento de Informática do Sistema Único de Saúde
DCV Doença Cardiovascular
DIC Doença Isquêmica do Coração
GBD Global Burden of Disease
IAM Infarto Agudo do Miocárdio
IAMCSST Infarto Agudo do Miocárdio com Supradesnível do Segmento ST
IAMSSST Infarto Agudo do Miocárdio sem Supradesnível do Segmento ST
IC Intervalo de Confiança
ICP Intervenção Coronária Percutânea
II Intervalo de Incerteza
IM Infarto do Miocárdio
MASS Medicine, Angioplasty, or Surgery Study
OMS Organização Mundial da Saúde
PIB Produto Interno Bruto
PNS Pesquisa Nacional de Saúde
RBSCA Registro Brasileiro de Síndrome Coronariana Aguda
SCA Síndrome Coronariana Aguda
SUS Sistema Único de Saúde
YLLs Anos potenciais de vida perdidos (do inglês, Years of Life Lost )

Panorama e Prevalência

A DAC, também conhecida como DIC, compreende um espectro de condições clínicas sintomáticas e assintomáticas tipicamente relacionadas à redução do fluxo sanguíneo para o músculo cardíaco. A causa mais comum é a doença aterosclerótica das artérias coronárias, uma condição crônica de apresentação variável, que progride desde uma longa fase assintomática até angina estável, IM e angina instável. A DAC é uma causa comum de insuficiência cardíaca, com fração de ejeção ventricular esquerda reduzida ou preservada, arritmias ventriculares e parada cardíaca súbita.

A DAC foi a principal causa de morte no Brasil na última década, para homens e mulheres. Devido ao seu amplo espectro de apresentação clínica, suas prevalência, incidência e mortalidade relatadas variam muito, dependendo da população e do contexto da atenção à saúde estudados.

Doença Arterial Coronariana

De acordo com dados do GBD 2017, a prevalência total de DAC foi 1,75% em brasileiros >20 anos. Homens apresentaram maior prevalência em comparação a mulheres, 2,33% e 1,19%, respectivamente. Para adultos de 15-49 anos, a prevalência estimada de DAC foi 0,53%; para aqueles de 50-69 anos, 4,34%; e para aqueles >70 anos, 10,99% (Figura 3-1).

A prevalência geral padronizada por idade de DAC foi 1,63% (1.564 por 100 mil habitantes), sendo 2,35% (2.229 por 100 mil habitantes) para homens e 1,05% (1.008 por 100 mil habitantes) para mulheres. Isso significa que pelo menos ~3,3 milhões de pessoas viviam com DAC nas unidades federativas brasileiras em 2017.

Houve uma diferença, entre as regiões brasileiras, na prevalência padronizada por idade de DAC, que foi maior nas regiões Sudeste e Sul (estado de São Paulo, 1.617 por 100 mil habitantes; Rio Grande do Sul, 1.642 por 100 mil habitantes) e menor nas regiões Norte e Centro-Oeste (Amazonas, 1.407 por 100 mil habitantes; Distrito Federal, 1.404 por 100 mil habitantes). A região Nordeste ocupou uma posição intermediária, mas com tendência a aumento da prevalência de DAC nas últimas décadas (Pernambuco, 1.523 por 100 mil habitantes) ( Tabela 3-1 ).

– Taxas de prevalência de doença arterial coronariana padronizadas por idade (por 100 mil habitantes) no Brasil e suas unidades federativas, para ambos os sexos, e para homens e mulheres, 1990 e 2017, e variação percentual das taxas
Unidades federativas Ambos os sexos Mulheres Homens
1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%)
Acre 1640.6 (1532.9;1756.6) 1483.4 (1387.7;1581.8) -9.6 (-6.5;-12.8) 1083.4 (1008.2;1165.6) 923.1 (852.4;993.5) -14.8 (-10.9;-18.5) 2120.8 (1978.5;2276.6) 2063.9 (1928.2;2201.2) -2.7 (1.7;-7.1)
Alagoas 1671.2 (1568;1784.7) 1506.8 (1412.5;1611.2) -9.8 (-6.8;-12.5) 1150.1 (1070.1;1235.1) 969.9 (901.4;1043.3) -15.7 (-11.8;-19.4) 2251.6 (2099.8;2410.2) 2164.3 (2031.8;2318.6) -3.9 (0.8;-7.7)
Amapá 1450.7 (1353.6;1551) 1435.3 (1340.1;1536.3) -1.1 (2.6;-4.4) 991.2 (916;1066.2) 903.8 (837.3;975.3) -8.8 (-4.6;-13.2) 1927.9 (1798.7;2058.4) 2003 (1862.3;2143.5) 3.9 (8.8;-0.4)
Amazonas 1411.5 (1316.1;1512.7) 1407.8 (1315.6;1504.9) -0.3 (3.5;-3.7) 956.9 (888.2;1034.4) 879.4 (815.1;947.3) -8.1 (-4.1;-12.2) 1865.3 (1737.9;2002.7) 1958.7 (1823.7;2096.5) 5 (9.8;0.5)
Bahia 1644.7 (1540.7;1753.3) 1558.9 (1459.5;1659.1) -5.2 (-2;-8.4) 1132.7 (1049.9;1215.3) 1001 (922;1077.6) -11.6 (-7.4;-15.8) 2218.2 (2076.7;2364.7) 2223.4 (2085;2372.7) 0.2 (4.8;-3.9)
Brasil 1674.5 (1573.5;1784) 1563.7 (1465.6;1669.4) -6.6 (-5.2;-7.8) 1159.3 (1082.7;1238.5) 1008 (938.1;1080.6) -13.1 (-11.4;-14.7) 2259.7 (2126.8;2403.2) 2229.4 (2098.2;2372.8) -1.3 (0.4;-2.9)
Ceará 1455.2 (1356.6;1559.7) 1452 (1350.5;1561.1) -0.2 (3.2;-3.8) 1009.3 (931.1;1092.2) 938.9 (860.1;1021.8) -7 (-2.1;-11.6) 1955.1 (1824;2091.9) 2066.7 (1922.7;2221.3) 5.7 (10.6;0.6)
Distrito Federal 1474.8 (1386;1569.3) 1404.4 (1315.5;1499.5) -4.8 (-1.8;-7.8) 1025.9 (952.7;1100.2) 915.8 (849.4;988.1) -10.7 (-6.8;-14.6) 2009.9 (1885;2147.1) 2046.6 (1914.8;2184.4) 1.8 (6.4;-2.4)
Espírito Santo 1563.5 (1462.6;1663.4) 1473.9 (1378.5;1573.3) -5.7 (-2.5;-8.7) 1072.1 (991.1;1153) 942 (867.7;1015.4) -12.1 (-7.8;-16.1) 2091.3 (1954.6;2229.9) 2094.4 (1960.9;2243.1) 0.1 (4.4;-4)
Goiás 1663.5 (1563.6;1775.3) 1596.3 (1498.4;1700.3) -4 (-0.5;-7.4) 1115.1 (1037.1;1195.5) 1006.6 (934.1;1083.7) -9.7 (-5.3;-14) 2184.7 (2051;2333.6) 2249.7 (2117.6;2405.1) 3 (7.9;-1.4)
Maranhão 1604.3 (1501;1714.3) 1491.9 (1391.9;1600.2) -7 (-3.8;-10.1) 1104.3 (1022.7;1183.9) 949.8 (877.8;1025.4) -14 (-9.9;-17.8) 2138.3 (1994.2;2294.4) 2095.5 (1953.1;2255) -2 (2.8;-6.7)
Mato Grosso 1633.2 (1524.5;1746.9) 1528.7 (1428.2;1637.1) -6.4 (-3.4;-9.5) 1072.6 (997.6;1154.4) 941.6 (873.1;1012.4) -12.2 (-8.2;-16.2) 2097.9 (1955.3;2247.1) 2099.9 (1963.9;2250.9) 0.1 (4.1;-4.3)
Mato Grosso do Sul 1671.6 (1569.6;1787.9) 1602.8 (1501.1;1711.9) -4.1 (-0.6;-7.2) 1114.7 (1034.9;1194.8) 1008 (931.9;1089.9) -9.6 (-5.3;-13.5) 2190.1 (2052.1;2342.3) 2253.6 (2104.9;2408.3) 2.9 (7.8;-1.7)
Minas Gerais 1635 (1533.4;1743.3) 1571.7 (1473.5;1676.6) -3.9 (-0.9;-6.9) 1130.7 (1054.5;1213.7) 1005 (931.7;1084.4) -11.1 (-7.2;-15.1) 2209.6 (2062.1;2361.5) 2230 (2092.6;2384.2) 0.9 (4.9;-3.1)
Pará 1494.5 (1393.7;1598.9) 1461.5 (1363.1;1567.8) -2.2 (1.3;-5.4) 1018.3 (939.5;1099.9) 914.1 (844.1;996.3) -10.2 (-5.8;-14.6) 1981.7 (1840.9;2123.7) 2031.3 (1893.8;2172.4) 2.5 (7.5;-1.7)
Paraíba 1580.3 (1473.9;1688.4) 1483.4 (1382.1;1589.2) -6.1 (-3;-9) 1093.7 (1010.1;1178.4) 958 (888.5;1032.7) -12.4 (-8.2;-16.4) 2137.4 (1994.7;2291.2) 2133.3 (1989.7;2288.1) -0.2 (4.4;-4.5)
Paraná 1751.9 (1639.3;1864.8) 1612.4 (1508;1723.5) -8 (-4.5;-10.9) 1193.9 (1111;1282.8) 1033.6 (959.7;1111.8) -13.4 (-9.4;-17.2) 2327.5 (2172.7;2484.7) 2290.6 (2147.7;2451.6) -1.6 (3.1;-6)
Pernambuco 1623.1 (1514.3;1734.5) 1523.7 (1426.1;1629.4) -6.1 (-2.8;-9.1) 1132.6 (1047.6;1214.9) 992.2 (916.5;1067) -12.4 (-8.1;-16.5) 2210.5 (2065.8;2374.7) 2206.4 (2064.2;2362.1) -0.2 (4.3;-4.6)
Piauí 1485.8 (1389.6;1590.6) 1446 (1348.2;1549) -2.7 (0.7;-5.8) 1021.5 (945.7;1100.5) 922.3 (853;992.7) -9.7 (-5.5;-13.8) 1992.1 (1858.4;2134.9) 2052.7 (1910.4;2199.7) 3 (7.7;-1.2)
Rio de Janeiro 1686.3 (1576;1809) 1572.3 (1471.2;1676.3) -6.8 (-3.7;-10) 1182.7 (1093.6;1286.2) 1027.8 (948.9;1110.8) -13.1 (-9;-17.2) 2341.8 (2186.6;2513.1) 2288.8 (2129;2438.1) -2.3 (2.1;-6.5)
Rio Grande do Norte 1458.3 (1361.9;1562.6) 1471.1 (1371.1;1572.6) 0.9 (4.4;-2.6) 1011.9 (935.3;1092.3) 953.8 (876.8;1029.9) -5.7 (-1.2;-10.1) 1954.9 (1823.4;2096.9) 2097.1 (1956.4;2244.8) 7.3 (12.2;2.3)
Rio Grande do Sul 1793.9 (1676.8;1914.8) 1641.5 (1532.1;1756.2) -8.5 (-5.4;-11.4) 1254.7 (1160.7;1358.6) 1064.5 (981.2;1149.1) -15.2 (-11.1;-19.1) 2457.9 (2294.2;2621.4) 2349.8 (2195.1;2513.4) -4.4 (-0.1;-8.3)
Rondônia 1648.7 (1539.6;1757.9) 1485.5 (1387.3;1588.9) -9.9 (-6.6;-13.3) 1072.2 (993.2;1153.8) 914.5 (842.3;990.6) -14.7 (-10.6;-18.4) 2101 (1957.3;2246.4) 2041.5 (1905;2179.1) -2.8 (1.8;-7.4)
Roraima 1583.8 (1480.2;1691.3) 1418.8 (1330.3;1512.8) -10.4 (-7.4;-13.5) 1021.1 (948.7;1092.6) 862.9 (798.2;925.9) -15.5 (-11.6;-19.1) 2010.7 (1870.7;2154) 1935.6 (1810.6;2075) -3.7 (0.5;-7.9)
Santa Catarina 1770.3 (1655.4;1892.5) 1651.5 (1547.2;1753.9) -6.7 (-3.5;-9.5) 1219 (1129.9;1317.9) 1054.9 (977.2;1138.7) -13.5 (-9.3;-17.2) 2383.9 (2230.9;2553.1) 2346.6 (2193.4;2503.1) -1.6 (2.6;-5.3)
São Paulo 1802.7 (1689.6;1922.7) 1617.6 (1515.9;1730.3) -10.3 (-7.3;-13) 1251.7 (1162.4;1346.3) 1051.7 (973.2;1132.7) -16 (-11.9;-19.8) 2455.1 (2298.6;2620) 2324 (2176.2;2488.7) -5.3 (-1.1;-9.1)
Sergipe 1497.6 (1400.5;1600.2) 1419.8 (1327.5;1520.9) -5.2 (-1.8;-8.3) 1041.2 (966.2;1120.6) 918.5 (844;988.3) -11.8 (-7.3;-16.1) 2024.6 (1889.5;2175) 2038.2 (1905.1;2188.1) 0.7 (5.2;-3.5)
Tocantins 1621 (1515.9;1725.6) 1553.5 (1450;1661.8) -4.2 (-0.7;-7.4) 1074.3 (1000.6;1152.9) 953.2 (878.9;1032.1) -11.3 (-6.8;-15.1) 2110.4 (1972.8;2257.3) 2133.4 (1993;2284.5) 1.1 (5.9;-3.2)

Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation.151

No período 1990-2017, a prevalência de DAC aumentou nos dois sexos (de 1,08% para 1,75%), de maneira mais proeminente em homens do que em mulheres. Tal aumento deveu-se provavelmente ao envelhecimento da população, pois as taxas de prevalência padronizadas por idade permaneceram estáveis nas 2 últimas décadas (variação anual, -0,25%) para ambos os sexos (Figura 3-2).

Angina Estável

Inquéritos populacionais regionais conduzidos antes de 2000, aplicando o questionário de Rose de angina em 2 cidades (Ribeirão Preto, em São Paulo, e Pelotas, no Rio Grande do Sul), identificaram prevalência de angina de 12,3% e 8,2%, respectivamente, em adultos com idade ≥ 40 anos. 110 , 111

O Inquérito Nacional de Saúde, conduzido em 2003 entre 5.000 indivíduos, mostrou prevalência de angina autorrelatada de 6,7% em brasileiros com idade ≥18 anos e de 13% naqueles com idade >50 anos. Apenas 72,8% dos indivíduos relataram adesão a terapia medicamentosa nas 2 semanas anteriores. 112

De acordo com a PNS 2013, um inquérito epidemiológico de base domiciliar e com representatividade nacional, a prevalência geral de angina classe I foi 7,6% (IC 95%, 7,2% - 8,0%), e de angina classe II, 4,2% (IC 95%, 3,9% - 4,5%). 113

A angina pectoris autorreferida foi mais prevalente em mulheres do que em homens em todos os estudos descritos.

É importante ressaltar as maiores taxas de prevalência observadas nos inquéritos prospectivos em comparação às estatísticas nacionais. Avaliações autorreferidas de angina são muito sensíveis, mas não específicas para DAC, pois não requerem exames confirmatórios nem relatórios de saúde. Além disso, considerando-se a natureza assintomática da DAC, a sua verdadeira epidemiologia pode estar sub-representada nas estatísticas nacionais.

Incidência

O GBD estimou uma incidência de 84 eventos de DAC por 100 mil habitantes em 2017 no Brasil. A incidência padronizada por idade foi 79 por 100 mil habitantes e os números ajustados por idade foram maiores para homens do que para mulheres, 104 e 58 por 100 mil habitantes, respectivamente. Houve aumento exponencial na incidência por grupo etário, de 19 por 100 mil habitantes no grupo de 15-49 anos para 198 por 100 mil habitantes no grupo de 59-69 anos, e 744 por 100 mil habitantes no grupo ≥ 70 anos. A variação temporal de 1990 a 2017 foi pequena, 1,03% bruta e -1,29% padronizada por idade anualmente.

De acordo com dados do DATASUS, em 2018, houve 142.982 novos casos de IAM e SCA.

Em revisão sistemática de dados de saúde pública em 2009, as taxas de SCA e IM por 100 mil habitantes foram 38 e 29,8, respectivamente. 114

Mortalidade

• De acordo com as estimativas do GBD 2017, houve 175.791 óbitos atribuídos a DAC, correspondendo a 13% do total de óbitos no Brasil ( Figura 3-3 ).

- Proporção de mortalidade por doença isquêmica do coração no Brasil para ambos os sexos (1990-2017). Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 151

A taxa de mortalidade bruta atribuída a DAC foi 83 por 100 mil habitantes em 2017 (GBD 2017), sendo maior para homens do que para mulheres (95 e 72, respectivamente). Como esperado, as taxas foram mais altas para os grupos etários avançados: 161 por 100 mil habitantes para o grupo de 50-69 anos e 837 por 100 mil habitantes para o grupo ≥ 70 anos.

Segundo o GBD 2017, a taxa de mortalidade padronizada por idade por DIC foi 80 (IC 95%, 78 - 82) por 100 mil habitantes, representando 13% das causas de morte no Brasil. A DIC foi a principal causa de morte em todas as unidades federativas brasileiras em 2017.

As variações regionais nas taxas de mortalidade são significativas. A menor taxa de óbito foi observada no Amazonas (59 por 100 mil habitantes), enquanto a maior, em Pernambuco (102 por 100 mil habitantes). Em todas as regiões brasileiras, a DIC foi a principal causa de morte nas últimas 3 décadas. 115

De acordo com dados submetidos à OMS e ao Banco Mundial, em 2015, houve 111.849 óbitos por DAC no Brasil, cerca de 50 por 100 mil indivíduos, fazendo da DAC a principal causa de mortalidade de 2010 a 2015. 116

De acordo com dados do Ministério da Saúde de 2009, de 962.931 mortes acima dos 30 anos, 95.449 foram causadas por DAC, enquanto 193.309, por aterosclerose. 117

Dados do GBD 2017 mostraram uma queda na mortalidade por DIC de 1990 a 2017 ( Figura 3-4 ), com variações anuais não ajustadas de -0,15%, correspondendo a uma variação acumulada de -53% (-54% a -51%) no período. Essa queda foi observada em todas as unidades federativas, sendo, no entanto, menos expressiva na região Nordeste (Ceará, -22%) do que na Sudeste (Minas Gerais, -63%). A taxa padronizada por idade diminuiu de 169 por 100 mil habitantes em 1990 para 80 por 100 mil habitantes em 2017. Essa tendência foi semelhante nos dois sexos e em todos os grupos etários ( Tabela 3-2 ).

- Taxas de mortalidade por doença isquêmica do coração padronizadas por idade no Brasil para ambos os sexos (1990-2017). Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 151

– Número de mortes e taxas de mortalidade por doença isquêmica do coração padronizadas por idade (por 100 mil habitantes) no Brasil e suas unidades federativas, 1990 e 2017, e variação percentual das taxas
Unidades federativas 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Acre 189.4 (182.1;196.3) 136.6 (131.4;141.7) 357.5 (333;378.2) 65.8 (61.2;69.6) -51.8 (-55.6;-48.2)
Alagoas 1651.4 (1570;1736.9) 130.1 (123.8;136.9) 2673 (2560.9;2792.4) 88.9 (85;93.1) -31.7 (-36.7;-26.7)
Amapá 98 (93.9;101.6) 125.3 (119.8;130) 272.6 (254;287.1) 64.1 (59.8;67.4) -48.9 (-51.9;-45.6)
Amazonas 759.2 (710.6;793.9) 119.1 (111.3;124.4) 1437.4 (1353.9;1501.7) 59.3 (56;62.1) -50.2 (-53.2;-47)
Bahia 7454.5 (7013;7908) 114.8 (108.1;121.6) 10948.6 (10506.6;11402.3) 68.9 (66;71.8) -40 (-44.1;-35.8)
Brasil 129011.3 (126506.8;131646) 169.1 (165.8;172.5) 175791.5 (171318.3;179410.1) 80 (77.9;81.7) -52.7 (-53.9;-51.4)
Ceará 3476.7 (3149.9;3838) 88 (79.8;97) 6852.5 (6528.4;7135.3) 68.7 (65.3;71.5) -22 (-30.1;-12.5)
Distrito Federal 693.4 (670.8;723.3) 163.8 (159.2;169) 1255 (1188.1;1334.8) 68.1 (64.3;72.4) -58.4 (-61;-55.5)
Espírito Santo 1962.9 (1903.6;2020.5) 184 (178.6;189.5) 2849 (2723.4;2991.5) 70.1 (67;73.5) -61.9 (-63.7;-60.2)
Goiás 2187.7 (2095.2;2284.9) 148.7 (142.7;155.3) 4608.3 (4418.6;4837.6) 73.8 (70.8;77.3) -50.3 (-52.7;-47.9)
Maranhão 2681.4 (2413.1;2998.8) 109.5 (98.6;122.8) 5059.4 (4771.1;5411.4) 81.3 (76.6;87) -25.8 (-31.9;-18.4)
Mato Grosso 1038.9 (971.1;1108.6) 157 (147.1;166.7) 2001.7 (1905.6;2108) 71.9 (68.5;75.7) -54.2 (-57.6;-50.4)
Mato Grosso do Sul 1279 (1236.9;1322.1) 178 (172.7;183.3) 2417 (2305.2;2535.9) 92.1 (87.8;96.5) -48.3 (-51.1;-45.2)
Minas Gerais 13676.9 (13229;14143.9) 174.9 (169.3;180.2) 16472.4 (15831.1;17142.3) 65.4 (62.8;68) -62.6 (-64.5;-60.6)
Pará 2429.1 (2281.2;2555) 132.1 (124;138.8) 4475.8 (4255.9;4707.2) 72.4 (68.9;76.1) -45.2 (-49;-41.4)
Paraíba 2656.4 (2457.3;2857.9) 119.5 (110.8;128.7) 4347.9 (4037.2;4662.3) 92.4 (85.8;99.2) -22.7 (-30.6;-12.9)
Paraná 7635.2 (7436.3;7844.1) 213.6 (208.1;218.8) 10022.2 (9595.8;10414) 83.9 (80.3;87.2) -60.7 (-62.5;-59)
Pernambuco 6654.6 (6472.6;6840.5) 172 (167;176.9) 9894.9 (9459.7;10308.8) 102.5 (97.8;106.9) -40.4 (-43.4;-37.4)
Piauí 1454.4 (1315.5;1623.6) 110.5 (100.2;123.7) 2657.7 (2534.2;2880.6) 73.5 (70;79.6) -33.5 (-39.4;-26.8)
Rio de Janeiro 19105.3 (18615.3;19589.5) 237.3 (231.6;242.9) 21214.7 (20296.2;22025.8) 99.8 (95.4;103.5) -58 (-59.7;-56.2)
Rio Grande do Norte 1678.9 (1569.7;1800.4) 107.4 (100.4;115.1) 3054.6 (2909.4;3207.9) 80.2 (76.3;84.4) -25.3 (-32;-17.8)
Rio Grande do Sul 10753.7 (10391.3;11026.2) 200.1 (193;205.2) 11915.8 (11240.8;12411.3) 80.6 (76.1;84.1) -59.7 (-61.5;-57.9)
Rondônia 483.1 (449.2;518.8) 183.3 (172.6;193.6) 1115.8 (1002.5;1234.4) 86.9 (78.3;95.9) -52.6 (-57.9;-47.2)
Roraima 67.3 (61.3;74) 180.3 (167.7;194) 207.7 (184.9;232.6) 82 (73.6;91.2) -54.5 (-60.4;-48)
Santa Catarina 3677.2 (3564.2;3771.3) 189.9 (183.9;195) 5461 (5194.3;5690.8) 77.7 (74;80.9) -59.1 (-61.1;-57.2)
São Paulo 33956.3 (33066.3;34860.2) 216.3 (210.7;221.3) 41732.9 (40054.1;43206.1) 84.2 (80.8;87.2) -61.1 (-62.6;-59.5)
Sergipe 882.9 (837.6;933.2) 108.6 (103.1;114.7) 1509.1 (1440.4;1579.9) 72.8 (69.5;76.3) -32.9 (-37.1;-28.4)
Tocantins 427.5 (379.8;475.3) 153.9 (139.6;169.6) 977 (912.6;1047.3) 73.4 (68.6;78.6) -52.3 (-57.4;-46.8)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 151

A análise temporal da mortalidade por DCV entre 1981 e 2001 mostrou que o coeficiente de mortalidade por DAC permaneceu estável para mulheres nas regiões Norte e Centro-Oeste, enquanto diminuiu nas regiões Sul e Sudeste e aumentou na região Nordeste. 118 Para homens, houve tendência a menor número de eventos nas regiões Sul e Sudeste. 118

Análise conduzida a partir de dados do DATASUS, de 1990 a 2009, mostrou uma redução nas mortes por DAC no Brasil. 117 A taxa caiu de 195 por 100 mil habitantes para 149 por 100 mil habitantes para homens e de 120 por 100 mil habitantes para 84 por 100 mil habitantes para mulheres ( Figura 3-5 ).

- Taxa de mortalidade por doença isquêmica do coração por 100 mil habitantes para homens e mulheres de 1990 a 2017. Dados derivados do DATASUS. 152

- Taxas de DALYs por doença isquêmica do coração padronizadas por idade no Brasil e em cada região brasileira. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 151

A proporção de óbitos por DAC permaneceu estável nas últimas décadas, com relatos variando de 26% a 32%, de acordo com o ano. Um estudo ecológico realizado em Porto Alegre, incluindo indivíduos com 45-64 anos, mostrou que a DCV foi responsável por 28,5% de todos os óbitos em 2009. Desses, 40% estavam relacionados a DAC, cuja proporção foi maior entre indivíduos com nível socioeconômico mais baixo (42,7%) do que entre aqueles com nível socioeconômico mais alto (26,3%). 119

Em um estudo ecológico nacional incluindo indivíduos com 35-64 anos, de 1999 a 2001, a taxa de morte relacionada a DAC foi 84 ± 30 por 100 mil habitantes. Nesse estudo, a incidência de eventos relacionou-se diretamente à taxa de pobreza e ao menor nível educacional. 120 É importante notar que houve grande variação nos resultados entre as 98 cidades participantes, provavelmente em razão da qualidade dos dados.

Mortalidade Relacionada à Síndrome Coronariana Aguda

De acordo com o DATASUS, houve 142.982 hospitalizações por IAM em 2018, com mortalidade hospitalar de 11%.

Vários registros brasileiros de SCA relataram os desfechos de indivíduos admitidos com SCA. Em geral, a mortalidade nos registros é menor do que a relatada nos Sistemas Nacionais de Informação em Saúde.

Entre 2003 e 2008, o Registro RBSCA arrolou 2.693 pacientes, 45% dos quais com IAM. A mortalidade hospitalar para aqueles com angina instável foi 3,1%, enquanto para aqueles com IM, foi 7,7%, levando a uma mortalidade geral de 5,5%. 121

Resultados do BRACE, um registro epidemiológico observacional transversal de pacientes com SCA, publicados em 2012 mostraram mortalidade hospitalar geral de 5,2% entre 1.150 pacientes de 72 hospitais incluídos no registro. 122 , 123

Em estudo retrospectivo multicêntrico de 3.745 pacientes admitidos com SCA entre 2010 e 2015 em hospital de São Paulo, a mortalidade hospitalar por todas as causas foi 3,3%, tendo 454 (12,2%) pacientes experienciado pelo menos um evento adverso maior (reinfarto, choque, sangramento, acidente vascular cerebral ou morte). 124

Em outro registro de base hospitalar, o Estudo ERICO, uma coorte de indivíduos com SCA admitidos em hospital comunitário regional do estado de São Paulo, as taxas de mortalidade em 30 dias e 1 ano foram 4,4% e 12%, respectivamente. 125

O Registro ACCEPT/SBC, conduzido de 2010 a 2011 em 47 hospitais, arrolou 2.485 pacientes com SCA, 35% com IAMSSST e 33% com IAMCSST. A mortalidade por todas as causas em 30 dias foi 1,8% para angina instável, 3,0% para IAMSSST, e 3,4% para IAMCSST. 126

Um estudo observacional longitudinal realizado de 2011 a 2014 em um hospital de alta complexidade, em Belo Horizonte, incluindo 1.129 pacientes com IAMCSST e IAMSSST, reportou mortalidade hospitalar de 8,7%. Dos pacientes com IAMCSST, 56% receberam terapia de reperfusão e 67% foram tratados de acordo com as práticas recomendadas nas diretrizes. 127

Em estudo do Projeto Minas Telecardio 2, conduzido em 2013 e 2014 em 6 unidades de emergência da cidade de Montes Claros, Minas Gerais, entre 593 pacientes com SCA, a mortalidade hospitalar foi 9,4%, variando de 4,9% para angina instável a 17% para os casos de IAMCSST. 128 Em um registro de atendimento ao IAMCSST na cidade de Salvador (RESISST), conectado a uma rede regional de atendimento ao IAM, de janeiro de 2011 a junho de 2013, apenas 41% dos pacientes receberam terapia de reperfusão, sendo a taxa de mortalidade em 30 dias de 15,3%. 129

Dados estaduais de Sergipe coletados de 2014 a 2017 identificaram 707 casos de IAMCSST, com mortalidade hospitalar de 10,9%. A taxa de mortalidade de indivíduos admitidos em hospitais públicos foi significativamente maior quando comparada à daqueles admitidos em hospitais privados (11,9% vs. 5,9%, respectivamente), como descrito em estudos prévios. 129 , 130

A. Mortalidade relacionada a intervenções coronárias percutâneas

De acordo com o DATASUS, em 2018, 10.811 angioplastias primárias foram realizadas por IAM, com mortalidade hospitalar de 6,3% e média de permanência hospitalar de 5,1 dias. Quando todos os outros procedimentos coronários foram considerados, 78.575 angioplastias coronárias foram identificadas, com mortalidade hospitalar de 2,96% e média de permanência hospitalar de 4,5 dias.

De acordo com o DATASUS, em um conjunto de dados de 3.874 indivíduos, a mortalidade hospitalar relacionada a ICP foi 2,33% entre 2005 e 2008. 121 Essa taxa foi menor na região Sudeste (2,03%) e maior na região Norte (3,64%) (p < 0,001). O volume de procedimentos não foi associado com desfecho naquelas análises. 121

Em um estudo de coorte realizado de 2009 a 2013, avaliando 4.806 pacientes submetidos a ICP (Registro ICP-BR) em 8 centros médicos terciários de referência, considerando todas as condições clínicas (69% com IM recente), a mortalidade hospitalar foi 2,6%. 131

No Registro ACCEPT/SBC, que arrolou 2.485 pacientes com SCA de 2010 a 2011, a maioria em centros terciários, mais de 90% deles foram submetidos a cateterismo cardíaco e cirurgia cardiovascular no local. Naqueles pacientes, a taxa de revascularização foi 39% para angina instável, 54% para IAMSSST e 78% para IAMCSST. No grupo de IAMCSST, a terapia de reperfusão foi usada em 88% dos pacientes, tendo a maioria (73%) sido submetida a angioplastia primária. O atraso no tratamento foi, em média, de 125 ± 90 minutos. 126

Outro registro de ICP, que incluiu 1.249 pacientes consecutivos em 2009, encontrou mortalidade total de 2,3%, variando de 0,2% para angina estável a 6,1% para IAMCSST. 132

Em outra série de ICP em hospitais públicos de 2005 a 2008, 166.514 procedimentos foram realizados em 180 hospitais. A mortalidade hospitalar média foi de 2,33%, variando de 0% a 11,35%. Essa taxa foi mais baixa na região Sudeste (2,03%) e mais alta na região Norte (3,64%). A taxa de mortalidade hospitalar foi 2,33% nos hospitais de alto volume, responsáveis por 101.218 (60,8%) ICP, tendo sido 2,29% nos hospitais de médio volume e 2,52% nos hospitais de baixo volume. A mortalidade foi maior entre mulheres e acima dos 65 anos. 133

A maioria dos relatos é proveniente de instituições públicas, sendo os dados dos hospitais privados limitados. Uma análise de 440 procedimentos realizados entre 2013 e 2014 em um hospital público e outro privado na cidade do Rio de Janeiro mostrou baixa mortalidade (0,5%), com taxas semelhantes nas duas instituições. 134

Dados sobre as taxas de sobrevida de longo prazo para pacientes submetidos a ICP são escassos. Em uma análise de procedimentos realizados no estado do Rio de Janeiro entre 1999 e 2000 em todos os hospitais públicos, incluindo 19.263 indivíduos, a sobrevida de 1 ano foi 93% e a de 15 anos, 57%. Nesse estudo, em comparação aos homens, as mulheres apresentaram maior taxa de sobrevida 15 anos após a ICP. 135

B. Mortalidade relacionada a revascularização cirúrgica

De acordo com dados de 2017 do Sistema Nacional de Saúde, 21.474 CRVM foram realizadas em instituições públicas no Brasil, com mortalidade hospitalar de 5,37% e média de permanência hospitalar de 12,2 dias ( Tabela 1-7 ).

O Projeto BYPASS é um banco de dados em andamento estabelecido em 2015 pela Sociedade Brasileira de Cirurgia Cardiovascular, envolvendo 17 instituições representativas de todas as regiões brasileiras. Entre os 2.292 pacientes arrolados até novembro de 2018, submetidos a CRVM isolada ou combinada, a mortalidade hospitalar foi 2,8%, 5,3% permaneceram em ventilação mecânica por mais de 24 horas e 1,2% apresentaram um acidente vascular cerebral intra-hospitalar. 136 , 137

O MASS II foi um ensaio clínico randomizado unicêntrico, desenhado para comparar os efeitos de longo prazo de terapia medicamentosa, angioplastia ou estratégias cirúrgicas para tratar DAC multivascular com angina estável e função ventricular preservada, conduzido antes de 2007. As taxas de mortalidade hospitalar para ICP e CRVM foram 2,4% e 2,5%, respectivamente. 138 As taxas de sobrevida de 10 anos não diferiram significativamente entre os grupos: 74,9% para CRVM, 75,1% para ICP e 69% para terapia medicamentosa (p=0,089). 139 No ensaio MASS III, taxas de sobrevida de 10 anos similares foram descritas. 140

Várias outras experiências unicêntricas, com análise tanto retrospectiva quanto prospectiva, relataram mortalidade hospitalar para pacientes submetidos a CRVM variando de 1,9% a 8,7%. 141 - 143

Carga de Doença

O GBD 2017 estimou 1.736 (IC 95%, 1.689 - 1.779) DALYs perdidos por DAC por 100 mil indivíduos, com taxas menores para mulheres (1.298; IC 95%, 1.340 - 1.250) do que para homens (2.194; IC 95%, 2.112 - 2.258). Essa perda de DALYs correspondeu a 6,1% (IC 95%, 5,5% - 6,7%) de todos os DALYs perdidos. Houve significativa queda nessas taxas nas 2 últimas décadas em todas as regiões (variação anual de -2,51%) (Figura 3-6).

De 1990 a 2017, houve declínio nos DALYs perdidos tanto para homens (-47%) quanto para mulheres (-52%) em todas as unidades federativas. Foram observadas reduções relativas mais expressivas nos estados do Sul e Sudeste, e menores reduções nos estados do Norte e Nordeste ( Tabela 3-3 ).

– Número de DALYs e taxas de DALYs padronizadas por idade (por 100 mil habitantes) por doença isquêmica do coração, no Brasil e suas unidades federativas, 1990 e 2017, e variação percentual das taxas
Unidades federativas 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Acre 4490.5 (4309.4;4679.4) 2481.7 (2383.9;2581.2) 7971 (7417;8477.2) 1295.1 (1208;1374.4) -47.8 (-51.7;-44.2)
Alagoas 38381.3 (36257.4;40572.7) 2644.8 (2506.1;2789.1) 58660.8 (55937.2;61544.4) 1852.2 (1766.3;1942.7) -30 (-35.3;-25.1)
Amapá 2256.8 (2161.6;2349.2) 2139.7 (2042.8;2217.4) 6578.5 (6114.7;6944.1) 1275.9 (1188.4;1345.7) -40.4 (-44;-36.6)
Amazonas 17148.9 (16081.9;18005.8) 2072.2 (1942.7;2171.1) 31464.8 (29293.6;33102.3) 1136.6 (1066.1;1192.7) -45.1 (-48.5;-41.7)
Bahia 166604.8 (156031.4;177498) 2294.4 (2154;2441) 231348.2 (220711.5;241597.1) 1457.6 (1390.2;1521.1) -36.5 (-41.1;-31.4)
Brasil 2959511 (2894436.2;3033217.1) 3159.1 (3091.6;3233.5) 3678315.8 (3579145.9;3768782) 1602.4 (1559.2;1641.9) -49.3 (-50.7;-47.8)
Ceará 71384.3 (64483.4;79273.1) 1691.4 (1530.8;1874.3) 128192.5 (121929.7;134050.4) 1307.4 (1243.4;1368.7) -22.7 (-30.6;-13.7)
Distrito Federal 19308.3 (18564.4;20275.2) 2845.7 (2756.4;2962.1) 27808.1 (26221.3;29618.7) 1121.3 (1059.8;1190.4) -60.6 (-62.8;-58.2)
Espírito Santo 44177 (42688.1;45695) 2975.1 (2882.6;3065.8) 59450.4 (56507.8;62558.7) 1381.9 (1314.9;1451.2) -53.6 (-55.8;-51.3)
Goiás 55914.3 (53327.6;58557.6) 2636.3 (2522.6;2754.3) 105343.2 (100500;110380.6) 1523.3 (1454.2;1595.6) -42.2 (-45.2;-39.3)
Maranhão 73066.2 (65836.5;81337.6) 2557 (2305.8;2845.1) 109267.8 (103121.4;115769.7) 1680.2 (1586.4;1780.6) -34.3 (-39.8;-27.3)
Mato Grosso 26946.1 (25171.5;28837) 3010.9 (2820.1;3213.2) 46202.4 (43768.5;48781) 1433.9 (1363;1510.9) -52.4 (-56.1;-48.3)
Mato Grosso do Sul 30871.7 (29551.5;32110.1) 3216 (3102.7;3326.8) 52574.5 (50174.7;55121.4) 1835.5 (1754.7;1923.1) -42.9 (-46.1;-39.5)
Minas Gerais 313998.9 (302102.3;326795.2) 3087.6 (2980.2;3202.3) 343731.3 (329343.3;358925.5) 1346.9 (1290.4;1406.4) -56.4 (-58.7;-53.9)
Pará 54735.8 (51421.7;57718.5) 2415.2 (2272.2;2540.5) 100381.7 (95156.5;105848.4) 1469.8 (1395.9;1547.3) -39.1 (-43.1;-35.1)
Paraíba 54949.7 (50451.8;59641.8) 2344.6 (2160.6;2543.5) 82981 (77060.1;89538.2) 1821.8 (1692;1966.4) -22.3 (-30.7;-12.1)
Paraná 174525.4 (169345.9;179809.9) 3561.7 (3464.6;3661) 206379.1 (196027.1;215789.4) 1595.2 (1516.5;1666.7) -55.2 (-57.4;-53.1)
Pernambuco 144001.4 (139657.6;148414.6) 3110.2 (3018.9;3200.9) 207666.8 (198225.5;216500.9) 2076.1 (1982.5;2164.9) -33.2 (-36.7;-29.9)
Piauí 33224.1 (29689.6;37114.1) 2189.2 (1970.8;2442.1) 54215.2 (51650.7;57900) 1502.3 (1430.9;1604.2) -31.4 (-37.5;-24.5)
Rio de Janeiro 454987.3 (442500.6;467807.1) 4481.1 (4365.5;4597) 450050 (429870;467261.3) 2063.8 (1970.8;2142.5) -53.9 (-55.9;-52)
Rio Grande do Norte 32424.2 (30203.4;34875.9) 1972.3 (1838.5;2120.1) 60710.1 (57559.4;64019.8) 1623.5 (1539.9;1712.6) -17.7 (-25.2;-9.2)
Rio Grande do Sul 242410.1 (233975.5;249439.7) 3573.4 (3449.5;3665.5) 231413.1 (216004.4;242521.6) 1542.5 (1439.4;1617.4) -56.8 (-59;-54.6)
Rondônia 14130.4 (13109.8;15219.2) 3388.7 (3169.3;3608.1) 24830 (22172.1;27619.4) 1657 (1487.6;1836.9) -51.1 (-57;-44.9)
Roraima 1916.4 (1730.6;2127) 2919.1 (2687.8;3186.5) 4797.3 (4262.1;5419.4) 1374.5 (1225;1539.8) -52.9 (-59.4;-45.6)
Santa Catarina 82034.2 (79539.6;84426.2) 3208.9 (3105;3295.8) 112363.3 (106011.6;117727.3) 1436.9 (1357.2;1503.9) -55.2 (-57.5;-53)
São Paulo 777221.4 (755207.8;800862.7) 3746.1 (3646.7;3850.3) 880339.1 (842359;915273) 1669.2 (1598.4;1735) -55.4 (-57.2;-53.5)
Sergipe 17580.3 (16558.7;18785.1) 2012.2 (1900.5;2143.3) 32232.2 (30675;33873.9) 1474.5 (1403.3;1547) -26.7 (-31.9;-21.1)
Tocantins 10821.1 (9291.9;12213.6) 2516.2 (2233.5;2791.5) 21363.6 (19891.7;22878) 1503.1 (1400.6;1606.9) -40.3 (-47.2;-32.3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 151

A taxa de YLLs por DIC foi 1.653 por 100 mil indivíduos (IC 95%, 1.607 - 1.688), sendo menor para mulheres do que para homens. Esses YLLs corresponderam a 9,7% (IC 95%, 9,4% - 9,9%) de todos os YLLs no GBD 2017.

Utilização e Custo da Atenção à Saúde (Ver Tabelas 1-6 a 1-9 e Figuras 1-15 e 1-16)

Uma análise da base de dados administrativos do SUS mostrou que, em 2018, a quantia total reembolsada por procedimentos coronários intervencionistas foi de R$ 569.314.580 (Int$ 280.727.110), dos quais, R$ 73.429.322 (13%) (Int$ 36.202.821) foram relacionados a angioplastias primárias. O valor médio pago por paciente foi de R$ 6.369 (Int$ 3.230). Quanto à CRVM, a quantia total foi de R$ 275.110.234 (Int$ 135.655.933), correspondendo a um valor médio de R$ 13.307 (Int$ 6.561) por hospitalização cirúrgica.

Os valores reembolsados não ajustados associados com procedimentos de revascularização coronária (códigos para angioplastia e CRVM) aumentaram significativamente de 2008 a 2018, embora em diferentes magnitudes. Para as angioplastias percutâneas, os valores médios subiram 16% (de R$ 5.437 para R$ 6.351) e para as CRVM, 46% (de R$ 9.192 para R$ 13.140) no período.

Em 2015, utilizou-se uma abordagem de modelagem global para avaliar o impacto econômico (sistema de saúde e produtividade) de quatro condições cardíacas no Brasil, com estimativas de custo anual para 2015. Estimou-se que as quatro condições cardíacas afetassem ˜45,7 milhões de pessoas no Brasil, correspondendo a 32,0% da população adulta. O IM representou o maior custo financeiro, com prevalência estimada de 0,2% (334.978 casos), com custo para o sistema de saúde por caso de US$ 48.118 e custo de produtividade de US$ 18.678. 115

O custo anualizado para um indivíduo com DAC crônica foi estimado em R$ 2.733 ± 2.307 pelo SUS, com o custo para paciente ambulatorial representando 54% do total. Para os planos de saúde privados, o custo foi estimado em R$ 6.788 ± 7.842, dos quais, 69% estavam relacionados a pacientes internados. Quanto ao custo dos pacientes ambulatoriais, os medicamentos foram responsáveis por R$ 1.154, representando, para os pagadores públicos e privados, 77% e 55% dos custos com os pacientes ambulatoriais, respectivamente, e 42% e 17% do custo total, respectivamente. 144

Outro registro de uma clínica de DIC de um hospital público mostrou um custo médio anual para manejo ambulatorial de US$ 1.521 por paciente (valores de 2015). O custo médio por hospitalização foi US$ 1.976 e os gastos foram maiores no primeiro e último anos de seguimento. Angina instável, procedimentos de revascularização, diabetes, hipertensão e obesidade foram preditores de maior custo de hospitalização. 145

Os custos anuais com atenção à saúde de indivíduos com DCV são 3 vezes maiores do que aqueles de indivíduos sem DCV no sistema público de saúde (R$ 4.626 vs . R$ 1.312). No setor privado de saúde, a diferença é ainda maior (R$ 13.453 vs . R$ 1.789 – ajustado para 2014). 146

De acordo com dados do DATASUS, de 2008 a 2014, 4.653.884 procedimentos cardíacos diagnósticos foram realizados no Brasil, incluindo 3.015.993 eletrocardiogramas, 862.627 angiografias invasivas e 669.969 testes nucleares, levando a um custo geral de US$ 271 milhões. Na avaliação geoespacial nacional do acesso à saúde, mortalidade por DAC foi associada a menor renda, assim como à realização de menor número de testes nucleares e maior número de testes de esforço e de cateterismos cardíacos. 147

De acordo com dados administrativos do SUS, na última década, houve aumento de 40% no número absoluto de angioplastias primárias para manejo de IAM, passando de 7.648 em 2008 (4,03 por 100 mil habitantes) para 10.811 (5,19 por 100 mil habitantes) em 2018. Observou-se tendência similar para admissões hospitalares por DAC. O número de angioplastias coronárias quase dobrou no período, enquanto o de CRVM permaneceu estável.

Quanto às angioplastias não classificadas como primárias segundo os dados administrativos do SUS (códigos de procedimento: 0406030073, 0406030014, 0406030065, 0406030022, 0406030030), a proporção daqueles procedimentos que ocorreu no contexto de hospitalização por IM aumentou de 2008 para 2018 (de 12% para 31%, respectivamente). Além disso, as angioplastias coronárias realizadas durante hospitalizações por IAM aumentaram em 518%, enquanto aquelas por DAC crônica aumentaram apenas em 70%. Isso revela uma mudança no perfil dos pacientes submetidos a intervenções coronárias, seguindo as recomendações das atuais diretrizes, nas quais angioplastias são mais recomendadas para DAC aguda do que para DAC crônica. De fato, em 2018, 70% de todas as angioplastias para as quais foi designado um daqueles códigos de procedimento ocorreram no contexto de DAC aguda.

A análise de custo de 101 pacientes submetidos a ICP em 2014 e 2015 mostrou um custo mediano de R$ 6.705 ± 3.116 por paciente. Esse custo foi menor para ICP eletiva, R$ 5.085 ± 16, do que aquele para SCA, R$ 6.854 ± 3.396. 148

Um estudo quantitativo, descritivo e transversal realizado em um hospital filantrópico de São Paulo, avaliando 1.913 pacientes consecutivos submetidos a CRVM em 2012, relatou um custo total médio por paciente de US$ 7.993 [mediana, US$ 6.463], uma receita do sistema público de saúde de US$ 3.450 [3.159] e um déficit estimado de -51% do custo total para os fornecedores. 149

Uma análise retrospectiva das solicitações médicas de beneficiários de planos de saúde foi realizada considerando os custos de hospitalização para pacientes admitidos com SCA entre 2010 e 2012. O custo médio por paciente em terapia medicamentosa apenas foi de R$ 18.262, o custo médio por paciente submetido a ICP, de R$ 30.611, e o custo médio por paciente submetido a CRVM, de R$ 37.455. 150

Pesquisa Futura

• Dados adicionais são necessários para a melhor compreensão da distribuição epidemiológica da DAC no Brasil, sugerindo-se, em particular:

— Desenvolvimento de bases de dados nacionais para coletar informação precisa em tempo real sobre a epidemiologia das diferentes apresentações clínicas da DAC, incluindo prestação do cuidado, e sobre medidas de desempenho e desfecho.

— Revisões sistemáticas de taxas de prevalência de SCA e mortalidade por SCA, pacientes estáveis e após ICP e CRVM, incluindo amostras representativas de todas as áreas geográficas do país.

— Avaliação da efetividade de programas estruturados em âmbito nacional para medir a qualidade e o desempenho dos diferentes fornecedores (público, com e sem fins lucrativos) para entender a atual situação, além de desenhar estratégias visando à redução da morbimortalidade por DCV.

Análises adicionais econômica e de custo-efetividade do impacto da DAC e de suas intervenções diagnóstica e terapêutica são necessárias, a partir de um nível macro e utilizando métodos de microcusteio para os sistemas de saúde público e privado.

É de fundamental importância que se desenvolvam programas estruturados para avaliar a prevalência, a incidência e o impacto clínico e econômico da DAC crônica no cenário ambulatorial.

4. CARDIOMIOPATIA E INSUFICIÊNCIA CARDÍACA ICD-10 I42; I50; B57.2.

Ver Tabelas 4-1 até 4-14 e Figuras 4-1 até 4-10

Abreviaturas usadas no Capítulo 4
BREATHE I Registro Brasileiro de Insuficiência Cardíaca
CID-10 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10a Revisão
CMCh Cardiomiopatia Chagásica
CMH Cardiomiopatia Hipertrófica
CMNCh Cardiomiopatia Não Chagásica
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year)
DCh Doença de Chagas
GBD Global Burden of Disease
HR Hazard Ratio
IC Intervalo de Confiança
II Intervalo de Incerteza
IIQ Intervalo Interquartil
OR Odds Ratio
RAP Risco Atribuível na População
REMADHE Repetitive Education and Monitoring for ADherence in Heart Failure
SDI Índice Sociodemográfico (do inglês, Sociodemographic Index )
SEADE Fundação Sistema Estadual de Análise de Dados
SIM Sistema de Informações sobre Mortalidade
SUS Sistema Único de Saúde
UF Unidade Federativa
YLDs Anos vividos com incapacidade (do inglês, Years Lived with Disability )

Cardiomiopatia e Miocardite Prevalência e Incidência

De acordo com as estimativas do Estudo GBD 2017, a prevalência padronizada por idade de cardiomiopatia e miocardite aumentou no Brasil em 9,4% (95 UI, 15,3-4,1) de 1990 a 2017, passando de 102,8 (II 95%, 82,5-125,7) para 112,4 (II 95%, 92,2-134,2), respectivamente ( Figura 4-1 .A e Tabela 4-1 ). Em número absoluto, as estimativas de prevalência de cardiomiopatia e miocardite no Brasil passaram de menos de 100 mil em 1990 para mais de 200 mil em 2017, principalmente devido ao crescimento e envelhecimento da população (Figura 4-1.B). A prevalência de cardiomiopatia e miocardite foi maior em mulheres (115; II 95%, 95-137) do que em homens (109; II 95%, 88-132) em 2017, mas o aumento da prevalência foi maior em homens naquele período, sendo o aumento percentual de 6,9 (II 95%, 0,2-14,2) para mulheres e de 12,3 (II 95%, 5,4-20) para homens.

- Taxa de prevalência padronizada por idade (A) e taxa de prevalência bruta (B) por cardiomiopatia e miocardite por 100 mil habitantes, por sexo, Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

– Taxa de prevalência padronizada por idade de cardiomiopatia e miocardite, por 100 mil habitantes, e variação percentual das taxas, para ambos os sexos e para homens e mulheres, no Brasil e suas unidades federativas, 1990 e 2017
Ambos os sexos Mulheres Homens
1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%)
Brasil 102.8 (82.5;125.7) 112.4 (92.2;134.2) 9.4 (15.3;4.1) 107.7 (86.2;131.2) 115 (95;137.4) 6.9 (14.2;0.2) 97.1 (77.5;119) 109 (88.3;131.7) 12.3 (20;5.4)
Acre 61 (49.2;75.6) 65.9 (53.2;81.1) 8 (21.6;-4.5) 63.8 (50.7;79.9) 66.3 (51.7;81.8) 3.9 (26.6;-13.3) 58.6 (46;74.4) 65.5 (51.5;82.3) 11.8 (32.5;-5.6)
Alagoas 84 (65.4;105.2) 103.3 (82.9;126.8) 23.1 (38.9;8.9) 86.6 (67.4;109.4) 101.4 (80.5;125.5) 17.1 (37.4;-0.5) 80.8 (60.5;104) 105.7 (82.7;133.3) 30.8 (56.3;9.4)
Amapá 104.9 (84.8;128.4) 106.4 (86.4;130.8) 1.4 (13.8;-9.1) 102.7 (83.2;126.6) 103.6 (82.8;128.4) 0.9 (19.5;-15) 107.1 (84.7;133.7) 108.9 (86.4;135.3) 1.6 (19.9;-12.4)
Amazonas 95.3 (76.7;117.9) 98.7 (78.8;120.6) 3.5 (15.3;-7.7) 94.3 (75.1;116.1) 95.7 (75.9;118) 1.5 (17.7;-13.2) 96.1 (74.8;120.2) 101.6 (79.7;126.8) 5.7 (24.6;-10.1)
Bahia 67.2 (51.5;84.9) 74.1 (58.9;91.2) 10.4 (25.4;-2.3) 70.4 (53.8;89.7) 73.8 (58.2;91.7) 4.7 (24.1;-11.1) 63.6 (47.9;82.5) 74.7 (58.6;95.4) 17.5 (41.8;-1.9)
Ceará 105.6 (83.9;128.9) 130.2 (105.9;157.5) 23.2 (37.7;10) 96.8 (76.9;119.8) 116.9 (92.7;142.9) 20.7 (41.8;2.5) 115.4 (90.2;145.4) 146.4 (117.2;181.7) 26.8 (49;9.5)
Distrito Federal 125.6 (92.7;161.3) 144 (113;179.2) 14.6 (32.7;1.3) 134.7 (98.8;171.7) 148.5 (116.4;183.6) 10.2 (33.1;-5.9) 116 (82.6;156.4) 138.9 (104.8;177.4) 19.8 (48.5;-0.3)
Espírito Santo 104.2 (83.5;127.5) 104 (84.4;126.2) -0.1 (10.8;-11.7 95.8 (76.3;120.3) 94.2 (75.1;115.8) -1.7 (15;-15.7) 112.9 (88.7;139.5) 115.2 (91.7;143) 2 (18.3;-11.9)
Goiás 99.1 (71.5;130.5) 125.9 (97.2;160.3) 27.1 (49.3;10.8) 116.1 (81;154.9) 141.2 (109.2;179.2) 21.6 (51.5;1.9) 83 (58.9;111.8) 108.7 (82.5;142.4) 31 (63.1;8.5)
Maranhão 61.3 (48.3;75.9) 76.7 (61.9;94.2) 25.2 (41.6;10.8) 58.7 (46;73.9) 69.1 (54.3;86.4) 17.6 (41.1;-1.4) 63.8 (48.5;81.1) 85.1 (67.2;106.1) 33.5 (60.4;12.1)
Mato Grosso 92.9 (74;115.1) 100.5 (80.4;123.5) 8.2 (21.7;-3.1) 100.3 (79.3;124.1) 106.4 (84.1;132.4) 6.1 (22.8;-8.4) 86.3 (65.6;109.5) 94.5 (73.9;118.4) 9.6 (30.4;-7.3)
Mato Grosso do Sul 126.2 (100.6;155.9) 141.5 (113.6;172.9) 12.1 (26.2;0.5) 131.9 (105;162.7) 140.3 (113;174) 6.4 (23.2;-9.8) 120.5 (91.5;154.7) 142.4 (112.8;175.3) 18.1 (40.9;0.6)
Minas Gerais 110.7 (85.9;139.6) 123.7 (98;152) 11.7 (27.3;-0.9) 123.3 (95.2;155.8) 132.4 (105.3;163.8) 7.3 (28;-7.5) 95.8 (70.1;124.4) 113 (87.8;142.4) 17.9 (42.6;-0.7)
Pará 72.9 (59;88.7) 74.8 (60.4;92.1) 2.6 (15.9;-9.4) 73.1 (57.6;90.4) 72.6 (58.3;91.3) -0.7 (16.4;-16.5 72.8 (57.8;90.9) 77.1 (60.5;95.1) 5.8 (25.4;-10.7)
Paraíba 116.2 (92.8;142.4) 138.3 (112.3;168.2) 19 (34.8;7) 118.5 (94.5;145.7) 140.4 (112.6;172.9) 18.5 (39.6;1.2) 113.5 (89.8;142.8) 135.7 (107.6;167.8) 19.6 (40.3;1.7)
Paraná 90.4 (71.4;111.4) 97 (77.5;118.8) 7.3 (21.1;-4.3) 95.8 (74.8;119.6) 99.5 (79.5;123) 3.8 (21.9;-11.1) 84.7 (64.6;106.9) 93.7 (73.7;117) 10.7 (32.5;-7.3)
Pernambuco 81.8 (64.8;101.5) 85.3 (68.5;104) 4.3 (17.8;-7.4) 80.5 (62.3;100.8) 81.9 (64.1;102.3) 1.8 (20.4;-14.8) 83.6 (64.2;106) 89.9 (70.6;112.4) 7.6 (29.5;-9.2)
Piauí 64.6 (50.1;80.1) 75.4 (60.2;92.7) 16.8 (33.1;3.5) 65.9 (51.4;82.2) 74.5 (58.7;92.7) 13.1 (34.9;-3.7) 63.1 (47.5;81.5) 76.4 (59.5;96.4) 21 (45.6;0.3)
Rio de Janeiro 117.3 (94.5;144.3) 113.9 (92.7;138.1) -2.9 (8.7;-12.7) 115.9 (92.9;145) 112.8 (91.5;137.7) -2.7 (12.4;-15.7 119.3 (93;149) 115.6 (91.9;142.1) -3.1 (13.9;-16.3)
Rio Grande do Norte 75.9 (60.8;95.4) 83.6 (67.4;102.5) 10.1 (23.8;-1.8) 68 (53.4;85.4) 74.7 (59.2;93.7) 9.8 (30.5;-6.9) 84.6 (67.8;107.3) 94.9 (75.6;116.7) 12.1 (32;-4.2)
Rio Grande do Sul 75.2 (59.7;93.4) 74.7 (60;91.3) -0.7 (12.1;-11.7 73.1 (57.3;92.8) 72.1 (57.7;89.4) -1.4 (17.2;-16.8 77 (60;96.4) 76.9 (60.5;95.5) 0 (18.5;-15.9)
Rondônia 69.9 (54.3;87.9) 76.3 (62;94.4) 9.2 (25.4;-3.8) 74.1 (57.7;94.9) 78.7 (63.2;98.4) 6.1 (25.9;-10.5) 66.2 (49.8;84.5) 74 (57.8;92.9) 11.7 (34.3;-7)
Roraima 141.5 (114.4;172.9) 145 (118.1;174.6) 2.5 (14.5;-7.8) 137.9 (111;168.4) 140.3 (111.4;171.8) 1.7 (18.3;-12.1) 143.8 (113.8;177.9) 149.2 (118.5;183.1) 3.7 (21.1;-10.2)
Santa Catarina 107.2 (86.6;131.2) 106.7 (86.6;130) -0.5 (10.2;-10.9 109.7 (88.8;135.7) 108.4 (86.2;133.7) -1.2 (14;-15.3) 103.5 (81.8;129) 103.6 (82.4;127.7) 0.1 (17.4;-14.5)
São Paulo 138.4 (108.2;171.2) 147.7 (120.7;178) 6.7 (21.3;-4.4) 152.1 (118.7;187.1) 158 (128;193.1) 3.8 (21.1;-10.7) 121.3 (92.5;156) 134.1 (105.8;164.7) 10.5 (29;-6.6)
Sergipe 100.2 (80.6;123.9) 115.3 (93.9;141.5) 15.2 (29.1;3.3) 102.5 (81.7;128.8) 115 (92.6;141.2) 12.2 (31.1;-3.9) 97.3 (75.4;120.9) 115.2 (91.3;142.9) 18.4 (39.4;2.2)
Tocantins 71.3 (53.8;89.6) 88.8 (70.6;109.2) 24.6 (43.3;9.2) 71.1 (54.4;91.9) 85.2 (67.3;106.3) 19.9 (45.4;0.7) 71.6 (53;92.1) 92.3 (71.6;116.4) 28.9 (59;7.9)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

De acordo com as estimativas do Estudo GBD 2017, a prevalência de cardiomiopatia e miocardite varia bastante entre as UF brasileiras, não tendo a variação percentual sido homogênea entre 1990 e 2017 ( Tabela 4-1 ). Em 2017, as maiores taxas foram observadas nos estados de São Paulo e Roraima e no Distrito Federal. De 1990 a 2017, houve diminuição da taxa de prevalência padronizada por idade nos estados do Rio de Janeiro, Rio Grande do Sul, Santa Catarina e Espírito Santo, e aumento em todas as outras UF.

Segundo as estimativas do Estudo GBD 2017, as taxas de incidência padronizadas por idade por 100 mil por ano foram 46,3 (II 95%, 41,5-52,1) em 1990 e 46,7 (II 95%, 41,8-52,6) em 2017, com uma pequena variação de 0,8% (II 95%, -0,3 a 1,8) no período ( Tabela 4-2 ). Os números absolutos de casos incidentes foram 54.520 (II 95%, 48.574-61.321) em 1990 e 103.879 (II 95%, 92.496-117.294) em 2017. Tal aumento acha-se relacionado ao crescimento e envelhecimento da população. A Tabela 4-3 mostra as taxas de incidência de cardiomiopatia e miocardite por 100 mil habitantes, por idade, para ambos os sexos, em 1990 e 2017, e a variação percentual das taxas. Houve um aumento de quase 3 vezes nas taxas de incidência do grupo etário de 15-49 anos para o de 50-69 anos, assim como do último para o de 70+ anos, tendo esses aumentos sido similares para mulheres e homens. De 1990 a 2017, a incidência aumentou em todos os grupos etários para mulheres, enquanto tendeu a diminuir na maioria dos grupos etários para homens.

– Número de casos incidentes e taxa de incidência (por 100 mil) padronizada por idade de cardiomiopatia e miocardite, e variação percentual das taxas, no Brasil e suas unidades federativas, 1990 e 2017
1990 2017
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Brasil 54520.4 (48574.3;61320.7) 46.3 (41.5;52.1) 103879.4 (92495.6;117294.5) 46.7 (41.8;52.6) 0.8 (-0.3;1.8)
Acre 125.8 (111;143) 44.8 (40;50.7) 340.7 (303.3;383.1) 46 (41.1;52) 2.8 (-0.5;6.4)
Alagoas 826.5 (732.4;929.4) 43.6 (38.8;49.3) 1551.4 (1378.8;1749) 46.5 (41.5;52.4) 6.8 (3.5;10.2)
Amapá 85.4 (75.2;97.2) 47.5 (42.5;53.4) 311.1 (274.3;352.6) 47.6 (42.5;53.6) 0.3 (-2.8;3.9)
Amazonas 645.3 (565.6;732.6) 46.4 (41.5;52.6) 1586.5 (1410.7;1793.3) 46.6 (41.6;52.8) 0.5 (-2.9;4.3)
Bahia 4183 (3713.7;4708.9) 45.3 (40.3;50.9) 7177 (6366.6;8059.8) 45.1 (40;50.7) -0.3 (-3.4;2.7)
Ceará 2232.8 (1990.7;2511.3) 43.2 (38.7;48.7) 4589.2 (4084.6;5197.2) 46.4 (41.4;52.7) 7.5 (3.4;11)
Distrito Federal 502.7 (439.4;574.4) 45.2 (40.3;51.3) 1258.3 (1107.5;1428.3) 45.3 (40.4;51) 0.2 (-3.3;3.7)
Espírito Santo 976.1 (856.5;1104.3) 48.1 (42.8;54.4) 1992.5 (1757;2263.2) 48.2 (42.9;54.4) 0.2 (-3.2;3.8)
Goiás 1391.1 (1220.9;1574.2) 46.3 (41.4;52.2) 3233.1 (2869.8;3671.6) 47.3 (42.2;53.5) 2.3 (-0.8;5.4)
Maranhão 1568.5 (1390.4;1771.6) 43.3 (38.6;48.9) 3314.6 (2958.6;3716.8) 46.7 (41.7;52.6) 8 (4.5;12)
Mato Grosso 628.1 (549.8;715.5) 45.6 (40.7;51.7) 1567.2 (1394.8;1780.2) 46.8 (41.9;52.9) 2.7 (-1;6.3)
Mato Grosso do Sul 648.6 (572.4;728) 48.6 (43.4;54.8) 1426.5 (1264.1;1616.6) 50.6 (45.2;57) 4.1 (0.8;7.7)
Minas Gerais 5880.7 (5207.1;6646.3) 46 (41;52) 11181 (10003.5;12646.6) 47 (42.2;53.2) 2.2 (-1;5.5)
Pará 1548.2 (1365.8;1749.4) 45.4 (40.6;51.3) 3561 (3155.4;4003.7) 45.5 (40.5;51.4) 0.2 (-3.2;3.9)
Paraíba 1181.3 (1051.4;1331.4) 43.2 (38.6;48.9) 2068.4 (1841.2;2347.2) 46.3 (41.2;52.5) 7.1 (3.6;10.5)
Paraná 3140.9 (2777.5;3572.6) 47.1 (41.9;53.3) 5728 (5060.1;6535.4) 47 (41.9;53.2) -0.2 (-3.8;3)
Pernambuco 2639 (2333.6;2961.8) 45.6 (40.5;51.3) 4609.7 (4098.5;5160.5) 46.1 (41.1;51.6) 1.1 (-2.4;4.5)
Piauí 865.4 (765.7;974.5) 43.8 (39;49.4) 1652.7 (1471;1863.8) 45.8 (40.7;51.6) 4.5 (0.8;8.3)
Rio de Janeiro 5321.9 (4706.8;6019.7) 46.7 (41.6;52.5) 9236.1 (8183.4;10524.9) 46.4 (41.3;52.5) -0.5 (-4.1;3.1)
Rio Grande do Norte 886.2 (790.4;995.2) 44.3 (39.7;49.8) 1723.7 (1535.1;1947.9) 46.2 (41.2;52.1) 4.2 (1;7.7)
Rio Grande do Sul 3927.6 (3482.4;4424.5) 49.5 (44.1;55.8) 6475.7 (5749;7325.7) 48.5 (43.2;54.5) -2.1 (-5.5;1.4)
Rondônia 330.5 (289.3;379.1) 45.6 (40.6;51.4) 746.3 (660.9;847.2) 46 (41.2;52.2) 0.9 (-2.6;4.4)
Roraima 61.2 (53.3;70.9) 46.1 (41.2;52) 212.3 (187.3;240.4) 46.4 (41.3;52.4) 0.9 (-2.4;4.2)
Santa Catarina 1694 (1503.4;1912.2) 47.8 (42.9;54.2) 3554.7 (3148.4;4033.5) 47.5 (42.4;53.4) -0.7 (-4.2;3.5)
São Paulo 12421.8 (10980.5;13984.7) 47.6 (42.4;53.5) 22999.9 (20352.4;26154.9) 46.6 (41.6;52.7) -1.9 (-5.5;1.4)
Sergipe 520.8 (463.6;584.1) 45.3 (40.5;51.4) 1075.4 (957.1;1218.6) 47.3 (42.1;53.4) 4.5 (1;7.8)
Tocantins 287 (253.9;325.8) 44.8 (40;50.5) 706.6 (629;798) 47.1 (42.1;53.1) 5.1 (1.6;8.9)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

– Taxas de incidência de cardiomiopatia e miocardite por 100 mil habitantes e variação percentual das taxas, por idade e sexo, Brasil, 1990 e 2017

Mortalidade

De acordo com as estimativas do Estudo GBD 2017, as taxas de mortalidade por cardiomiopatia e miocardite pareceram aumentar na década de 1990, mas diminuíram nas 2 décadas seguintes ( Figura 4-2 ). Como mostra a Tabela 4-4 , as taxas de mortalidade foram 10,9 (II 95%, 9,57-11,38) em 1990 e 8,59 (II 95%, 8,16-9,93) em 2017 por 100 mil habitantes, uma redução de 21,2% (II 95%, -26,8 a -2,6). Apesar dessa diminuição nas taxas de mortalidade, o número de mortes por cardiomiopatia e miocardite aumentou naquele período devido ao crescimento e envelhecimento da população. Cardiomiopatia e miocardite foram responsáveis por 9.734 (II 95%, 8.417-10.163) mortes em 1990, número que se elevou para 18.812 (II 95%, 17.885-21.745) em 2017. As estimativas do Estudo GBD 2017 das taxas de mortalidade por cardiomiopatia referem-se a casos com cardiomiopatia listada como causa básica de morte. As mortes por insuficiência cardíaca que resulta de outras causas específicas são atribuídas à doença de base, i.e., mortes relacionadas a cardiomiopatia isquêmica são codificadas como devidas a doença isquêmica do coração. Além disso, para o projeto GBD, a insuficiência cardíaca não é considerada uma causa de morte primária e, portanto, todas as mortes codificadas como relacionadas a insuficiência cardíaca são recodificadas para a condição de base (ver adiante).

- Taxa de mortalidade padronizada por idade por cardiomiopatia e miocardite, por 100 mil habitantes, por sexo, Brasil, 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

– Número de mortes e taxa de mortalidade padronizada por idade (per 100 mil) por cardiomiopatia e miocardite, e variação percentual das taxas, no Brasil e suas unidades federativas, 1990 e 2017
Localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Brasil 9734 (8417;10163) 10.9 (9.6;11.4) 18812 (17885;21745) 8.6 (8.2;9.9) -21.2 (-26.8;-2.6)
Acre 11 (10;15) 5.7 (5.2;7.9) 29 (25;45) 4.8 (4.1;7.6) -15.2 (-28;26.1)
Alagoas 172 (137;194) 10.6 (8.4;11.9) 262 (239;289) 8.4 (7.7;9.3) -20.7 (-32.3;1.9)
Amapá 7 (6;9) 6.7 (6;8.4) 32 (28;42) 6.7 (5.9;8.7) -0.1 (-13.5;36)
Amazonas 55 (50;69) 6.3 (5.8;8) 135 (118;210) 4.9 (4.3;7.7) -22.4 (-33.1;18.6)
Bahia 581 (503;639) 7.9 (6.6;8.8) 892 (800;1189) 5.6 (5;7.5) -28.9 (-39.9;10.5)
Ceará 362 (296;425) 7.4 (5.9;8.7) 642 (592;704) 6.5 (6;7.1) -11.8 (-27.5;15.6)
Distrito Federal 95 (71;103) 16.2 (12.5;17.5) 268 (221;299) 13.1 (10.8;14.5) -19.4 (-28.2;-5)
Espírito Santo 138 (121;147) 10.5 (9.3;11.3) 261 (236;355) 6.4 (5.8;8.7) -39.7 (-47.2;-13.5)
Goiás 345 (246;378) 20.1 (14.7;22.2) 730 (609;792) 11.8 (9.8;12.8) -41.2 (-47.9;-24.8)
Maranhão 232 (193;286) 6.2 (5;8.1) 303 (268;458) 4.6 (4.1;7.1) -25.7 (-41.7;3.6)
Mato Grosso 75 (68;83) 8.7 (7.8;9.7) 202 (182;277) 7.1 (6.3;9.5) -18.5 (-29;14)
Mato Grosso do Sul 122 (89;133) 14.5 (10.6;15.9) 261 (236;293) 10 (9.1;11.2) -30.8 (-39.9;2.9)
Minas Gerais 1238 (962;1334) 13.1 (10.3;14) 2059 (1903;2288) 8.4 (7.7;9.3) -36 (-42.8;-16.7)
Pará 114 (102;162) 4.9 (4.5;7) 314 (274;482) 4.8 (4.2;7.3) -3.6 (-15.2;29.3)
Paraíba 279 (220;318) 11.3 (8.9;12.9) 456 (392;515) 9.8 (8.4;11.1) -12.9 (-27.5;8)
Paraná 567 (479;605) 13 (11;13.9) 769 (685;1168) 6.6 (5.9;9.9) -49.2 (-56.2;-19.1)
Pernambuco 330 (306;367) 7.1 (6.6;8) 775 (700;884) 7.9 (7.1;9.1) 11.3 (-2.9;26.3)
Piaui 124 (102;146) 7.3 (5.9;8.9) 183 (165;233) 5.1 (4.6;6.5) -30.7 (-43.4;3.1)
Rio de Janeiro 830 (749;1076) 8.9 (8.2;11.5) 2749 (2069;2994) 13.1 (10;14.2) 46.2 (12.6;63.3)
Rio Grande do Norte 92 (80;119) 5.1 (4.4;6.8) 176 (153;256) 4.6 (4;6.8) -8.8 (-25.2;34.4)
Rio Grande do Sul 298 (268;487) 4.8 (4.3;7.8) 709 (617;1221) 4.9 (4.3;8.5) 2.7 (-7;14.1)
Rondônia 30 (27;36) 7.8 (7.1;9.3) 83 (70;120) 6.1 (5.2;8.8) -22.6 (-34.2;4.1)
Roraima 10 (7;11) 17.1 (12.1;19.4) 40 (33;47) 13.5 (11.2;16.1) -20.9 (-36.3;12.7)
São Paulo 3260 (2466;3519) 17.6 (13.5;19) 5766 (4987;6355) 11.8 (10.3;12.9) -33.1 (-39.7;-16.4)
Santa Catarina 246 (229;264) 10.9 (10;11.8) 493 (449;681) 7 (6.3;9.5) -36.3 (-43.8;-14.8)
Sergipe 82 (73;90) 8.7 (7.7;9.7) 139 (125;173) 6.5 (5.9;8.1) -24.6 (-35.6;2)
Tocantins 41 (31;49) 10.2 (8.1;12.4) 87 (77;113) 6.3 (5.5;8.3) -38.5 (-51.3;-5.2)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

A Tabela 4-4 também mostra o número total de mortes e taxa de mortalidade padronizada por idade (por 100 mil habitantes) por cardiomiopatia e miocardite, além da variação percentual, por UF e no Brasil, em 1990 e em 2017. Na maioria das UF houve diminuição das taxas de mortalidade, sendo as maiores porcentagens de redução entre 1990 e 2017 observadas no Paraná e em Goiás. Por outro lado, houve aumento das taxas de mortalidade de 1990 a 2017 apenas em 3 UF, sendo o maior aumento, 46,2% (II 95%, 12,6-63,3), observado no estado do Rio de Janeiro. Em 2017, as UF com as mais baixas taxas de mortalidade (abaixo de 5,0) foram Acre, Amazonas, Maranhão, Pará, Rio Grande do Norte e Rio Grande do Sul.

A Tabela 4-5 mostra as taxas de mortalidade por cardiomiopatia e miocardite de acordo com o sexo e os grupos etários, com base nas estimativas do Estudo GBD 2017. As mulheres apresentaram as mais baixas taxas de mortalidade padronizadas por idade, assim como uma redução mais pronunciada de 1990 a 2017. As taxas de mortalidade por cardiomiopatia e miocardite em mulheres foram 9,20 (II 95%, 8,81-9,93) por 100 mil habitantes em 1990 e 6,3 (II 95%, 6-6,6) por 100 mil habitantes em 2017, uma redução de 31,3% (II 95%, -35,5 a -26,2). As taxas nos homens foram 12,83 (II 95%, 9,96-13,67) por 100 mil habitantes em 1990 e 11,27 (II 95%, 10,46-14,39) por 100 mil habitantes em 2017, uma variação de 12,1% (II 95%, -20,9 a 28,2). Como esperado, as mais altas taxas de mortalidade foram observadas no grupo de 70+ anos, sendo, em 1990, 84,2 (II 95%, 74,2-89,1) por 100 mil habitantes e, em 2017, 76,6 (II 95%, 72,0-89,9) por 100 mil habitantes. Para o grupo de 50-69 anos, as taxas foram 21,2 (II 95%, 17,7-22,5) por 100 mil habitantes em 1990 e 16,5 (II 95%, 15,3-19,3) por 100 mil habitantes em 2017. No geral, as taxas de mortalidade diminuíram entre 1990 e 2017 na maioria dos grupos etários, tendo permanecido estável no grupo de 15-49 anos.

– Taxa de mortalidade (por 100 mil habitantes) por cardiomiopatia e miocardite e variação percentual das taxas, por idade e sexo, Brasil, 1990-2017
1990 2007 Variação percentual (II 95%)
Ambos os sexos
Padronizada por idade 10,9 (9,6;11,4) 8,6 (8,2;9,9) -21,2 (-26,8;-2,6)
Abaixo de 5 4,8 (4;5,6) 2,5 (2,2;2,8) -47,1 (-56,4;-31,1)
5-14 anos 0,4 (0,4;0,5) 0,4 (0,3;0,4) -11,3 (-22,3;2,2)
15-49 anos 2,4 (2;2,6) 2,5 (2,2;2,7) 1,4 (-6,7;21,7)
50-69 anos 21,2 (17,7;22,5) 16,5 (15,3;19,3) -22,4 (-29,3;-0,2)
70+ anos 84,2 (74,2;89,1) 76,6 (72,1;90) -9 (-16,8;14,7)
Todas as idades 6,5 (5,6;6,8) 8,9 (8,4;10,3) 36,3 (26,6;68,8)
Masculino
Padronizada por idade 12,8 (10;13,7) 11,3 (10,5;14,4) -12,1 (-20,9;28,2)
Abaixo de 5 4,8 (3,3;5,7) 2,7 (2,3;3,2) -43 (-57,1;-3,5)
5-14 anos 0,4 (0,4;0,5) 0,4 (0,4;0,5) -3,9 (-20;15,3)
15-49 anos 3,3 (2,5;3,6) 3,6 (3,2;4,2) 9,5 (-1;43,7)
50-69 anos 26,2 (19,1;28,4) 23,6 (21,4;29,7) -10,1 (-20,9;31,7)
70+ anos 91,6 (69,7;99,7) 89,3 (81,2;119,5) -2,5 (-15,1;53,7)
Todas as idades 7,4 (5,6;7,9) 10,7 (10;13,6) 44,8 (30,7;109,6)
Feminino
Padronizada por idade 9,2 (8,8;9,6) 6,3 (6;6,6) -31,3 (-35,5;-26,2)
Abaixo de 5 4,7 (3,9;5,9) 2,3 (2;2,6) -51,5 (-64,1;-37,5)
5-14 anos 0,4 (0,3;0,5) 0,3 (0,3;0,4) -19,9 (-31,7;-4,4)
15-49 anos 1,6 (1,5;1,6) 1,3 (1,2;1,4) -15,9 (-23,1;-7,1)
50-69 anos 16,6 (15,6;17,6) 10,2 (9,5;11) -38,6 (-43,7;-32,3)
70+ anos 78,3 (73,7;83,3) 67,4 (63,2;71,9) -13,9 (-21,1;-5,9)
Todas as idades 5,7 (5,4;5,9) 7,1 (6,8;7,5) 26,3 (18,6;35,3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

O Estudo GBD 2017 usa o SDI como uma estimativa do nível socioeconômico de uma localidade. A Figura 4-3 mostra a correlação entre o SDI e a taxa de mortalidade padronizada por idade por cardiomiopatia e miocardite, por 100 mil habitantes, em 1990 e em 2017. As correlações observadas em 1990 e 2017 foram similares e não significativas.

Em estudo relatando dados da Fundação SEADE, do estado de São Paulo, as cardiomiopatias foram responsáveis por um total de 3.571 óbitos, correspondendo a 23,3% das mortes relacionadas a insuficiência cardíaca em 2006, a saber: cardiomiopatia dilatada, responsável por 17,2% das mortes; cardiomiopatia alcoólica, por 0,45%; e cardiomiopatias restritivas, por 0,37%. A CMCh e a cardiomiopatia alcoólica foram responsáveis por 7,8% e 0,45% das mortes relacionadas a insuficiência cardíaca, respectivamente. 153

Dados de cardiomiopatias específicas são escassos. Em estudo de coorte de 214 pacientes com CMH, acompanhados por 7 anos em um hospital terciário de São Paulo, a idade média foi 37±16 anos, sendo 52% mulheres. Houve 22 mortes (10%), 15 diretamente relacionadas à CMH (11 mortes súbitas). As taxas de sobrevida acumulada foram 94,5% em 5 anos, 91% em 10 anos e 87,9% em 15 anos, com taxa de mortalidade anual de 1%, que é baixa, considerando que o estudo foi realizado em um centro de referência. 154

Carga de Doença

De acordo com as estimativas do GBD 2017, as tendências das taxas de DALYs padronizadas por idade por cardiomiopatia e miocardite foram similares àquelas de mortalidade, com pequeno aumento na década de 1990 e diminuição nas décadas seguintes. A Figura 4-4 mostra os DALYs por 100 mil habitantes, em 1990-2017, no Brasil e suas regiões. A região Centro-Oeste apresentou os mais altos DALYs nas 2 primeiras décadas, com redução depois disso, principalmente após 2004. Em 2017, a região Sudeste apresentou os mais altos DALYs, enquanto as regiões Norte e Sul, os mais baixos. Como mostra a Tabela 4-6 , as taxas de DALYs padronizadas por idade foram 286 (II 95%, 247-301) em 1990 e 222 (II 95%, 211-251) em 2017, por 100 mil habitantes, com uma diminuição de 22,4% (II 95%, -27,6 a -7). Tais mudanças são similares àquelas observadas nas taxas de mortalidade. A despeito dessa diminuição nos DALYs, cardiomiopatia e miocardite foram responsáveis por 328.636 (II 95%, 283.325-346.746) DALYs no Brasil em 1990 e por 490.572 (II 95%, 465.903-556.886) DALYs no Brasil em 2017, o que representa 0,81% de todos os DALYs.

– Número de DALYs e taxa de DALYs padronizada por idade (por 100 mil) por cardiomiopatia e miocardite, e variação percentual das taxas, no Brasil e suas unidades federativas, 1990 e 2017
Localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
Brasil 328636.2 (283325;346745.9) 286.3 (246.7;300.6) 490571.8 (465903.3;556885.7) 222.3 (211.1;250.9) -22.4 (-27.6;-7)
Acre 497.4 (436.2;639.6) 160.9 (145;211.8) 892.9 (770.2;1353.6) 128.3 (110.6;194.8) -20.3 (-32.5;10.3)
Alagoas 7445.3 (5810.9;8943.2) 325.1 (260.1;373.1) 7889.4 (7045.9;8603.6) 238.4 (215;260) -26.7 (-37.3;-12.9)
Amapá 260.3 (235.6;324.2) 162.7 (147.6;202.1) 1030.8 (926.3;1349.3) 172.1 (154.9;223) 5.8 (-6.7;41)
Amazonas 2178.8 (1943.2;2658.8) 162.5 (148;203.1) 4500.2 (3953.1;6675.2) 137.2 (120.4;205.4) -15.6 (-25.7;19.1)
Bahia 19212.5 (17344.2;21147.3) 212.7 (188;232.3) 27181.1 (24338.5;33355.6) 175.2 (156.2;214.1) -17.6 (-29.2;10.8)
Ceará 16413.7 (13000.4;20157.3) 260.6 (210.1;309.8) 18369.4 (16682.7;20144.2) 188.2 (170.6;206.9) -27.8 (-41.3;-10.1)
Distrito Federal 3658.3 (2766.2;3988) 376.3 (286.8;405.1) 7351.8 (6159.1;8113.1) 276.6 (233.7;305.7) -26.5 (-33;-14.2)
Espírito Santo 4540.9 (4041.7;4871.1) 241 (213.7;258.1) 7341.7 (6712.8;9314.8) 177 (161.6;223.8) -26.5 (-34.9;-2.3)
Goiás 11003.3 (8024.8;12004.6) 428.7 (312.4;467.9) 18299.6 (15675.5;19752.8) 272.9 (234.7;293.9) -36.3 (-43;-16)
Maranhão 13001.5 (10067.9;16807.4) 242.9 (200.7;299.4) 10003.6 (8755.1;13529.3) 137.8 (121.5;190.6) -43.3 (-56.7;-23.3)
Mato Grosso 3073.7 (2771.1;3438.3) 229.1 (209.1;254.1) 5796.7 (5242.4;7786.8) 177.7 (161.1;236.5) -22.4 (-31.3;2.3)
Mato Grosso do Sul 3865.2 (2943.9;4262.8) 329.7 (247;361.6) 6710.7 (6101.4;7492.7) 242 (221.4;268.6) -26.6 (-35.7;6.5)
Minas Gerais 39564.4 (30507.2;42826) 327.1 (253.6;352.7) 51182.3 (47035.5;56511.4) 216.8 (198.6;238.8) -33.7 (-40.5;-13.2)
Pará 4344.5 (3801.9;5889.4) 129.8 (116.4;180.3) 9977.8 (8660.1;14959.6) 132.8 (115.4;198.5) 2.3 (-9.4;25.4)
Paraíba 10241.9 (8039.5;12095.6) 341.3 (272.3;396.2) 11470.6 (9717.3;12811.3) 257.1 (217.9;287.7) -24.7 (-36.3;-9.2)
Paraná 17321.6 (15163;18438.9) 292.2 (250.6;309.9) 19045.2 (16983.3;28587.7) 160.6 (142.8;234.4) -45 (-52.3;-14.1)
Pernambuco 11872 (10716.4;13371.5) 200.8 (184.9;220.9) 21914.4 (19857.6;24316.1) 218.9 (198.9;243.3) 9 (-3.7;22.2)
Piauí 5486.8 (4473.4;6582.1) 227.8 (188.3;269.8) 5211.8 (4701.4;6542.5) 145.4 (130.7;182.9) -36.2 (-48;-13)
Rio de Janeiro 28335.5 (24866.7;35902.2) 249.5 (221.8;316.3) 68879.7 (50970.5;75152.9) 334.9 (253.6;363.3) 34.2 (2.5;48.6)
Rio Grande do Norte 3445.5 (2978.7;4084.9) 153.8 (134.2;188.6) 5076.1 (4420.6;6901.5) 137.6 (119.9;186.8) -10.6 (-24.8;18.6)
Rio Grande do Sul 9946.1 (8932.6;15081.7) 128.4 (115.3;197.2) 16836.2 (14705.4;28348.6) 124.5 (109.3;204.3) -3.1 (-11.8;8.7)
Rondônia 1298.7 (1165.9;1533.3) 197.3 (178.5;234.3) 2395.2 (2053.6;3399.5) 153.1 (132.1;214.9) -22.4 (-33.3;0.6)
Roraima 435.5 (314.2;500.3) 376.2 (264.9;423.8) 1242.6 (1054;1445.5) 296.9 (253.9;344.2) -21.1 (-35.7;10)
Santa Catarina 7573.9 (7109.4;8246.8) 244.7 (229.3;262.6) 12498.4 (11367.3;16891.4) 168.5 (153.3;225.2) -31.2 (-38.2;-12.2)
São Paulo 98920.7 (75875.1;106392.2) 410.9 (316.9;441.8) 142836.1 (123464.2;155246.1) 288.1 (253.2;311.2) -29.9 (-36;-15)
Sergipe 2898.6 (2556.6;3238.8) 237.8 (211.1;262.1) 4042.2 (3652.6;4946.7) 180.8 (163.1;219.5) -24 (-34.8;-0.4)
Tocantins 1799.9 (1350.9;2222.4) 255.1 (199.3;307.4) 2595.3 (2275.4;3210.4) 174.4 (152.9;216.8) -31.6 (-45.1;-1.4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

A Tabela 4-7 mostra as taxas de DALYs por cardiomiopatia e miocardite de acordo com sexo e grupo etário, a partir das estimativas do Estudo GBD 2017. As taxas de DALYs padronizadas por idade foram menores nas mulheres, que também apresentaram a redução mais pronunciada de 1990 a 2017. As taxas de DALYs, para mulheres, foram 234 (II 95%, 223-247) por 100 mil habitantes em 1990 e 153 (II 95%, 145-161) por 100 mil habitantes em 2017, uma redução de 34,3% (II 95%, -38,6 a -30). As taxas de DALYs, para homens, foram 343 (II 95%, 262-366) por 100 mil habitantes em 1990 e 299 (II 95%, 280-363) por 100 mil habitantes em 2017, uma redução de 12,8% (II 95%, -21 a 17,6). Como esperado, as mais altas taxas de DALYs foram observadas no grupo de 70+ anos, seguido pelo grupo de 50-69 anos. No geral, as taxas de DALYs diminuíram de 1990 para 2017 na maioria dos grupos etários, aumentando apenas nos homens de 15-49 anos.

– Taxas de DALYs por cardiomiopatia e miocardite, por 100 mil habitantes, e variação percentual das taxas, por idade e sexo, Brasil, 1990 e 2017
Grupo etário 1990 2017 Variação percentual (II 95%)
Todos
Padronizada por idade 286,3 (246,7;300,6) 222,3 (211,1;250,9) -22,4 (-27,6;-7)
Abaixo de 5 414 (345,2;487) 219,9 (195,5;246,4) -46,9 (-56,3;-30,9)
5-14 anos 35,3 (29,9;39,3) 31,3 (28,2;34,5) -11,3 (-21,8;1,5)
15-49 anos 126,4 (107,3;133,9) 125,6 (115,7;139,5) -0,7 (-8,1;19,3)
50-69 anos 624 (522,3;660,5) 492,5 (458,8;569,8) -21,1 (-27,9;-0,2)
70+ anos 1165 (1027,8;1237,6) 957,2 (888,7;1110,9) -17,8 (-24,6;2,9)
Todas as idades 219,9 (189,6;232,1) 231,6 (220;262,9) 5,3 (-2;24,8)
Masculino
Padronizada por idade 343,1 (262,8;365,7) 299 (279,9;363,4) -12,8 (-21;17,6)
Abaixo de 5 419,5 (287,2;498,1) 239,9 (202,9;283,3) -42,8 (-57;-3,3)
5-14 anos 36,9 (30,7;41,7) 35,3 (30,6;41,1) -4,5 (-19,7;13,8)
15-49 anos 172,3 (132,9;185,4) 184,3 (164,1;213) 7 (-3,2;40,7)
50-69 anos 769,4 (565,3;832,5) 699,1 (634,3;864) -9,1 (-19,9;30,9)
70+ anos 1293,3 (990,1;1415,9) 1165 (1058,4;1512,1) -9,9 (-21,7;39,8)
Todas as idades 258,5 (198,1;276,9) 302,3 (282,1;367,3) 16,9 (5,5;55,7)
Feminino
Padronizada por idade 233,8 (222,7;247,3) 153,5 (145,5;161,5) -34,3 (-38,6;-30)
Abaixo de 5 408,3 (336,9;516,1) 199 (171,3;225) -51,3 (-63,9;-37,2)
5-14 anos 33,6 (28,6;37,5) 27,2 (23,5;30,4) -19,1 (-30,3;-4,4)
15-49 anos 82 (77,2;87) 68,4 (64,2;73) -16,6 (-23,2;-8,8)
50-69 anos 489,8 (460,6;520) 309,6 (288,2;332,4) -36,8 (-41,7;-30,8)
70+ anos 1061,9 (993,3;1138,6) 806,3 (749,9;868,8) -24,1 (-30,4;-17,1)
Todas as idades 182,2 (172,3;194,9) 164 (155,3;172,6) -10 (-16,9;-3,3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

À semelhança do observado para a taxa de mortalidade padronizada por idade, não houve correlação entre o SDI e as taxas de DALYs por cardiomiopatia e miocardite.

Doença de Chagas Crônica e Cardiomiopatia Chagásica Prevalência e Incidência 3

A prevalência de DCh no Brasil em 2010 foi estimada em 1.156.821 pela Organização Mundial da Saúde, 155 sendo essa a última estimativa oficial disponível, publicada em 2015. De acordo com tal estimativa, o número de indivíduos com CMCh no Brasil era 231.364. 3 Esses números revelam uma tendência significativa de diminuição de casos humanos de DCh no Brasil em relação a estimativas anteriores, sendo isso atribuído a vários fatores, mas principalmente à quase completa interrupção da transmissão vetorial e transfusional no Brasil.

De acordo com as estimativas do Estudo GBD 2017, a prevalência padronizada por idade de DCh diminuiu significativamente no Brasil, 44% (II 95%, 42-27), de 1990 a 2017, passando de 1.811 (II 95%, 1.531-2.131) por 100 mil habitantes em 1990 para 1.011 (II 95%, 843-1.198) por 100 mil habitantes em 2017. A prevalência de DCh no Brasil em 2017 foi maior entre os homens [1.029 (II 95%, 863-1.205)] do que entre as mulheres [991 (II 95%, 824-1.186)].

Em uma revisão sistemática de estudos de base populacional sobre a prevalência de DCh no Brasil realizados de 1980 a setembro de 2012, 42 artigos com dados relevantes de prevalência foram identificados a partir de um total de 4.985 referências. 156 A estimativa combinada de prevalência de DCh a partir dos estudos para todo o período foi 4,2% (IC 95%, 3,1-5,7), variando de 4,4% (IC 95%, 2,3-8,3) na década de 1980 a 2,4% (IC 95%, 1,5-3,8) após 2000. A prevalência estimada de DCh para homens e mulheres foi similar (4,1% [IC 95%, 2,6-6,6], 4,2% [IC 95%, 2,6-6,8], respectivamente). A maior estimativa combinada de prevalência foi observada em indivíduos com idade >60 anos (17,7%; IC 95%, 11,4-26,5), nas regiões Nordeste (5,0%; IC 95%, 3,1-8,1) e Sudeste (5,0%; CI, 2,4-9,9) e em áreas mistas (urbana/rural) (6,4%; IC 95%, 4,2-9,4). Estima-se que cerca de 4,6 milhões (IC 95%, 2,9-7,2 milhões) de pessoas tenham sido infectadas com T. cruzi em 2010. Essas estimativas são bem maiores do que as da Organização Mundial da Saúde para 2010. 155 Os autores observaram grande heterogeneidade na maioria das estimativas combinadas (I(2)>75%; p< 0,001).

No estudo de coorte retrospectivo sobre Chagas dos National Institutes of Health , REDS-II, doadores de sangue inicialmente saudáveis com uma doação-índice soropositiva para T. cruzi pareados por idade, sexo e período com doadores soronegativos foram acompanhados por 10 anos. 157 A incidência diferencial de cardiomiopatia foi 1,85 por 100 pessoas-ano atribuível à infecção por T. cruzi .

Mortalidade

De acordo com o Estudo GBD 2017, o número de mortes por DCh no Brasil diminuiu nas últimas décadas (Figura 4-5). Na década de 1990, a DCh foi responsável por 7.049 (II 95%, 6.816-7.323) mortes, que diminuíram para 5.493 (II 95%, 5.221-6.015) em 2017. A taxa de mortalidade padronizada por idade apresentou redução mais marcante (variação de -67,5%), passando de 7,3 (II 95%, 7,0-7,6) mortes por 100 mil habitantes em 1990 para 2,5 (II 95%, 2,3-2,7) por 100 mil habitantes em 2017, correspondendo a 0,4% de todas as mortes no país. Em 2017, os homens apresentaram maiores taxas de mortalidade padronizadas por idade do que as mulheres (3,1, II 95%, 2,9-3,4; e 1,9, II 95%, 1,8-2,1, respectivamente).

A Tabela 4-8 demonstra o número total de mortes por DCh, as taxas de mortalidade padronizadas por idade (por 100 mil habitantes), para ambos os sexos, além da variação percentual, por UF e no Brasil, em 1990 e 2017. O número de mortes e as taxas de mortalidade variaram significativamente entre as UF nos dois anos. Em 1990, as maiores taxas de mortalidade (> 10 por 100 mil habitantes) foram observadas em Goiás, Minas Gerais, Bahia e Distrito Federal, com pico em Goiás (60 por 100 mil habitantes, II 95%, 58-66). Todas as UF apresentaram redução nas taxas de mortalidade, que variaram de 43% (II 95%, 52-33) na Bahia a 75% (II 95%, 78-72) em Minas Gerais e Goiás. As Tabelas 4-9 e 4-10 revelam dados estratificados por sexo.

– Número de mortes e taxa de mortalidade padronizada por idade por 100 mil habitantes por doença de Chagas, em 1990 e 2017, e variação percentual das taxas, no Brasil e suas unidades federativas
Localização 1990 2017 Variação percentual (II 95%)
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%)
Acre 1.8 (1.6;1.9) 0.9 (0.9;1) 2.1 (1.8;2.4) 0.3 (0.3;0.4) -63.9 (-69.7;-56.2)
Alagoas 68.4 (54.3;78.8) 4.8 (3.8;5.5) 79.9 (72;90.2) 2.5 (2.3;2.9) -46.6 (-56.5;-28.3)
Amapá 0.5 (0.5;0.5) 0.5 (0.4;0.5) 1 (0.9;1.1) 0.2 (0.2;0.2) -58.2 (-63.9;-52)
Amazonas 3.8 (3.5;4.1) 0.4 (0.4;0.5) 4.6 (4.1;5.5) 0.2 (0.1;0.2) -61.3 (-66.6;-53.6)
Bahia 682.2 (629.5;736.3) 9.2 (8.5;9.9) 788.1 (728;871.6) 5 (4.6;5.5) -45.7 (-51.7;-39.2)
Brasil 7049.3 (6816.6;7323.9) 7.3 (7;7.6) 5493.6 (5221.2;6014.7) 2.5 (2.3;2.7) -66.3 (-68.3;-63.5)
Ceará 44.2 (36.7;55.8) 1 (0.9;1.3) 53.8 (48.3;61.5) 0.5 (0.5;0.6) -47.6 (-59.4;-34.1)
Distrito Federal 235.6 (223.8;249.1) 34.9 (33.1;36.8) 211 (191.3;248.7) 9.7 (8.8;11.5) -72.2 (-74.9;-67.6)
Espírito Santo 10.7 (9.9;11.6) 0.7 (0.7;0.8) 9.2 (8.2;10.9) 0.2 (0.2;0.3) -69.8 (-73.4;-64.5)
Goiás 1131.6 (1067;1212.8) 55.2 (51.9;59.4) 815.2 (753.8;917.7) 13 (12;14.6) -76.4 (-78.2;-74.2)
Maranhão 15.7 (12.4;19.5) 0.6 (0.5;0.7) 17.5 (15.5;20.8) 0.3 (0.2;0.3) -52.4 (-61.3;-32.7)
Mato Grosso 39.6 (35.8;44.1) 4.4 (4;4.9) 57 (51.1;68.5) 1.8 (1.7;2.2) -58.3 (-63.6;-50.8)
Mato Grosso do Sul 55 (50.5;59.3) 5.7 (5.3;6.1) 53 (47.6;60.1) 1.9 (1.7;2.2) -66.4 (-70.5;-61.6)
Minas Gerais 2195.4 (2095;2316.9) 21 (20;22.1) 1390.3 (1294.6;1519.6) 5.5 (5.1;6) -73.6 (-75.7;-71.4)
Pará 24.1 (21.9;26.3) 1 (1;1.1) 29.1 (25.4;35.6) 0.4 (0.4;0.5) -58.3 (-64.6;-48.2)
Paraíba 35.3 (27.2;42.3) 1.5 (1.2;1.8) 38.3 (34.3;42.9) 0.8 (0.7;0.9) -45.1 (-57.6;-24.7)
Paraná 384.7 (365.1;406.4) 7.4 (7;7.8) 251.4 (232.2;277.9) 2 (1.9;2.2) -72.7 (-75.1;-69.5)
Pernambuco 163.5 (149.3;175.1) 3.5 (3.2;3.8) 143.4 (130.4;157.7) 1.5 (1.3;1.6) -58.7 (-63.5;-51.8)
Piauí 59.5 (49.7;71.3) 4.1 (3.4;4.9) 71 (64;81.2) 2 (1.8;2.3) -51.4 (-60.2;-38.5)
Rio de Janeiro 77 (71.5;82.6) 0.8 (0.7;0.8) 58.6 (53.1;65.7) 0.3 (0.2;0.3) -64.8 (-68.7;-60)
Rio Grande do Norte 14.7 (12.8;17.1) 0.9 (0.8;1) 16.2 (14.3;18.3) 0.4 (0.4;0.5) -51.4 (-62.5;-39.8)
Rio Grande do Sul 61.3 (56.8;65.7) 0.9 (0.9;1) 48.7 (44.4;55.6) 0.3 (0.3;0.4) -64.8 (-68.6;-58.9)
Rondônia 25 (22.3;27.9) 5.8 (5.2;6.4) 24.1 (20.7;28.4) 1.7 (1.4;1.9) -71.3 (-75.8;-65.3)
Roraima 0.5 (0.5;0.6) 0.7 (0.6;0.8) 0.8 (0.6;1) 0.2 (0.2;0.3) -69.2 (-75.4;-60.8)
Santa Catarina 13.1 (12.1;14.1) 0.5 (0.5;0.5) 12.4 (11.1;14.3) 0.2 (0.1;0.2) -68.2 (-72.2;-62.2)
São Paulo 1653.4 (1583.9;1727.4) 7.4 (7.1;7.8) 1248.9 (1168.1;1356.1) 2.4 (2.3;2.7) -67 (-69.2;-64)
Sergipe 10.6 (9.4;12.1) 1.2 (1.1;1.4) 11.8 (10.7;13.3) 0.5 (0.5;0.6) -55.3 (-62.9;-44.5)
Tocantins 42.3 (34.1;52.3) 10.1 (8.4;12.3) 56.3 (50.2;64.6) 4.1 (3.6;4.7) -59.6 (-68.4;-48.4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

A redução nas taxas de mortalidade foi mais acentuada (variação de 80%, UI 82-77) no grupo etário de 5-14 anos, passando de 2,6 (UI 2,5-2,7) para 0,5 (UI 0,5-0,6) por 100 mil habitantes. Para os outros grupos etários, a maioria das mortes ocorreu em indivíduos com 70+ anos, que apresentaram a menor redução percentual (47%, UI 51-42) no período 1990-2017: de 41 (UI 39-43) para 22 (20-24) por 100 mil habitantes. A diminuição na taxa de mortalidade padronizada por idade por 100 mil habitantes correlaciona-se com o SDI das UF brasileiras (R2 = 0,40, p=0,01), tendo a UF com mais alto SDI em 1990 apresentado a maior diminuição percentual naquela taxa de 1990 a 2017 (Figura 4-6).

Vários estudos de base populacional mostraram uma redução na mortalidade por DCh no Brasil nas últimas décadas. Martins-Melo et al . 158 relataram uma redução gradual em todo o país das taxas de mortalidade padronizadas, de 3,78 (1999) para 2,78 (2007) mortes/ano por 100 mil habitantes (-26,4%). Nóbrega et al . 159 mostraram que as taxas de mortalidade padronizadas diminuíram em todo o país em 32,4%, passando de 3,4% em 2000 para 2,3% em 2010. A taxa de mortalidade por envolvimento cardíaco diminuiu em todas as regiões do Brasil, exceto na região Norte, onde aumentou em 1,6%. A região Nordeste apresentou a menor redução, enquanto a região Centro-Oeste, a maior. Simões et al ., 160 estudando a evolução da mortalidade por DCh no Brasil de 1980 a 2014, fizeram uma previsão para a mortalidade de 2015 a 2034. Esses autores estimaram um declínio progressivo na mortalidade por DCh, que seria maior entre os jovens. A redução média esperada foi de 76,1% em comparação ao último período observado (2010-2014) e ao último período previsto (2030-2034). As regiões Centro-Oeste, Sudeste e Sul apresentaram uma redução na taxa de mortes por DCh entre 2000 e 2014. A taxa de mortalidade na região Nordeste não diferiu estatisticamente em nenhum período analisado, mas, na região Norte, apresentou tendência a aumento.

Tendo por base o SIM, cuja abrangência é nacional, um estudo analisou todas as declarações de óbito emitidas entre 1999 e 2007 no Brasil 158 e concluiu que a DCh foi mencionada em 53.930 (0,6%) declarações de óbito: como causa básica em 44.537 (82,6%) declarações de óbito, e como uma causa de morte associada em 9.387 (17,4%) declarações de óbito. A DCh aguda foi responsável por 2,8% das mortes. A taxa de mortalidade padronizada média foi 3,36 por 100 mil habitantes/ano, que é 21% mais alta do que a taxa de mortalidade quando se considera apenas a causa básica de morte (2,78 mortes por 100 mil habitantes/ano). A mortalidade proporcional, considerando-se múltiplas causas de morte foi 0,6%. Os indivíduos que morreram por DCh foram predominantemente do sexo masculino (57%), com idade superior a 60 anos (62,8%) e residentes da região Sudeste (53,6%). A região Centro-Oeste apresentou a maior mortalidade proporcional de todas as regiões (2,17%). 158

Na mesma base de dados, calculando a taxa de mortalidade média para cada município de residência e usando Empirical Bayesian Smoothing , uma análise espacial identificou um grande cluster com alto risco de mortalidade por DCh, envolvendo 9 estados na região central do Brasil (Figura 4-7). 161

Nóbrega et al ., em estudo descritivo usando dados do SIM sobre todas as mortes por DCh no Brasil entre 2000 e 2010, observaram que, no período 2000-2010, a maioria (85,9%) ocorreu em homens com mais de 60 anos, tendo sido causadas por comprometimento cardíaco. No período estudado, a taxa de mortalidade diminuiu em todos as faixas etárias, exceto naquela a partir de 80 anos (Figura 4-8). 159

Um estudo de coorte retrospectivo utilizou ligação probabilística para identificar entre doadores de sangue de 1996 a 2000 (2.842 soropositivos e 5.684 soronegativos para DCh) aqueles que morreram até 2010. 162 Os autores identificaram 159 mortes entre os doadores soropositivos (5,6%) e 103 mortes entre os soronegativos (1,8%). Os doadores soropositivos apresentaram um risco 2,3 vezes maior de morte por todas as causas (IC 95%, 1,8-3,0) em comparação aos soronegativos. Entre os doadores soropositivos, apenas 26 tiveram, como causa básica de morte, o código da CID-10 indicativo de DCh (B57.0/B57.5). 162 Os autores concluíram que a DCh é uma causa de morte subnotificada na base de dados brasileira de mortalidade.

Ayub-Ferreira et al . compararam o mecanismo de morte na insuficiência cardíaca por CMCh com aquele de outras etiologias em um ensaio clínico prospectivo, o REMADHE, que incluiu pacientes a partir de 18 anos, com insuficiência cardíaca crônica irreversível por pelo menos 6 meses e fração de ejeção ventricular esquerda inferior a 50%. Dos 342 pacientes analisados, 185 (54,1%) morreram, sendo que desses, 56,4% eram portadores de DCh e 53,7% não. De todas as mortes no grupo com DCh, 48,4% foram relacionadas a piora da insuficiência cardíaca, 25,7% a morte súbita e 6,4% a acidente vascular cerebral. A incidência acumulada de mortalidade por todas as causas e mortalidade por insuficiência cardíaca foi significativamente maior em pacientes com DCh do que naqueles sem DCh. 163 Não houve diferença na incidência acumulada de mortalidade por morte súbita entre os dois grupos. Na DCh cardíaca grave, insuficiência cardíaca progressiva é o principal mecanismo de morte.

No Estudo de Coorte de Idosos de Bambuí, um grande estudo de base populacional de idosos residentes em uma área endêmica para DCh, 1.479 indivíduos com idade igual ou superior a 60 anos (38,1% com teste positivo para T. cruzi ) foram acompanhados de 1997 a 2007. Durante o acompanhamento médio de 8,72 anos, 567 participantes morreram. A infecção por T. cruzi foi um preditor de mortalidade entre os membros da coorte, e essa associação permaneceu altamente significativa após ajustes para idade, sexo e fatores de risco cardiovascular convencionais (HR = 1,56; IC 95%, 1,32-1,85). No geral, o RAP de mortalidade por infecção por T . cruzi foi 13,2% (IC 95%, 9,8-16,4). 164

Nadruz et al . estudaram as tendências temporais no RAP de CMCh para mortalidade em 2 anos entre pacientes com insuficiência cardíaca arrolados nos períodos 2002-2004 (era 1) e 2012-2014 (era 2) em um hospital universitário brasileiro. Foram estudados prospectivamente 362 (15% com CMCh) e 582 (18% com CMCh) pacientes com insuficiência cardíaca e fração de ejeção ≤ 50% nos períodos 1 e 2, respectivamente, tendo-se estimado o RAP de CMCh para mortalidade em 2 anos. Embora os números absolutos de morte tenham diminuído com o tempo nos grupos de CMCh e CMNCh, o RAP de CMCh para mortalidade aumentou entre os pacientes com insuficiência cardíaca [RAP (era 1) = 11,0 (IC 95%: 2,8-18,5%); RAP (era 2) = 21,9 (IC 95%: 16,5-26,9); p=0.023 vs. era 1], devido a aumento no HR associado com DCh. 165

Carga de Doença

Utilizando achados do Estudo GBD 2016, um estudo mostrou que, em 2016, 141.640 DALYs (II 95%, 129.065-155.941) por DCh foram estimados no Brasil, com redução relativa de 36,7% em comparação a 1990 (223.879 DALYs; II 95%, 209.372-238.591). As taxas de DALYs padronizadas por idade diminuíram em nível nacional (-69,7%) e em todas as UF brasileiras entre 1990 e 2016, mas com diferentes padrões regionais (Figura 4-9). A diminuição nas taxas de DALYs foi primariamente devida a uma redução consistente nos anos de vida perdidos, o principal componente do total de DALYs por DCh. A maior carga fatal e não fatal por DCh foi observada entre os homens e os idosos e nas UF brasileiras com importantes áreas endêmicas de transmissão vetorial no passado, como Goiás, Tocantins, Minas Gerais, Bahia e Distrito Federal. 166

Insuficiência Cardíaca

• Como a insuficiência cardíaca não é considerada uma causa básica de morte (i.e., código garbage ) no Estudo GBD, todas as mortes atribuídas a insuficiência cardíaca nas declarações de óbito são reclassificadas e/ou redistribuídas para outras causas, de acordo com o método do GBD. Assim, não há dados do GBD sobre mortalidade por insuficiência cardíaca. A insuficiência cardíaca é classificada pelo GBD como um “comprometimento”, portanto, os únicos indicadores do GBD para insuficiência cardíaca são prevalência e YLDs, que é o componente de morbidade do DALYs.

Prevalência e Incidência

De acordo com as estimativas do Estudo GBD 2017, a prevalência padronizada por idade de insuficiência cardíaca no Brasil passou de 818 (II 95%, 718-923) em 1990 para 772 (II 95%, 680-875) em 2017, uma diminuição de 5% (95 UI, -7,1 a -3) no período (Tabela 4-10). Em números absolutos, as estimativas de prevalência de insuficiência cardíaca no Brasil subiram de 0,67 milhão em 1990 para quase 1,7 milhão em 2017, principalmente devido a crescimento e envelhecimento da população. A prevalência de insuficiência cardíaca variou entre as UF brasileiras e a variação percentual não foi uniforme entre 1990 e 2017 ( Tabela 4-11 ). Em 2017, as mais altas taxas foram observadas no Rio Grande do Norte e as mais baixas, no Acre. De 1990 a 2017, taxas de prevalência padronizadas por idade decrescentes foram observadas na maioria das UF, tendo aumento nas taxas ocorrido em 8 UF, principalmente na região Nordeste.

– Prevalência e taxa de prevalência padronizada por idade de insuficiência cardíaca por todas as causas (por 100 mil habitantes) e variação percentual das taxas, 1990 e 2017, no Brasil e suas unidades federativas.
Localização 1990 Taxa (II 95%) 2017 Taxa (II 95%) Variação percentual (II 95%)
Número (II 95%) Número (II 95%)
Brasil 670194.8 (589952.6;753672.6) 818.1 (718.1;922.8) 1686320.1 (1478563.8;1890537.3) 777.2 (680;874.8) -5 (-7.1;-3)
Acre 1235.9 (1083.5;1395.6) 764.3 (668.5;869) 4025.6 (3559.4;4534.9) 728.8 (638.1;830.1) -4.6 (-10.1;1.8)
Alagoas 9783 (8509.2;11210.5) 752.5 (654.5;861.9) 22691.5 (19784.3;25922) 764.8 (664.4;879.3) 1.6 (-5.7;8.3)
Amapá 748.2 (662;841.1) 779.1 (680.7;889.6) 3278.9 (2865.5;3672.3) 749.3 (651.9;845.2) -3.8 (-9.5;2.6)
Amazonas 6097.6 (5376.6;6855.3) 809.8 (709.1;919) 19459.2 (17131;21872.1) 775.9 (678.8;884.1) -4.2 (-10.2;1.9)
Bahia 52840.3 (46323.4;60082) 783.5 (685.2;893) 118062.7 (103361.3;134066.1) 753.3 (656.9;857.9) -3.8 (-9.6;2.5)
Ceará 30093.8 (26385.1;34137.4) 739.5 (648;842.1) 77144.8 (67097.6;87800.2) 785.5 (682.6;896) 6.2 (-0.8;14.2)
Distrito Federal 4256.7 (3710.8;4838.9) 813.3 (701.7;932) 16100.7 (13996.8;18333.4) 753.5 (654.5;850.2) -7.4 (-13.1;-0.6)
Espírito Santo 11320.9 (9847.7;12942.2) 841.5 (730.3;961.6) 31391.5 (27390.7;35566.7) 782.7 (680;889.7) -7 (-13.2;-0.6)
Goiás 14142 (12371.7;16150.6) 800.7 (703.5;912.7) 46168.1 (40298.2;52244.1) 753 (655.9;854) -6 (-12.9;1)
Maranhão 18235.7 (15857.1;20802.4) 747.2 (650.9;852.8) 49180.9 (43277;55993.9) 795.1 (697.6;907.8) 6.4 (0.2;13.5)
Mato Grosso 5774.8 (5067;6502.3) 819.3 (712.6;938) 21845.3 (19017.4;24622) 789.4 (688;895.4) -3.7 (-9.6;3)
Mato Grosso do Sul 6795.1 (5934.8;7652) 846.4 (740.2;961.2) 21183 (18418.4;24002) 816 (710.9;922.6) -3.6 (-9.3;3.4)
Minas Gerais 74411.2 (64608;84527.1) 826.9 (722;940.5) 187809.8 (163412.5;214570.5) 759.5 (659.4;867) -8.1 (-14.2;-1.6)
Pará 16002.3 (14153.8;18014.5) 789.4 (694.3;893.2) 46324.1 (40809.4;52186.1) 746.6 (652.1;844.8) -5.4 (-11.3;0.9)
Paraíba 17922.4 (15619.1;20442.3) 772 (675.4;881) 36827.2 (32186.6;41911.1) 794.6 (693.4;902.5) 2.9 (-3.6;10.2)
Paraná 35843.5 (31360.3;40661.2) 834.4 (726.6;948.5) 93386.5 (81689;106563.6) 779.7 (684;892.6) -6.6 (-12.2;0.1)
Pernambuco 34084.1 (29826.4;39017.2) 793.9 (695;908.1) 72004 (62756.3;81953.9) 753.9 (655.5;862.9) -5 (-11.2;1.3)
Piauí 11016.2 (9596.9;12503.6) 803.5 (698.9;912.6) 29097.2 (25425.9;33105.2) 812.7 (708.9;927) 1.1 (-5.6;8.5)
Rio de Janeiro 72976.8 (63619.5;83192) 850.4 (744;970.5) 162697.6 (140265.7;185508.6) 778.9 (674.2;887.1) -8.4 (-14.1;-1.7)
Rio Grande do Norte 13462.3 (11756.9;15396.2) 827 (720.5;948.1) 31332.8 (27529.6;35470.6) 839 (734;955.6) 1.5 (-4.9;8.1)
Rio Grande do Sul 51590.7 (45263.1;58166.6) 862.8 (754.1;980) 115132.9 (100064.2;130860) 787.4 (685.2;894.6) -8.7 (-14.7;-2.9)
Rondônia 2451.8 (2150.6;2766.5) 813.4 (710.9;925.4) 9980.6 (8742.3;11325) 766 (669.2;872.1) -5.8 (-11.9;1)
Roraima 419.1 (368.5;471.8) 809.3 (706.3;925) 2297.9 (2000.3;2611) 774.6 (674.4;884.7) -4.3 (-10.5;2)
Santa Catarina 19387.5 (16978;21842.4) 847 (741.4;957.7) 55662.9 (48893.1;63470.8) 779.6 (685.4;894.9) -8 (-13.7;-2)
São Paulo 150009 (131202;169778.7) 842.8 (734.6;959.2) 387169.5 (336629;442688.8) 787.9 (685;899.2) -6.5 (-12.8;-0.4)
Sergipe 6409.8 (5592.5;7302.6) 754.4 (657.2;860.7) 15587.4 (13661.6;17664.6) 763.8 (668.4;870.4) 1.2 (-4.7;8.8)
Tocantins 2884.2 (2501.8;3284.4) 789.5 (691.7;906.1) 10477.4 (9147.4;11899) 796.5 (692.4;907.9) 0.9 (-5.9;8.5)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation.188

A Tabela 4-12 mostra a prevalência de insuficiência cardíaca de acordo com sexo e grupo etário, a partir das estimativas do Estudo GBD 2017. A prevalência de insuficiência cardíaca foi maior em mulheres (795; II 95%, 694-901) do que em homens (751; II 95%, 656-845) em 2017, e a redução na prevalência de 1990 a 2017 foi mais pronunciada nos homens, sendo a porcentagem de diminuição 7,5 (II 95%, -10,2 a -4,8) para homens e 3,2 (II 95%, -6,5 a -0,1) para mulheres. Quanto aos grupos etários, as taxas de incidência aumentaram 10 vezes do grupo de 15-49 anos ao de 50-69 anos, e 6 vezes do último grupo ao de 70+ anos, tendo esses aumentos sido similares para mulheres e homens. De 1990 a 2017, a prevalência aumentou apenas no grupo de 15-49 anos, enquanto diminuiu nos demais, provavelmente em associação com a elevação de eventos isquêmicos naquele grupo etário.

– Taxa de prevalência de insuficiência cardíaca, por 100 mil habitantes, e variação percentual das taxas, por sexo e grupos etários, Brasil, 1990 e 2017
Grupo etário 1990 2017 Variação percentual (II 95%)
Prevalência Prevalência
Padronizada por idade 818,1 (718,1;922,8) 777,2 (680;874,8) -5 (-7,1;-3)
Abaixo de 5 46,3 (32;63,8) 45 (30,8;61,9) -2,9 (-5,5;-0,1)
5-14 anos 34,7 (24,2;47,2) 34,1 (23,6;46,7) -1,6 (-4,5;1,3)
15-49 anos 107,1 (90,7;124,8) 119 (100,2;139,3) 11,1 (5,5;15,6)
50-69 anos 1391,6 (1172,1;1627,5) 1330,4 (1125,6;1570,4) -4,4 (-6,9;-1,8)
70+ anos 8249,1 (6918,9;9752,5) 8530,2 (7265,9;9922,9) 3,4 (-1;8)
Todas as idades 448,5 (394,8;504,4) 796,1 (698,1;892,6) 77,5 (72,3;82,4)
Masculino
Padronizada por idade 811,8 (714;916,9) 750,6 (656,2;845) -7,5 (-10,2;-4,8)
Abaixo de 5 46,8 (32,2;64,5) 45,2 (31;62,1) -3,6 (-7,2;0,4)
5-14 anos 34,3 (23,7;46,9) 33,4 (23,1;45,9) -2,5 (-6,6;1,7)
15-49 anos 105,3 (89;122,4) 114,2 (95,6;134,7) 8,5 (0,5;14,2)
50-69 anos 1386,9 (1164,2;1643,5) 1311,3 (1102,4;1555,5) -5,4 (-9,1;-1,5)
70+ anos 8083,9 (6784,9;9549,3) 7926,1 (6721,2;9286,2) -2 (-6,4;2,9)
Todas as idades 415,6 (367,7;466,8) 685 (602,9;770) 64,8 (59,3;70,4)
Feminino
Padronizada por idade 820,9 (721;933,2) 794,7 (694,4;900,6) -3,2 (-6,5;-0,1)
Abaixo de 5 45,8 (31,6;63,3) 44,8 (30,7;63,3) -2,1 (-5,7;2,2)
5-14 anos 35,1 (24,7;47,9) 34,9 (24,3;47,2) -0,7 (-4,6;3,1)
15-49 anos 109 (91,7;126,6) 123,7 (103,9;144) 13,5 (8,8;18,3)
50-69 anos 1395,9 (1183,9;1632,2) 1347,3 (1137,1;1586,4) -3,5 (-6,9;0,3)
70+ anos 8381,9 (7012,1;9982,4) 8968,9 (7622,9;10482,3) 7 (1,1;12,8)
Todas as idades 480,8 (422,3;544,4) 902,3 (790,2;1020,9) 87,7 (81;94,4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

Uma revisão sistemática, avaliando a carga de insuficiência cardíaca na América Latina, incluiu 143 artigos publicados entre janeiro de 1994 e junho de 2014, com pelo menos 50 participantes com idade ≥ 18 anos; a maioria dos estudos incluídos (64%) foi do Brasil. 167 A idade média dos pacientes foi 60±9 anos, a fração de ejeção média, 36±9%, e a prevalência de insuficiência cardíaca, 1% (IC 95%, 0,1-2,7). Dos estudos incluídos, apenas um avaliou incidência, com 1.091 indivíduos identificados através de amostragem probabilística em múltiplas etapas na cidade de Porto Alegre. A idade média foi 42,8±16,9 anos e 55% eram mulheres. A incidência de insuficiência cardíaca em um estudo com apenas uma população fornecendo essa informação foi de 199 casos por 100 mil pessoas-ano. 168

Em estudo de base populacional em atenção primária de uma cidade brasileira de tamanho médio, 633 indivíduos com idade ≥45 anos foram selecionados aleatoriamente e registrados em um programa de atenção primária. A idade média foi 59,6±10,4 anos e 62% eram mulheres. A prevalência de insuficiência cardíaca sintomática (estágio C) foi 9,3% e a de insuficiência cardíaca estágio B (anormalidades estruturais) foi 42,7%. Dos pacientes com insuficiência cardíaca, 59% apresentavam fração de ejeção preservada e 41% apresentavam fração de ejeção reduzida. 169

Outro estudo de base populacional com residentes da Zona da Mata, Minas Gerais, envolveu 7.113 idosos frágeis. A idade média foi 72,4 ± 8,0 anos, 67,6% eram mulheres e a prevalência de insuficiência cardíaca foi 7,9%. 170

Em estudo que incluiu 166 pacientes da área rural de Valença, Rio de Janeiro, a idade média foi 61 ±14 anos e 51% eram homens. As principais etiologias foram hipertensiva e isquêmica, sendo 51% portadores de insuficiência cardíaca com fração de ejeção reduzida , com características similares àquelas de coortes de centros terciários não rurais. 171

Mortalidade

Em estudo avaliando dados do SIM de 2008 a 2012, insuficiência cardíaca foi um código garbage usado com frequência no Brasil. Foi listada como causa básica de morte em 123.268 (3,7%) daqueles registros e como causa múltipla de morte em 233.197 (7%). Utilizando 2 métodos de redistribuição para causas específicas de morte, apenas 38,7-44,8% puderam ser reclassificadas para uma causa definida de morte com o diagnóstico principal, dependendo do método de reclassificação. 172 A insuficiência cardíaca não deve ser considerada uma causa básica de morte, mas constar da cadeia de eventos que levam à morte. Portanto, qualquer análise de dados do SIM que use insuficiência cardíaca como causa básica de morte a partir das declarações de óbito deve ser interpretada com cautela, pois pode estar estimando de maneira errada a verdadeira carga de insuficiência cardíaca.

Dados obtidos da Fundação SEADE para mortalidade no estado de São Paulo em 2006 avaliaram 242.832 mortes em estimativa de 41.654.020 habitantes. 153 Insuficiência cardíaca e etiologias a ela associadas (exceto doença valvar primária) foram responsáveis por 6,3% do total de mortes. Para esses dados, não houve distribuição nem reclassificação das causas básicas de morte, tendo todas as etiologias associadas com insuficiência cardíaca sido incluídas ao se considerar o impacto da insuficiência cardíaca na mortalidade total.

Um estudo sobre mortalidade por insuficiência cardíaca nos estados do Rio de Janeiro, São Paulo e Rio Grande do Sul incluiu dados de 2.960.857 declarações de óbito de 1999 a 2005. As porcentagens de morte por insuficiência cardíaca foram 3,0% no formato restrito (insuficiência cardíaca como causa básica de morte) e 9,0% no formato abrangente (insuficiência cardíaca mencionada em qualquer linha da declaração de óbito) em 1999. As porcentagens diminuíram com o tempo, passando para 2,4% e 8,6%, respectivamente, em 2005. As taxas de mortalidade decresceram na maioria dos grupos etários, exceto naquele a partir de 80 anos. As taxas aumentaram com a idade e foram claramente mais elevadas entre homens até os 80 anos de idade. 173

Um estudo de coorte brasileiro mostrou dados de 1.220 pacientes ambulatoriais de uma clínica especializada em insuficiência cardíaca, acompanhados por 26±26 meses, de 1991 a 2000. Os pacientes encontravam-se em classe funcional III e IV, tinham idade média de 45,5±11 anos e 78% deles eram homens. As principais etiologias foram cardiomiopatia dilatada (37%), DCh (20%) e cardiomiopatia isquêmica (17%). Durante o período de acompanhamento, 415 (34%) pacientes morreram e 71 (6%) foram submetidos a transplante cardíaco. A DCh foi preditor de mau prognóstico. 174

Dados mais recentes de 700 pacientes consecutivos com insuficiência cardíaca com fração de ejeção reduzida de uma clínica ambulatorial de um centro de saúde terciário em São Paulo mostraram mortalidade de 1 ano de 6,8% (47 pacientes). O desfecho composto de morte e hospitalização foi observado em 123 pacientes (17,7%) e 7 pacientes (1%) foram submetidos a transplante cardíaco. A idade média dos pacientes foi 55,4±12,2 anos e 67% eram homens. As principais etiologias foram cardiomiopatia hipertensiva (26,0%), isquêmica (21,9%) e chagásica (17,0%). Níveis séricos elevados de ureia e de peptídeo natriurético cerebral, assim como pressão arterial sistólica baixa, foram preditores independentes de mortalidade geral em 1 ano na amostra. 175

Em estudo relatando dados do Banco Nacional de Marcapasso Multissítio, incluindo 3.526 pacientes de 2002 a 2007 atendidos no SUS, a idade média dos pacientes foi 59,8±13,3 anos e 66% eram homens. A sobrevida geral dos pacientes submetidos à terapia de ressincronização cardíaca no Brasil foi 80,1% (IC 95%, 79,4-80,8) em 1 ano e 55,6% (IC 95%, 54,6-56,6) em 5 anos, enquanto a mediana da sobrevida geral foi 30,3 meses (IIQ, 16,1-50,9). Observou-se ainda melhora da sobrevida na coorte estudada de 2002 a 2007 (p=0,055). 176

Hospitalizações

As hospitalizações são a principal consequência de insuficiência cardíaca descompensada, resultando em pior prognóstico e elevando os custos. O Estudo BREATHE avaliou uma amostra de pacientes admitidos por insuficiência cardíaca descompensada aguda. No total, 1.263 pacientes foram incluídos de 51 centros de diferentes regiões brasileiras em 2011 e 2012. A mortalidade hospitalar foi 12,6% e os indicadores de qualidade assistencial baseados nas recomendações de alta hospitalar foram alcançados em menos de 65% dos pacientes. 177

Outros estudos sobre taxa de mortalidade, anteriores ao estudo BREATHE, 178 - 180 mostraram taxas de mortalidade hospitalar similares, variando de 9% a 17%. 179

Em uma comparação de pacientes com insuficiência cardíaca descompensada entre hospitais universitários terciários no Brasil e nos Estados Unidos, os pacientes dos Estados Unidos eram mais velhos (p < 0,01) e apresentaram maior prevalência da etiologia isquêmica (p < 0,01). A permanência hospitalar foi significativamente mais curta (5 [IIQ, 3-9] vs. 11 [6-19] dias; p < 0,001) e a mortalidade hospitalar, menor (2,4% vs. 13%; p < 0,001) na coorte dos Estados Unidos, mas menos eventos clínicos nos 3 meses que se seguiram à alta foram observados nos pacientes brasileiros (42% vs. 54%; p = 0,02). Esse estudo ressalta a importância de se melhorar o conhecimento sobre insuficiência cardíaca em pacientes brasileiros para que se melhorem a assistência e os desfechos. 181

Na revisão sistemática citada anteriormente, que avalia a carga de insuficiência cardíaca na América Latina, com 64% dos estudos incluídos provenientes do Brasil, 167 as taxas de hospitalização foram 33%, 28%, 31% e 35% em acompanhamentos de 3, 6, 12 e 24 a 60 meses, respectivamente. A mediana de permanência hospitalar foi 7,0 [IIQ, 5,20-11,00] dias. A mortalidade hospitalar foi 11,7% (IC 95%, 10,4%-13,0%), sendo as taxas maiores nos pacientes com fração de ejeção reduzida, doença isquêmica do coração ou DCh. A taxa de mortalidade em 1 ano foi 24,5% (IC 95%, 19,4-30,0).

A partir de dados do SUS, foram descritos os números de hospitalizações e mortes por insuficiência cardíaca em São Paulo de 1992 a 2010. A taxa de mortalidade hospitalar por insuficiência cardíaca foi 15%. Ao se compararem os períodos de 1992-1993 e 2008-2009, houve diminuição de 32% no número de hospitalizações por insuficiência cardíaca (p = 0,002), aumento de 15% na mortalidade (p = 0,004) e aumento na permanência hospitalar por insuficiência cardíaca de 8,8 para 11,3 dias (p = 0,001). 182

Em 2019, um estudo mais recente com dados do DATASUS avaliou as admissões por insuficiência cardíaca no Brasil no período de 2007 a 2016, comparando-as com as do Rio Grande do Sul e as de Porto Alegre, uma cidade com vários centros de referência. Como ilustra a Figura 4-10, o estudo mostrou declínio nas taxas de mortalidade hospitalar de 2007 a 2016 no Brasil (19% de redução) e no Rio Grande do Sul (25% de redução), e declínio ainda mais pronunciado em Porto Alegre (65%). 183

Carga de Doença

De acordo com estimativas do GBD 2017 ( Tabela 4-13 ), as taxas de YLDs padronizadas por idade por insuficiência cardíaca foram 112 (II 95%, 83-141) em 1990 e 109 (II 95%, 81-134) em 2017 por 100 mil habitantes, correspondendo a diminuição de 3% (II 95%, -6,7 a 0,3). Tais variações são similares às observadas nas taxas de prevalência de insuficiência cardíaca. A despeito dessa diminuição nas taxas de YLDs, a insuficiência cardíaca resultou em 88.114 (II 95%, 64.078-112.624) DALYs no Brasil em 1990 e em 234.169 (II 95%, 174.338-291.188) DALYs em 2017, devido ao crescimento e envelhecimento da população.

– Número de YLDs e taxa de YLDs padronizada por idade (por 100 mil habitantes) por insuficiência cardíaca por todas as causas, e variação percentual das taxas, 1990 e 2017, no Brasil e suas unidades federativas
Localização 1990 Taxa (II 95%) 2017 Taxa (II 95%) Variação percentual (II 95%)
Número (II 95%) Número (II 95%)
Brasil 88114.2 (64078.1;112623.9) 112.2 (82.8;141.2) 234168.9 (174338.9;291187.7) 108.8 (81.4;134.5) -3 (-6.7;0.3)
Acre 188.7 (140.7;234.7) 123.8 (95.3;148.9) 636.8 (490.6;767.6) 119.8 (93.4;142.4) -3.2 (-9.6;5.2)
Alagoas 1230.4 (880.5;1587.3) 97.7 (70.9;124.1) 2951 (2189.4;3685.1) 101 (75;125.8) 3.3 (-5.8;12)
Amapá 100.2 (73.7;127.2) 112.2 (84.5;139.2) 451.5 (337.3;558.9) 108.9 (83.4;132.6) -3 (-9.5;5)
Amazonas 810.4 (592.2;1020.8) 115.9 (87.9;141.5) 2702.1 (2050;3305.1) 112.2 (86.1;135.8) -3.1 (-10;3.9)
Bahia 6684.8 (4893.5;8540.9) 101.7 (75.5;129) 15736.9 (11812.7;19456) 100.8 (75.3;125.3) -0.8 (-7.7;7.9)
Ceará 3969.6 (2897.9;5084.5) 99.2 (72.8;126.2) 10451.4 (7838.4;12882.6) 106.6 (79.8;132) 7.4 (-1.3;17)
Distrito Federal 431.1 (298.6;581.8) 97.6 (70.8;128.8) 1940.3 (1366.1;2560) 96.9 (69.9;125.4) -0.8 (-8.1;9.2)
Espírito Santo 1462.1 (1054.4;1878.9) 113.4 (84.3;143.6) 4162.7 (3063.9;5243.2) 104.9 (77.5;131.9) -7.5 (-14.4;0.1)
Goiás 1592.7 (1128;2094.6) 103.8 (76.7;132.4) 6291.2 (4685;7868.1) 106.1 (79.5;131.7) 2.2 (-6.5;11.5)
Maranhão 2190.7 (1560.1;2873.3) 92 (66.4;119.5) 5992.2 (4402.4;7553.5) 97.8 (72;122.9) 6.3 (-1.6;15.9)
Mato Grosso 725.4 (526.7;941) 113.1 (83.9;142.3) 3003 (2248.2;3728.7) 112 (84.7;137.3) -0.9 (-8.1;7.7)
Mato Grosso do Sul 850.1 (609.1;1106.8) 113.3 (83.8;142.8) 2829.1 (2072.2;3549.4) 110.8 (82.1;137.7) -2.2 (-9.5;6.5)
Minas Gerais 9477.1 (6808.4;12335.3) 110.9 (82.3;141.3) 25557 (18974.8;31992.6) 103.6 (77.2;129.4) -6.5 (-14.4;1.6)
Pará 2221.3 (1651.1;2795.8) 115.7 (88.1;142.8) 6624.9 (5036.2;8052.8) 109.8 (84.8;132.1) -5.2 (-12.2;2.3)
Paraíba 2298.3 (1666.9;2947.6) 99.5 (72.4;126.3) 4808 (3560.3;5995.7) 103.4 (76.3;129.4) 4 (-4.2;12.5)
Paraná 4964.3 (3563.3;6413.6) 123.5 (92.3;154.2) 13883.5 (10128.6;17249.1) 117 (86.8;144.4) -5.2 (-12.7;3.3)
Pernambuco 4627.4 (3326;5865.3) 110.9 (81.9;137.8) 10375.1 (7650.4;12784) 109.6 (81;134.6) -1.2 (-9;7.3)
Piauí 1230.3 (866.5;1647.8) 92.1 (65.6;122) 3402.3 (2478.9;4365.3) 95.1 (69.4;122.2) 3.3 (-5;11.9)
Rio de Janeiro 9922.7 (7229.9;12662.8) 119.7 (88.6;150.3) 22953.2 (16743.8;28786) 110 (81.3;137.7) -8.1 (-14.7;-0.4)
Rio Grande do Norte 1606.1 (1145.6;2057.5) 99.5 (71.8;126.6) 3856.8 (2838.4;4879.3) 103.5 (75.7;132) 4 (-3.9;12)
Rio Grande do Sul 8134 (5994.6;10280.5) 140.5 (106.7;171.9) 18696.6 (14241.9;22612.8) 126.9 (97;152.5) -9.7 (-16.6;-2.5)
Rondônia 300.3 (209.4;397.4) 117.4 (86.9;145.5) 1408.5 (1062.2;1750.7) 111.9 (85.8;137) -4.7 (-11.7;4.4)
Roraima 46.3 (32.4;62.3) 101.5 (74.8;130.8) 276.8 (197.7;358.6) 98.7 (72.2;125.2) -2.8 (-9.7;5)
Santa Catarina 2880 (2095.3;3688.1) 133.3 (99.4;165.6) 8433.4 (6334.3;10482.5) 119.7 (90.8;147.4) -10.2 (-16.8;-3.4)
São Paulo 18988.5 (13523.4;24849.5) 112.8 (81.9;144.5) 53360.6 (38622.8;68602.6) 109.6 (80.1;140.1) -2.9 (-10.6;5.1)
Sergipe 853.9 (627.3;1082.5) 102.4 (75.6;129) 2085.5 (1551.2;2578.3) 103.7 (77.4;127.2) 1.3 (-6.3;9.9)
Tocantins 327.5 (226.3;438.8) 96.4 (69.6;126.2) 1298.6 (952.1;1635.1) 100.3 (73.9;125.9) 4 (-4.3;14.5)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

A Tabela 4-14 mostra as taxas de YLDs por insuficiência cardíaca de acordo com o sexo e os grupos etários, a partir de estimativas do Estudo GBD 2017. As taxas de YLDs padronizadas por idade foram similares para mulheres e homens em 1990, mas as de 2017 foram 105 (II 95%, 82-127) para homens e 111 (II 95%, 80-141) para mulheres, devido a redução de 6,8% (II 95%, -10,9 a -2,6) para homens e quase nenhuma redução para mulheres (-0,3%, IC 95%, -4,9 a 4,2). Como esperado, as mais altas taxas de YLDs foram observadas no grupo de 70+ anos, seguido pelo grupo de 50-69 anos. À semelhança das variações observadas na prevalência, de 1990 a 2017, os maiores aumentos de YLDs foram verificados no grupo de 15-49 anos.

– Taxa de YLDs por insuficiência cardíaca (por 100 mil habitantes) e variação percentual das taxas, por idade e sexo, Brasil, 1990 e 2017
Grupo etário 1990 2017 Variação percentual (II 95%)
Ambos os sexos
Padronizada por idade 112,2 (82,8;141,2) 108,8 (81,4;134,5) -3 (-6,7;0,3)
Abaixo de 5 4,5 (2,7;7) 4,3 (2,6;6,8) -3,4 (-6;-0,6)
5-14 anos 3,2 (1,9;5,1) 3,2 (1,9;5) -1,4 (-4,4;1,5)
15-49 anos 8,7 (5,7;12,6) 10,4 (6,8;14,8) 18,7 (12,3;25,5)
50-69 anos 165,8 (112,7;226,8) 166,4 (115,3;228,9) 0,3 (-3,8;5,5)
70+ anos 1263,1 (919,3;1599,5) 1308,3 (988,6;1586) 3,6 (-3,2;10,2)
Todas as idades 59 (42,9;75,4) 110,6 (82,3;137,5) 87,5 (78,8;96,2)
Masculino
Padronizada por idade 112,9 (86,9;137,4) 105,2 (81,6;127,1) -6,8 (-10,9;-2,6)
Abaixo de 5 4,5 (2,7;7,1) 4,3 (2,6;6,8) -4,2 (-7,8;-0,2)
5-14 anos 3,2 (1,9;5) 3,1 (1,8;4,9) -2,2 (-6,4;2)
15-49 anos 7,9 (5,1;11,6) 9,5 (6,1;13,8) 19,8 (10,2;29,3)
50-69 anos 165,5 (111,9;230,9) 165,8 (113,5;229,4) 0,2 (-5,9;6,8)
70+ anos 1282,5 (973,9;1555,8) 1225,7 (980;1439,6) -4,4 (-11,1;3,4)
Todas as idades 55 (40,6;68,5) 94,5 (72,6;115,7) 71,9 (63,1;81,5)
Feminino
Padronizada por idade 111,2 (79,9;145) 110,9 (80,1;140,6) -0,3 (-4,9;4,2)
Abaixo de 5 4,4 (2,7;7) 4,3 (2,6;6,7) -2,6 (-6,3;1,7)
5-14 anos 3,2 (1,9;5,2) 3,2 (1,9;5,1) -0,6 (-4,5;3,2)
15-49 anos 9,5 (6,3;13,4) 11,2 (7,4;15,9) 17,9 (10,5;26,4)
50-69 anos 166,1 (112,5;225,8) 166,9 (116,6;228,9) 0,5 (-5;6,7)
70+ anos 1247,5 (876,2;1659,2) 1368,3 (992,5;1714,5) 9,7 (0,6;17,6)
Todas as idades 62,9 (44,1;82,5) 125,9 (90,9;159,5) 100,2 (88,8;111,5)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

Utilização e Custo da Atenção à Saúde (Ver Tabelas 1-6 a 1-9 e Figuras 1-15 a 1-16)

De acordo com dados do SUS, houve 2.862.739 hospitalizações por insuficiência cardíaca de 2008 a 2018. Esse número representa um terço do total de hospitalizações clínicas relacionadas às condições cardiovasculares no período estudado. Os custos não ajustados foram R$ 3.597.824.618. Em dólares internacionais, valores convertidos para paridade do poder de compra e ajustados para US$ 2018, os custos foram Int$ 866.945.691.

No período observado, houve redução no número de hospitalizações clínicas por insuficiência cardíaca, que passaram de 298.474 (157 por 100 mil) em 2008 para 222.394 (107 por 100 mil) em 2018, sendo a redução uniforme ao longo dos anos. A despeito dessa redução no número de admissões, os gastos em saúde não ajustados estimados a partir do pagamento direto por assistência a pacientes com insuficiência cardíaca aumentaram de 2008 para 2018 em quase 28%, passando de R$ 272.280.662 (2018 Int$ 65.609.798) em 2008 para R$ 348.832.330 (2018 Int$ 172.008.052) em 2018. O número decrescente de hospitalizações e o gasto crescente representam maiores custos por admissão no período observado (R$ 912 em 2008 para R$ 1.568 em 2018). Insuficiência cardíaca foi responsável pela maioria dos custos relacionados às hospitalizações clínicas por doenças cardiovasculares.

A carga econômica de insuficiência cardíaca no Brasil foi avaliada usando-se o custo padrão da estrutura da doença para considerar os custos em 2015. Foram analisados a prevalência e os gastos associados ao tratamento, à perda de produtividade por redução do emprego, aos custos da provisão de cuidado formal e informal e à perda de bem-estar. O estudo relatou que a insuficiência cardíaca determina um custo financeiro de R$ 22,1 bilhões/US$ 6,8 bilhões, o segundo dentre as quatro principais condições cardíacas no Brasil: infarto do miocárdio, insuficiência cardíaca, hipertensão e fibrilação atrial. 184

Em estudo utilizando dados do DATASUS sobre admissões por insuficiência cardíaca em 10 anos, Nicolao et al . 183 mostraram um aumento de 97% no custo médio por paciente das hospitalizações relacionadas com insuficiência cardíaca de 2007 a 2016. Dados de Porto Alegre, uma cidade com vários hospitais de referência, mostraram um aumento ainda mais pronunciado (135%), como também uma diminuição mais pronunciada na mortalidade, em comparação aos dados do Brasil (ver acima).

Transplante Cardíaco Aberto e Implantação de Dispositivo de Assistência Ventricular

O número de transplantes cardíacos realizados no Brasil aumentou de 149 em 2006 para 357 em 2016 e, embora esse aumento tenha sido significativo naquele período, representa cerca de um quinto da necessidade estimada da população. A sobrevida de 1 ano foi 73% (dados de sobrevida de 2010). 185

Uma análise de custo de transplante cardíaco no Brasil, com todos os receptores consecutivos de transplante cardíaco em um único centro de julho de 2015 a junho de 2017, mostrou, para os 27 pacientes incluídos, uma média de custo total de US$ 74.341, que é mais baixa do que as relatadas para países desenvolvidos, mas excede em 60% o valor de reembolso por paciente. 186

Em estudo descritivo de hospital público de referência em cardiologia localizado em Fortaleza, 16 pacientes foram submetidos a implantação de dispositivo de assistência ventricular de 2008 a 2015. A idade média foi 40,1±3,4 anos e 87,5% eram homens. Cardiopatia chagásica foi a principal etiologia (37,5%). Todos os pacientes apresentaram complicações durante o uso do dispositivo, sendo sangramento a mais frequente [11 (68,8%)]. Quanto ao desfecho clínico, 10 pacientes (62,5%) foram submetidos a transplante cardíaco e 5 (31,3%) morreram. 187

Pesquisa Futura

Por ser a insuficiência cardíaca considerada um código garbage quando designada como causa básica de morte, são necessários estudos que investiguem o melhor método para reclassificar e redistribuir essa causa de modo a reduzir viés e propiciar melhor comparabilidade de dados para o aperfeiçoamento das políticas de saúde.

Estudos brasileiros de coorte sobre cardiomiopatias são raros, tendo alguns estudos clínicos no Brasil informado dados de insuficiência cardíaca, havendo, no entanto, poucos estudos multicêntricos com dados da população brasileira. Vale ressaltar a importância de se poder contar com dados tanto de insuficiência cardíaca quanto de cardiomiopatia, assim como de pacientes ambulatoriais e hospitalizados, além de se compreender de maneira ampla a carga crescente da insuficiência cardíaca nas doenças cardiovasculares. São necessários mais estudos multicêntricos de larga escala para melhor descrever a carga, os desfechos e os custos da insuficiência cardíaca na população brasileira.

Além disso, estudos que explorem a qualidade e os custos da assistência na insuficiência cardíaca auxiliariam no desenvolvimento de políticas de saúde para melhorar a conscientização, o acesso a intervenções que salvam vidas, a doação de órgãos, assim como o uso de recursos nesta doença tão complexa.

Embora as taxas de mortalidade por DCh tenham diminuído substancialmente nas últimas décadas, a DCh permanece uma importante causa de morte no Brasil. Há, na verdade, evidência de que a DCh seja uma causa de morte subnotificada, assim como, provavelmente, de hospitalização. São necessários mais dados sobre taxas de hospitalização e desfechos de pacientes com CMCh.

5. DOENÇA VALVAR DO CORAÇÃO CID-9 424; CID-10 I34 a I38

Ver Tabelas 5-1 a 5-4 e Figuras 5-1 a 5-10

Abreviaturas usadas no Capítulo 5
CID Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde
CID-9 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 9 a Revisão
CID-10 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10 a Revisão
CRVM Cirurgia de Revascularização do Miocárdio
DAC Doença Arterial Coronariana
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DCR Doença Cardíaca Reumática
DVNR Doença Valvar Não Reumática
ECG Eletrocardiograma
FA Fibrilação Atrial
FRA Febre Reumática Aguda
GBD Global Burden of Doença
IC Intervalo de Confiança
II Intervalo de Incerteza
OR Odds Ratio
SDI Índice Sociodemográfico (do inglês, Sociodemographic Index )
SUS Sistema Único de Saúde
TAVI Implantação Percutânea de Valva Aórtica (do inglês, Transcatheter Aortic Valve Implantation )
UF Unidade Federativa
YLLs Anos potenciais de vida perdidos (do inglês, Years of Life Lost )

Prevalência Doença Cardíaca Reumática

De acordo com o Global Atlas on Cardiovascular Disease Prevention and Control , estima-se que a DCR afete atualmente cerca de 33 milhões de pessoas em todo o mundo, sendo responsável por 1% a 1,5% (319.400 mortes) de todas as mortes cardiovasculares. 189 Até a metade do século 20, a DCR foi a principal causa de doença valvar cardíaca no mundo. Melhores condições de saúde, identificação precoce das infecções por Streptococcus pyogenes , além do uso de antibióticos, reduziram significativamente a prevalência de DCR em países de alta renda. Dados publicados em 2016 estimaram que a DCR seja a causa primária de 2,5% das doenças valvares cardíacas nos Estados Unidos e no Canadá, chegando a 22% na Europa. 190 Taxas ainda mais altas foram relatadas no Brasil, sendo a DCR responsável por cerca de 50% das cirurgias valvares no SUS. 191 - 193

Em países de renda baixa e média, por outro lado, a prevalência de DCR está estimada em 444 por 100 mil habitantes. 194 No Brasil, a DCR persiste como a principal etiologia das doenças valvares cardíacas, em especial em pacientes do SUS. Avaliações anteriores mostraram prevalência de 3,6 por 1.000 habitantes no Brasil. 195 Outras avaliações encontraram prevalência variando de 1 a 7 por 1.000 crianças em idade escolar. 196

No Brasil, dos 174 pacientes com doença valvar cardíaca aguda que se apresentaram na emergência do Instituto do Coração de São Paulo, observou-se envolvimento reumático em 60%, seguindo-se doença valvar aórtica degenerativa (15%) e prolapso de valva mitral (13%). No total, 27,5% dos pacientes apresentavam regurgitação mitral isolada e 11% tinham estenose mitral, estando a doença valvar aórtica presente nos demais. 197

Um estudo recente no Brasil mostrou que as taxas de resolução da doença valvar cardíaca, em especial em pacientes com FRA moderada/grave, podem ser menores do que anteriormente descrito. Apenas 22/69 pacientes (31,9%) apresentaram resolução total da regurgitação mitral após cardite reumática. A resolução total da regurgitação aórtica também foi menos frequente do que a relatada em estudos anteriores à ‘era ecocardiográfica’ (18%). A maioria dos casos persistiu com regurgitação mitral leve ou aórtica residual. 198 Em outro estudo envolvendo 258 crianças e adolescentes com FRA acompanhados por 2 a 15 anos, involução das lesões valvares ocorreu em 25% dos pacientes com cardite leve, em 2,5% daqueles com cardite moderada e em nenhum daqueles com cardite grave. 199

De acordo com o GBD 2017, de 1990 a 2017, a prevalência padronizada por idade de DCR apresentou discreto aumento de 3,0% (II 95%, 1,6 - 4,3), passando de 721,4 (II 95%, 688,7 - 754,5) para 743,2 (II 95%, 709 - 778,6) por 100 mil habitantes, permanecendo mais alta em mulheres do que em homens em todo o período ( Tabela 5-1 e Figura 5-1.A ). Ainda que pequeno em ambos os sexos, o aumento percentual foi numericamente mais pronunciado em mulheres (4,4%) do que em homens. Os aumentos percentuais foram mais altos no Piauí (região Nordeste), Tocantins e em Roraima (região Norte). Embora as estimativas centrais fossem mais altas nesses estados, os II 95% foram amplos e se sobrepuseram àqueles de outras UF ( Tabela 5-1 ). 200 Entretanto, pode-se levantar a hipótese de que o pequeno aumento na prevalência de DCR observado no período reflita o avanço ocorrido na coleta de dados epidemiológicos e nas estatísticas de saúde. 201

– Taxas de prevalência padronizadas por idade de doença valvar do coração por 100 mil, e variação percentual das taxas, para ambos os sexos e para homens e mulheres, no Brasil e unidades federativas, 1990 e 2017
Causa de morte e grupo etário Ambos os sexos Mulheres Homens
1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%)
B.2.1 - Doença cardíaca reumática
Acre 703.8 (665.8;739.9) 729.7 (693.1;768.5) 3.7 (7.7;-0.3) 775 (730.9;820.8) 815.5 (768.6;865.4) 5.2 (11.2;0.2) 637.6 (602;673.8) 643.2 (608.9;683.8) 0.9 (6.3;-4.6)
Alagoas 716 (680.1;754.7) 742.7 (704.3;784.6) 3.7 (8.3;-0.2) 792.6 (748;840.8) 831.5 (783;883.6) 4.9 (11.4;-0.9) 633.3 (596;671.4) 644.2 (604.8;683.5) 1.7 (8.5;-4.2)
Amapá 717.6 (682.8;756.8) 738.1 (699;779.4) 2.9 (7;-1.2) 788 (746;835.3) 825.5 (778.8;872.7) 4.8 (10.6;-0.4) 647.3 (612.4;686.3) 649.1 (611.5;689.5) 0.3 (6;-5.3)
Amazonas 725.7 (690.9;766) 745.4 (701.9;787.1) 2.7 (6.6;-1.4) 806.5 (761.8;856.7) 837.9 (785.6;893.9) 3.9 (9.7;-2.3) 646.3 (609.2;688.4) 652.9 (614.4;690.3) 1 (7.2;-5.6)
Bahia 698.3 (664.2;739.1) 726.2 (689.5;765.3) 4 (7.7;-0.1) 764.8 (722.7;814.7) 809.5 (763.4;859.3) 5.8 (11;0.6) 627.7 (589.6;669.6) 637.3 (602.1;676.4) 1.5 (7.7;-4.5)
Brasil 721.4 (688.7;754.5) 743.2 (709;778.6) 3 (4.3;1.6) 797 (758.9;835.7) 832.2 (793.3;871.2) 4.4 (6.1;2.6) 641.9 (611.4;672.8) 648.9 (619;682.4) 1.1 (2.8;-0.7)
Ceará 721.8 (682.3;759.9) 747.5 (708.2;785.5) 3.6 (7.4;0) 798.7 (753;847.5) 838 (787.6;887.3) 4.9 (10.2;-1) 636.7 (596.7;676) 649.9 (611.1;688.1) 2.1 (7.8;-3.5)
Distrito Federal 727.1 (689.8;767.7) 744.2 (705.1;781.2) 2.3 (6.5;-1.6) 802.3 (758.5;851.6) 831.2 (783.8;881.5) 3.6 (9.6;-1.8) 643.2 (607.9;683.5) 646.7 (609.8;685.7) 0.5 (6.4;-5.4)
Espírito Santo 723.1 (686.9;761.9) 743.5 (705.8;783.6) 2.8 (7.2;-1.2) 802.6 (759.6;849.1) 834.1 (785;885.2) 3.9 (9.9;-1.8) 642.2 (602.5;682.4) 648.9 (611;692.3) 1 (7.6;-4.8)
Goiás 712.2 (676.2;749.8) 731.3 (695.6;769.8) 2.7 (6.3;-1.3) 785 (744.4;829.9) 818.3 (772.2;869.3) 4.2 (10.6;-1.6) 640.6 (605.3;678.1) 641.7 (605.2;680.2) 0.2 (6;-5.5)
Maranhão 697.8 (662.7;735.1) 723.3 (686.3;761.1) 3.7 (8.2;0.2) 763.4 (720.7;810.6) 808.1 (761.7;855.2) 5.9 (13;0.7) 629.9 (594.6;666.9) 634.3 (598.3;671.6) 0.7 (6.9;-5.1)
Mato Grosso 718.2 (679.8;759.1) 741.6 (703.4;783) 3.3 (7.8;-1.2) 803.2 (754.4;856.1) 835.7 (789.3;887) 4 (10.1;-2.3) 642.9 (604;683.2) 650.5 (613.5;691.9) 1.2 (7.8;-4.9)
Mato Grosso do Sul 721.6 (682.2;762.9) 743.9 (707;786.6) 3.1 (7.1;-1) 801.8 (755.3;852.3) 836.1 (787.1;887.1) 4.3 (10.1;-1.4) 644.1 (604.1;685.3) 649.6 (613.7;693) 0.9 (7.1;-5.4)
Minas Gerais 724.4 (685;763.2) 746.6 (707;789.2) 3.1 (7.3;-0.8) 801.8 (752.5;848.6) 838 (791;889.4) 4.5 (10.1;-0.9) 643.6 (607;682.9) 651.3 (611.4;692.4) 1.2 (7.5;-5.5)
Pará 697.5 (659.7;733.9) 725.6 (687.9;766.2) 4 (7.8;0.4) 764.8 (718.8;811.3) 812.4 (764.3;861.1) 6.2 (13.1;0.3) 632 (596.3;670.2) 638.8 (601.1;676.1) 1.1 (6.7;-4.3)
Paraíba 722.5 (685.6;764.3) 745.9 (708;784.5) 3.2 (7.7;-0.7) 798.1 (752.6;848.6) 835.4 (788.5;885.1) 4.7 (11.6;-0.4) 637.5 (601.1;676.8) 648.6 (608.5;687.3) 1.7 (7.7;-3.9)
Paraná 726.1 (688.1;765.9) 749 (710.7;789) 3.2 (7.1;-0.8) 805.2 (761.2;853.1) 839.6 (789.9;892.7) 4.3 (10.3;-1.9) 645.8 (608.5;686.5) 653.7 (616.8;695.5) 1.2 (7;-4.8)
Pernambuco 698 (662.3;735) 725.4 (688.9;764.7) 3.9 (8.4;0.2) 765.2 (722.9;809.1) 807.6 (762;853.5) 5.6 (11.7;0) 622.3 (583.7;661.9) 634.3 (597.7;673.3) 1.9 (7.9;-3.3)
Piauí 695.7 (660.7;733) 728.9 (691.5;769.8) 4.8 (9.2;0.6) 760.9 (719.6;805.7) 812.4 (765.2;862.7) 6.8 (13.6;0.6) 625.6 (591.2;663.8) 639.7 (605.1;678.2) 2.3 (8.4;-3.5)
Rio de Janeiro 724 (687.3;761.5) 744.2 (706;786.6) 2.8 (6.7;-1.2) 798.6 (752.6;845.5) 832.1 (784.7;881) 4.2 (10.3;-2.1) 641 (605.8;678.1) 647.6 (609.7;690.4) 1 (7.3;-5.1)
Rio Grande do Norte 728.2 (691.7;770.1) 748.7 (710;789.2) 2.8 (7;-1.5) 807.1 (762.2;859.6) 840.3 (789.7;889.8) 4.1 (10.7;-2.5) 641.6 (603;682.9) 650.7 (611.7;691.2) 1.4 (7.9;-4.9)
Rio Grande do Sul 736 (696.2;776.3) 751.4 (711.4;791) 2.1 (6.2;-2.1) 814.7 (768.3;865.5) 842.7 (791.8;893.9) 3.4 (10.5;-2.6) 652.1 (609.9;690.5) 654.9 (615.9;693.4) 0.4 (6.3;-5.9)
Rondônia 715.4 (677.7;753.8) 739.2 (700.9;778.6) 3.3 (7.5;-0.1) 801.5 (755.8;853.8) 833 (785.4;884.3) 3.9 (10.5;-2) 640.7 (601.2;677.1) 647.5 (608.9;685.7) 1.1 (6.9;-4.3)
Roraima 708.8 (672.4;748.4) 737.8 (697.7;780.1) 4.1 (8.6;0) 798.3 (751.2;847.9) 831.4 (782.3;881.2) 4.1 (11;-2.3) 641.5 (604.8;680.2) 648.6 (610.6;689.5) 1.1 (7.1;-4.4)
Santa Catarina 738 (700.8;775.2) 756.4 (714.4;799.4) 2.5 (6.3;-0.9) 819.4 (771.8;869.5) 849.2 (797.9;900.5) 3.6 (9.8;-1.9) 655.2 (616;694.9) 661.3 (623.1;702.9) 0.9 (7.2;-4.3)
São Paulo 733.8 (694.9;775.3) 753.5 (713;794.1) 2.7 (6.6;-1.4) 813.1 (765.5;864.3) 844.5 (793.5;897.4) 3.9 (9.9;-1.9) 650.5 (611.9;690) 656.5 (615.6;697.4) 0.9 (7.4;-5)
Sergipe 709.6 (673;747.4) 733.5 (695.4;772.8) 3.4 (7.9;-1.2) 776.6 (733.6;822) 816 (769.1;870.3) 5.1 (11.1;-0.7) 636.9 (599.1;673.6) 642.7 (606.2;680.8) 0.9 (7.8;-5.4)
Tocantins 694.9 (660.5;733.7) 726.2 (688.6;767.1) 4.5 (8.4;0.7) 763.1 (720.4;810.2) 813.3 (767.8;861.3) 6.6 (12.5;1.4) 631.9 (596.2;668.5) 640.4 (600.7;679.6) 1.4 (6.8;-3.8)
B.2.5 - Doença valvar do coração não reumática
Acre 205.7 (195;216.6) 224.6 (212.8;236.5) 9.2 (15.3;3.5) 204.6 (191.3;218.3) 222.1 (207.8;236) 8.6 (17.7;0.3) 206.4 (192.7;219.8) 227.3 (212.2;242.4) 10.2 (18.6;2.2)
Alagoas 196.1 (185.1;207.4) 217.3 (205.8;228.9) 10.8 (17.5;4.6) 196.3 (183;210.4) 215 (200.9;228.9) 9.5 (18.8;1.4) 196.1 (181.9;211.2) 220.6 (205.6;236.6) 12.5 (22.1;3.6)
Amapá 215 (204.2;227) 232 (218.9;243.8) 7.9 (13.9;2.2) 213.9 (200.3;228.3) 228.1 (213.2;242.2) 6.7 (15.1;-1.6) 216.6 (202.3;232) 236.6 (220.5;252.2) 9.3 (18.6;1)
Amazonas 212.8 (201.5;223.1) 231.9 (219.4;244.2) 9 (15.1;3) 210.1 (196.7;223.6) 227.8 (212.6;242.9) 8.4 (17.1;0.2) 215.8 (201.1;229.7) 236.5 (219.9;252.6) 9.6 (18.2;1.5)
Bahia 203.9 (192.4;214.8) 221.9 (210;234.1) 8.9 (15.5;2.6) 202.4 (187.9;216.5) 219 (204.8;234.2) 8.2 (17.9;-0.8) 205.7 (191.5;219.8) 226 (211;241.8) 9.9 (18.8;1.7)
Brasil 216.2 (207.9;224.6) 233.9 (224.6;243.2) 8.2 (10.5;6.2) 214.2 (205.6;222.8) 231 (221.7;240.5) 7.8 (10.8;5.1) 218.7 (209.3;228.2) 238.1 (227.4;249.1) 8.9 (12.1;5.8)
Ceará 199.9 (188.5;211.5) 220.7 (208.5;232.9) 10.4 (17.2;4.2) 200 (187;213.9) 219.1 (205;233.9) 9.5 (19.2;1.3) 199.9 (184.7;215.4) 223.3 (207.3;237.7) 11.7 (21.3;2.9)
Distrito Federal 240.9 (227.1;253.5) 258.6 (245.2;271.6) 7.3 (13.1;1.7) 237.1 (221.3;252.1) 254.1 (237.7;270.7) 7.2 (15.7;-0.9) 245.8 (228.3;263.5) 265.5 (248;282.5) 8 (16.6;0.2)
Espírito Santo 220.3 (209.2;233) 236.8 (225.2;250) 7.5 (13.5;1.8) 218 (204.7;233) 233.5 (218.6;248.8) 7.1 (16.2;-1.2) 222.9 (209.1;238.9) 241.2 (225.8;257.4) 8.2 (16.8;0)
Goiás 212.7 (201.9;224.4) 229.7 (217.4;242) 8 (14.4;2.2) 212.7 (197.9;227.3) 227.2 (212.7;241.9) 6.8 (15.8;-1.3) 212.6 (198.6;227.5) 232.8 (216.2;248.7) 9.5 (18.5;1.1)
Maranhão 195.1 (184.6;205.8) 214.5 (202.2;227.9) 9.9 (16.4;3.9) 194.9 (182.5;208.7) 211.6 (197;225.9) 8.6 (17.4;0.3) 195.7 (181.7;209) 218.1 (203.1;233.7) 11.4 (21.2;2.3)
Mato Grosso 214.7 (203.5;226) 233.1 (220.6;245.6) 8.6 (15.4;2.5) 212.6 (198.1;226.8) 229.7 (215;245) 8.1 (17.4;-0.4) 216.3 (202.2;231.3) 236.5 (220.9;252.5) 9.3 (18.2;1.2)
Mato Grosso do Sul 216.7 (204.9;228.2) 233.5 (220.7;246) 7.8 (14.1;1.8) 214 (199.5;227.8) 229.7 (214.8;244.4) 7.4 (16.6;-0.6) 219.1 (203.9;233.4) 238 (222.4;255.5) 8.6 (17.5;0.1)
Minas Gerais 214.7 (203.5;226.9) 232 (220.1;244.2) 8 (14.2;2.1) 212.3 (199.1;227) 228.8 (214.3;243.2) 7.8 (16.3;-0.6) 217.9 (203.8;233.2) 236.2 (220.7;253.4) 8.4 (17;0.1)
Pará 201.6 (191;213) 221.3 (209.1;233.7) 9.8 (16;3.7) 200.7 (187.3;215.1) 218 (202.3;232.6) 8.7 (17.9;0.4) 202.9 (189.7;217.7) 225 (210.3;240.2) 10.9 (19.4;2.5)
Paraíba 199.4 (188.2;210.9) 219.5 (207.7;231.3) 10.1 (16.1;4) 197.7 (183.8;211.4) 217.2 (203.3;232) 9.8 (19.2;1.6) 201.2 (186.2;216.6) 222.9 (207;238.5) 10.8 (19.7;2.8)
Paraná 223.8 (211.7;236.2) 239.7 (228;253) 7.1 (13.1;1.3) 220.7 (207.1;235.2) 236.4 (222;251.8) 7.1 (16.1;-0.8) 227.1 (212.7;243) 244.1 (228.7;261.2) 7.5 (15.9;-0.7)
Pernambuco 204.2 (193.4;215.1) 223 (209.8;235.2) 9.2 (15.5;3.2) 203.7 (190.6;217.2) 221.1 (206.2;236.5) 8.5 (17.1;0.3) 205 (191.8;220.3) 226.3 (210.5;241.5) 10.4 (20.1;2.5)
Piauí 197.2 (186.5;208) 215.7 (204.1;228) 9.4 (16;3) 196.4 (183.2;208.8) 213.2 (199.2;227.8) 8.5 (16.9;0.4) 198.3 (184;212.8) 219 (204.6;235.2) 10.5 (20.3;1.6)
Rio de Janeiro 220.5 (209.3;232.1) 238.3 (224.6;250.7) 8.1 (14.4;2) 219 (204.4;233.4) 235.5 (219.4;250.4) 7.5 (16.6;-1.2) 223.5 (209.1;239) 243.1 (227.6;261) 8.8 (17.2;0.8)
Rio Grande do Norte 203.5 (193;214.7) 223.7 (211.6;235.9) 9.9 (16.1;3.6) 202.9 (188.7;216.4) 221.3 (206;235.7) 9.1 (18.1;0.7) 204.2 (190.3;218.4) 227.3 (212.4;243.5) 11.3 (20.2;3.2)
Rio Grande do Sul 227.5 (215.2;239.3) 241.9 (229.2;254.8) 6.3 (12.6;0.6) 224.4 (208.7;239.5) 237.8 (223;253.3) 6 (14.5;-2) 232.2 (216.5;247.3) 247.8 (231.7;265.4) 6.7 (15.7;-0.9)
Rondônia 209.2 (197.9;220.7) 227.1 (215;239.8) 8.6 (15.4;2.6) 205 (190.9;219) 223.9 (208.6;239.1) 9.2 (18.7;0.9) 212.3 (197.7;226.5) 230.2 (214.3;246.5) 8.4 (17.7;0.1)
Roraima 212 (200;223.9) 229.5 (217;242.8) 8.3 (14.4;2.4) 212.3 (198.8;227.8) 226.9 (211.8;242.6) 6.9 (15.5;-1.2) 211.9 (197.6;226.9) 231.9 (216.3;247.8) 9.4 (18.6;1.3)
Santa Catarina 228.3 (215.6;240.1) 242.5 (229.2;256.5) 6.2 (11.8;0.5) 225.6 (210.8;239.8) 238.7 (223.3;255.3) 5.8 (14.4;-1.9) 231.7 (216.6;248.1) 247.8 (230.8;264.6) 6.9 (15.7;-1.1)
São Paulo 229.8 (217.3;241.6) 244.9 (232.6;258.6) 6.6 (12.6;1.1) 226.1 (211;239.7) 241.7 (225.7;257.7) 6.9 (15.2;-0.9) 234.9 (219.1;251.4) 250 (232.9;267.1) 6.4 (15.1;-1.3)
Sergipe 201.1 (190.2;212.8) 223.1 (210.6;235.4) 11 (17.7;5) 201.1 (187.9;215.2) 220.7 (205.4;235.6) 9.7 (18.3;1.2) 201.2 (187.4;215.7) 226.7 (211.9;242.3) 12.6 (21.7;3.9)
Tocantins 206.2 (194.6;217) 223.1 (210.7;236) 8.2 (14.6;2) 204.3 (190.8;218.4) 219.4 (203.7;234.3) 7.4 (16.5;-1.2) 207.8 (193.3;221.3) 226.6 (210.1;242.4) 9 (17.8;1.2)
B.2.5.1 - Doença valvar aórtica calcífica não reumática
Acre 49.8 (44.5;55.8) 61.3 (54.1;68.9) 23.1 (31.2;16) 40.7 (36;45.6) 51.9 (45.5;58.4) 27.5 (38.3;18.7) 57.6 (51.3;64.6) 71.1 (62.4;80.2) 23.4 (34.1;14)
Alagoas 43.4 (38.7;49.1) 58.1 (51;66.2) 34 (42.5;26.3) 36.7 (32.4;41.7) 50 (44.1;57.1) 36.2 (46.5;26.7) 50.9 (45;57.6) 68.2 (59.6;77.9) 34 (46.2;23.8)
Amapá 54.6 (48.7;61.6) 65.6 (58.2;74.2) 20 (27.4;13.1) 45.3 (40.3;51.1) 54.7 (48.1;61.5) 20.7 (30.6;12.2) 64.6 (57.1;72.7) 77.6 (68.8;87.9) 20.2 (30.1;11.4)
Amazonas 51.3 (45.9;58) 63.9 (56.7;72) 24.5 (32.1;17.2) 41 (36.3;46.4) 53.1 (46.5;60.3) 29.4 (39.9;20.2) 62 (55.2;70.2) 75.4 (66.5;85.8) 21.7 (31.1;12.9)
Bahia 48.3 (43.1;54.2) 59 (52.4;67) 22.4 (30.1;15.3) 40.4 (35.8;45.5) 50.1 (43.8;57) 24.2 (35;16) 57.3 (50.9;65.1) 70 (61.5;79.3) 22.2 (31.7;13.3)
Brasil 53.5 (48.1;59.9) 64.4 (57.2;72.5) 20.4 (25.4;16) 44.2 (39.8;49.6) 54.9 (48.7;62) 24.2 (29.7;19.1) 64.3 (57.5;72) 76.2 (67.3;85.6) 18.5 (24.2;13.7)
Ceará 46 (40.9;52.2) 59.6 (52.5;67.7) 29.4 (37;22.2) 38.7 (33.9;44.3) 51 (44.8;58) 31.6 (40.6;22.4) 54.3 (47.8;62) 70.2 (61;80.2) 29.3 (39.1;19.6)
Distrito Federal 63.1 (56.5;70.5) 73.3 (64.7;82.1) 16.2 (23.5;9.5) 51.3 (45.7;58) 62.5 (55;70.6) 21.8 (32;12.6) 77.4 (68.7;87.1) 88.2 (77.6;99.8) 13.9 (22.5;5.8)
Espírito Santo 55.5 (49.5;61.9) 64.9 (57.5;73.3) 17.1 (23.9;10.8) 45.5 (40.4;51.3) 55 (48.4;62.4) 20.7 (29.8;12.5) 66.3 (58.9;74.6) 76.9 (67.6;86.9) 16 (24.5;7.8)
Goiás 52.9 (46.9;59.3) 62.4 (55;70.1) 18.1 (25.3;11.4) 44.8 (39.7;50.6) 52.9 (46.6;59.4) 18.2 (27.4;10.7) 60.5 (53.5;67.8) 73.1 (64.3;83) 20.8 (30.4;11.5)
Maranhão 43.9 (38.9;49.6) 57 (50.1;64.9) 29.9 (37.2;22.8) 36.9 (32.3;42.1) 48.5 (42.5;55.5) 31.3 (41.2;22.2) 51.8 (45.9;58.7) 66.8 (58.8;76.5) 29 (38.5;19.4)
Mato Grosso 52.4 (46.7;58.7) 64.1 (56.6;72.4) 22.4 (30;15.2) 41.8 (37.4;47.1) 53.8 (47.6;61) 28.6 (38.8;19.9) 61.3 (54.3;68.9) 74.3 (65.2;84.3) 21.2 (31.3;11.9)
Mato Grosso do Sul 55.3 (49.5;62) 65.6 (58.3;74.3) 18.7 (26.3;11.8) 45.4 (40.4;51.1) 55.4 (48.6;62.5) 21.9 (31;13.7) 64.5 (57.2;72.6) 77 (67.9;87.4) 19.4 (29.9;9.9)
Minas Gerais 51.9 (46.5;58.3) 63.1 (55.9;71.4) 21.6 (29.2;14.7) 42.7 (38.1;48.1) 53.5 (47.2;60.6) 25.4 (34.1;18) 62.7 (55.9;70.9) 74.7 (65.7;84.8) 19 (28.9;9.5)
Pará 46.9 (41.7;53) 60 (53.2;67.4) 27.8 (35.1;20.3) 38.8 (34.1;44) 50.2 (43.9;57.3) 29.4 (39.6;20.8) 55.7 (49.5;63.2) 70.4 (62;79.3) 26.4 (35.8;16.2)
Paraíba 46.3 (40.4;52.6) 58.8 (51.8;66.9) 26.9 (33.9;21) 38.2 (33.8;43.5) 50.2 (43.8;57.5) 31.2 (41.8;21.7) 55.5 (47.5;63.8) 69.8 (60.8;79.5) 25.7 (36.4;16.8)
Paraná 58.8 (52.7;66.1) 67.9 (59.9;76.5) 15.5 (23.5;8.6) 48.4 (42.9;54.4) 57.7 (50.5;65.4) 19.4 (28.9;10.9) 69.6 (62.3;78.2) 80.1 (70.3;90.4) 15.1 (25.8;6.7)
Pernambuco 47 (41.9;53.1) 60.2 (53;68) 28.2 (35.5;20.8) 39.2 (34.7;44.1) 51.9 (45.4;58.5) 32.2 (42.2;22.9) 56.5 (50.1;63.9) 71.4 (62.5;80.8) 26.5 (36.8;16.7)
Piauí 45.8 (40.5;51.5) 57.8 (51;66) 26.2 (34.8;18.5) 38.1 (33.2;43.4) 49.1 (43;56.1) 28.9 (38.8;20.1) 54.5 (48.4;61.4) 68.2 (59.9;78) 25.1 (36.2;15.5)
Rio de Janeiro 53.1 (47.6;59.6) 64.6 (57.1;72.9) 21.6 (29;14.8) 44.3 (39.5;49.6) 55.5 (48.9;62.9) 25.4 (34.9;16.2) 65.2 (57.8;73.7) 77.1 (67.7;87.3) 18.2 (29;8.7)
Rio Grande do Norte 47.8 (42.7;53.9) 61.4 (54.2;69.4) 28.3 (35.9;21.6) 39.6 (35.1;45) 52.3 (45.9;59.4) 31.9 (42.5;23) 57 (50.5;64.3) 72.8 (64.1;82.2) 27.7 (36.8;18.8)
Rio Grande do Sul 60.4 (54;67.4) 68.6 (60.3;77.2) 13.5 (21.4;6.7) 50.2 (44.6;56.4) 58.5 (51.3;66.5) 16.6 (26.8;7.5) 73.6 (65.3;82.2) 81.6 (71.7;92.5) 10.8 (20.8;2.1)
Rondônia 51.4 (45.7;57.8) 62.6 (55.5;70.1) 21.9 (29.6;14.9) 40 (35.4;45.4) 52.2 (45.7;59) 30.4 (40.4;20.9) 60.4 (53.7;67.8) 72.8 (64.3;81.9) 20.4 (30.1;11.2)
Roraima 53.5 (47.5;59.9) 63.7 (56.3;71.7) 19.1 (26.6;12.4) 45.4 (40.2;51.2) 54.4 (47.7;61.5) 19.7 (29.3;10.8) 59.7 (52.8;67.2) 72.3 (63.9;81.6) 21.2 (30.9;12.1)
Santa Catarina 61.1 (54.5;68.6) 69 (60.8;77.5) 13.1 (20.6;6.4) 50.9 (44.9;57.7) 58.8 (51.3;66.5) 15.5 (26.3;6.6) 72.7 (64.4;82.2) 81.5 (71.7;92) 12.2 (21.6;4.5)
São Paulo 60.2 (53.8;67.5) 68.8 (60.9;77.4) 14.3 (22.1;7.9) 49.1 (43.6;55.2) 58.7 (51.8;66.3) 19.7 (28.7;11) 73.7 (65;83.2) 82 (72.5;92.5) 11.2 (20.4;3.3)
Sergipe 44.7 (39.3;50.9) 59.2 (52.1;67.4) 32.5 (40;25.8) 37.5 (32.7;43) 50.6 (44.6;58.2) 34.8 (45.1;26.2) 53.1 (46.5;60.8) 70.1 (61.2;80.1) 32 (42.5;23.5)
Tocantins 49.8 (44.3;56) 61.4 (54.7;69.2) 23.3 (30.7;16.4) 40.6 (35.6;46.1) 51.2 (45.4;57.8) 26.2 (36.3;18) 58.2 (51.7;65.8) 71.2 (62.5;80.6) 22.2 (31.6;13.3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 236

A prevalência bruta de DCR, entretanto, aumentou 16,0% (II 95%, 14,4 - 17,5%) de 1990 a 2017, passando de 690,2 (657,9 – 723,6) para 800,3 (764,1 – 838,2) por 100 mil habitantes, permanecendo também maior nas mulheres no período ( Figura 5-1.B ). À semelhança da tendência das taxas de prevalência padronizadas por idade, o aumento na prevalência bruta foi mais pronunciado entre as mulheres do que entre os homens. 200

A prevalência proporcional de DCR na população brasileira, portanto, mostrou o mesmo padrão observado para a prevalência padronizada por idade e a bruta, com leve aumento para ambos os sexos de 1990 a 2017 ( Figura 5-1.C ). 200

Mesmo com as tendências relativamente estáveis mostradas através da modelagem GBD 2017, a DCR é a causa mais prevalente de doença valvar mitral no Brasil de acordo com os dados publicados, considerando-se tanto estenose (mais de 90%) quanto regurgitação mitral (cerca de 55-60%). 197

Estenose mitral ocorre com maior frequência em mulheres do que em homens, na razão de 3 para 2. Trata-se de sequela frequente de FRA, afetando mais de 85% dos casos mesmo em países de alta renda, como os europeus, 202 com padrão similar ao observado no Brasil. 193 , 197 Mais raramente, a estenose mitral está associada com outras doenças, como calcificação do anel mitral, mucopolissacaridose, artrite reumatoide e síndrome carcinoide congênita. 190 , 197

Estudos mais recentes de rastreio em larga escala, analisando DCR subclínica, mostraram prevalência de 42 por 1.000 crianças em idade escolar, com idade média de 11 anos, em Minas Gerais, sendo 37 por 1.000 para DCR borderline e 5 por 1.000 para DCR definitiva (0,5%). Nesses estudos, maior prevalência foi observada em meninas (48 por 1.000 vs. 35 por 1.000) e em crianças acima dos 12 anos. 191 O mesmo projeto concluiu que os centros de atenção primária são o cenário ideal para rastreio de DCR, considerando-se as maiores taxas de participação e envolvimento da população. 203

Doença Valvar do Coração Não Reumática

De acordo com o GBD 2017, a prevalência padronizada por idade de DVNR permaneceu relativamente estável no Brasil de 1990 a 2017, com aumento borderline de 8,2%, passando de 216,2 (II 95%, 207,9 – 224,6) por 100 mil em 1990 para 233,9 (224,6 – 243,2) por 100 mil em 2017. A variação percentual foi similar para homens e mulheres (8,9% vs. 7,8%) (Figura 5-2.A). Por outro lado, a doença valvar aórtica calcífica mostrou uma tendência crescente (20,4%), passando de 53,5 (II 95%, 48,1 – 59,9) por 100 mil em 1990 para 64,4 (II 95%, 57,2 – 72,5) por 100 mil em 2017, tanto para homens (18,5%) quanto para mulheres (24,2%). Para doença valvar mitral degenerativa e outras DVNR, a prevalência padronizada por idade também ficou estável, com leves aumentos de 4,0% e 3,8%, respectivamente ( Tabela 5-1 ). 200

Em contraste com as taxas padronizadas por idade, a prevalência bruta mostrou aumento significativo de 89,4% (II 95%, 85,3 – 93,8) de 1990 [131,9 (II 95%, 126,7 – 137,5)] a 2017 [249,9 (II 95%, 239,8 – 260,1)] por 100 mil ( Tabela 5-1 e Figura 5-2.B ). O aumento foi homogêneo para homens e mulheres, sugerindo que a prevalência esteja aumentando desproporcionalmente nas faixas de idade mais avançada (Figura 5-2.B). 200

De modo diferente da doença valvar mitral, a doença valvar aórtica é predominantemente degenerativa ou calcífica. Estudos observacionais mostraram que a estenose aórtica é vista em 4,5% da população com idade superior a 75 anos em países de alta renda, como os Estados Unidos. 204 De acordo com estudos observacionais 197 , 205 e dados do GBD 2017, 200 no Brasil, assim como no resto do mundo, tem-se observado uma tendência para aumento da doença valvar aórtica degenerativa em comparação a de outras etiologias, como DCR.

Portanto, o aumento na prevalência de DVNR em todas as idades tem sido ‘puxado’ principalmente pela doença valvar aórtica calcífica [114,2% (II 95%, 105,5 – 124,3)], em especial para os grupos mais idosos ( Tabela 5-2 ), mas as taxas também têm sido significativas para doença valvar mitral degenerativa, 79,8% (II 95%, 78,3 – 81,1), e outras DVNR, a despeito da limitada qualidade dos dados sobre as últimas ( Tabela 5-1 ). A prevalência proporcional de DVNR também aumentou significativamente em ambos os sexos de 1990 a 2017 ( Figura 5-2.C ). 200

– Morte e taxas de DALYs por 100 mil e variação percentual das taxas, por idade e causa de morte, no Brasil, 1990 e 2017
Causa de morte e grupo etário 1990 2017 Variação percentual (II 95%) 1990 2017 Variação percentual (II 95%)
Morte (padronizada por idade) Taxa de DALYs (padronizada por idade)
B.2.1- Doença cardíaca reumática
15-49 anos 1.4 (1.3;1.4) 0.6 (0.6;0.6) -56.5 (-59.3;-52.9) 121.8 (104.9;143.4) 79.3 (62.4;101.4) -34.9 (-41.7;-28.1)
50-69 anos 4.8 (4.6;5) 2.6 (2.5;2.8) -45.1 (-48.2;-41.2) 179.7 (164.5;198.4) 117.5 (102.8;136.9) -34.6 (-39;-30.1)
5-14 anos 0.7 (0.6;0.8) 0.2 (0.2;0.2) -69.8 (-72.4;-65.6) 71.3 (61.1;80.6) 34.7 (28;43.5) -51.4 (-58;-43.6)
70+ anos 11.4 (11;11.7) 7.5 (7.2;7.8) -33.9 (-37.1;-30.3) 174.2 (165.3;184.2) 113.8 (105.3;123.7) -34.7 (-38.1;-31.1)
Padronizada por idade 2.4 (2.3;2.5) 1.2 (1.1;1.2) -50.3 (-52.4;-47.5) 118.9 (106.1;134.7) 71.2 (59;87.2) -40.1 (-45.4;-34.6)
Todas as idades 1.8 (1.7;1.8) 1.3 (1.2;1.3) -28.5 (-31.7;-24.3) 109.3 (97;124.6) 76.5 (63.3;93.7) -30 (-36.3;-23.9)
Abaixo de 5 anos 0.6 (0.5;0.8) 0.1 (0.1;0.1) -82.5 (-87.9;-74.4) 52.8 (40.6;68.7) 11 (9.3;13.1) -79.1 (-85.3;-70.4)
B.2.5- Doença valvar do coração não reumática
15-49 anos 0.5 (0.4;0.5) 0.4 (0.4;0.5) -23.5 (-30;1.2) 27 (21.7;28.8) 20 (18.5;24.3) -26.1 (-32.2;-1.6)
50-69 anos 3.5 (2.9;3.7) 3.3 (2.6;3.4) -6.9 (-14.5;-1.6) 104.1 (86.8;111.4) 94.9 (78.6;101.4) -8.9 (-15.4;-3.8)
70+ anos 13.1 (11.7;15.1) 19 (14;20.2) 45.6 (10;57.1) 201 (179.1;230.6) 254.6 (194.7;280) 26.7 (1.3;35.5)
Padronizada por idade 1.7 (1.5;1.9) 1.8 (1.4;1.9) 7.1 (-9.1;13) 42.9 (36.6;45.8) 39.4 (33.2;42.2) -8 (-15.6;-4)
Todas as idades 1 (0.9;1.1) 1.9 (1.5;2) 87.5 (63.5;96.9) 30.5 (25.9;32.5) 42.3 (35.8;45.3) 38.8 (27.5;47.2)
B.2.5.1- Doença valvar aórtica calcífica não reumática
15-49 anos 0.3 (0.2;0.3) 0.2 (0.2;0.3) -18.6 (-30.8;37.4) 14.3 (9.8;15.8) 11.3 (10.2;15.3) -21.2 (-32.9;33.7)
50-69 anos 2.2 (1.6;2.4) 2.1 (1.9;2.5) -4.1 (-14.1;25.2) 64.6 (47.3;70.3) 60.6 (54.6;71.2) -6.2 (-16;23.2)
70+ anos 9.1 (7.5;9.9) 14.4 (11.1;15.6) 57.4 (35.7;73.3) 127.3 (102.9;138.2) 173.9 (136.8;188.7) 36.6 (22.9;52.4)
Padronizada por idade 1.1 (0.9;1.2) 1.3 (1.1;1.4) 16.3 (9.6;34) 25.4 (19.1;27.4) 25.1 (22.1;28.7) -1.2 (-9.1;24.2)
Todas as idades 0.6 (0.5;0.7) 1.3 (1.1;1.5) 108.3 (94.8;146.2) 17.7 (13;19.2) 26.9 (23.9;31) 51.5 (38.3;94.9)
B.2.5.2- Doença valvar mitral degenerativa não reumática
15-49 anos 0.2 (0.2;0.3) 0.2 (0.1;0.2) -31.4 (-49.9;-22.8) 11.8 (9.8;14.5) 7.8 (5.6;8.7) -33.9 (-51.3;-25.7)
50-69 anos 1.2 (1;1.6) 1 (0.6;1.2) -12.7 (-47.4;3) 37.6 (32.6;49.1) 32.4 (19.6;36.8) -14 (-44;-0.2)
70+ anos 3.7 (3.3;5.3) 4.3 (2.2;5.2) 17.7 (-42.1;39.2) 70.5 (57.7;92.6) 77.4 (50.2;94.7) 9.8 (-31.8;24.3)
Padronizada por idade 0.5 (0.5;0.7) 0.5 (0.3;0.5) -10.8 (-47.6;2.4) 16.4 (14.4;20.8) 13.4 (8.8;15.2) -18.7 (-43.4;-9.3)
Todas as idades 0.3 (0.3;0.5) 0.5 (0.3;0.6) 50.1 (-9.7;71.8) 12 (10.4;15.1) 14.4 (9.5;16.4) 20.3 (-15.9;35.4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 236

Contrário ao observado para a etiologia reumática, houve aumento de prolapso de valva mitral como etiologia de regurgitação mitral primária no Brasil: embora na população geral ele atinja taxas de 1% a 2,5% com bom prognóstico na maioria dos casos, entre os pacientes admitidos com doença valvar cardíaca em uma emergência brasileira em 2009 (56±17 anos, 54% mulheres), 13% apresentavam prolapso de valva mitral como etiologia. 196 Inversamente, em um registro hospitalar de cirurgia cardíaca de uma das maiores capitais do país (Salvador), de 2002 a 2005, apenas uma pequena proporção de casos foi associada a prolapso mitral. 193 Esse resultado é semelhante aos de um estudo com 78.808 pacientes usando 2 grandes bases de dados nacionais (o Sistema Brasileiro de Informações Hospitalares e o Sistema Brasileiro de Informações sobre Mortalidade) de 2001 a 2007, em que apenas 0,24% (187) dos casos informavam prolapso mitral como causa básica. 206 Entretanto, os dados podem apresentar viés em razão da ausência de atribuição de código para as etiologias de doença valvar cardíaca no sistema público de saúde e na maior parte do sistema privado de saúde.

Incidência

De acordo com um estudo baseado em dados hospitalares no Nordeste do Brasil, de 2002 a 2005 (1.320 cirurgias), a incidência anual média de cirurgia valvar cardíaca foi 4,75 por 100 mil residentes e positivamente associada com a idade. As incidências anuais médias de DCR e doença valvar degenerativa foram 2,86 e 0,73 por 100 mil de população, respectivamente. 193

Doença Cardíaca Reumática

Para a DCR, a incidência específica por idade seguiu uma distribuição bimodal de acordo com a fonte do reembolso da cirurgia, aumentando quase que linearmente em 1 caso por 100 mil de população para cada década de vida até a idade de 40–49 anos, com pico em 4,85 casos por 100 mil de população. Após um declínio, um segundo pico ocorreu na faixa etária de 60–69 anos (6,54 casos por 100 mil de população). 193

A incidência de DCR apresentou pequeno aumento de 1,9% (II 95%, 0,8 – 3,1) no Brasil, passando de 21,4 (II 95%, 20,4 – 22,4) por 100 mil em 1990 para 21,8 (II 95%, 20,8 – 22,8) por 100 mil em 2017, de acordo com dados do GBD 2017. Esse pequeno aumento foi relativamente homogêneo em todo o país, com superposição de II 95% mesmo nos estados mais pobres das regiões Norte e Nordeste. 200

Em geral, o aumento na incidência foi ‘puxado’ pelos grupos etários ‘abaixo de 5 anos’, 4,3% (II 95%, 2,5 – 6,2), e ‘5-14 anos’, 2,9% (II 95%, 1,5 – 4,3), enquanto, em indivíduos com idade de 15-49 anos, observou-se redução significativa de 12,1% (II 95%, -13,7 a -10,5). Embora tal padrão seja inesperado, uma vez que, em geral, a incidência cai primeiro nas idades mais jovens e, em seguida, nos adultos jovens, ele pode estar hipoteticamente associado à melhora no diagnóstico precoce e à incorporação de dados de doença subclínica na modelagem GBD. 2 00

Doença Valvar do Coração Não Reumática

Em um padrão diferente daquele da DCR, a incidência de DVNR apresentou aumento significativo de 7,9% (II 95%, 6,7 – 9,3), passando de 224,5 (II 95%, 217,5 – 231,6) por 100 mil em 1990 para 242,4 (II 95%, 233,8 – 250,8) por 100 mil em 2017, de acordo com estimativas do GBD 2017. Esse aumento foi ‘puxado’ principalmente pelo aumento de 20,4% (II 95%, 16,0 – 25,4) na doença valvar aórtica calcífica, em especial em indivíduos com idade >70 anos, 37,2% (II 95%, 30,6 – 44,2). 200

Entretanto, a incidência crescente de doença valvar aórtica calcífica também em indivíduos com idade de 15-49 anos, 23,4% (II 95%, 18,1 – 28,7), é atípica considerando-se a epidemiologia da doença, devendo ser interpretada com cautela como uma possível limitação da modelagem GBD, 200 pois dados primários para essa causa são escassos no Brasil.

Mortalidade

Doença valvar do coração é uma das principais causas de morte cardiovascular no Brasil, em particular em regiões economicamente desassistidas, e a DCR – a etiologia com maior componente social – ocupou a 8 a /9 a posição entre as principais causas nas últimas décadas. 19 No cenário mais desassistido, a DCR tem desempenhado importante papel por décadas, com tendência decrescente – nem sempre adequadamente capturada pela modelagem estatística – seguindo melhoria socioeconômica. 189 , 194 , 206

Doença Cardíaca Reumática

Contrastando com a tendência crescente de prevalência, as taxas de mortalidade padronizadas por idade atribuíveis à DCR diminuíram significativamente em 50,3% no Brasil, passando de 2,4 (II 95%, 2,3 – 2,5) para 1,2 (II 95%, 1,1 – 1,2) por 100 mil, de acordo com o estudo GBD 2017. A redução percentual foi similar para homens e mulheres ( Tabela 5-3 e Figura 5-3.A ). Observou-se tendência similar para as taxas brutas de mortalidade (Figura 5-3.B). No período, o número total de mortes permaneceu estável [2.648 (II 95%, 2.550 – 2.728) e 2.682 (II 95%, 2.585 – 2.797) em 1990 e 2017, respectivamente], apesar do crescimento da população ( Tabela 5-3 ). Essas tendências podem refletir uma melhoria nas condições de saúde, além de melhor e mais precoce acesso à assistência em saúde. 207 , 208

– Número de mortes, taxa de mortalidade padronizada por idade (por 100 mil) e variação percentual das taxas, por grupo cardiovascular de causa de morte, no Brasil e suas unidades federativas, 1990 e 2017
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.1- Doença cardíaca reumática
Acre 6.8 (6.3;7.3) 2.6 (2.5;2.8) 9.6 (8.8;10.4) 1.4 (1.3;1.5) -46.2 (-51.8;-40.2)
Alagoas 43.8 (37.3;51.6) 2.2 (1.9;2.5) 37.5 (34.9;40.2) 1.1 (1.1;1.2) -47.3 (-54.4;-36.5)
Amapá 2.7 (2.5;2.9) 1.8 (1.7;2) 6.6 (6;7.3) 1.1 (1;1.3) -37.3 (-44.6;-29.1)
Amazonas 18.3 (16.9;19.7) 1.5 (1.4;1.6) 26 (23.7;28.2) 0.8 (0.8;0.9) -44.7 (-49.7;-39)
Bahia 171.9 (155.9;186.2) 1.8 (1.6;1.9) 172 (159.2;185.3) 1.1 (1;1.2) -40.3 (-46;-33.1)
Brasil 2647.8 (2549.9;2727.7) 2.4 (2.3;2.5) 2682.3 (2584.5;2796.7) 1.2 (1.1;1.2) -50.3 (-52.4;-47.5)
Ceará 62.6 (51.4;72) 1.2 (1;1.3) 64.6 (60.2;69.2) 0.7 (0.6;0.7) -44.3 (-51.3;-33.7)
Distrito Federal 33.4 (31.2;35.8) 3.7 (3.5;4) 38.9 (35.8;42.7) 1.6 (1.5;1.8) -56.8 (-61;-52.4)
Espírito Santo 40.3 (38.1;42.6) 2.2 (2.1;2.4) 46.8 (43.4;50.8) 1.1 (1;1.2) -50.6 (-54.7;-45.8)
Goiás 74.6 (69.8;79.9) 2.8 (2.6;3) 100.8 (93.9;108.4) 1.5 (1.4;1.6) -46.8 (-51.2;-42)
Maranhão 100.4 (80.9;123.3) 2.3 (2;2.8) 59.8 (55.6;64.6) 0.9 (0.8;0.9) -62.6 (-68.9;-55.4)
Mato Grosso 23.9 (22.1;26) 1.9 (1.8;2.1) 32.3 (30;34.9) 1 (0.9;1.1) -47.7 (-52.6;-42)
Mato Grosso do Sul 25 (22;27.3) 2.1 (2;2.3) 33.3 (30.8;36.2) 1.2 (1.1;1.3) -44.7 (-50;-38.8)
Minas Gerais 331.2 (311.9;350.1) 2.8 (2.6;2.9) 343 (321;367.1) 1.4 (1.3;1.5) -50.6 (-54.5;-46.2)
Pará 52.4 (47;57.1) 1.7 (1.6;1.8) 70.3 (65.5;75.3) 1 (0.9;1) -43.5 (-48.8;-37.2)
Paraíba 61.5 (53.4;70.2) 2.2 (2;2.5) 49.1 (44.5;53.8) 1.1 (1;1.2) -51.8 (-58.3;-43.7)
Paraná 186.5 (177.8;196) 3.3 (3.1;3.4) 206.6 (193;221.9) 1.6 (1.5;1.8) -49.5 (-53.4;-45.3)
Pernambuco 113.9 (105.4;122.5) 2 (1.8;2.1) 132.3 (122.1;143.1) 1.3 (1.2;1.4) -33.3 (-38.9;-26.3)
Piauí 26.2 (19.9;31.3) 1.3 (1.1;1.5) 25.1 (23.3;27.1) 0.7 (0.6;0.7) -47.5 (-55.3;-34.8)
Rio de Janeiro 242.4 (230.8;253.8) 2.2 (2.1;2.3) 230.3 (215.4;247) 1.1 (1;1.2) -49.2 (-53;-44.7)
Rio Grande do Norte 31.9 (28.4;35.1) 1.6 (1.5;1.8) 44.1 (40.4;48.1) 1.2 (1.1;1.3) -28.4 (-37.4;-16.5)
Rio Grande do Sul 136.7 (129.5;143.6) 1.9 (1.8;2) 128.1 (118.5;137.7) 0.9 (0.8;1) -52.3 (-56.1;-48.1)
Rondônia 14.5 (13.3;15.8) 2.4 (2.2;2.6) 18.6 (16.5;21) 1.2 (1.1;1.4) -49.5 (-56.3;-41.7)
Roraima 1.8 (1.6;2) 1.8 (1.7;2) 3.5 (3;4) 0.9 (0.8;1.1) -49.1 (-56.6;-39.5)
Santa Catarina 72.3 (68.4;76) 2.4 (2.3;2.6) 86.2 (79.9;92.9) 1.2 (1.1;1.2) -52.9 (-56.6;-48.6)
São Paulo 735.7 (704.1;764.8) 3.1 (3;3.2) 671.8 (632;718.7) 1.3 (1.2;1.4) -57.8 (-60.6;-54.7)
Sergipe 24.3 (22.2;26.6) 2.1 (2;2.3) 28.2 (26.2;30.6) 1.3 (1.2;1.4) -41.2 (-46.6;-34.5)
Tocantins 12.6 (8.5;15.5) 2.3 (1.8;2.7) 16.9 (15.3;18.6) 1.1 (1;1.3) -49.7 (-57.7;-37.2)
B.2.5- Doença valvar do coração não reumática
Acre 2.4 (2.2;2.8) 1.4 (1.3;1.7) 8.6 (7.3;9.5) 1.5 (1.3;1.7) 6.3 (-18.1;22)
Alagoas 14.4 (12.8;19) 1.1 (0.9;1.4) 42.3 (37.9;50.9) 1.4 (1.2;1.7) 31.4 (8.4;50.9)
Amapá 1.9 (1.3;2.1) 1.9 (1.4;2.1) 9.8 (6.4;10.9) 2.1 (1.4;2.4) 10.7 (-13.2;24.9)
Amazonas 11.9 (10.2;13.6) 1.5 (1.3;1.7) 40.5 (33.5;44.9) 1.5 (1.3;1.7) 5.5 (-12.3;18.3)
Bahia 96.1 (85.1;116.3) 1.4 (1.2;1.7) 197.5 (179.7;255.7) 1.2 (1.1;1.6) -9 (-19.7;14.4)
Brasil 1495.1 (1284.4;1620.4) 1.7 (1.5;1.9) 3974.4 (3116.8;4165.1) 1.8 (1.4;1.9) 7.1 (-9.1;13)
Ceará 33.7 (26;60.7) 0.8 (0.6;1.5) 106.6 (96.7;136.7) 1.1 (1;1.4) 33.1 (-13.6;68.6)
Distrito Federal 13.4 (10.3;14.5) 2.3 (1.8;2.5) 41.6 (36.3;47.7) 2.1 (1.9;2.5) -6.6 (-18.4;16.3)
Espírito Santo 30.9 (20.9;33.9) 2.4 (1.7;2.6) 86.1 (59.1;95.1) 2.1 (1.4;2.4) -10.9 (-19.2;-2.6)
Goiás 31.4 (26.2;34.1) 1.7 (1.4;1.9) 97.3 (83.6;106.9) 1.5 (1.3;1.7) -9.9 (-17;-0.9)
Maranhão 26.1 (19.5;46) 1 (0.7;1.8) 62.2 (52.7;100.7) 1 (0.8;1.6) -1.9 (-16.9;19)
Mato Grosso 12.9 (11.4;14.5) 1.6 (1.4;1.8) 46.2 (39.6;51.2) 1.6 (1.4;1.8) 3.3 (-10.8;15.6)
Mato Grosso do Sul 16.5 (13;18) 1.9 (1.5;2.1) 50.6 (39.1;56) 1.9 (1.5;2.1) -0.4 (-12.2;10.7)
Minas Gerais 153.8 (135.2;169.9) 1.6 (1.5;1.8) 419.1 (332.3;454.1) 1.7 (1.3;1.8) 2.8 (-15.8;13.1)
Pará 27.3 (24.8;34.4) 1.3 (1.1;1.6) 90.3 (81.5;107) 1.4 (1.3;1.7) 11.1 (-5.4;24.9)
Paraíba 17.5 (13.9;31.9) 0.8 (0.6;1.4) 39.3 (32.8;68.9) 0.8 (0.7;1.5) 10.1 (-11.1;33.2)
Paraná 105.3 (71.9;114.2) 2.4 (1.7;2.6) 293.1 (178.1;325.9) 2.5 (1.5;2.7) 4.1 (-14.8;14.3)
Pernambuco 66.5 (59.1;75.4) 1.5 (1.4;1.8) 172.1 (138.3;188.5) 1.8 (1.4;2) 17.2 (-4;31)
Piauí 13.1 (10.2;24.1) 0.9 (0.7;1.7) 34 (29.9;51.7) 0.9 (0.8;1.4) 1.1 (-22.9;23.9)
Rio de Janeiro 150.6 (135.6;201.8) 1.6 (1.5;2.3) 357.5 (305.4;408) 1.7 (1.5;1.9) 3.7 (-15.2;14.2)
Rio Grande do Norte 16.5 (13.9;24.9) 1 (0.8;1.5) 49 (44.2;62.1) 1.3 (1.2;1.6) 28.6 (-9.9;57.7)
Rio Grande do Sul 140.6 (98.8;152.4) 2.3 (1.6;2.5) 389.2 (217.1;436.1) 2.7 (1.5;3) 15.2 (-12.5;27.8)
Rondônia 5.9 (5.2;7.1) 1.6 (1.4;1.9) 19.5 (16.9;24.1) 1.4 (1.2;1.8) -9.1 (-20.9;3.3)
Roraima 0.9 (0.8;1.2) 1.7 (1.4;2.4) 4.3 (3.7;5.6) 1.5 (1.3;1.9) -6.7 (-32.7;15.8)
Santa Catarina 61 (37.5;67.1) 2.7 (1.6;3) 177.4 (104.2;198.4) 2.5 (1.5;2.9) -4.4 (-15.1;4.4)
São Paulo 431.6 (309.8;460.1) 2.2 (1.7;2.3) 1097 (770;1195.5) 2.2 (1.6;2.4) 1.9 (-14.5;10.9)
Sergipe 7.7 (6.6;12.2) 0.9 (0.8;1.4) 23.3 (20.8;33.8) 1.1 (1;1.6) 24.3 (-0.4;44.1)
Tocantins 5.2 (4.1;7.4) 1.5 (1.2;2.3) 19.9 (17.6;22.7) 1.5 (1.3;1.7) -3.3 (-38.6;21.9)
B.2.5.1- Doença valvar aórtica calcífica não reumática
Acre 1.4 (1.1;1.6) 0.9 (0.7;1) 5.6 (4.8;6.8) 1 (0.9;1.2) 14.9 (-4.1;52.3)
Alagoas 7.2 (6.1;9.1) 0.6 (0.5;0.7) 26.8 (23.5;34.2) 0.9 (0.8;1.1) 60.5 (35.4;93.6)
Amapá 1.1 (0.6;1.3) 1.2 (0.7;1.4) 6.3 (4.5;7.4) 1.4 (1;1.7) 17.3 (-0.1;59.6)
Amazonas 7.9 (4.9;8.9) 1 (0.7;1.1) 29.4 (24.2;33) 1.2 (0.9;1.3) 13 (-2.6;56.4)
Bahia 62.9 (40.6;72.3) 0.9 (0.6;1) 134.5 (120.5;178) 0.8 (0.8;1.1) -7.2 (-24.2;59)
Brasil 950.4 (722.7;1016.7) 1.1 (0.9;1.2) 2806 (2349.2;3132) 1.3 (1.1;1.4) 16.3 (9.6;34)
Ceará 17.3 (12.9;29.7) 0.4 (0.3;0.7) 68.6 (59.3;99.2) 0.7 (0.6;1) 62.7 (21;108.7)
Distrito Federal 8.3 (7.1;9.9) 1.5 (1.3;1.8) 29.2 (24.8;40.5) 1.6 (1.3;2.2) 1.4 (-14.4;36.2)
Espírito Santo 17.6 (11.7;19.9) 1.4 (1;1.6) 56.9 (43.8;64.3) 1.4 (1.1;1.6) -1.9 (-14.3;21.5)
Goiás 19.4 (13.8;21.9) 1.1 (0.8;1.3) 67.5 (60;77.2) 1.1 (1;1.2) -3.8 (-16.4;24.2)
Maranhão 13.2 (10.3;18.6) 0.5 (0.4;0.8) 41.1 (34.9;62.2) 0.7 (0.6;1) 25.3 (5.3;61.9)
Mato Grosso 7.7 (6;8.8) 1 (0.8;1.1) 30.9 (27.5;37) 1.1 (1;1.3) 10.3 (-4.6;41.6)
Mato Grosso do Sul 10.6 (7.1;12) 1.3 (0.9;1.5) 36 (28.9;40.3) 1.4 (1.1;1.5) 6.4 (-7.6;38.8)
Minas Gerais 98 (73.1;109) 1.1 (0.8;1.2) 295 (242.1;330.1) 1.2 (1;1.3) 10.4 (0.3;30.5)
Pará 15.1 (12.3;17.6) 0.7 (0.6;0.9) 55.4 (48;72.2) 0.9 (0.8;1.1) 19.9 (3.5;47.8)
Paraíba 8.9 (6.7;17.1) 0.4 (0.3;0.8) 25.8 (20.1;49.3) 0.6 (0.4;1.1) 39.6 (10.9;72.5)
Paraná 66.8 (42.3;75.1) 1.6 (1;1.8) 213.8 (136.2;240.2) 1.8 (1.2;2) 15.2 (3;34.3)
Pernambuco 35.8 (29.4;41.1) 0.8 (0.7;1) 111.3 (95.1;129.6) 1.2 (1;1.3) 36.7 (19.2;56.2)
Piauí 6 (4.6;10.6) 0.4 (0.3;0.8) 20 (16.4;33.7) 0.6 (0.5;0.9) 24 (-0.4;61.9)
Rio de Janeiro 94.3 (81.2;132.4) 1.1 (0.9;1.5) 262.7 (234.5;331) 1.3 (1.1;1.6) 17.9 (1.2;32.7)
Rio Grande do Norte 10.2 (8.3;13.1) 0.6 (0.5;0.8) 34.5 (30.4;44.4) 0.9 (0.8;1.2) 44 (17.3;86.2)
Rio Grande do Sul 93.5 (61.7;103.8) 1.6 (1.1;1.8) 289 (173.5;325.4) 2 (1.2;2.2) 25.1 (4.5;43.9)
Rondônia 3.5 (2.6;4.1) 1 (0.8;1.2) 13.1 (11;17.3) 1 (0.8;1.3) -3 (-21.4;30.3)
Roraima 0.6 (0.4;0.7) 1.2 (0.9;1.4) 3.3 (2.7;4.1) 1.2 (1;1.5) 3.7 (-16.7;46.1)
Santa Catarina 40.2 (21.4;46.1) 1.8 (1;2.1) 132.6 (80.9;149.9) 1.9 (1.1;2.2) 4.8 (-6.6;29.4)
São Paulo 296.7 (198;326.2) 1.5 (1.1;1.7) 790.7 (611;885) 1.6 (1.2;1.8) 5.1 (-4;27.3)
Sergipe 3.8 (3.1;6.3) 0.5 (0.4;0.7) 14 (11.4;23.5) 0.7 (0.5;1.1) 48.6 (25.2;76.3)
Tocantins 2.5 (2;3.5) 0.8 (0.6;1.2) 12 (10.3;15.9) 0.9 (0.8;1.2) 13.4 (-11.5;49.4)
B.2.5.2- Doença valvar mitral degenerativa não reumática
Acre 0.8 (0.7;1.4) 0.4 (0.4;0.8) 2.3 (1.7;2.8) 0.4 (0.3;0.5) -13.6 (-53.6;12)
Alagoas 6.4 (5.2;9.7) 0.4 (0.4;0.7) 13.8 (10.5;16.7) 0.4 (0.3;0.5) -1 (-35.6;24.3)
Amapá 0.6 (0.5;0.9) 0.6 (0.5;0.9) 2.8 (1.5;3.5) 0.6 (0.3;0.7) -5.4 (-54.4;19)
Amazonas 3.6 (2.9;6.3) 0.4 (0.3;0.7) 9.6 (7.2;12) 0.3 (0.3;0.4) -13.8 (-52.1;11.2)
Bahia 30.9 (24.8;55.3) 0.4 (0.3;0.8) 58.3 (44.5;75.6) 0.4 (0.3;0.5) -12.5 (-45.7;11.9)
Brasil 510.6 (450.7;676.7) 0.5 (0.5;0.7) 1086.1 (621.9;1214.9) 0.5 (0.3;0.5) -10.8 (-47.6;2.4)
Ceará 14.5 (6.7;28.8) 0.3 (0.2;0.7) 34.4 (22.8;39.9) 0.3 (0.2;0.4) 2.3 (-51.5;71.2)
Distrito Federal 4.8 (2.8;5.5) 0.7 (0.4;0.8) 11.4 (4.4;14.4) 0.5 (0.2;0.7) -25.4 (-61.7;-7.7)
Espírito Santo 12.7 (7.9;16.4) 0.9 (0.6;1.2) 27.2 (12.3;32.9) 0.7 (0.3;0.8) -25.7 (-53.2;-11.9)
Goiás 11.2 (9.8;15.1) 0.5 (0.5;0.8) 27.1 (17.8;31.5) 0.4 (0.3;0.5) -23.2 (-50.5;-5.8)
Maranhão 10.8 (4.8;26.3) 0.4 (0.2;1) 17.1 (9.6;37.7) 0.3 (0.1;0.6) -33.4 (-48.1;-10.8)
Mato Grosso 4.8 (4;6.5) 0.5 (0.4;0.7) 14.1 (8.2;16.5) 0.5 (0.3;0.5) -10.3 (-50.3;12.3)
Mato Grosso do Sul 5.6 (4.7;7.5) 0.6 (0.5;0.8) 13.7 (7.5;16.9) 0.5 (0.3;0.6) -14.8 (-51.4;5.8)
Minas Gerais 52.7 (46.2;74.3) 0.5 (0.5;0.8) 116.6 (70;135.7) 0.5 (0.3;0.5) -12.1 (-50.7;7.4)
Pará 11.1 (8.9;16.6) 0.5 (0.4;0.7) 30.4 (20.2;35.2) 0.5 (0.3;0.5) -3.9 (-40.7;18.8)
Paraíba 7.3 (3.7;14.5) 0.3 (0.2;0.6) 11.2 (7.1;19.1) 0.2 (0.2;0.4) -22 (-45;5.2)
Paraná 36.5 (25.4;49.7) 0.7 (0.5;1) 74.2 (32.6;98.5) 0.6 (0.3;0.8) -18.9 (-53.8;-3.3)
Pernambuco 29.2 (24.3;36) 0.6 (0.5;0.8) 57.2 (32.8;66.9) 0.6 (0.3;0.7) -8.1 (-41.3;8.9)
Piauí 6 (2.9;12.6) 0.4 (0.2;0.9) 12 (8.1;17) 0.3 (0.2;0.5) -18.7 (-50.7;20.3)
Rio de Janeiro 54 (41.3;69.8) 0.6 (0.4;0.7) 89.8 (52;104.2) 0.4 (0.2;0.5) -23 (-52;-9)
Rio Grande do Norte 5.5 (3.1;11.5) 0.3 (0.2;0.7) 12.5 (9.9;16.1) 0.3 (0.3;0.4) 1.3 (-46.2;62.2)
Rio Grande do Sul 44.8 (30.8;61.3) 0.7 (0.5;0.9) 94.5 (39;135.6) 0.6 (0.3;0.9) -6.7 (-49.3;10.9)
Rondônia 2.1 (1.7;3.4) 0.5 (0.4;0.8) 5.3 (3.9;6.7) 0.4 (0.3;0.5) -25.1 (-52.5;-2.4)
Roraima 0.2 (0.2;0.6) 0.4 (0.2;1) 0.7 (0.5;1.5) 0.2 (0.2;0.5) -41.8 (-65.4;-12.9)
Santa Catarina 19.9 (13.3;30.3) 0.8 (0.5;1.3) 42.4 (18.9;60.8) 0.6 (0.3;0.9) -25.7 (-54.3;-10.7)
São Paulo 128.9 (98.6;180) 0.6 (0.5;0.9) 292.7 (118.9;351.9) 0.6 (0.2;0.7) -5.7 (-55.2;16.5)
Sergipe 3.4 (2.1;5.8) 0.4 (0.2;0.7) 8 (5.3;9.6) 0.4 (0.2;0.4) -2.4 (-41.6;23.1)
Tocantins 2.3 (1.4;3.7) 0.6 (0.3;1) 6.8 (4.2;8) 0.5 (0.3;0.6) -19.2 (-63.8;33.1)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 236

A mortalidade proporcional atribuível à DCR no Brasil também mostrou um padrão decrescente no mesmo período, com uma tendência menos vertiginosa (Figura 5-3.C). 207 , 208

Em 1990, a DCR ocupou a 9 a posição entre as causas de morte no Brasil (8 a ou 9 a em diferentes estados), tendo passado para a 12 a posição em 2017 (10 a a 12 a na maioria dos estados, permanecendo como 9 a apenas na Paraíba). 207 , 208

A redução mais significativa nas taxas de mortalidade foi observada nas idades menores, especialmente nos grupos etários ‘abaixo de 5 anos’ e ‘5-14 anos’, -82,5% (II 95%, -87,9 a -74,4) e -69,8% (II 95%, -72,4 a -65,6) por 100 mil, respectivamente (Tabela 5-2). 207 , 208 Isso pode estar associado ao melhor tratamento das apresentações precoces e agudas, ainda que as sequelas crônicas persistam sendo um desafio.

De acordo com dados do GBD 2017, não houve correlação entre as taxas de mortalidade padronizadas por idade e o SDI em 1990 (r 2 =0,275, p=0,59) nem em 2017 (r 2 =0,233, p=0,83). Entretanto, houve correlação significativa entre a variação percentual nas taxas de mortalidade padronizadas por idade e o SDI em 1990 (Figura 5-4) (r 2 =0,073, p< 0,001), que não alcançou significância estatística em 2017 (r 2 =0,064, p=0,06). Considerando-se a DCR como a etiologia com maior componente social entre as doenças valvares cardíacas, tal incompatibilidade pode estar associada com: a) diferenças no SDI entre as UF, com padrões socioeconômicos discrepantes nas sub-regiões dos estados, o que poderia enviesar o modelo; b) a variação percentual ao longo das décadas pode representar uma medida mais precisa do aperfeiçoamento do modelo, e a redução no hiato socioeconômico entre as UF brasileiras de 1990 a 2017 pode ter contribuído para reduzir a magnitude da correlação estatística.

Doença Valvar do Coração Não Reumática

De acordo com o estudo GBD 2017, as taxas de mortalidade padronizadas por idade atribuíveis a DVNR permaneceram relativamente estáveis de 1990 a 2017, com um pequeno aumento de 7,1% (II 95%, -9,1 – 13,0) (Tabela 5-3 e Figura 5-5.A). Entretanto, para as taxas de mortalidade brutas, o aumento foi significativo, 87,5% (II 95%, 63,5 – 96,9), com uma considerável contribuição das idades mais avançadas, em especial acima de 70 anos, 45,6% (II 95%, 10,0 – 57,1) (Tabela 5-3 e Figura 5-5.B). Os padrões foram similares para homens e mulheres. Tendências semelhantes foram observadas para as taxas de mortalidade por doença valvar aórtica calcífica, com acentuado aumento de 108% nos idosos (≥70 anos), refletindo associação com envelhecimento populacional (Tabela 5-2). Para a doença valvar mitral degenerativa, as taxas de mortalidade padronizadas por idade diminuíram em 10,8% (II 95%, -47,6 a 2,4), em oposição ao aumento de 50,1% na prevalência bruta (Tabelas 5-1 e 5-3), como resultado das taxas crescentes, 17,7% (II 95%, -42,1 a 39,2), nos septuagenários e mais idosos (Tabela 5-2). 207 , 20 8

As taxas de mortalidade crescentes nas idades mais avançadas por DVNR contrastam bastante com as tendências observadas para DCR, podendo refletir uma maior prevalência e, consequentemente, mortalidade nos grupos etários >70 anos, para DVNR tanto aórtica quanto mitral (Tabela 5-2). De 1990 a 2017, uma carga crescente de doença valvar aórtica calcífica, em homens e mulheres, associou-se com um aumento na mortalidade naquele grupo etário. Os II 95%s são muito amplos em geral para as estimativas de mortalidade por DVNR, em especial para cada doença específica em separado. 207 , 208

A mortalidade proporcional atribuível a DVNR no Brasil mostrou um padrão marcadamente crescente no mesmo período, possivelmente ‘puxada’ pela tendência mais abrupta da doença valvar aórtica calcífica (Figura 5-5.C). 208

Em 1990, a DVNR ocupou a 10 a posição entre as causas de morte no Brasil (8 a a 11 a em diferentes estados), tendo passado para o 9 o lugar em 2017 (8 o ao 10 o na maioria dos estados, permanecendo no 11 o apenas em Sergipe) (Figura 5-4). 208

Os dados do GBD 2017 demonstraram correlações significativas e fortes entre o SDI e as taxas de mortalidade padronizadas por idade por DVNR em geral em 1990 (r 2 =0,62, p=0,002) e 2017 (r 2 =0,618, p=0,001), assim como padrão similar para a doença valvar aórtica calcífica (1990: r 2 =0,65, p=0,002; e 2017: r=0,65, p< 0,001) (Figura 5-6). Como o desenvolvimento socioeconômico se correlaciona com a transição epidemiológica e a expectativa de vida, um maior SDI está associado com indivíduos mais idosos com risco para condições valvares degenerativas e menos propensos a etiologias infecciosas, como a DCR.

Além disso, as variações percentuais nas taxas de mortalidade padronizadas por idade de 1990 a 2017 também se correlacionaram com o SDI em 1990 e 2017 para doença valvar aórtica calcífica (1990: r 2 =0,17, p=0,005; e 2017: r 2 = 0,23, p = 0,003), mas não para DVNR em geral.

Para a doença valvar mitral degenerativa e outras DVNR, não foram observadas significativas correlações entre o SDI e as taxas de mortalidade padronizadas por idade – e suas variações percentuais ao longo do tempo.

Carga de Doença Doença Cardíaca Reumática

De acordo com dados do GBD 2017, a taxa de DALYs padronizada por idade atribuível a DCR diminuiu significativamente em 40% no Brasil, passando de 118,9 (II 95%, 106,1 – 134,7) por 100 mil em 1990 para 76,5 (II 95%, 63,3 – 93,7) por 100 mil em 2017 (Figura 5-7.A). As taxas decrescentes observadas no período foram similares para homens e mulheres, 44,4% (II 95%, 31,2 – 42,3) e 37,9% (II 95%, 31,8 – 44,0), respectivamente (Tabela 5-4). 209

As taxas de DALYs padronizadas por idade diminuíram em todos os estados brasileiros, com tendência mais vertiginosa nas regiões com as mais altas taxas em 1990: Centro-Oeste e Sudeste (Tabela 5-2). A proporção de DALYs mostrou uma tendência mais estável para o Brasil, com discreta redução, embora tenha persistido aumento nas regiões Norte e Nordeste (Figura 5-7.B). As regiões Sudeste e Centro-Oeste apresentaram as mais altas taxas de DALYs padronizadas por idade e DALYs proporcionais no período analisado. 209

Um padrão decrescente similar foi observado para as taxas de YLLs padronizadas por idade por DCR, que variaram de 84,9 (II 95%, 81,1 – 87,8) por 100 mil em 1990 a 36,1 (II 95%, 34,8 – 37,8) por 100 mil em 2017, uma redução de 57,4% (II 95%, 54,8 – 59,4). 200 , 209

As estimativas do GBD 2017 mostraram significativa correlação entre as taxas de DALYs padronizadas por idade e o SDI em 1990 (r 2 =0,056, p=0,001) e em 2017 (r 2 =0,068, p=0,001). Além disso, houve significativa correlação entre a variação percentual nas taxas de DALYs padronizadas por idade e o SDI em 1990 (r 2 =0,03, p< 0,008), embora isso não tenha sido observado em 2017 (r 2 =0,019, p=0,146) (Figura 5-8), sugerindo que as áreas menos desenvolvidas socialmente em 1990 – com maior carga de doença – apresentassem mais espaço para melhoria, acompanhando o desenvolvimento social ao longo das décadas.

Doença Valvar do Coração Não Reumática

De acordo com o GBD 2017, as taxas de DALYs padronizadas por idade atribuíveis a DVNR diminuíram discretamente (8,0%) no Brasil, passando de 42,8 (II 95%, 36,6 – 45,8) por 100 mil em 1990 para 39,4 (II 95%, 39,4 – 42,2) por 100 mil em 2017 (Tabela 5-4 e Figura 5-9.A). A discreta redução nas taxas observada no período foi similar para homens e mulheres. Com relação às doenças específicas, as taxas diminuíram mais significativamente para a doença valvar mitral degenerativa, -18,7% (II 95%, -9,3 a -43,4), em comparação à doença valvar aórtica calcífica e a outras doenças valvares, embora os IIs fossem amplos nesse caso. As tendências observadas para os YLLs foram similares. 200 , 209

A tendência relativamente estável foi similar em todos os estados brasileiros e as taxas de DALYs padronizadas por idade permaneceram mais altas nas regiões Sul e Sudeste em todo o período, sendo seguidas pelas regiões Centro-Oeste, Norte e Nordeste (Figura 5-9.A).

À semelhança do observado para mortalidade, as taxas estáveis de DALYs padronizadas por idade contrastam com o aumento das taxas brutas [38,7% (II 95%, 27,5 – 47,2)] no período, mais uma vez sugerindo que a morbidade associada com DVNR esteja se deslocando para os idosos, possivelmente seguindo mudanças na composição etária da população. 209 , 210

As taxas de DALYs proporcionais no Brasil aumentaram e, de 1990 a 2017, as regiões Sul e Sudeste foram responsáveis pelas maiores proporções de DALYs no período, de acordo com as estimativas do GBD (Figura 5-9.B). 209 , 210

Ainda segundo dados do GBD 2017, houve significativa correlação entre as taxas de DALYs padronizadas por idade por DVNR em geral e o SDI em 1990 (r 2 =0,65, p=0,043), mas não em 2017 (r 2 =0,49, p=0,067). As variações percentuais nas taxas de DALYs padronizadas por idade (1990 – 2017) correlacionaram-se com o SDI em 1990 (r 2 =0,32, p=0,003) e em 2017 (r 2 =0,33, p=0,002). Para a doença valvar aórtica calcífica, foram observadas correlações significativas entre DALYs e SDI em 1990 (r 2 =0,67, p=0,002) e em 2017 (r 2 =0,57, p=0,004) (Figura 5-10), assim como entre as variações percentuais nas taxas de DALYs e o SDI nos dois anos, sugerindo um efeito determinante do desenvolvimento socioeconômico para alguns tipos de DVNR.

Para a doença valvar mitral degenerativa e outras DVNR, entretanto, não foi observada correlação entre as taxas de DALYs padronizadas por idade – e suas variações percentuais ao longo do tempo – e o SDI, exceto uma fraca associação entre as taxas de DALYs e o SDI em 2017 (r 2 =0,08, p=0,02), com base nas estimativas do GBD.

Complicações e Doenças Associadas Arritmias Associadas com Doença Valvar

A FA também é um fator complicador para pacientes com doença valvar do coração, ocorrendo, em geral, naqueles com história natural da doença mais avançada. Acha-se mais comumente associada com doença valvar mitral, em especial estenose mitral. A FA foi observada em 34% de uma coorte de 427 pacientes (idade média de 50±16 anos, 84% mulheres) com estenose mitral grave, tendo sido mais frequente naqueles que morreram durante o acompanhamento (27/41, 66%) em comparação aos que sobreviveram (114/378, 30%), reforçando seu papel de marcador de prognóstico na doença valvar cardíaca. 211

A FA também pode se desenvolver na doença valvar aórtica grave, especialmente em pacientes mais idosos e no pós-operatório. Em uma coorte retrospectiva de 348 pacientes (idade média, 76,8±4,6 anos), FA pós-operatória foi observada em 32,8% (n = 114), mas as taxas foram mais altas entre os pacientes com idade a partir de 80 anos (42,9% vs. 28,8% em pacientes com idade de 70-79 anos, p=0,017). 212

Em outra avaliação retrospectiva conduzida em Pernambuco (Nordeste do Brasil), envolvendo 491 pacientes consecutivos após cirurgia por doença valvar do coração, a incidência de FA foi 31,2% e associada com idade >70 anos (OR=6,82; IC 95%, 3,34 – 14,10, p < 0,001), doença valvar mitral (OR=3,18; IC 95%, 1,83 – 5,20, p< 0,001) e a não utilização de betabloqueadores no período peroperatório, entre outros fatores. 213

Doença valvar do coração (17,5%) e arritmias (FA e flutter atrial – 50,7%) foram as principais fontes cardioembólicas para acidente vascular cerebral em estudo que envolveu 256 pacientes (60,2 ± 6,9 anos, 132 homens) na região Sul do Brasil. 214

Associação entre Doença Valvar do Coração e Doença Arterial Coronariana

Devido ao elevado risco cirúrgico da combinação de procedimentos valvares e revascularização coronária, é essencial que se reconheça a prevalência de DAC obstrutiva em associação com doença valvar do coração. Estudos mostraram menor prevalência de DAC em pacientes com DCR em comparação àqueles com DVNR, possivelmente como reflexo da menor mediana de idade dos pacientes com DCR e da maior prevalência de fatores de risco coronariano na DVNR. 215

Em estudo no Rio de Janeiro incluindo 1.412 candidatos a cirurgia cardíaca por qualquer indicação, 294 casos com doença cardíaca valvar primária de etiologia reumática e não reumática foram selecionados. Todos os pacientes tinham idade ≥40 anos e foram submetidos a angiografia coronária. As prevalências de DAC em pacientes com DCR e DVNR foram 4% e 33,6% (p < 0,0001), respectivamente. Características e fatores de risco, como idade, dor precordial típica, hipertensão, diabetes mellitus e dislipidemia, foram significativamente associados com DAC obstrutiva. 216

Em outro estudo no Brasil avaliando 712 pacientes com doença valvar do coração e idade média de 58±13 anos, a incidência de DAC obstrutiva foi 20%. Entretanto, em pacientes mais jovens (<50 anos), a prevalência foi mais baixa (3,3%). 217 Esses dados são similares aos observados em outro estudo que incluiu 3.736 pacientes (idade média, 43,7 anos), nos quais a prevalência de DAC obstrutiva combinada com doença valvar do coração foi 3,42%. 215

Utilização e Custo da Atenção à Saúde (Ver Tabelas 1-6 a 1-9 e Figuras 1-15 e 1-16)

De acordo com a base de dados administrativos do SUS, o total de despesas brutas (reembolso) com hospitalização para tratamento clínico de doença valvar do coração no Brasil aumentou significativamente em 94%, passando de R$ 1.051.959,34 em 2008 para R$ 2.043.358 em 2018, em um padrão quase linear. Ajustando e convertendo esses valores para dólares internacionais de 2018, o total de custos no sistema público de saúde para hospitalização por condições valvares foi de $ 1.014.294 em 2008 e de $ 1.007.587 em 2018.

Da mesma forma, os custos não ajustados associados com procedimentos cirúrgicos/intervencionistas valvares (códigos relacionados com cirurgia valvar, comissurotomia mitral percutânea e outros tipos de valvuloplastia) também aumentaram de 2008 a 2018, passando de R$ 130.588.598 (2018Int$ 125.912.942) para R$ 180.735.108 (2018Int$ 89.119.874), embora com menor magnitude em comparação àqueles de internações clínicas (94% vs. 38%). 201

O número de internações cirúrgicas/intervencionistas relacionadas às doenças valvares não cresceu muito no Brasil de 2008 a 2018, variando de 13.129 em 2008 a 14.294 em 2018. Isso está provavelmente associado com a complexidade e os custos crescentes das intervenções (em especial, dispositivos e próteses) e denota a carga econômica imposta pela incorporação de novos procedimentos e tecnologias, além do efeito marcante da inflação sobre os custos da atenção à saúde, considerando-se valores ajustados para Int$. Nesse cenário, a futura incorporação de terapias bem estabelecidas ainda não reembolsadas pelo SUS, como a TAVI, contribuirá para aumentar a carga econômica, embora as despesas com demandas judiciais possam exceder os custos ordinários. 218

O número total de internações no período foi de 172.126, tendo a maioria ocorrido na região Sudeste (41,2%), seguida pelas regiões Nordeste (25,7%), Sul (20,2%), Centro-Oeste (7,5%) e Norte (5,4%). 201

Observou-se queda dramática em alguns tipos de procedimentos, a despeito de suas crescentes indicações, como a comissurotomia mitral percutânea. Especificamente para esse procedimento, os números decrescentes podem estar associados com o atraso das tabelas de reembolso do SUS, limitando o número de hospitais que realizam aquela intervenção. O número absoluto de cirurgias valvares abertas permaneceu estável no período, variando de 12.201 (2008) a 12.088 (2018), a despeito do crescente número de casos de doença valvar do coração – em especial DVNR – e da crescente carga para os idosos. 200 , 201

• Em nenhum dos períodos, o aumento no número de internações encontrou paralelo nas despesas crescentes, sugerindo uma progressiva complexidade – e, consequentemente, custo – dos procedimentos para tratar doença valvar cardíaca. 201

A partir da base de dados administrativos do SUS, os procedimentos valvares associados com sequelas de DCR não puderam ser diferenciados daqueles associados com outras etiologias, devido à ausência de código específico disponível, além da imprecisão da notificação dos códigos da CID. 201

É interessante notar que estudos observacionais enfatizaram que a DCR permanece sendo a principal etiologia associada com cirurgia cardíaca em jovens no Brasil, atingindo até 60% em um estudo realizado em Salvador, Bahia. 193 No Instituto do Coração de São Paulo, o número de cirurgias cardíacas valvares associadas com DCR aumentou substancialmente nos últimos 10 anos, de cerca de 400 cirurgias/ano em 1990 para mais de 600 após 2000. 219 Entre 2008 e 2015, houve 26.054 hospitalizações por sequelas de FRA, 45% das quais por doença cardíaca, levando a um custo total possivelmente subestimado de US$ 3,5 milhões ao ano. 192 , 201

Em geral, as doenças valvares de origem reumática são responsáveis por cerca de 90% das cirurgias cardíacas em crianças e por mais de 30% das cirurgias cardíacas em adultos, a maioria jovem, 220 ainda de acordo com estudos observacionais e registros de base hospitalar. Entretanto, poucos estudos epidemiológicos estimaram a carga da doença valvar por causa específica no Brasil.

Doença Valvar Mitral

Com base em dados administrativos do SUS de 2001 a 2007 e referentes a cirurgia de valva mitral, em uma série retrospectiva de 78.808 pacientes cirúrgicos consecutivos, a idade média foi de 50,0 anos (35,9 – 62,5) e 40.106 eram mulheres (50,9%). Novamente a DCR foi a principal etiologia, responsável por 53,7% do total de pacientes submetidos a cirurgia e a mais de 94% dos pacientes submetidos a procedimentos para estenose mitral, que representou a maior indicação cirúrgica única, responsável por 38,9% do total. No geral, a substituição valvar foi realizada em 69,1% das cirurgias. A mortalidade hospitalar foi 7,6%. 206

A mortalidade cirúrgica foi discretamente maior em mulheres do que em homens (7,8% vs. 7,3%; p < 0,001) e consideravelmente mais alta nos indivíduos com idade ≥80 anos. Por outro lado, a mais baixa mortalidade foi observada naqueles entre 20 e 39,9 anos (p < 0,001). Os pacientes com cirurgias aórtica e mitral combinadas (refletindo etiologia reumática) foram os mais jovens (mediana, 43,3 anos). A cirurgia para estenose aórtica foi mais comum em indivíduos mais idosos (mediana, 58,0 anos) (p < 0,001). Reparo valvar apresentou menor mortalidade (3,5%) em comparação a substituição valvar (6,9%), reparo/substituição valvar múltipla (8,2%) e CRVM concomitante (14,6%) (p< 0,001). Associação com CRVM ocorreu em 7.147 pacientes (9,1% da amostra). 206

Quanto à comissurotomia percutânea, estudos no Brasil mostraram uma proporção muito maior de mulheres (85%) – coincidente com a epidemiologia da DCR e principalmente da estenose mitral – e de jovens (<40 anos). 221 , 222

Doença Valvar Aórtica

Uma coorte de 724 pacientes consecutivos, submetidos a cirurgia cardíaca no Instituto do Coração de São Paulo, evidenciou, à semelhança de outros estudos, maior taxa de mulheres (55%) e predominância de DCR (60%). Entretanto, nessa série, houve grande proporção de doença valvar aórtica (396 casos) em comparação a doença valvar mitral (306 casos) e outras séries. Dos pacientes com doença valvar mitral, 39,9% apresentavam estenose, 38,4% apresentavam regurgitação e 21,7% apresentavam disfunção de prótese mitral. Em pacientes submetidos a intervenção valvar aórtica, observaram-se estenose em 51,6%, regurgitação em 29,3% e disfunção de prótese em 19,1%. O estudo sugere um aumento de doença valvar aórtica em comparação a doença valvar mitral em hospital terciário da região Sudeste do Brasil. 223

Outro estudo retrospectivo de coorte foi conduzido em Porto Alegre (Sul do Brasil), com 1.065 pacientes (idade média, 61,4 ± 11,8 anos; 38% mulheres). Substituição de valva aórtica foi realizada em 18,8% e de valva mitral, em 13,4%. Revascularização coronária concomitante foi realizada em 60,3% da amostra e cirurgias valvares, em 32,7%. A mortalidade hospitalar geral foi 7,8%, sendo menor para CRVM isolada (5,9%), intermediária para cirurgia valvar (aórtica e/ou mitral e/ou tricúspide = 8,6%) e maior para a combinação de procedimentos valvares e CRVM (20,0%). 224

Implantação Percutânea de Valva Aórtica no Brasil

Como em outros países, a TAVI ganhou importância no Brasil nos últimos 20 anos. Estima-se que mais de 100 mil TAVI já foram realizadas no mundo. 205 ,2018 A primeira TAVI no Brasil ocorreu em 2008. O registro brasileiro de TAVI relatou a realização de 418 TAVI em 18 centros até 2014, tendo esse número crescido exponencialmente desde então. O acesso femoral foi escolhido em 96,2% dos procedimentos e as próteses usadas foram CoreValve ® (86,1%) e Sapien XT ® (13,9%). Nessa experiência inicial, as mortalidades por todas as causas em 30 dias e 1 ano foram 9,1% e 21,5%, respectivamente. 225

Dados do registro de TAVI atualizados em 2017 revelaram um total de 819 pacientes em acompanhamento clínico, demonstrando que o procedimento tem baixa incidência de complicações – em especial desfechos clínicos duros precoces – e ressaltando taxas de insuficiência renal pós-procedimento em torno de 18%. 226 , 227

Em outra avaliação realizada na cidade do Rio de Janeiro com 136 pacientes submetidos a TAVI [mediana de idade, 83 (80-87) anos; 51% homens], a mortalidade peroperatória foi 1,5%, a mortalidade de 30 dias, 5,9%, a mortalidade hospitalar, 8,1% e a mortalidade de 1 ano, 15,5%. 228

De 819 valvas aórticas implantadas por via percutânea até 2017, 135 pacientes (20,1%) precisaram de colocação de marcapasso permanente. Esses pacientes eram mais velhos (82,5 vs. 81,1 anos; p=0,047), predominantemente homens (59,3% vs 45%; p=0,003) e tinham bloqueio de ramo direito prévio (OR=6,19; IC 95%, 3,56 – 10,75, p≤0,001). O uso da prótese CoreValve ® (OR=3,16; IC 95%, 1,74 – 5,72, p≤0,001) e gradiente transaórtico basal >50 mmHg (OR=1,86; IC 95%, 1,08 – 3,20, p=0,025) foram preditores independentes de implantação de marcapasso permanente. 227

Pesquisa Futura

Apesar da notável melhora nas últimas décadas, ainda há escassez de dados primários sobre a epidemiologia da doença valvar do coração no Brasil e muito espaço para pesquisa futura. Há alguns desafios administrativos para a coleta de dados e o desenvolvimento de registros no âmbito nacional associados com a codificação de hospitalizações e procedimentos. Em especial no SUS, os códigos atuais não permitem a discriminação de variáveis cruciais, como a valva envolvida, o tipo de disfunção valvar, o tipo de prótese e, especialmente, a etiologia e a associação com doenças sistêmicas. Portanto, o refinamento do sistema de codificação ou a implementação mandatória de relatórios clínicos e cirúrgicos – como feito anteriormente para as intervenções coronárias percutâneas – podem ser um passo inicial para melhorar a acurácia na aquisição de dados.

Como o país tem algumas coortes significativas de pacientes com doença valvar do coração, o acompanhamento de médio e longo prazo dessas amostras deve ser garantido. Importante notar que há iniciativas de pesquisa que requerem incentivos e financiamento para sua continuação, como os estudos em andamento sobre prognóstico de longo prazo de DCR subclínica em crianças e adolescentes, 191 , 203 determinantes genéticos e imunes da resposta às infecções estreptocócicas que leva a DCR, 229 preditores clínicos e relacionados a procedimento de eventos de curto e longo prazo após comissurotomia mitral percutânea, 211 , 230 além de um registro nacional de TAVI. 225

Com relação ao rastreio com ecocardiografia para DCR, dados primários sugerem que a estratégia parece ser custo-efetiva no Brasil, 231 mas sua aplicação fora da pesquisa e integração nos sistemas de saúde precisam de esforços investigativos continuados, à semelhança de outros países. Um escore de risco ecocardiográfico para prever a progressão da DCR foi obtido a partir de uma coorte brasileira, 232 mas aguarda validação mais ampla em outros cenários. Além disso, esforços continuados foram direcionados para o desenvolvimento de vacinas contra infecções estreptocócicas, 229 devendo-se garantir estudos colaborativos sobre sua eficácia e aplicação clínica para reduzir a carga de DCR. No oposto do espectro da doença valvar do coração, a incorporação da TAVI no SUS parece próxima, 232 sendo que a avaliação do seu verdadeiro impacto clínico, orçamentário e social nos desfechos da atenção à saúde pública requer extensa pesquisa.

Por fim, outra estratégia promissora para fornecer diagnóstico precoce e priorizar referências nas áreas de poucos recursos deve ser investigada no Brasil. Como exemplo, a disponibilidade de modalidades de exames de imagem para o manejo da doença valvar do coração – em especial ecocardiografia – é limitada e distribuída de maneira desigual no país. Nesse cenário, avaliou-se a implementação de tele-ecocardiografia, com a mudança da tarefa de aquisição de imagem para não médicos (ainda não permitida fora da pesquisa pela regulamentação da atenção à saúde brasileira) e sua leitura remota. 233 Apesar do seu bom desempenho para diagnóstico e discriminação de pacientes com alto risco cardiovascular, 234 o impacto sobre os desfechos clínicos, assim como a viabilidade e a custo-efetividade da estratégia, ainda aguardam avaliação. À semelhança do observado para outras novas modalidades, como tele-ECG, rastreio de FA 235 e consultas remotas, a incorporação das inovações em técnicas de imagem para melhorar o acesso ao cuidado cardiovascular no Brasil pode requerer extensas discussões baseadas em sólida evidência científica.

6. FIBRILAÇÃO ATRIAL E FLUTTER ATRIAL CID-10 I48

Ver Tabelas 6-1 até 6-7 e Figuras 6-1 até 6-3

Abreviaturas usadas no Capítulo 6
AIT Ataque Isquêmico Transitório
AVC Acidente Vascular Cerebral
BNP Peptídeo Natriurético Cerebral
CID-10 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10a Revisão
CRVM Cirurgia de Revascularização do Miocárdio
DALYs Anos de vida perdidos ajustados por incapacidade (do inglês, Disability-Adjusted Life-Year )
DCh Doença de Chagas
DP Desvio-Padrão
ECG Eletrocardiograma
ELSA-Brasil Estudo Longitudinal da Saúde do Adulto
FA Fibrilação Atrial
GARFIELD-AF Global Anticoagulant Registry in the FIELD-AF
GBD Global Burden of Disease
HR Hazard Ratio
IC Intervalo de Confiança
II Intervalo de Incerteza
IMPACT-AF A Multifaceted Intervention to Improve Treatment with Oral Anticoagulants in Atrial Fibrillation
INR Índice Internacional Normalizado (do inglês, International Normalized Ratio )
NOAC Novos Anticoagulantes Orais
OR Odds Ratio
PPC Paridade do Poder de Compra
SDI Índice Sociodemográfico (do inglês, Sociodemographic Index )
SUS Sistema Único de Saúde
TTR Tempo na Faixa Terapêutica (do inglês, Time in Therapeutic Range )
UF Unidade Federativa
UTI Unidade de Terapia Intensiva
AVK Antagonista da Vitamina K

Prevalência e Incidência

De acordo com as estimativas do Estudo GBD 2017, a taxa de prevalência padronizada por idade de FA e flutter apresentou pequeno aumento no Brasil: de 619 (II 95%, 516-728) em 1990 para 641 (II 95%, 537-751) em 2017, por 100 mil habitantes, para ambos os sexos, com uma variação de 3,5% (II 95%, 1,7-5,3) no período. A prevalência de FA e flutter foi maior nos homens [em 1990: 759 (II 95%, 630-893); em 2017: 787 (II 95%, 657-925)] do que nas mulheres [em 1990: 499 (II 95%, 418-587); em 2017: 522 (II 95%, 440-610)], embora com maior variação percentual para as mulheres (4,6%; II 95%, 2,3-7) do que para os homens (3,7%; II 95%, 1,4-5,9) no período. Em números absolutos, as estimativas de prevalência de FA e flutter no Brasil subiram de 0,5 milhão em 1990 para 1,4 milhão em 2017, principalmente em razão do crescimento e envelhecimento da população (Tabela 6-1 e Figura 6-1). Em 2017, a proporção de pacientes com FA prevalente foi de 0,67% (II 95%, 0,56-0,78).

De acordo com o Estudo GBD 2017, a taxa de prevalência de FA e flutter difere entre as UF brasileiras, tendo sido maior nas UF da região Sudeste em 1990 e 2017 (estados de São Paulo, Rio de Janeiro e Minas Gerais) e menor nas UF das regiões Nordeste ou Norte (Maranhão, Pernambuco e Alagoas em 1990, e Maranhão, Pernambuco e Pará em 2017). Isso pode resultar de um atraso na transição epidemiológica e da menor taxa de diagnóstico nas UF de mais baixa renda. Os homens apresentaram consistentemente taxas de prevalência mais altas nos dois períodos em todas as UF (Figura 6-1).

De acordo com as estimativas do Estudo GBD 2017, as taxas de incidência padronizadas por idade por 100 mil por ano foram 44 (II 95%, 36-54) em 1990 e 46 (II 95%, 38-55) em 2017. Essas taxas foram também mais altas para os homens nos dois períodos [mulheres, 1990: 38 (II 95%, 31-45), 2017: 39 (II 95%, 32-47); homens, 1990: 53 (II 95%, 43-64), 2017: 54 (II 95%, 44-65)].

Dados do ELSA-Brasil, um estudo de coorte com servidores públicos no Brasil de seis centros incluindo 14.424 adultos com ECG válido (45,8% homens, idade variando de 35 a 74 anos), mostraram prevalência de 0,3% (48 casos) de FA e flutter atrial (homens, 0,5%; mulheres, 0,2%) no ECG basal. A chance de apresentar FA ou flutter atrial aumentou com a idade para ambos os sexos, sendo a maior prevalência observada nos mais idosos, entre 65 e 74 anos (mulheres: OR: 17; IC 95%, 2,1-135,9; homens: OR: 52,3; IC 95%, 3,1-881,8). Não houve diferença na prevalência de acordo com a raça autorrelatada, para ambos os sexos (homens: negros, 0,3%; pardos, 0,4%; brancos, 0,6%; p=0,42; e mulheres: negras, 0,3%; pardas, 0,2%; brancas, 0,2%; p=0,84). 237

O Registro GARFIELD-AF é um estudo mundial que incluiu pacientes (≥18 anos) com diagnóstico de FA nas 6 semanas anteriores e pelo menos um fator de risco adicional para AVC segundo avaliação do investigador do estudo. No Brasil, 41 sites (82,3% cardiologistas) incluíram 1.065 pacientes com FA não valvar entre 2010 e 2014 (idade média [DP]: 68 [13] anos; 55% homens). A prevalência dos tipos de FA foi a seguinte: primeiro episódio de FA, 52% dos pacientes; FA paroxística, 25%; FA persistente, 14%; e FA permanente, 8%. 238 A alta prevalência de primeiro episódio de FA pode ser atribuída ao critério de inclusão: FA diagnosticada nas 6 semanas anteriores.

Outro estudo transversal de base populacional em uma área desassistida de São Paulo, incluindo 1.524 indivíduos com 65 anos ou mais de idade, relatou FA em 2,4% dos participantes (homens, 3,9%; mulheres, 2,0%). 239

Os sistemas de telessaúde no Brasil forneceram vastos dados epidemiológicos sobre arritmias, ao incluir pacientes atendidos nas unidades de atenção primária e de emergência. Entre 262.685 pacientes dos centros de atenção primária submetidos a ECG através de telessaúde em Minas Gerais em 2011, a prevalência de FA foi 1,8% e aumentou bruscamente com a idade (OR: 1,08; IC 95%, 1,07-1,08), tendo sido maior nos homens (2,4%) em todos os grupos etários, variado de 0,2% (20-29 anos de idade) a 14,6% (nonagenários), em comparação às mulheres (1,3%), variando de 0,1% (20-29 anos de idade) a 8,7% (nonagenárias), (OR: 1,77; IC 95%, 1,68-1,89). 240 , 241

O serviço de telemedicina da Universidade Federal de São Paulo analisou 676.621 ECG de pacientes (idade média 51±19 anos; 57,5% mulheres) em visitas rotineiras a 125 centros de atenção primária de janeiro de 2009 a abril de 2016. A prevalência de FA em 7 anos foi de 2,2% (n = 14.968). O estudo projetou uma prevalência de FA no Brasil para 2025 de 1,7%. 246

De 260.879 ECG realizados entre março e setembro de 2015 em centros de atenção primária usando um sistema de telessaúde em Minas Gerais, 304 (0,1%) foram estratificados como emergência cardiovascular. Fibrilação atrial e flutter com resposta ventricular baixa ou alta foram a causa de 22% dessas emergências. 243

A prevalência de FA em 1.518 indivíduos (idade média 58±16 anos; 66% mulheres), que aguardavam por um ecocardiograma na atenção primária e foram rastreados para FA com um dispositivo portátil, foi de 6,4%. Idade mais avançada foi um fator de risco (9,3% vs. 4,8% naqueles com idade acima e abaixo de 65 anos, respectivamente, P=0,001), tendo FA sido associada com doença cardíaca no ecocardiograma (OR: 3,9; IC 95%, 2,1-7,2, p < 0,001). Os autores sugerem que o rastreio de FA possa ser uma ferramenta útil na atenção primária para estratificar risco e priorizar o ecocardiograma. 244

Mortalidade

De acordo com o Estudo GBD 2017, o número de mortes por FA no Brasil aumentou nos últimos anos em razão do crescimento e envelhecimento da população. Na década de 1990, a FA foi responsável por 2.649 (II 95%, 2.428-2.836) mortes, que subiram para 10.059 (II 95%, 9.390-10.698) em 2017. Entretanto, a taxa de mortalidade padronizada por idade por FA permaneceu estável, sendo 4,7 (II 95%, 4,4-5,1) por 100 mil habitantes em 1990 e 4,8 (II 95%, 4,5-5,2) por 100 mil habitantes em 2017, correspondendo a 0,7% de todas as mortes no país. Embora as taxas de prevalência padronizadas por idade fossem consistentemente mais altas nos homens, as mulheres apresentaram maiores taxas de mortalidade padronizadas por idade em 2017 (mulheres: 4,9, II 95%, 4,8-5,3; homens: 4,6, II 95%, 3,9-5,2), dados coerentes com os de outros países. 245 , 246 Ao considerar indivíduos com idade >70 anos, a taxa de mortalidade aumenta de 1990 (52, II 95%, 48-55) a 2017 (74, II 95%, 69-79). É importante notar que, como a mortalidade baseada apenas em dados de registro vital fornece um implausível aumento vertiginoso ao longo do tempo, possivelmente em consequência de mudanças na apuração mais do que da epidemiologia da FA, o Estudo GBD 2017 presume, a priori , que as taxas de mortalidade específicas para idade e sexo não estejam aumentando nem diminuindo com o tempo. 247 Assim sendo, as pequenas variações com o tempo aqui relatadas são intencionalmente mais baixas do que as reais variações em dados brutos.

A Tabela 6-2 mostra o número total de mortes, a taxa de mortalidade padronizada por idade por FA (por 100 mil habitantes, ambos os sexos) e a variação percentual, por UF e no Brasil, em 1990-2017. As UF com os maiores percentuais de redução observados entre 1990 e 2017 foram Espírito Santo, Roraima, Goiás e Minas Gerais, nessa ordem. Por outro lado, as UF com os maiores percentuais de aumento observados entre 1990 e 2017 foram Distrito Federal, Alagoas e Sergipe. Entretanto, esses dados devem ser interpretados com cautela, pois pode haver inconsistência em virtude de questões de notificação. As Tabelas 6-3 e 6-4 mostram os dados estratificados por sexo.

Com relação às taxas de mortalidade por FA de acordo com os grupos etários, o aumento mais significativo foi observado nos mais idosos: grupo de 70+ anos (51,6, II 95%, 47,7-55,3 por 100 mil em 1990; e 74, II 95%, 69,3-78,7 por 100 mil em 2017), com variação percentual de 43,4 (II 95%, 35,9-50,6), seguido pelo grupo de 50-69 anos (2,6, II 95%, 2,3-2,8 por 100 mil em 1990; e 2,8, II 95%, 2,5-3,0 por 100 mil em 2017), com variação percentual de 6,0 (II 95%, 0,3-10,9).

O Estudo GBD 2017 usa o SDI como uma estimativa do nível socioeconômico da localidade. Como ilustrado na Figura 6-2, não há correlação estatisticamente significativa entre a taxa de mortalidade padronizada por idade por FA e flutter por 100 mil habitantes e o SDI das UF brasileiras (p=0,37), provavelmente porque a prevalência seja mais baixa nas UF de mais baixa renda, como já mencionado.

Em uma análise prospectiva do estudo de coorte de Bambuí, que incluiu todos os moradores dessa localidade, área endêmica de DCh, com idade ≥ 60 anos em 1 de janeiro de 1997, um total de 1.462 participantes com (38%) e sem DCh [idade média de 69 (63-74) anos; 61% mulheres] foi seguido por 10 anos. Morte ocorreu em 556 participantes. A presença de FA ou flutter na linha de base foi independentemente associada com aumento da mortalidade por todas as causas (HR: 2,35; IC 95%, 1,53-3,62) nos pacientes com e sem DCh (HR: 1,92; IC 95%, 1,05-3,51). 248

Um estudo avaliando 302 pacientes [idade média (DP), 58 (15) anos; 53% mulheres] com FA valvar (32%) e FA não valvar, seguidos por 1 ano, mostrou taxa de mortalidade de 10% e nenhuma diferença entre os portadores de FA valvar e não valvar. As causas de morte foram insuficiência cardíaca em 25 pacientes (83%), morte súbita cardíaca em 3 (10%) e trombose em prótese valvar mecânica em 2 (7%). 249

Carga de Doença

De acordo com as estimativas do GBD 2017, a FA resultou em 226.810 (II 95%, 187.976-272.166) DALYs no Brasil em 2017, que representam 0,37% de todos os DALYs. A taxa de DALYs padronizada por idade foi 104 (II 95%, 86-124) por 100 mil em 2017, maior para homens (115; II 95%, 92-141) do que para mulheres (93; II 95%, 79-109), embora a proporção de DALYs seja maior nas mulheres (0,43%; II 95%, 0,39-0,48) do que nos homens (0,33%; II 95%, 0,28-0,39). Em comparação a 1990, houve pequeno aumento nas taxas de DALYs no país de 4,6% (UI 95%, 1,7-7,2). O número de DALYs e taxas de DALYs por FA e flutter em 1990 e 2017, de acordo com as UF brasileiras, para ambos os sexos, são mostrados nas Tabelas 6-5 a 6-7.

Não se encontrou associação entre o SDI e as taxas de DALYs padronizadas por idade por FA no Brasil, à semelhança do relatado para as taxas de mortalidade padronizadas por idade (Figura 6-3).

Utilização e Custo da Atenção à Saúde (Ver Tabelas 1-6 a 1-9 e Figuras 1-15 e 1-16)

De 2008 a 2018, houve 321.866 hospitalizações por FA e 1.250 procedimentos de ablação para FA e flutter foram realizados pelo SUS, com custos não ajustados de R$ 231.850.160 e R$ 6.950.612, respectivamente. Após ajuste para a inflação brasileira, os custos passaram a R$ 418.504.911 e R$ 12.546.315, respectivamente. Em dólares internacionais convertidos em PPC ajustados para US$ 2018, os valores foram $ 403.520.568 e $ 6.701.749, respectivamente.

Uma análise da carga econômica das condições cardíacas no Brasil estimou uma prevalência de FA de 0,8% (1.202.151 casos) em 2015. Os autores estimaram um custo total para FA de R$ 3.921 milhões (US$ 1,2 bilhão). 250

Complicações Acidente Vascular Cerebral

Um registro de AVC na cidade de Joinville descreveu todos os 429 casos de AVC que ocorreram em 2015, dos quais, 87,2% (374/429) foram AVC isquêmicos. Fibrilação atrial foi detectada em 11,4% (49/429) dos pacientes e em 58% (49/84) de todos os AVC cardioembólicos. 251 Similarmente, detectou-se FA em 58% de 359 pacientes com AVC cardioembólico em uma amostra consecutiva de um único centro em Curitiba. 252

Em uma análise retrospectiva de 215 pacientes hospitalizados por AVC, FA ocorreu em 16,3%, tendo havido associação de FA com o avançar da idade: enquanto a prevalência de FA foi 5% em pacientes com idade <65 anos, naqueles com idade > 80 anos, a prevalência de FA aumentou para 26% (p=0,01). 253

Entre pacientes hospitalizados por AVC isquêmico agudo ou AIT, um sistema de escore para diagnóstico de FA com base em variáveis clínicas e ecocardiográficas foi desenvolvido e validado em uma coorte brasileira. Idade (OR: 1,04; IC 95%, 1,02-1,08), uso da escala do National Institutes of Health para avaliar AVC na admissão (OR: 1,10; IC 95%, 1,05-1,16) e aumento do átrio esquerdo (OR: 2,5; IC 95%, 1,01-6,29) foram preditores de FA e AIT (estatística-C = 0,76; IC 95%, 0,69-0,83). 254

Insuficiência Cardíaca

Em um estudo retrospectivo de 659 pacientes com hospitalizações consecutivas por insuficiência cardíaca descompensada em 2011, a prevalência de FA foi 40% (73% de FA permanente). Fibrilação atrial foi associada com o avançar da idade (p < 0,0001), etiologia não isquêmica (p = 0,02), disfunção ventricular direita (p = 0,03), pressão sistólica mais baixa (p = 0,02), maior fração de ejeção (p < 0,0001) e aumento do átrio esquerdo (p < 0,0001). Pacientes com FA apresentaram maior mortalidade hospitalar (11,0% vs . 8,1%, p = 0,21) e mais longa permanência hospitalar (20,5 ± 16 dias vs . 16,3 ± 12, p = 0,001). 255

Quedas

Dados de um estudo retrospectivo incluindo 107 pacientes com FA e idade média de 78 anos revelaram que 51% haviam relatado pelo menos uma queda no ano anterior. O risco foi maior entre pacientes com diabetes e em uso de amiodarona. 256

Demência

Em um estudo transversal com 1.524 participantes com idade > 65 anos, demência foi diagnosticada em 11% daqueles com FA em comparação a 4% daqueles sem FA (p=0,07). Os autores encontraram OR para demência de 2,8 (IC 95%, 1,0-8,1; p = 0,06) entre indivíduos com FA. 257

Tipos de Fibrilação Atrial e Complicações

Em um estudo retrospectivo, dados de 407 pacientes tratados para FA na emergência da cardiologia no primeiro trimestre de 2012 revelaram que as prevalências de insuficiência cardíaca e de AVC foram maiores em pacientes com FA persistente (n=188) e flutter (n=51) do que naqueles com FA paroxística (n=168) (insuficiência cardíaca: 51,2% vs. 45,1% vs. 19,7%; p < 0,01; e AVC: 10,7% vs. 9,8% vs. 1,6%; p < 0,01). 258

Influência dos Fatores de Risco em Fibrilação Atrial e Flutter 1

O Registro GARFIELD-AF, um estudo observacional sem intervenção, de âmbito mundial, incluiu 1.065 pacientes (≥ 18 anos) com FA não valvar diagnosticada nas 6 semanas anteriores em 41 sites no Brasil (82,3% cardiologistas). A idade média (DP) foi 68 (13) anos e 55% eram homens. Tabagismo atual/prévio foi encontrado em 32%, hipercolesterolemia, em 42%, obesidade, em 29%, diabetes, em 25% e hipertensão, em 81% dos pacientes. 2 38

Em uma amostra de 262.685 pacientes em centros de atenção primária, submetidos a ECG usando-se telessaúde em Minas Gerais em 2011, a prevalência autorreferida de fatores de risco entre aqueles com FA foi: hipertensão, 51,8%; diabetes, 7,3%; tabagismo, 6,7%; dislipidemia, 3,5%. Apenas hipertensão apresentou associação significativa com FA na comparação com indivíduos sem FA (51,8% vs. 31,7%; OR ajustada para idade e sexo: 1,32; IC 95%, 1,24-1,40).

Um estudo transversal comparando indivíduos com FA a controles saudáveis encontrou maior frequência de apneia do sono no grupo de FA em comparação ao grupo controle (81,6% vs. 60%, p = 0,03). 259

Doenças Associadas e Comorbidades

A incidência de FA entre 300 idosos (idade média, 75±8 anos; 56% mulheres) monitorados com marcapassos, sem FA na linha de base, foi 22% em um seguimento de 435 dias, 2 60 chegando a 85% dos pacientes com marcapassos e doença renal crônica em seguimento de 1 ano. 261

Em pacientes com doença cardiovascular que procuraram a emergência, a prevalência de FA foi 40% naqueles com insuficiência cardíaca descompensada 255 e 44% naqueles com doença valvar cardíaca. 262

Um estudo incluindo pacientes de uma UTI encontrou incidência de FA de 11% durante a permanência na unidade. 263

Fibrilação Atrial Peroperatória e Cirurgia Cardiovascular

No pós-operatório de cirurgia cardíaca, FA ocorreu em 12% a 33% dos pacientes. 264 - 266 As cirurgias de substituição valvar foram associadas com maior ocorrência de FA (31%-33%) durante a hospitalização em comparação à CRVM (12%-16%).

Idade avançada, doença valvar mitral e não uso de betabloqueadores foram associados com FA no pós-operatório de cirurgia valvar. 267 Entre aqueles submetidos a CRVM, a incidência de FA no pós-operatório foi associada com átrio esquerdo > 40,5 mm e idade > 64,5 anos. 268

Fibrilação Atrial e Doença de Chagas

Relatos de caso descreveram FA em pacientes com DCh aguda adquirida por via oral, 269 provavelmente relacionada com miocardite chagásica aguda.

No estudo de coorte de Bambuí, 1.462 participantes com idade ≥ 60 anos (idade média, 69 anos; DCh n=557, 38,1%) e ECG na linha de base foram seguidos por 10 anos; o desfecho foi mortalidade. Fibrilação atrial foi mais frequentemente observada nos indivíduos com DCh, 6,1% vs. 3,4% (OR: 3,43; IC 95%, 1,87-6,32, ajustada para idade, sexo e variáveis clínicas), e foi um fator de risco independente para morte (HR: 2,35; IC 95%, 1,53-3,62, ajustada para idade, sexo, variáveis clínicas e níveis de BNP) nos indivíduos com DCh. 248

Em uma grande amostra de 264.324 pacientes submetidos a tele-ECG em uma unidade de atenção primária à saúde em 2011, DCh foi autorrelatada por 7.590 (2,9%). A idade média dos indivíduos com DCh foi 57,0 (DP: 13,7) anos e a daqueles sem DCh foi 50,4 (DP: 19,1) anos, com 5% de octogenários nos dois grupos. Fibrilação atrial foi observada em 5,35% dos indivíduos com DCh e em 1,65% daqueles sem DCh (OR: 3,15; IC 95%, 2,83-3,51, ajustada para idade, sexo e comorbidades autorrelatadas). Nos octogenários, a prevalência de FA alcançou 16,26% dos pacientes: 15,47% das mulheres e 17,95% dos homens. 270

Na linha de base do estudo de coorte do Projeto NIH-SaMi-Trop, que recrutou pacientes chagásicos (n=1.959; 67,5% mulheres; mediana da idade 59, Q1-Q3: 49-69 anos) com suspeita de doença cardíaca em 21 municípios do norte de Minas Gerais, a prevalência de FA foi 4,5%, sendo maior em homens do que em mulheres (5,6 vs. 2,6%, p< 0,001) e naqueles com níveis altos em comparação a normais de NT-ProBNP (14,6% vs. 2,1%, p< 0,001). 271

Em uma revisão sistemática e meta-análise, Rojas et al . avaliaram a frequência de anormalidades eletrocardiográficas da DCh na população geral. Foram selecionados 49 estudos, incluindo 34.023 pacientes (12.276 chagásicos e 21.747 não chagásicos). A prevalência de FA foi significativamente mais alta nos chagásicos (OR: 2,11; IC 95%, 1,40-3,19). 272

Em uma amostra de 424 pacientes chagásicos com idade inferior a 70 anos [41,7% mulheres; idade média, 47 (DP:11)], seguidos por 7,9 (DP: 3,2) anos, Rassi et al . encontraram prevalência de FA de 13,3 (DP: 3,1%), com forte associação a risco de morte (HR: 5,43; 2,91-10,13) em análise univariada. 273

Em 330 pacientes com DCh (idade média, 49±12 anos; 58% homens), 26 dos quais com FA, uma análise explorando os fatores de risco para eventos cerebrovasculares isquêmicos não encontrou aumento do risco de AVC entre os chagásicos com FA em comparação aos chagásicos em ritmo sinusal. 274

Conscientização, Tratamento e Controle Anticoagulação

Houve grande variação no uso de anticoagulação entre os pacientes com FA, de 1,5% a 91%. Estudos com amostras da atenção primária apresentaram maior probabilidade de baixo uso de anticoagulação em comparação a amostras recrutadas de centros terciários ou de cardiologistas, como detalhado a seguir.

Entre 4.638 indivíduos com FA em centros de atenção primária de 658 municípios em Minas Gerais [idade média (DP), 70 (14) anos; 54% homens], submetidos a ECG através de telessaúde em 2011, o uso de AVK foi relatado por 1,5% e o de aspirina, por 3,1%. 241

Em um estudo de pacientes de 125 centros de atenção primária em 9 estados de 4 regiões geográficas brasileiras, de janeiro de 2009 a abril de 2016, identificou-se um subconjunto de pacientes com FA (n=301), 189 (63%) dos quais com alto risco de AVC; apenas 28 (15%) faziam uso regular de anticoagulantes orais e 102 (54%), de aspirina. 242

O Registro GARFIELD-AF é um estudo mundial que incluiu pacientes (≥18 anos) com diagnóstico de FA nas 6 semanas anteriores e pelo menos um fator de risco adicional para AVC segundo avaliação do investigador do estudo. No Brasil, entre os 1.041 pacientes incluídos (82,3% por cardiologistas) entre 2010 e 2014, a média (DP) de idade foi 68 (13) anos, 55% eram homens, 86% tinham escore CHA 2 DS 2 -VASc ≥2, 19% não usavam anticoagulação na linha de base, 26% estavam recebendo apenas terapia antiplaquetária, 29% estavam usando AVK e 26% estavam usando NOAC. 238

O IMPACT-AF, 275 um ensaio randomizado por cluster para aperfeiçoar o tratamento com anticoagulantes em pacientes com FA, conduzido na Argentina, China, Índia, Romênia e no Brasil, mostrou que dois terços dos pacientes usavam anticoagulação oral na linha de base: 83%, AVK e 15%, um NOAC. Dos pacientes do Brasil (n=360), 91% usavam anticoagulação oral na linha de base e 27% usavam NOAC. De todos os pacientes tomando AVK no Brasil, 40,3% apresentavam valores de INR entre 2 e 3 antes da visita na linha de base.

Um estudo transversal incluindo 162 pacientes de um hospital universitário em Porto Alegre [idade média (DP), 69 (12) anos; 57% homens; 96% com CHA 2 DS 2 -VASc ≥2] identificou 55 (34%) pacientes em uso de anticoagulantes e 80 (50%), de aspirina. 276

Um estudo transversal de um hospital universitário na cidade do Rio de Janeiro incluiu 659 hospitalizações consecutivas por insuficiência cardíaca descompensada de janeiro de 2006 a dezembro de 2011. Os pacientes com FA (n=264; 40%) apresentaram uma mediana de 4 do escore CHA 2 DS 2 -VASc, que foi ≥2 em 90% dos pacientes. A taxa de anticoagulação foi 53% na admissão e 67% na alta. 255

Um registro de AVC na cidade de Joinville descreveu todos os 429 casos de AVC que ocorreram em 2015, dos quais, 87,2% (374/429) foram AVC isquêmicos. Fibrilação atrial foi detectada em 11,4% (49/429) dos pacientes e em 58% (49/84) de todos os AVC cardioembólicos. Dos 26 pacientes que sabidamente tinham FA prévia, 19 (73%) não estavam anticoagulados, 20 (77%) tinham escore CHA 2 DS 2 -VASc ≥ 3 e 21 (81%) tinham escore HAS-BLED < 3. 251

A qualidade da terapia com varfarina foi avaliada usando TTR como parâmetro em diferentes amostras no Brasil, que, em geral, não são compostas apenas por portadores de FA. Os pacientes com FA em uso de anticoagulantes apresentaram pior TTR em comparação àqueles com outras indicações, como próteses valvares. O TTR variou entre 46% e 67% nos estudos. 249 , 277 - 279 Idade > 65 anos, mas não letramento em saúde, foi associada com um TTR mais longo. 278

Controle de Ritmo ou Frequência (Medicamento, Cardioversão, Ablação por Cateter)

Um estudo transversal com 167 pacientes com FA relatou que controle da frequência foi mais comum do que controle do ritmo como estratégia de tratamento (79% vs. 21%; p < 0,001). No subgrupo de FA paroxística, ambas as estratégias foram igualmente usadas (controle da frequência, 53%; controle do ritmo, 47%; p = 0,69). Pacientes com FA persistente apresentaram maior probabilidade de serem tratados com controle de frequência (96% vs. 4%; p < 0,001). Entre aqueles tratados com controle de ritmo, as drogas mais prescritas foram amiodarona (43%), sotalol (16%) e propafenona (14%). Os betabloqueadores foram prescritos para 81% dos pacientes em tratamento com controle de frequência. 280 Amiodarona foi mencionada por 83% dos médicos como a escolha para controle de ritmo. 281

Dados de 125 centros de atenção primária mostraram que, entre os pacientes com FA (n=301), 91 (30,2%) não recebiam qualquer tipo de tratamento para controle de frequência ou ritmo. Dos 210 pacientes restantes em tratamento, 147 (70%) usavam agentes para controle de frequência (betabloqueadores, digoxina, diltiazem ou verapamil) e 25 (12%) usavam pelo menos um antiarrítmico (amiodarona ou propafenona). O uso simultâneo de antiarrítmicos e betabloqueadores foi relatado por 36 (17%) respondentes. 242

Ablação de FA foi relatada no Primeiro Registro de Ablação Transcateter da América Latina, que incluiu 742 pacientes de ablação de FA, tanto procedimentos de primeira vez quanto repetição, realizados entre 1 de janeiro e 31 de dezembro de 2012 em 18 centros no Brasil. 282

Em uma série de casos de um único centro, 225 pacientes com FA paroxística [64 mulheres (29%) e 161 homens (61%)] foram submetidos a ablação por cateter, havendo recorrência de 21% entre as mulheres e de 20% entre os homens (p = 0,89) em seguimento de 1 ano. 283

Pesquisa Futura

O estudo RECALL, o primeiro registro cardiovascular brasileiro de FA, encerrou a inclusão de pacientes em 2019, com 4.584 indivíduos, e deverá ser publicado em 2020. Será o maior registro brasileiro com dados de todas as regiões do país, relacionados às características e ao tratamento de pacientes com FA de 73 centros no Brasil. 284

Estudos de coorte em andamento, como o ELSA-Brasil, têm potencial para preencher os hiatos de informação sobre incidência, fatores de risco, predição de risco – incluindo genética – e prevenção de FA no Brasil. Até onde se sabe, não há estudo original publicado com informação sobre a incidência de FA no Brasil nem dados longitudinais sobre fatores de risco.

Estudos desenhados para rastrear FA em uma base populacional ou populações selecionadas através do uso de ECG ou dispositivos de rastreio estão em andamento e deverão fornecer informação sobre a relevância da inclusão dessa estratégia em centros de atenção primária ou especializados.

Estratégias de implementação para aumentar o uso da anticoagulação entre pacientes com FA devem ser encorajadas, em particular no contexto da atenção primária.

–Valores totais reembolsados não ajustados e ajustados para Int$2018 das internações clínicas cardiovasculares pagas pelo SUS de 2008 a 2018. Dados expressos em milhares (1.000)
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 TOTAL
R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ R$ + IPCA 10 ANOS Int$ 2018
Doença isquêmica do coração crônica 7.799 7.519 6.861 6.167 6.593 5.465 6.251 4.781 5.690 4.031 5.248 3.460 6.214 3.798 5.141 2.921 5.327 2.800 5.532 2.811 5.672 2.797 66,328 125,224 46,550
Acidente vascular cerebral 142.062 136.975 188.450 169.388 198.813 164.774 205.448 157.139 218.628 154.902 228.141 150.393 242.664 148.315 252.441 143.442 263.771 138.669 272.140 138.253 286.293 141.170 2,498,850 4,717,691 1,643,419
Doenças valvares 1.052 1.014 1.589 1.428 1.439 1.193 1.607 1.229 1.509 1.069 1.510 995 1.584 968 1.672 950 1.675 881 1.679 853 2.043 1.008 17,361 32,776 11,590
Fibrilação atrial 13.791 13.297 17.396 15.636 18.537 15.363 18.858 14.424 20.371 14.433 19.969 13.164 22.637 13.835 23.330 13.256 23.929 12.580 26.061 13.239 26.971 13.300 231,850 437,720 152,529
Infarto do miocárdio (clínico) 65.020 62.691 84.308 75.780 92.969 77.051 97.324 74.439 104.898 74.328 106.246 70.040 119.583 73.088 128.724 73.143 134.912 70.925 136.438 69.313 143.349 70.685 1,213,077 2,291,532 791,479
Insuficiência cardíaca 272.281 262.532 322.849 290.192 327.914 271.771 330.492 252.781 317.586 225.015 321.712 212.077 326.141 199.336 337.610 191.834 345.566 181.670 346.841 176.203 348.832 172.008 3,598,825 6,792,495 2,435,420
Cardiomiopatias 1.288 1.242 1.902 1.709 2.144 1.777 1.900 1.453 2.110 1.495 2.302 1.517 2.696 1.648 2.682 1.524 3.065 1.611 2.556 1.299 3.120 1.538 25,764 48,641 16,813
Síndromes coronarianas agudas 44.711 43.110 57.922 52.063 64.612 53.550 65.586 50.165 75.210 53.288 74.619 49.190 83.607 51.100 82.095 46.648 80.185 42.155 82.072 41.694 80.037 39.466 790,657 1,492,716 522,427
Total 548.001 528.381 681.277 612.364 713.021 590.944 727.466 556.412 746.003 528.555 759.747 500.835 805.126 492.089 833.695 473.719 858.430 451.291 873.320 443.665 896.319 441.972 8,442,405 15,938,795 5,620,226
Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 29

– Valores totais reembolsados não ajustados e ajustados para Int$2018 das internações para intervenções cardiovasculares pagas pelo SUS de 2008 a 2018. Dados expressos em milhares (1.000)
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 TOTAL
R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ R$ + IPCA Int$ 2018
Ablação de fibrilação atrial 360 348 378 339 471 390 457 349 690 489 788 520 771 471 906 515 707 372 691 351 732 361 6.951 11.430 5.636
Angioplastia coronariana 210.529 202.991 266.654 239.681 295.641 245.024 337.972 258.502 372.063 263.613 388.920 256.381 411.252 251.355 412.073 234.147 433.590 227.946 466.696 237.091 495.885 244.519 4.091.276 6.728.694 3.317.896
CRVM 176.032 169.730 208.585 187.486 214.484 177.762 287.851 220.167 297.844 211.027 290.541 191.528 294.854 180.213 289.638 164.577 286.160 150.439 282.175 143.351 275.110 135.656 2.903.274 4.774.145 2.354.114
Cirurgia valvar 125.954 121.445 140.684 126.453 142.383 118.006 179.111 136.995 183.271 129.851 178.564 117.711 180.088 110.069 176.814 100.469 175.319 92.168 176.134 89.481 177.584 87.566 1.835.908 3.018.967 1.488.643
Angioplastia primária 45.267 43.647 37.888 34.055 37.113 30.759 35.577 27.211 35.545 25.185 37.288 24.581 45.883 28.044 56.101 31.877 66.515 34.968 71.624 36.387 73.429 36.208 542.231 891.645 439.667
Cardiomiopatias 168.993 163 545 490 192 159 326 249 436 309 354 233 306 187 298 169 527 277 452 230 426 210 4.031 6.623 3.266
Outras valvuloplastias 1.519 1.464 1.662 1.493 1.718 1.423 1.919 1.468 1.871 1.325 2.052 1.352 2.128 1.301 2.086 1.185 1.594 838 1.889 960 1.690 833 20.126 33.095 16.319
Valvuloplastia mitral 3.115 3.004 3.585 3.223 3.147 2.608 3.228 2.469 2.718 1.926 2.970 1.958 2.809 1.717 2.394 1.360 1.378 724 1.721 874 1.462 721 28.525 46.907 23.130
Total 562.946 542.790 659.980 593.221 695.149 576.132 846.441 647.411 894.438 633.724 901.476 594.265 938.091 573.356 940.309 534.300 965.790 507.732 1.001.383 508.723 1.026.318 506.074 9.432.322 15.510.510 7.648.180

CRVM: cirurgia de revascularização do miocárdio.

Fonte: Sistema de Informações sobre Mortalidade – SIM/DATASUS. 29

– Número de mortes e taxa de mortalidade padronizada por idade (por 100 mil) por hemorragias intracerebral e subaracnóidea no Brasil e suas unidades federativas, 1990 e 2017, e variação percentual das taxas
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.3.2 - Hemorragia Intracerebral
Acre 76 (72;80) 48,6 (46;51) 169 (157;181) 30,8 (28,4;33) -36,7 (-42,1;-31,1)
Alagoas 892 (840;948) 66,8 (63;70,9) 1220 (1147;1292) 40,7 (38,3;43,2) -39 (-43,7;-34,4)
Amapá 37 (34;39) 40,5 (37,7;42,7) 130 (120;140) 29,4 (27;31,7) -27,3 (-33,1;-20,8)
Amazonas 362 (336;383) 48,7 (45,2;51,4) 761 (711;806) 30,8 (28,8;32,7) -36,8 (-41,7;-31,4)
Bahia 3297 (3089;3521) 47,9 (44,9;51,1) 4782 (4521;5060) 30,4 (28,6;32,2) -36,6 (-41,6;-31,4)
Brasil 50247 (49123;51383) 58,6 (57,3;59,9) 61518 (59874;63290) 27,9 (27,1;28,7) -52,4 (-53,8;-51,1)
Ceará 1646 (1506;1782) 40,2 (36,6;43,6) 2649 (2491;2795) 26,9 (25,3;28,4) -33,1 (-39,2;-26,5)
Distrito Federal 302 (288;322) 56,1 (53,6;59,1) 498 (463;537) 25,4 (23,6;27,3) -54,8 (-58,3;-50,7)
Espírito Santo 1035 (996;1079) 79,5 (76,3;82,6) 1124 (1059;1194) 27,6 (26;29,2) -65,3 (-67,5;-63)
Goiás 1078 (1027;1143) 59,9 (57,1;63,4) 1543 (1447;1638) 24,6 (23;26,1) -59 (-61,9;-56,1)
Maranhão 1396 (1276;1520) 53,2 (48,5;58,2) 2198 (2042;2416) 35,3 (32,8;38,8) -33,7 (-39,7;-26,9)
Mato Grosso 325 (300;351) 43,3 (39,9;46,5) 733 (686;785) 25,7 (24,1;27,6) -40,6 (-46,1;-33,8)
Mato Grosso do Sul 516 (492;540) 60,6 (57,8;63,3) 831 (781;883) 31,3 (29,5;33,3) -48,2 (-52;-44,6)
Minas Gerais 5752 (5521;6069) 60,5 (58,1;63,3) 6361 (6029;6729) 25,3 (23,9;26,8) -58,3 (-61,1;-55,5)
Pará 1060 (979;1128) 52,1 (48,1;55,6) 2025 (1888;2161) 32,6 (30,4;34,7) -37,5 (-43;-31,5)
Paraíba 1008 (938;1082) 44,1 (41;47,2) 1419 (1306;1550) 30,6 (28,1;33,4) -30,6 (-38,1;-22,5)
Paraná 3442 (3301;3597) 80,3 (76,8;83,8) 3538 (3335;3750) 29,3 (27,7;31,1) -63,4 (-65,9;-60,8)
Pernambuco 3010 (2866;3154) 70,7 (67,5;74,1) 3459 (3259;3659) 35,8 (33,7;37,9) -49,4 (-52,5;-45,9)
Piauí 746 (682;809) 53,5 (48,8;57,9) 1156 (1085;1276) 32,2 (30,1;35,5) -39,9 (-45,1;-33,8)
Rio de Janeiro 7389 (7096;7680) 79,6 (76,6;82,8) 6678 (6329;7056) 31,2 (29,5;32,9) -60,8 (-63,4;-58,1)
Rio Grande do Norte 515 (477;553) 31,9 (29,5;34,2) 842 (783;908) 22,5 (20,9;24,3) -29,4 (-36,1;-21,3)
Rio Grande do Sul 3471 (3287;3636) 56,9 (53,9;59,7) 4291 (4020;4547) 28,9 (27,1;30,7) -49,2 (-52,4;-45,5)
Rondônia 225 (208;243) 69,2 (64;74,6) 394 (352;442) 30 (26,9;33,6) -56,7 (-61,7;-50,8)
Roraima 28 (25;31) 58,4 (53,7;63,5) 80 (70;91) 29,5 (26;33,4) -49,5 (-56,8;-41,3)
São Paulo 10472 (10014;10931) 55,4 (52,9;57,9) 11829 (11219;12484) 23,6 (22,3;24,9) -57,5 (-60,1;-54,3)
Santa Catarina 1508 (1438;1573) 68 (64,8;71) 1727 (1613;1825) 24,4 (22,9;25,9) -64,1 (-66,6;-61,5)
Sergipe 453 (428;476) 53,7 (50,8;56,5) 677 (638;716) 32,9 (31;34,9) -38,7 (-43,1;-33,8)
Tocantins 206 (181;230) 58 (52,1;63,5) 404 (373;439) 30,2 (27,9;32,9) -47,9 (-53,5;-40,8)
B.2.3.3 - Hemorragia Subaracnóidea
Acre 19 (18;20) 8,7 (8,1;9,4) 38 (35;41) 6 (5,5;6,6) -30,8 (-38,1;-23,1)
Alagoas 168 (147;186) 10 (8,8;11) 215 (197;239) 6,7 (6,1;7,5) -33 (-42,5;-19,3)
Amapá 8 (7;9) 6,4 (5,9;7,5) 29 (26;33) 5,4 (4,9;6,1) -15,8 (-24,5;-6,4)
Amazonas 70 (64;76) 6,9 (6,4;7,8) 154 (142;169) 5,3 (4,9;5,9) -23 (-30,9;-14,5)
Bahia 641 (591;706) 8 (7,3;8,9) 968 (899;1065) 6 (5,6;6,7) -24,2 (-32;-16)
Brasil 9809 (8917;10192) 9,6 (8,8;9,9) 13811 (13189;14611) 6,1 (5,8;6,4) -36,5 (-39,8;-32,2)
Ceará 340 (294;402) 7,1 (6,2;8,3) 530 (489;573) 5,4 (4,9;5,8) -24,1 (-37,1;-13,3)
Distrito Federal 81 (70;87) 10,2 (8,8;10,9) 139 (121;153) 5,8 (4,9;6,4) -43,8 (-49,1;-36,8)
Espírito Santo 191 (155;204) 11,8 (9,6;12,6) 254 (232;274) 5,9 (5,5;6,4) -49,7 (-54,5;-38,7)
Goiás 219 (202;234) 9,3 (8,6;9,9) 378 (348;416) 5,5 (5,1;6,1) -40,2 (-45,4;-33,2)
Maranhão 354 (286;418) 10,5 (8,2;12,7) 482 (423;527) 7,3 (6,4;8) -30,6 (-41,4;-18,5)
Mato Grosso 85 (78;93) 8 (7,3;8,8) 181 (167;199) 5,6 (5,2;6,2) -29,8 (-37,3;-21,9)
Mato Grosso do Sul 103 (93;111) 9,7 (8,9;10,4) 180 (165;197) 6,3 (5,8;6,9) -34,8 (-41,1;-27,3)
Minas Gerais 1130 (977;1203) 10,1 (8,9;10,7) 1529 (1402;1639) 6,1 (5,5;6,5) -40 (-45,2;-33,5)
Pará 191 (175;211) 7,2 (6,7;8,1) 416 (381;459) 5,9 (5,4;6,6) -17,9 (-25,6;-8,7)
Paraíba 209 (179;243) 8,5 (7,2;9,9) 274 (247;305) 6 (5,4;6,7) -29,7 (-42,5;-15,7)
Paraná 624 (516;667) 11,7 (9,7;12,5) 810 (739;871) 6,4 (5,8;6,9) -45,2 (-50,2;-37,7)
Pernambuco 438 (410;487) 8,9 (8,3;10) 665 (615;733) 6,7 (6,2;7,3) -25,6 (-32,9;-18,1)
Piaui 153 (128;179) 9,1 (7,6;10,7) 216 (200;235) 6 (5,5;6,5) -34 (-43,5;-21,9)
Rio de Janeiro 1375 (1099;1473) 12,9 (10,4;13,8) 1452 (1314;1571) 6,8 (6,2;7,3) -47,4 (-52,3;-38,2)
Rio Grande do Norte 100 (88;125) 5,5 (4,8;7,1) 163 (149;212) 4,3 (3,9;5,6) -21,3 (-32,2;-9,9)
Rio Grande do Sul 593 (554;667) 8,4 (7,8;9,5) 835 (768;922) 5,7 (5,2;6,3) -32,1 (-38,5;-25,1)
Rondônia 49 (45;53) 9,6 (8,8;10,6) 88 (77;101) 5,8 (5,1;6,6) -40 (-48,2;-30,3)
Roraima 7 (7;8) 9,1 (8,1;10,9) 19 (17;24) 5,6 (4,9;6,6) -38,6 (-48,5;-27,7)
São Paulo 2259 (2009;2403) 9,6 (8,8;10,3) 3190 (2945;3415) 6,1 (5,7;6,6) -36,3 (-42,3;-30)
Santa Catarina 275 (251;292) 9,8 (8,9;10,5) 392 (362;439) 5,2 (4,8;5,8) -47,4 (-52,3;-40,2)
Sergipe 77 (71;85) 7,8 (7,2;8,7) 125 (115;138) 5,7 (5,2;6,3) -27,4 (-36,2;-17,9)
Tocantins 48 (38;57) 9,6 (7,9;11,3) 90 (82;99) 6,2 (5,7;6,8) -35,2 (-46,1;-21,6)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Número de DALYs, taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, para homens, no Brasil e unidades federativas, 1990 e 2017, e variação percentual das taxas
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.3- AVC
Acre 2185.8 (2055.7;2310) 2076.4 (1959.4;2190.7) 4056.6 (3718;4393) 1351.9 (1238.4;1462.5) -34.9 (-40.6;-28.6)
Alagoas 23037.9 (21383.3;24816.4) 3180.3 (2982.5;3389.5) 25242.2 (23619.6;26883.8) 1808.9 (1691.8;1922.6) -43.1 (-47.4;-38.5)
Amapá 1034.6 (965.2;1094.9) 1809.2 (1692.8;1912.7) 3381.8 (3134.1;3607) 1374.3 (1282.1;1461.9) -24 (-29.8;-17.9)
Amazonas 9553.6 (8816.9;10213.4) 2093.4 (1938.6;2239.5) 17349.2 (15990.9;18542.4) 1276.7 (1184.2;1362.4) -39 (-44;-33.1)
Bahia 79746.6 (73741.8;86039.8) 2199.7 (2029.8;2372.4) 105759.2 (99250.7;112353.9) 1484.6 (1393.9;1577.1) -32.5 (-38.3;-26.2)
Brasil 1340726.1 (1301608;1381197.7) 2901.8 (2824.3;2983.3) 1365881.1 (1320048.1;1415334.4) 1334.5 (1289.5;1381.5) -54 (-55.4;-52.5)
Ceará 40155.1 (36356.6;44353) 1867.9 (1704.3;2040.7) 52142.8 (49017.4;55405.8) 1187.3 (1115.9;1260.7) -36.4 (-42.4;-29.7)
Distrito Federal 8537.6 (8039.6;9059.3) 2500.7 (2380;2633.5) 11737.5 (10824.2;12680.1) 1133 (1049;1220.2) -54.7 (-58.4;-50.9)
Espírito Santo 27222.3 (26107.5;28325.5) 3603.3 (3461.5;3739.1) 24872.8 (23306.7;26481.7) 1282 (1202.4;1361.2) -64.4 (-66.8;-61.8)
Goiás 29376.9 (27812.5;31309.7) 2478.4 (2351.1;2632) 36251.9 (33907.6;38650.9) 1128.3 (1056.4;1200.3) -54.5 (-57.7;-50.9)
Maranhão 48618.1 (43268.6;54586.2) 3233.4 (2920.4;3559.2) 52331.8 (48765.6;56040.7) 1736.2 (1619.1;1857) -46.3 (-52.5;-39.3)
Mato Grosso 10626.9 (9676.9;11652.5) 2101.4 (1919.4;2294.5) 18983.8 (17675.4;20267.4) 1183.4 (1106.4;1259.7) -43.7 (-49;-37.5)
Mato Grosso do Sul 14122.2 (13298.1;14951) 2705.6 (2569.5;2851.5) 18664 (17425.5;19960.7) 1387.8 (1299.8;1482.5) -48.7 (-52.3;-44.6)
Minas Gerais 161794.5 (154754.4;170766.6) 3124.2 (2993.3;3285.8) 143536.1 (135085.5;153049.9) 1231.9 (1157.6;1313.9) -60.6 (-63.5;-57.7)
Pará 28382.9 (26206.8;30473.3) 2437.9 (2254.7;2606.9) 51273.2 (47548.3;54706.6) 1571.3 (1462.4;1670.3) -35.5 (-41.2;-29.3)
Paraíba 22193 (20368;24263.9) 1936.3 (1764.3;2121.9) 27109.7 (24423.5;30026.9) 1350.3 (1216.8;1495.6) -30.3 (-38.8;-20.4)
Paraná 92749.7 (88831.5;96784.9) 3678.5 (3538.6;3825.8) 80945 (75854.2;86058.7) 1400.7 (1313.7;1487) -61.9 (-64.5;-59.2)
Pernambuco 65395.8 (62156.5;68861.5) 2991 (2847;3142.5) 69666.6 (65443.1;74126) 1614.1 (1513.1;1713.9) -46 (-49.6;-42.1)
Piauí 19669.4 (17738.3;21781.8) 2619.3 (2388.7;2872.8) 23916.7 (22435.2;25778.9) 1448.6 (1356.9;1561.6) -44.7 (-50;-38.8)
Rio de Janeiro 184276.5 (175451.6;192077) 3962.5 (3782.2;4120.9) 137791.2 (129209;147280.8) 1484.8 (1394;1583.2) -62.5 (-65.1;-59.8)
Rio Grande do Norte 13443.1 (12350.1;14560.8) 1633.8 (1495.3;1773.6) 18039.1 (16816.2;19404) 1085.1 (1009.3;1170.2) -33.6 (-40.6;-26.1)
Rio Grande do Sul 90124.8 (85087.9;94419.2) 2897.9 (2730.7;3029.6) 85557 (78513.9;91514.3) 1310.6 (1204.4;1399.5) -54.8 (-58.2;-51.3)
Rondônia 7265.8 (6579.4;8016.9) 3011.3 (2742.2;3291.6) 9560.1 (8267.2;11057.2) 1294.1 (1124.2;1488.5) -57 (-63.3;-49.7)
Roraima 949.2 (833.8;1085.1) 2284.8 (2043.1;2564.1) 2144.1 (1803.1;2514.8) 1185.9 (1008.1;1374.6) -48.1 (-57.3;-38.1)
Santa Catarina 37772.9 (35903.6;39627.8) 3023.9 (2877.4;3170.4) 37174.2 (34286.7;39901.5) 1075 (995.5;1150.9) -64.4 (-67;-61.7)
São Paulo 306031.7 (291022;320718.4) 2950.4 (2815.7;3084) 284773.8 (266487.2;302539.1) 1234.2 (1156.7;1308.1) -58.2 (-61;-55)
Sergipe 10495.6 (9904.8;11088.7) 2433.8 (2298.2;2564.6) 14207 (13364.2;15173.1) 1497.7 (1410.4;1596.9) -38.5 (-43.4;-33.2)
Tocantins 5963.4 (4989.1;6786.8) 2363.3 (2064.7;2648.7) 9413.7 (8582.8;10360.7) 1316 (1200;1448.6) -44.3 (-51.5;-34.9)
B.2.3.1- AVC Isquêmico
Acre 618.6 (570.6;666.7) 717.8 (663.9;771.4) 1173.2 (1053.7;1293.6) 441.9 (397;487.4) -38.4 (-45.2;-31.1)
Alagoas 7174.6 (6632.2;7849.1) 1129.9 (1044.1;1234.1) 8207.6 (7511.2;8930.5) 631.6 (579.3;686.7) -44.1 (-50.1;-37.8)
Amapá 321.8 (294.1;347.8) 700 (641.2;755.6) 983.4 (886.2;1080.5) 479 (432.3;523.2) -31.6 (-38.3;-24.5)
Amazonas 2794 (2546.9;3043.9) 750.3 (685.8;817.2) 4980.4 (4506.6;5491.5) 422.3 (382.8;464.2) -43.7 (-49.3;-37.3)
Bahia 23360.8 (21326.4;25677.3) 723.9 (659.9;793.4) 32950.3 (30333.4;35703.4) 486 (447.3;526.4) -32.9 (-40;-25.2)
Brasil 399936.6 (384258.7;417610.5) 1011 (973.7;1050.4) 444686.8 (419137.4;471530) 463.4 (436.9;490.2) -54.2 (-56.5;-52.2)
Ceará 11960.3 (10725.4;13374.7) 616.7 (550.4;690.6) 17787 (16310.4;19333.8) 418.8 (383.3;456.6) -32.1 (-41;-23.5)
Distrito Federal 2081.9 (1927.3;2271.5) 863.5 (801.5;934.9) 3486.6 (3111.4;3853.3) 415.1 (374.3;456) -51.9 (-56.9;-46.2)
Espírito Santo 8136.6 (7612.8;8726.9) 1280.8 (1203.2;1368.2) 7872 (7206.4;8608.3) 435.9 (399.3;475.3) -66 (-69.1;-62.6)
Goiás 7772.7 (7148.3;8470.7) 799.3 (741.5;864.3) 10856.7 (9840;11962.2) 369.8 (336.1;405.8) -53.7 (-58.1;-48.6)
Maranhão 11361.5 (10150.7;12898.4) 901.9 (799.8;1020.4) 16393.4 (14900.7;17870.1) 578.9 (527.5;630.6) -35.8 (-43.4;-26.8)
Mato Grosso 3275.8 (2935.7;3611.7) 809.8 (728.8;890) 5907.8 (5344;6475.2) 410.9 (371.6;449.3) -49.3 (-54.9;-43.2)
Mato Grosso do Sul 4003.7 (3719.2;4320.3) 920.9 (857.5;990.1) 5616.4 (5139.2;6154.2) 451.4 (413.3;493.6) -51 (-55.7;-45.4)
Minas Gerais 45397.8 (42188;49142.4) 1032 (966.8;1106.1) 45377.1 (41325.5;49776.8) 404.9 (369;443.4) -60.8 (-64.6;-56.6)
Pará 9746.8 (8897.6;10553.4) 988.9 (905.2;1067) 16640.4 (15023.9;18274.6) 567 (512.9;618.9) -42.7 (-48.5;-35.9)
Paraíba 7338.7 (6537.4;8331.7) 662.5 (589.7;752.4) 8861 (7875.9;9862.6) 451.6 (402;502.2) -31.8 (-42.2;-19.6)
Paraná 29844.1 (27803.5;31821.9) 1395.8 (1309.4;1479.1) 29745 (27186.2;32365.5) 545.8 (499;592.4) -60.9 (-64.7;-56.8)
Pernambuco 20621.5 (19138.5;22088.7) 1056.1 (986.5;1126.5) 20528.9 (18761.4;22301) 512.2 (469;555.5) -51.5 (-56.3;-46.5)
Piauí 5761.5 (5099.4;6525) 885.1 (784;1003.8) 7811.8 (7126.5;8529.2) 487.7 (445.2;532.9) -44.9 (-51.4;-37.5)
Rio de Janeiro 49857.6 (46267.7;53745.2) 1274.3 (1191;1361.4) 41594.5 (37885.7;45512.7) 476.1 (433.5;520.1) -62.6 (-66.3;-58.8)
Rio Grande do Norte 5114.5 (4628.4;5664.3) 660.2 (597.4;731) 6177.2 (5613.2;6753.1) 387.4 (351.2;423.7) -41.3 (-48.9;-33.4)
Rio Grande do Sul 31368.4 (29142.6;33607.5) 1192.5 (1112.2;1269.8) 29881.3 (26896.7;32904.7) 479.7 (434.4;526.7) -59.8 (-63.4;-55.4)
Rondônia 1976.1 (1763.6;2194.1) 1102.7 (997.2;1205.7) 3130.3 (2728.8;3606.5) 471.6 (411.8;543.1) -57.2 (-63.5;-49.8)
Roraima 232.6 (203.3;266.8) 829.1 (738.7;936) 622.5 (532.3;717.9) 422.1 (361.6;485.3) -49.1 (-57.1;-39.7)
Santa Catarina 12066 (11272.6;12969.4) 1161.9 (1090.7;1245.2) 12855.1 (11617.8;14085.1) 406.9 (370.4;444.8) -65 (-68.3;-61.2)
São Paulo 92643.3 (86120.5;99963.6) 1076.5 (1003.8;1149) 97487.5 (88497;106189.9) 452.3 (411.4;491.7) -58 (-62;-53.9)
Sergipe 3514.4 (3243.3;3784.8) 896.1 (827.4;963) 4688.6 (4301.9;5103) 537 (492.6;584.8) -40.1 (-46.2;-32.9)
Tocantins 1590.9 (1380.1;1806.6) 799.2 (704.9;903.2) 3070.7 (2762.7;3412.2) 454.9 (409.6;504.6) -43.1 (-50.8;-33.4)
B.2.3.2- Hemorragia Intracerebral
Acre 1167.7 (1091.3;1249.8) 1103.5 (1027.3;1177) 2307.8 (2068.3;2536.5) 749.5 (674.7;823.3) -32.1 (-39.6;-23.9)
Alagoas 12772.1 (11548.1;13954.3) 1755.3 (1608.7;1896.2) 14334.6 (13275.7;15483.4) 1004.8 (929.5;1085.5) -42.8 (-48.1;-36.7)
Amapá 560.5 (514.3;598.7) 932.7 (858.7;997.3) 1937.6 (1732.9;2099.3) 748.9 (677.5;810.1) -19.7 (-27.5;-11)
Amazonas 5416 (4917.7;5858.5) 1146.7 (1043.6;1240.1) 10027.2 (8951.6;10869.8) 713.8 (645.2;772.7) -37.8 (-44;-30.6)
Bahia 44882.2 (40975.9;49072.8) 1234.7 (1126.8;1348.4) 59717.2 (55175.3;64266.8) 825.2 (762.5;886.5) -33.2 (-40.1;-25.3)
Brasil 770369.3 (745080;807453.6) 1601 (1552.2;1665.3) 746738 (720304;771926) 709.9 (684.6;733.7) -55.7 (-57.5;-53.9)
Ceará 21836.7 (19497.2;24283.5) 1026.3 (913.7;1136) 27995 (25907.6;30104.9) 631 (584.4;678.5) -38.5 (-44.8;-30)
Distrito Federal 5129.2 (4782;5672.3) 1378.5 (1293.1;1493.8) 6413 (5860.8;7055.5) 577.3 (530.7;632.9) -58.1 (-62.2;-53.6)
Espírito Santo 15950.1 (15082.9;17014.5) 2001.8 (1896;2121.2) 13712.2 (12714;14769.9) 687.1 (637.9;738.7) -65.7 (-68.6;-62.6)
Goiás 17762.5 (16634;19235.8) 1430.3 (1342.8;1543.6) 20310.6 (18792.9;21876.5) 613.1 (566.7;659.2) -57.1 (-61.3;-52.8)
Maranhão 28903.2 (24480.3;33872.2) 1930 (1685.5;2188.7) 28870.1 (26565.9;31653.8) 946.4 (871.3;1037.4) -51 (-58.3;-42.1)
Mato Grosso 5628.1 (5070.6;6250.4) 1062.2 (956.7;1176.1) 10360.1 (9507.4;11268.1) 622.6 (573.7;675.4) -41.4 (-48.1;-33.7)
Mato Grosso do Sul 8383 (7809.6;8980.7) 1528.5 (1437.3;1632.1) 10743.1 (9937.4;11597) 776.6 (718.3;836.1) -49.2 (-53.7;-44.1)
Minas Gerais 96380.6 (91111.2;106323.6) 1776.3 (1681.8;1936) 78424.5 (72806.4;84694.7) 659.8 (613.3;712.3) -62.9 (-66.6;-59.4)
Pará 15142.2 (13771.6;16408.1) 1245 (1128.4;1348.2) 28065.2 (25497.2;30355.1) 832.9 (758.6;901.5) -33.1 (-40.6;-24.6)
Paraíba 11940.1 (10701.6;13143.1) 1052.4 (943.8;1157.3) 15086.6 (13425.1;17023.7) 746.3 (664.9;841.2) -29.1 (-39;-17.3)
Paraná 52954.5 (49873.2;56180.2) 1974.1 (1867.5;2087) 41469.1 (38186.9;44696.4) 694.9 (641.3;748.6) -64.8 (-68.2;-61.6)
Pernambuco 38213.7 (35818.5;40711.7) 1697.4 (1591.6;1806.2) 40983.9 (38031;44233.3) 927.6 (861.4;998.2) -45.4 (-49.9;-40.2)
Piauí 11080.4 (9834.8;12452) 1461.3 (1308.5;1628.8) 13195.7 (12198.6;14309.5) 791.9 (731.9;859.9) -45.8 (-51.9;-38.3)
Rio de Janeiro 112722 (106431.2;121878.2) 2297.5 (2175.7;2458.4) 79599.8 (73519.4;85665.3) 832.6 (772;895.4) -63.8 (-66.8;-60.5)
Rio Grande do Norte 6460 (5806.7;7074.2) 795 (712.9;873.8) 9624.8 (8747.5;10531.3) 571.4 (519.9;624.3) -28.1 (-37.1;-17.4)
Rio Grande do Sul 49620.5 (46236.1;52719.3) 1469.8 (1370.4;1556.4) 46196.2 (41693.4;49971.8) 687 (620.3;740.7) -53.3 (-57.8;-48.8)
Rondônia 4291.7 (3827.1;4779.5) 1649.2 (1485.9;1829.5) 5219.4 (4433.5;6116.6) 681.4 (579.1;794.2) -58.7 (-65.9;-50.3)
Roraima 540.1 (467.9;624.4) 1208.3 (1063.9;1371.2) 1177.9 (971;1399.6) 616 (514.5;726.2) -49 (-59.4;-37.6)
Santa Catarina 21310.9 (20042.4;22571.8) 1599.1 (1505.4;1692.3) 19391.8 (17418.6;21070.9) 538.4 (485.1;583.1) -66.3 (-69.7;-63)
São Paulo 172309 (162089.8;184997.1) 1566.5 (1474;1673.6) 148579.1 (137505.7;159473) 622.3 (576.6;667) -60.3 (-63.5;-56.5)
Sergipe 5586 (5171.6;5990.8) 1301.8 (1199.4;1396) 7869.5 (7245.8;8471.6) 807.4 (743.9;870.3) -38 (-44.4;-30.7)
Tocantins 3426.4 (2825.3;3946.7) 1306.7 (1114.8;1488.8) 5125.9 (4593.1;5697.7) 703.9 (629.4;782.3) -46.1 (-53.8;-35.7)
B.2.3.3- Hemorragia Subaracnóidea
Acre 399.5 (338.4;452.9) 255 (224.7;282.1) 575.6 (512.3;647.3) 160.5 (142.9;180.2) -37.1 (-46.3;-25.3)
Alagoas 3091.2 (2560.5;3728.8) 295.1 (256.9;338.7) 2700.1 (2424.9;3128.4) 172.5 (155.2;198.2) -41.5 (-51.6;-28)
Amapá 152.3 (137.1;172.9) 176.6 (159.2;208.9) 460.9 (405.1;563.3) 146.5 (129;179.3) -17.1 (-28.4;-3.6)
Amazonas 1343.6 (1203.1;1505.9) 196.3 (176.8;224.8) 2341.6 (2099;2674.1) 140.6 (126.5;160.4) -28.4 (-37.6;-17.3)
Bahia 11503.7 (10112.3;12962.3) 241.1 (213.5;272.3) 13091.8 (11817.2;15500) 173.4 (156.8;204.8) -28.1 (-37.4;-15.5)
Brasil 170420.1 (137803.5;181911.2) 289.9 (237.9;307.2) 174456.3 (165617.4;190897.1) 161.2 (152.9;175.4) -44.4 (-48.2;-31.2)
Ceará 6358.1 (4960.5;8487.7) 224.9 (181.7;281.6) 6360.8 (5714;7533.9) 137.4 (123.6;162) -38.9 (-51.8;-23.8)
Distrito Federal 1326.5 (1012.9;1471.9) 258.7 (192.2;284.4) 1837.9 (1527.4;2085.5) 140.6 (113.6;158.6) -45.7 (-52.6;-36.5)
Espírito Santo 3135.6 (2225.9;3470.1) 320.7 (225.1;353.4) 3288.6 (2923.6;3700.8) 159 (141.6;178.1) -50.4 (-57.2;-31.6)
Goiás 3841.6 (3321.9;4212.2) 248.8 (213.8;272.9) 5084.6 (4525.1;5969.8) 145.5 (130.1;169.2) -41.5 (-48.9;-27.5)
Maranhão 8353.4 (6626.3;10082.5) 401.5 (324.6;464) 7068.2 (6109.5;7958.4) 210.9 (181.9;237.7) -47.5 (-55.7;-34.1)
Mato Grosso 1723 (1532.7;1937.7) 229.3 (203.9;259.4) 2715.9 (2409.9;3105) 149.9 (133.5;169.8) -34.6 (-43.9;-24.4)
Mato Grosso do Sul 1735.6 (1459.8;1929.6) 256.1 (216.3;282.8) 2304.4 (2053.5;2587.7) 159.7 (142.7;178.4) -37.7 (-46.5;-26.4)
Minas Gerais 20016 (14378.2;22114) 315.9 (228;348.2) 19734.6 (17598.5;21729.3) 167.2 (149.8;183.9) -47.1 (-53.4;-30.5)
Pará 3493.9 (3052.8;3985.1) 204 (180.5;243) 6567.6 (5796.3;7642.6) 171.5 (151.3;200.7) -15.9 (-26.5;-2.6)
Paraíba 2914.1 (2445;3552.5) 221.5 (186.3;261.9) 3162 (2739.4;3774.1) 152.3 (132;181.2) -31.2 (-44.8;-12.3)
Paraná 9951.1 (7039.7;10916.8) 308.7 (213.4;339.7) 9730.8 (8612.3;10810.2) 160 (141.5;176.9) -48.2 (-54.6;-32.2)
Pernambuco 6560.6 (5947.2;7353.4) 237.5 (216.1;264.8) 8153.8 (7346.1;9731.2) 174.3 (157.3;207.5) -26.6 (-35.5;-15.6)
Piauí 2827.6 (2252.6;3497.2) 273 (224.6;324.2) 2909.2 (2626.4;3236.3) 168.9 (152.7;187.7) -38.1 (-49;-24.2)
Rio de Janeiro 21696.8 (12606.3;24282.3) 390.7 (228.4;436.3) 16596.8 (14887;18587.5) 176.1 (157.6;196.4) -54.9 (-61.3;-27.9)
Rio Grande do Norte 1868.7 (1569.2;2321.5) 178.6 (151.8;242.9) 2237 (1953.7;3000.2) 126.3 (110.4;169.3) -29.3 (-41.4;-13.1)
Rio Grande do Sul 9135.9 (8004;9984.6) 235.6 (207.7;257.1) 9479.5 (8496.8;10627.1) 143.9 (129.5;161.1) -38.9 (-46;-29.1)
Rondônia 998 (861.6;1120.5) 259.4 (226.5;292.9) 1210.5 (998.6;1457.5) 141.1 (116.3;169) -45.6 (-56.4;-32.5)
Roraima 176.6 (151.6;207.6) 247.4 (214.1;288.5) 343.6 (283.1;418.6) 147.7 (122.5;178.1) -40.3 (-52.6;-26)
Santa Catarina 4396 (3777.2;4803.4) 262.9 (223.5;286.9) 4927.3 (4405.4;5845.1) 129.8 (117;151.9) -50.6 (-57.1;-36.4)
São Paulo 41079.4 (30860;45135.8) 307.4 (238.8;335.9) 38707.2 (35088.4;43735.2) 159.6 (144.9;178.4) -48.1 (-54.5;-31.5)
Sergipe 1395.2 (1215.1;1623.4) 235.9 (209.6;267.2) 1648.9 (1489.4;1907.3) 153.3 (138.8;176.8) -35 (-44.4;-23.1)
Tocantins 946.1 (683.9;1191.2) 257.4 (195.8;315.3) 1217 (1071.4;1397.6) 157.3 (138.6;181.4) -38.9 (-51.6;-20.1)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Número de DALYs, taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, para mulheres, no Brasil e unidades federativas, 1990 e 2017, e variação percentual das taxas
Causa de morte e localização 1990 2017 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.3- AVC
Acre 1767.8 (1667.5;1870.6) 1862.6 (1754.2;1968.1) 3210.2 (2987;3441.9) 1026.8 (954.3;1102.8) -44.9 (-49.1;-40.5)
Alagoas 20195.9 (18814.5;21710) 2493.7 (2346.1;2633.1) 24797.1 (23207.9;26570.3) 1438.5 (1347.2;1540) -42.3 (-46.8;-36.9)
Amapá 885.9 (829.3;941.5) 1535.4 (1426.6;1629.7) 2656 (2406.8;2886.7) 998.8 (904.3;1088) -34.9 (-40.6;-29)
Amazonas 8123.3 (7479.5;8682.2) 1784.6 (1640.3;1906.5) 14351.6 (13285.1;15406.9) 1007.4 (932.8;1079.1) -43.5 (-48.1;-38.3)
Bahia 77106.2 (71098.5;83950.6) 1933.3 (1780.5;2103.5) 89411.6 (83626.9;95362.2) 1033.8 (966.7;1102) -46.5 (-51.4;-41.3)
Brasil 1107653.4 (1072336.2;1140018.5) 2162.9 (2095.1;2225.5) 1228780.5 (1175631.6;1283687.7) 990.7 (947.7;1034.7) -54.2 (-55.9;-52.7)
Ceará 37337.5 (33441.1;40681.5) 1555.4 (1404.6;1695.6) 51423.9 (47690.4;54659.7) 951.5 (881.9;1012.3) -38.8 (-44.5;-32.1)
Distrito Federal 8067.4 (7639.3;8468) 2039.3 (1936;2134.4) 10665.5 (9807.7;11556.2) 770.8 (709.6;836.4) -62.2 (-65.4;-58.8)
Espírito Santo 21284.7 (20412.8;22164.8) 2644.9 (2544.4;2750.1) 21595.1 (20097.5;23121.8) 941.9 (877;1008) -64.4 (-67;-61.7)
Goiás 23755.9 (22547.1;25022.6) 2280.3 (2172.2;2397.1) 30858.1 (28577.4;33385.6) 870.2 (806.8;940.7) -61.8 (-64.7;-58.9)
Maranhão 26645.2 (23289;30127.1) 1598.1 (1391.9;1827.3) 38732.2 (35890.3;42214.2) 1118.5 (1036;1221.3) -30 (-37.8;-20.8)
Mato Grosso 7767.3 (7044.7;8529.5) 1700 (1544;1865.8) 14325.6 (13207.9;15664.7) 918.2 (846.6;1003.1) -46 (-52.2;-38.9)
Mato Grosso do Sul 10877.7 (10222.6;11460.6) 2195.2 (2083.8;2306.8) 15366.3 (14302.6;16510.3) 1046.1 (973.5;1122.9) -52.3 (-56.3;-48.4)
Minas Gerais 123754.1 (117958.9;129630.2) 2196.3 (2102.1;2298.1) 127819.1 (119352.2;136487.9) 939 (876.7;1002.2) -57.2 (-60.1;-54.4)
Pará 25165.5 (23222.5;26905.8) 2068.3 (1909.5;2211.6) 37338 (34648.9;39990.2) 1071.3 (992.2;1149.1) -48.2 (-52.7;-43.4)
Paraíba 22951.4 (21103.1;24889.3) 1790 (1649;1937.3) 27800.7 (25165.5;30858.9) 1093.1 (988.4;1214.1) -38.9 (-45.7;-30.9)
Paraná 68876 (65849.9;71792.3) 2694.2 (2581.2;2801.1) 70346.7 (65904.8;75129.8) 1027.9 (964.2;1097.5) -61.8 (-64.3;-59.1)
Pernambuco 65476.7 (62212.1;68590.4) 2548.1 (2424;2666.7) 66471.3 (61893.2;70853.2) 1189.6 (1108.5;1266.9) -53.3 (-56.3;-50)
Piauí 14762.7 (13259.2;16152.3) 1745.7 (1576.7;1913.4) 21016.8 (19347.1;23129.4) 1080.9 (996;1188.6) -38.1 (-44;-30.8)
Rio de Janeiro 163177.5 (155826.3;170272.8) 2857.2 (2732.3;2972.6) 135969.3 (127343.8;144657.3) 1113.5 (1043.6;1182.9) -61 (-63.6;-58.3)
Rio Grande do Norte 12237.7 (11243.8;13264.5) 1354.1 (1243.1;1464.4) 16462.8 (15243.4;17811.1) 800.9 (741;867.3) -40.9 (-46.3;-34.5)
Rio Grande do Sul 82214.5 (78371.8;85849.8) 2219.2 (2112.8;2314.9) 84773.5 (78795.6;90367.8) 1020.9 (950.7;1088.9) -54 (-57.2;-50.6)
Rondônia 4807.8 (4391.3;5259.5) 2385 (2193.9;2590.8) 7762.8 (6762.2;8807.3) 1058.4 (926.2;1198.1) -55.6 (-62.1;-48.7)
Roraima 619.9 (547.3;696.3) 2014.6 (1792.5;2238) 1500.1 (1285.1;1737.4) 914.8 (787.5;1048.3) -54.6 (-62;-45.2)
Santa Catarina 32138 (30574;33582.2) 2345.2 (2228.7;2447.9) 34801.4 (32383.6;37454.8) 846.2 (788.9;910.2) -63.9 (-66.6;-61.2)
São Paulo 233492.6 (222621.3;243756.9) 2013.9 (1920.5;2105.9) 257929.8 (239779.5;274998.1) 894 (832.2;952.5) -55.6 (-58.7;-52.6)
Sergipe 9537.5 (8911.3;10080.5) 1935.3 (1815.6;2042.8) 13345 (12402.1;14314.6) 1112.9 (1034.8;1191.9) -42.5 (-47.1;-37.1)
Tocantins 4626.6 (3885.4;5271.5) 2097.4 (1835.7;2348.9) 8049.8 (7349.6;8763.6) 1151.2 (1051.9;1253.8) -45.1 (-52.1;-36.8)
B.2.3.1- AVC Isquêmico
Acre 444.9 (409.5;479.3) 608.7 (561.8;654.7) 902.7 (811.5;996.9) 326.8 (294.5;360.3) -46.3 (-51.5;-40.3)
Alagoas 6023.2 (5547.1;6516) 856.7 (788.5;926.5) 7766.5 (7055.1;8495.2) 470.6 (428;514.9) -45.1 (-50.8;-38.9)
Amapá 265.9 (242.6;289.3) 581.6 (530;629.3) 765.2 (674.4;854.7) 336.3 (297;375.7) -42.2 (-48.1;-35.8)
Amazonas 2290.6 (2070;2488.4) 624 (566.8;677.8) 4150 (3727.4;4582.2) 329.5 (295.8;363.5) -47.2 (-52.5;-41.2)
Bahia 22713.7 (20772.4;24878.4) 623.8 (569.8;683.6) 27251.9 (24803.3;29866.6) 310.7 (282.1;341) -50.2 (-55.4;-44.5)
Brasil 331981.3 (316368.4;347711) 747.7 (713.7;780.1) 401935.6 (371989.2;433351) 326.3 (302.2;351.8) -56.4 (-58.8;-54.1)
Ceará 10460.7 (9309.4;11614.4) 483.2 (430.3;536) 17418.5 (15794.8;18990.5) 315.7 (285.6;344.3) -34.7 (-42.2;-25.5)
Distrito Federal 1824.5 (1676.1;1966.4) 685.8 (636.7;737.7) 3106.5 (2760.9;3501.9) 266.2 (237.8;298.3) -61.2 (-65.4;-56.8)
Espírito Santo 6145.4 (5729.6;6600.7) 927.7 (871.2;989.9) 6859.1 (6208.3;7536.9) 304 (275.3;334.3) -67.2 (-70.2;-63.9)
Goiás 6143.4 (5644.8;6602.7) 804.8 (746.4;862.9) 9041.8 (8039.9;10070.3) 277 (247.5;307) -65.6 (-69;-61.8)
Maranhão 6015.4 (5053;7099.9) 444.2 (367.5;530.1) 10822.4 (9615.6;12156.4) 324.4 (288.3;364.7) -27 (-37.1;-14.1)
Mato Grosso 1936.9 (1730.7;2144.1) 579.9 (519.9;639.6) 4094.2 (3653.7;4555.7) 300.5 (269;333.6) -48.2 (-54.3;-40.9)
Mato Grosso do Sul 2719.9 (2519.2;2923.8) 696.2 (644.8;746.8) 4484.7 (4031.8;4957.1) 324.5 (292.4;358.5) -53.4 (-58.3;-48.2)
Minas Gerais 35992.5 (33442.6;38488.3) 745.3 (697.4;793.9) 41120.2 (37036.1;45138.4) 296.9 (267;326.4) -60.2 (-63.8;-56.4)
Pará 8549.8 (7800.8;9221) 821.7 (750.3;883.5) 11848 (10668.4;13072.2) 370.9 (334.4;408.8) -54.9 (-60;-49.8)
Paraíba 6790.1 (6100.7;7542.4) 562.3 (505.8;621.7) 9145.2 (8214.6;10210.5) 345.4 (310;386.5) -38.6 (-46.9;-30)
Paraná 21328.3 (19837.5;22825.2) 1018.3 (954.7;1085.5) 25351.3 (22978.4;27818.6) 381.4 (346;418.7) -62.5 (-65.9;-58.8)
Pernambuco 20813.8 (19337.3;22311.5) 897.4 (835.9;959.7) 20486 (18571.5;22484.9) 371.3 (336.9;407.6) -58.6 (-62.6;-54.3)
Piauí 3806.7 (3359.2;4298.2) 518 (458.2;583.8) 6861.3 (6175.8;7614.2) 348.2 (313.2;386.4) -32.8 (-40.7;-24)
Rio de Janeiro 45951.2 (42906.6;49127.3) 911.1 (852.2;970.1) 42263.4 (38418.9;46502.1) 336.1 (305.4;369.6) -63.1 (-66.4;-59.5)
Rio Grande do Norte 4389.4 (3954;4826.9) 516.8 (465.8;567.9) 5556.1 (4975.4;6161.1) 265.8 (237.2;294.6) -48.6 (-54.5;-41.7)
Rio Grande do Sul 29458.4 (27295.1;31550.4) 895.7 (833.5;953.9) 31776.4 (28691.4;34814.6) 367.6 (331.6;403.4) -59 (-62.7;-55.1)
Rondônia 1058.6 (955.1;1174.3) 804 (731.9;882.3) 2282.1 (1981;2588.8) 357.4 (311.9;404) -55.5 (-62.1;-48.7)
Roraima 140 (122.6;157.4) 739.9 (656.3;827) 433 (371.9;499.1) 331.8 (287.4;379.6) -55.2 (-62.2;-46.2)
Santa Catarina 10349.1 (9571.8;11121) 910.1 (847;972.5) 12306.8 (11098;13645.2) 310.4 (281;342.7) -65.9 (-69.2;-62.4)
São Paulo 72124.2 (66732.6;77418.9) 733.7 (681.9;784.3) 89212.1 (80399.2;97949) 310.1 (280.1;340.3) -57.7 (-61.6;-53.7)
Sergipe 3143.7 (2870.4;3420.7) 683.8 (624.9;743.8) 4299.2 (3883.7;4707.7) 372 (335.7;406.8) -45.6 (-51.6;-39.2)
Tocantins 1101.1 (958.3;1252.5) 685.3 (606.7;768.8) 2331.2 (2078.4;2585.9) 360.1 (321.8;399.9) -47.5 (-54.6;-39.4)
B.2.3.2- Hemorragia Intracerebral
Acre 874.7 (812.9;936.3) 923.1 (856.1;989.3) 1599.2 (1461.9;1744.8) 505.7 (461;552.2) -45.2 (-51.2;-39.3)
Alagoas 9872.6 (9062.5;10730.1) 1226.4 (1127.7;1322.2) 12763.3 (11791.5;13850.8) 733.8 (676.7;796.4) -40.2 (-46.2;-33.1)
Amapá 439.7 (406.5;470) 729.9 (668.2;779.6) 1319.2 (1165.7;1460.5) 485.9 (429.7;538.1) -33.4 (-40.7;-24.9)
Amazonas 4241.5 (3841.4;4559.2) 918 (830.8;989.4) 7271.3 (6627.5;7883.3) 503.5 (459.3;545.9) -45.1 (-50.5;-38.7)
Bahia 39495.1 (36010.5;43294.5) 993.4 (903.6;1090.2) 44388.6 (40962.7;47759) 515.9 (475.7;555.3) -48.1 (-53.8;-42.1)
Brasil 563999.7 (545387.7;584682.8) 1070.2 (1035.3;1106.6) 580172.8 (555092.6;606176.7) 465.2 (445;485.9) -56.5 (-58.7;-54.5)
Ceará 18233.6 (16299.5;20228.9) 772.8 (688.7;861.4) 24338.9 (22304.9;26159.7) 453.1 (415.4;487.5) -41.4 (-48.8;-33.2)
Distrito Federal 4240.9 (3979.9;4508.9) 1005.6 (949;1069.6) 4945.6 (4453.2;5505.7) 345.3 (314.1;384.1) -65.7 (-69.4;-61.7)
Espírito Santo 11142.1 (10603;11788.2) 1321.2 (1257.8;1394.8) 10272.9 (9453.4;11232.8) 445.3 (409.9;487.5) -66.3 (-69.3;-63.3)
Goiás 12855.7 (12049.1;13698) 1147.9 (1079.5;1224.7) 15021.7 (13681.7;16488.2) 415.3 (379.8;455) -63.8 (-67.3;-60.4)
Maranhão 12042.9 (9978.3;14209.6) 765.5 (599.9;923.2) 19249 (17310;21828.7) 557.1 (499.7;633.4) -27.2 (-37.8;-11.3)
Mato Grosso 3853.5 (3437.3;4288.6) 817 (728.9;905.6) 6957.4 (6329.9;7833.2) 433.6 (394.8;486.6) -46.9 (-54.1;-38.6)
Mato Grosso do Sul 5943.8 (5561.7;6313.3) 1148.3 (1080.5;1215) 7653.1 (7025.6;8338.4) 513.4 (471.2;560.2) -55.3 (-59.8;-50.7)
Minas Gerais 64366 (60674.3;68220.4) 1099.1 (1037.2;1163.7) 60695 (56080.7;65783.6) 445.7 (411.9;483) -59.4 (-63;-55.4)
Pará 12175.4 (11139.9;13184) 978.4 (892.1;1059.1) 18001 (16375.4;19576.3) 509.9 (464;555.1) -47.9 (-54;-41.2)
Paraíba 11111.2 (10082.5;12219.4) 868.2 (787.5;953.5) 13504.5 (12040;15189.3) 535.8 (476.9;602.6) -38.3 (-46.7;-28.4)
Paraná 35261.9 (33355.6;37203.2) 1301.5 (1228.2;1375.8) 31095.5 (28671.9;33664.6) 447.4 (412.9;484.6) -65.6 (-68.7;-62.4)
Pernambuco 35167.1 (32910.5;37242.7) 1332.3 (1249;1406.7) 33631.6 (31062.3;36327.8) 599.2 (553.1;646.5) -55 (-59;-50.7)
Piauí 7420.7 (6473.6;8346.5) 888.3 (775.7;998.5) 10247.3 (9366.6;11531.5) 529 (483;595.7) -40.4 (-47.8;-31.4)
Rio de Janeiro 88936.8 (84337.9;93896) 1501.8 (1423.9;1582.9) 68013.5 (62977;73431) 555.9 (515.3;599.1) -63 (-66.3;-59.6)
Rio Grande do Norte 5639.4 (5056.1;6175) 626.4 (561.9;686.3) 7840.9 (7108.5;8599.3) 383.7 (347.4;421.2) -38.7 (-46.2;-29.8)
Rio Grande do Sul 40495.5 (37779.2;42885.8) 1036.9 (967.6;1098.7) 39133.7 (35903.4;42395.5) 472.7 (432.7;511.1) -54.4 (-58.6;-49.5)
Rondônia 2628.7 (2371.6;2911.8) 1227.9 (1117.7;1354.8) 3779.6 (3245.4;4369.3) 501 (433.1;579.1) -59.2 (-65.6;-51.6)
Roraima 328.6 (286.2;373.3) 992.7 (870.9;1116.1) 736.9 (617.6;867) 430 (361.4;504.1) -56.7 (-64.8;-46.4)
Santa Catarina 16220.7 (15245.9;17192.1) 1118.6 (1052.1;1188.3) 15768.8 (14405.3;17123) 377.2 (345.2;409.4) -66.3 (-69.7;-62.9)
São Paulo 113907.8 (107421.3;120928.2) 942.3 (886.5;1000.5) 111325 (103027.9;120702.2) 383.3 (354.6;414.6) -59.3 (-63;-55.4)
Sergipe 4704.6 (4381.8;5022.3) 963.7 (897.4;1029.7) 6663.5 (6108.6;7225.7) 552.1 (505.7;600.2) -42.7 (-48.5;-35.7)
Tocantins 2399.1 (1989.3;2787) 1052.1 (902.5;1202.8) 3955.6 (3568.2;4425.3) 560.4 (506.6;627.1) -46.7 (-54.7;-36.9)
B.2.3.3- Hemorragia Subaracnóidea
Acre 448.2 (407.7;497.6) 330.8 (302.6;363.3) 708.2 (638.6;792.2) 194.2 (174.9;216.9) -41.3 (-48.2;-34)
Alagoas 4300.1 (3589.8;5036.8) 410.6 (351;468.2) 4267.3 (3820.8;4772.1) 234.1 (208.7;261.8) -43 (-52.3;-29.4)
Amapá 180.3 (163.7;201.9) 223.8 (202.9;252.3) 571.6 (511;643.2) 176.7 (158;198.7) -21.1 (-31.2;-9.9)
Amazonas 1591.2 (1418;1789.1) 242.6 (217.8;270.9) 2930.3 (2642.6;3273.2) 174.4 (156.1;192.6) -28.1 (-37.5;-18.8)
Bahia 14897.5 (13287.5;16507.2) 316.1 (283.5;351.9) 17771.1 (16139.9;19611.7) 207.1 (188.6;228.5) -34.5 (-42.6;-24.3)
Brasil 211672.4 (199208.9;221899.8) 345.1 (324.7;363.2) 246672.1 (231937.6;260803.4) 199.2 (187.4;210.1) -42.3 (-46.1;-39)
Ceará 8643.3 (6852.4;10486.6) 299.4 (244.9;357.4) 9666.5 (8677.7;10600.5) 182.6 (164.3;200.1) -39 (-50.4;-26.6)
Distrito Federal 2002 (1803;2168.1) 347.8 (316.2;375.5) 2613.4 (2319;2911.4) 159.4 (141;177.5) -54.2 (-59.3;-47.8)
Espírito Santo 3997.2 (3523.8;4296.8) 396 (345.6;425) 4463.2 (4009.2;4908.2) 192.6 (173.2;211.2) -51.4 (-56.9;-43.7)
Goiás 4756.8 (4346.9;5221.2) 327.6 (300.5;359.9) 6794.6 (6134.7;7577.9) 177.8 (160.7;197.9) -45.7 (-51.6;-38.3)
Maranhão 8586.9 (6391.4;11138.3) 388.5 (299.2;491.9) 8660.9 (7731.3;9594.6) 237 (211.2;263.3) -39 (-51.4;-23.6)
Mato Grosso 1976.9 (1748.4;2227.8) 303.1 (269.1;341.7) 3274 (2926.5;3658.6) 184.1 (165.4;204.9) -39.2 (-47.7;-29.8)
Mato Grosso do Sul 2214 (1954.7;2430) 350.7 (315.4;383.4) 3228.6 (2883.8;3619.9) 208.3 (186.4;233) -40.6 (-48.1;-31.7)
Minas Gerais 23395.6 (21454;25318.2) 351.9 (322.6;381.9) 26003.9 (23613.8;28559.9) 196.4 (178.8;214.9) -44.2 (-50;-37.7)
Pará 4440.4 (3942.4;4957.1) 268.2 (240.2;299.8) 7488.9 (6775.2;8285.9) 190.5 (171.6;211.1) -29 (-37.1;-19.3)
Paraíba 5050.1 (4155.5;5968.1) 359.5 (295.4;422.2) 5151 (4436.2;5838.5) 211.9 (182.7;240.2) -41.1 (-53;-27.7)
Paraná 12285.8 (11347.4;13264.7) 374.4 (343.4;405.7) 13900 (12510.5;15373.5) 199.1 (179.6;219.1) -46.8 (-53;-40.1)
Pernambuco 9495.7 (8636;10672.6) 318.4 (290.2;361.1) 12353.7 (11186.9;13775.6) 219.1 (198.7;243.7) -31.2 (-39.6;-22.6)
Piauí 3535.2 (2860;4197.6) 339.4 (278.5;403.6) 3908.2 (3521;4310.2) 203.7 (183.8;224.5) -40 (-49.9;-27.8)
Rio de Janeiro 28289.5 (25607.4;30525.9) 444.3 (403.8;479.4) 25692.3 (23122.1;28299.6) 221.6 (200.2;244.4) -50.1 (-55.6;-43.3)
Rio Grande do Norte 2208.9 (1905.2;2660.8) 210.9 (182.9;259.7) 3065.8 (2734.3;3771.2) 151.5 (135.3;186) -28.2 (-39.4;-16.6)
Rio Grande do Sul 12260.7 (11247.3;14498.1) 286.6 (262.9;339.3) 13863.3 (12280.1;15559.9) 180.6 (160.3;202.5) -37 (-44.8;-29)
Rondônia 1120.6 (1002.6;1250.6) 353.1 (315.9;395.2) 1701.2 (1439.6;1988.5) 200 (169.9;234.3) -43.4 (-53.1;-32.1)
Roraima 151.2 (130.8;181.3) 282 (242.8;345.6) 330.2 (273;406.4) 153 (127.5;188.8) -45.8 (-56.1;-32.4)
Santa Catarina 5568.2 (5137.7;6024.6) 316.5 (290.8;342.4) 6725.8 (6071.4;7486.2) 158.6 (143.3;176.2) -49.9 (-55.5;-43.4)
São Paulo 47460.6 (43883.2;51172.3) 337.9 (312.7;365.3) 57392.7 (51539.2;62558) 200.5 (180.5;218) -40.7 (-47.3;-33.9)
Sergipe 1689.1 (1486.9;1900.9) 287.8 (256.9;325.8) 2382.3 (2149.2;2638.5) 188.8 (170.3;210.1) -34.4 (-43.9;-25.1)
Tocantins 1126.4 (839.2;1386.1) 360 (280.2;438.7) 1763.1 (1534.2;1962.8) 230.6 (201.3;256.2) -35.9 (-48.5;-18.3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, para homens, no Brasil, 1990 e 2017, e variação percentual das taxas
Causa de morte e grupo etário 1990 2017 Variação percentual (II 95%)
B.2.3- AVC
15-49 anos 986,5 (948,5;1024,5) 432,8 (415,2;452,5) -56,1 (-58,4;-53,6)
50-69 anos 7867,2 (7612,7;8119,2) 3538 (3397,9;3689,8) -55 (-56,9;-53,1)
5-14 anos 83,1 (69,7;91,1) 35,7 (31,8;39,7) -57,1 (-62,4;-50,4)
70+ anos 17208,4 (16711,1;17728,9) 9407,6 (9006,8;9773,9) -45,3 (-47,4;-43,3)
Padronizadas por idade 2901,8 (2824,3;2983,3) 1334,5 (1289,5;1381,5) -54 (-55,4;-52,5)
Todas as idades 1814,8 (1761,9;1869,6) 1319,5 (1275,2;1367,3) -27,3 (-29,6;-24,7)
Abaixo de 5 410,2 (325,6;536,1) 70,8 (58,7;84,7) -82,8 (-87,9;-75,9)
B.2.3.1- AVC Isquêmico
15-49 anos 146,5 (137,3;158,8) 66,3 (60;73,2) -54,7 (-59,7;-50,7)
50-69 anos 2283,9 (2165,8;2401,8) 952,4 (887,3;1020) -58,3 (-61,1;-55,6)
5-14 anos 10,9 (8,9;13,6) 4,2 (3,3;5,5) -61,2 (-66,6;-55,8)
70+ anos 8926,8 (8590,6;9283,7) 4660,5 (4394,5;4925) -47,8 (-50,4;-45,3)
Padronizadas por idade 1011 (973,7;1050,4) 463,4 (436,9;490,2) -54,2 (-56,5;-52,2)
Todas as idades 541,4 (520,1;565,3) 429,6 (404,9;455,5) -20,6 (-25;-17)
Abaixo de 5 24,6 (16,8;34,3) 3 (2,2;3,9) -87,6 (-93,3;-78,5)
B.2.3.2- Hemorragia Intracerebral
15-49 anos 644,8 (614,9;701,4) 257,6 (241,6;271,2) -60,1 (-64,4;-57,1)
50-69 anos 4886,7 (4702,7;5077,9) 2143 (2055,1;2228,8) -56,1 (-58,2;-54)
5-14 anos 25 (20,4;28,9) 10 (8,2;11,8) -60,1 (-69,4;-49,4)
70+ anos 7674,2 (7361,5;7956,2) 4238,2 (4048,2;4415,7) -44,8 (-47,4;-41,9)
Padronizadas por idade 1601 (1552,2;1665,3) 709,9 (684,6;733,7) -55,7 (-57,5;-53,9)
Todas as idades 1042,8 (1008,5;1093) 721,4 (695,9;745,7) -30,8 (-34,2;-27,8)
Abaixo de 5 108,9 (61,6;169) 12,1 (8,8;16) -88,9 (-94,1;-76,9)
B.2.3.3- Hemorragia Subaracnóidea
15-49 anos 195,1 (150,6;208,4) 108,9 (102;128,8) -44,2 (-49,5;-22,9)
50-69 anos 696,6 (566,1;745,5) 442,6 (414,3;479,7) -36,5 (-41,7;-23,2)
5-14 anos 47,2 (39,3;52,5) 21,4 (18,9;24,2) -54,6 (-60,4;-44,4)
70+ anos 607,4 (558;657,4) 508,9 (436,7;551,9) -16,2 (-24,4;-7,6)
Padronizadas por idade 289,9 (237,9;307,2) 161,2 (152,9;175,4) -44,4 (-48,2;-31,2)
Todas as idades 230,7 (186,5;246,2) 168,5 (160;184,4) -26,9 (-32,5;-7,7)
Abaixo de 5 276,7 (203,1;344,3) 55,7 (46,8;65,9) -79,9 (-85,1;-70,4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

– Taxas de DALYs padronizadas por idade (por 100 mil) por AVC e subtipos de AVC, para mulheres, no Brasil, 1990 e 2017, e variação percentual das taxas.
Causa de morte e grupo etário 1990 2017 Variação percentual (II 95%)
B.2.3- AVC
15-49 anos 817,7 (790,3;848,7) 421,7 (400,5;440) -48,4 (-51,1;-45,8)
50-69 anos 5185 (4992,7;5389,2) 2392,8 (2276,5;2511) -53,9 (-56;-51,8)
5-14 anos 69,9 (60,4;76,3) 32,7 (29,4;36,3) -53,2 (-57,8;-47,5)
70+ anos 13838,3 (13364,1;14288,7) 7055,4 (6735,7;7403,1) -49 (-51;-46,9)
Padronizadas por idade 2162,9 (2095,1;2225,5) 990,7 (947,7;1034,7) -54,2 (-55,9;-52,7)
Todas as idades 1466,3 (1419,5;1509,1) 1134,6 (1085,5;1185,3) -22,6 (-25,6;-20)
Abaixo de 5 337,3 (257,9;439) 49,3 (41,5;60,4) -85,4 (-89,9;-78,1)
B.2.3.1- AVC Isquêmico
15-49 anos 104,9 (97,4;113,8) 55,1 (48,1;62,3) -47,5 (-53,4;-42,3)
50-69 anos 1382,3 (1287,6;1474,6) 571,4 (514,2;629,2) -58,7 (-61,7;-55,6)
5-14 anos 7,5 (6,2;9,1) 4,3 (3,2;5,5) -43 (-49,6;-36,6)
70+ anos 7472,4 (7131,5;7787,8) 3643,1 (3416,1;3892) -51,2 (-53,8;-48,8)
Padronizadas por idade 747,7 (713,7;780,1) 326,3 (302,2;351,8) -56,4 (-58,8;-54,1)
Todas as idades 439,5 (418,8;460,3) 371,1 (343,5;400,1) -15,5 (-20,3;-11,3)
Abaixo de 5 18,4 (13;29,6) 2,4 (1,9;3) -87 (-93,1;-79,5)
B.2.3.2- Hemorragia Intracerebral
15-49 anos 460,3 (440,4;483,1) 207 (194,5;220,2) -55 (-58,2;-51,4)
50-69 anos 2968,9 (2849,9;3089,3) 1272,5 (1215,6;1335,2) -57,1 (-59,8;-54,7)
5-14 anos 20,3 (17,3;22,7) 9,4 (8,1;10,8) -53,5 (-60,8;-45,8)
70+ anos 5659,7 (5417,6;5890,7) 2879,7 (2743,7;3027,5) -49,1 (-52;-46,1)
Padronizadas por idade 1070,2 (1035,3;1106,6) 465,2 (445;485,9) -56,5 (-58,7;-54,5)
Todas as idades 746,6 (722;774) 535,7 (512,6;559,7) -28,2 (-31,8;-24,9)
Abaixo de 5 69,4 (45,1;118,1) 7,9 (5,9;10,3) -88,6 (-94,6;-79,9)
B.2.3.3- Hemorragia Subaracnóidea
15-49 anos 252,5 (238,8;265,9) 159,6 (149,6;169,8) -36,8 (-41,6;-31,8)
50-69 anos 833,8 (780,9;891,9) 548,9 (513;588,7) -34,2 (-39,3;-29,1)
5-14 anos 42,1 (35,8;46,5) 19 (17;21,3) -54,8 (-59,7;-48,2)
70+ anos 706,2 (661,2;794,7) 532,6 (494,2;573,3) -24,6 (-32,3;-18,3)
Padronizadas por idade 345,1 (324,7;363,2) 199,2 (187,4;210,1) -42,3 (-46,1;-39)
Todas as idades 280,2 (263,7;293,7) 227,8 (214,2;240,8) -18,7 (-24,1;-13,6)
Abaixo de 5 249,5 (190,9;317,3) 39 (32,9;48,1) -84,4 (-89,1;-77,2)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 109

Grupo etário 1990 2017 Variação percentual (II 95%)
Ambos os sexos
Padronizada por idade 46,3 (41,5;52,1) 46,7 (41,8;52,6) 0,8 (-0,3;1,8)
Abaixo de 5 11,2 (8,9;13,9) 11,3 (9;14,1) 1,1 (-0,8;3,5)
5-14 anos 16,5 (12;22,2) 16,7 (12,3;22,6) 1,1 (-1,4;3,6)
15-49 anos 32,8 (27,1;39) 34,2 (28,2;40,6) 4,2 (0,4;8,2)
50-69 anos 82,4 (67,1;102) 83,4 (67,5;103,2) 1,2 (-1;3,5)
70+ anos 203,1 (165,4;252,3) 214,8 (176,5;263,2) 5,8 (2,2;10,1)
Todas as idades 36,5 (32,5;41) 49 (43,7;55,4) 34,4 (29;39,9)
Masculino
Padronizada por idade 46 (41,1;51,8) 45,5 (40,7;51,5) -1 (-2,5;0,5)
Abaixo de 5 11,2 (8,8;13,8) 11 (8,7;13,7) -1,3 (-4,1;2,5)
5-14 anos 16,5 (11,9;22,2) 16,2 (11,9;22) -1,5 (-5,1;2,7)
15-49 anos 32,6 (26,9;38,7) 33,2 (27,4;39,5) 1,9 (-2,5;5,9)
50-69 anos 81,6 (65,9;100,9) 81,6 (66;101,9) 0 (-3,2;2,9)
70+ anos 198,9 (161,2;247,1) 205,6 (167,7;253,2) 3,4 (-0,4;7,7)
Todas as idades 35,4 (31,4;39,9) 45,7 (40,6;51,9) 29,1 (23,9;34,9)
Feminino
Padronizada por idade 46,6 (41,6;52,4) 47,7 (42,7;53,8) 2,3 (0,8;3,8)
Abaixo de 5 11,3 (9;14) 11,7 (9,4;14,6) 3,7 (0,8;7,2)
5-14 anos 16,6 (12,2;22,2) 17,2 (12,7;23,1) 3,7 (0,3;7,1)
15-49 anos 33 (27,2;39,4) 35,2 (29;41,8) 6,4 (2,1;11)
50-69 anos 83,2 (67,6;103) 85,1 (69,1;105,6) 2,3 (-1;5,3)
70+ anos 206,5 (168,6;257,1) 221,6 (182,6;270,7) 7,3 (2,9;12,4)
Todas as idades 37,6 (33,4;42,3) 52,3 (46,6;59) 39,1 (33,3;45,3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation, 188

– Número de mortes e taxa de mortalidade padronizada por idade por doença de Chagas, por 100 mil habitantes, para homens, em 1990 e 2017, e variação percentual das taxas, no Brasil e suas unidades federativas
Localização 1990 2017 Variação percentual (II 95%)
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%)
Acre 1.3 (1.2;1.5) 1.3 (1.2;1.5) 1.4 (1.2;1.7) 0.5 (0.4;0.6) -64.1 (-71.8;-55.1)
Alagoas 42.6 (32.8;50.5) 6.2 (4.8;7.4) 46.5 (40.2;54.3) 3.3 (2.8;3.8) -47.3 (-58.1;-26.3)
Amapá 0.3 (0.3;0.4) 0.6 (0.6;0.7) 0.7 (0.6;0.8) 0.3 (0.2;0.3) -57.3 (-64.9;-48)
Amazonas 2.9 (2.5;3.2) 0.6 (0.6;0.7) 3.3 (2.8;4.1) 0.2 (0.2;0.3) -62.6 (-69.1;-53.3)
Bahia 449.9 (402.3;501.3) 12.7 (11.3;14.2) 511.7 (459;580.7) 7.2 (6.4;8.1) -43.3 (-51.7;-33)
Brasil 4411.2 (4207.8;4651.3) 9.5 (9;10) 3094.4 (2868.4;3448.7) 3.1 (2.9;3.4) -67.5 (-70.1;-63.8)
Ceará 30.1 (24;40.2) 1.5 (1.2;2) 34.5 (29.7;40.3) 0.8 (0.7;0.9) -48.3 (-62;-32.1)
Distrito Federal 136.9 (127;147.8) 41.3 (38.2;44.7) 108 (93.7;132.2) 11.2 (9.7;13.7) -72.9 (-76.6;-67.7)
Espírito Santo 7.5 (6.8;8.4) 1 (0.9;1.1) 5.9 (5.1;7.3) 0.3 (0.3;0.4) -70.4 (-75;-63.1)
Goiás 684.1 (634.4;744.1) 60.3 (55.7;66) 453.1 (406.4;522.9) 15.1 (13.6;17.4) -75 (-77.7;-71.7)
Maranhão 11.4 (8.5;13.6) 0.9 (0.7;1.1) 11.9 (10.3;14.3) 0.4 (0.3;0.5) -54.2 (-63.5;-31.4)
Mato Grosso 27 (23.5;30.8) 5.5 (4.8;6.2) 36 (31.3;43.8) 2.2 (2;2.7) -58.8 (-65.7;-49.3)
Mato Grosso do Sul 38.9 (34.9;42.8) 7.6 (6.9;8.4) 33.5 (29.3;39.5) 2.5 (2.2;3) -66.8 (-71.9;-60.5)
Minas Gerais 1342.2 (1256.4;1447) 26.6 (24.9;28.7) 744.3 (672;833.9) 6.5 (5.9;7.3) -75.5 (-78.1;-72.3)
Pará 17.3 (15.4;19.4) 1.5 (1.3;1.7) 20.8 (17.5;26) 0.6 (0.5;0.8) -58 (-66.1;-47)
Paraíba 22.1 (16.8;27.9) 2 (1.5;2.5) 23 (19.9;26.6) 1.1 (1;1.3) -43.6 (-58.9;-17.5)
Paraná 253.3 (234.6;273.2) 9.6 (8.9;10.3) 139.8 (125;159.6) 2.5 (2.2;2.8) -74.2 (-77.5;-70.2)
Pernambuco 103.2 (92.7;113) 4.8 (4.3;5.3) 83.8 (73.8;95) 2 (1.7;2.2) -59.4 (-65.6;-51.2)
Piauí 40.4 (33.2;49.7) 5.8 (4.8;7.2) 44.6 (39.4;52.1) 2.7 (2.4;3.1) -53.9 (-63.5;-40.1)
Rio de Janeiro 47.4 (42.8;52.3) 1.1 (1;1.2) 31.7 (27.2;36.8) 0.3 (0.3;0.4) -67.4 (-72.5;-61.1)
Rio Grande do Norte 10.6 (9;12.8) 1.4 (1.1;1.6) 11.3 (9.6;13.1) 0.7 (0.6;0.8) -50.4 (-63.4;-35.3)
Rio Grande do Sul 40.4 (36.3;44.5) 1.3 (1.2;1.5) 28.9 (25.3;34.2) 0.4 (0.4;0.5) -67.3 (-72.2;-60.5)
Rondônia 18.1 (15.5;20.7) 7.2 (6.2;8.2) 14.5 (11.8;18) 1.9 (1.6;2.4) -73.2 (-78.8;-65.6)
Roraima 0.5 (0.4;0.5) 1.1 (0.9;1.3) 0.6 (0.5;0.8) 0.3 (0.3;0.4) -68.4 (-76;-58.3)
Santa Catarina 8.6 (7.7;9.5) 0.7 (0.6;0.8) 7.3 (6.2;8.7) 0.2 (0.2;0.2) -69.9 (-74.9;-62.9)
São Paulo 1039.3 (976.2;1108.4) 9.7 (9.1;10.4) 655 (592.6;739.1) 2.9 (2.7;3.3) -69.8 (-73.2;-65.6)
Sergipe 7 (6;8.3) 1.7 (1.5;2) 7.7 (6.7;8.8) 0.8 (0.7;0.9) -54.3 (-64.5;-42)
Tocantins 27.7 (21.6;34.8) 12 (9.6;15.1) 34.6 (29.6;40.9) 4.9 (4.2;5.7) -59.4 (-69.7;-45.9)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

– Número de mortes e taxa de mortalidade padronizada por idade por doença de Chagas, por 100 mil habitantes, para mulheres, em 1990 e 2017, e variação percentual das taxas, no Brasil e suas unidades federativas
Localização 1990 2017 Variação percentual (II 95%)
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%)
Acre 0.4 (0.4;0.5) 0.5 (0.5;0.6) 0.6 (0.5;0.7) 0.2 (0.2;0.2) -58.7 (-65.8;-49.8)
Alagoas 25.8 (20.2;30.7) 3.5 (2.7;4.2) 33.4 (28.8;38.2) 1.9 (1.7;2.2) -44.4 (-57.5;-24.8)
Amapá 0.2 (0.1;0.2) 0.3 (0.3;0.3) 0.3 (0.3;0.4) 0.1 (0.1;0.1) -58.5 (-67;-49.9)
Amazonas 0.9 (0.8;1) 0.2 (0.2;0.2) 1.3 (1.2;1.6) 0.1 (0.1;0.1) -56.4 (-63.1;-46.9)
Bahia 232.2 (210.6;255.3) 6.1 (5.5;6.7) 276.5 (253.1;304.8) 3.2 (2.9;3.5) -47.8 (-54.4;-40)
Brasil 2638.1 (2545.4;2737.8) 5.3 (5.1;5.5) 2399.2 (2255.9;2597.1) 1.9 (1.8;2.1) -63.7 (-66.3;-60.7)
Ceará 14.1 (11.5;18) 0.6 (0.5;0.8) 19.3 (17;22.2) 0.4 (0.3;0.4) -44.4 (-59.3;-27.6)
Distrito Federal 98.7 (91.8;106.5) 29.2 (27.3;31.3) 103 (91.5;121.4) 8.5 (7.6;10.1) -70.9 (-74.4;-66.1)
Espírito Santo 3.2 (2.9;3.5) 0.4 (0.4;0.5) 3.3 (2.9;3.9) 0.1 (0.1;0.2) -67.3 (-72.1;-61.3)
Goiás 447.5 (419.6;480.6) 50.1 (46.8;54.1) 362 (329.1;407.7) 11.1 (10.1;12.5) -77.9 (-80;-75.4)
Maranhão 4.3 (3;6.8) 0.3 (0.2;0.5) 5.6 (4.9;6.8) 0.2 (0.1;0.2) -47.1 (-64.2;-23.3)
Mato Grosso 12.6 (11;14.5) 3.2 (2.8;3.6) 21 (18.4;25.5) 1.4 (1.3;1.7) -55.4 (-62.5;-45.2)
Mato Grosso do Sul 16.1 (14.6;17.8) 3.6 (3.3;4) 19.5 (17;22.6) 1.4 (1.2;1.6) -62.8 (-68.3;-56.2)
Minas Gerais 853.2 (809.6;904.2) 15.9 (15.1;16.8) 646 (593.4;706.5) 4.6 (4.3;5.1) -70.8 (-73.7;-67.6)
Pará 6.8 (6;7.6) 0.6 (0.5;0.7) 8.3 (7.2;10) 0.2 (0.2;0.3) -58.6 (-65.5;-49.1)
Paraíba 13.3 (9.7;15.6) 1.1 (0.8;1.3) 15.3 (12.9;17.7) 0.6 (0.5;0.7) -45.9 (-58.7;-22.1)
Paraná 131.4 (122;140.3) 5.3 (4.9;5.6) 111.6 (100.4;125.1) 1.7 (1.5;1.9) -68.8 (-72.3;-64.8)
Pernambuco 60.3 (53.4;66.2) 2.4 (2.2;2.7) 59.7 (52.8;67.5) 1.1 (0.9;1.2) -56.4 (-62.7;-47)
Piauí 19 (15.4;24.5) 2.5 (2;3.2) 26.3 (23.1;30.8) 1.3 (1.2;1.6) -46.1 (-59.2;-30)
Rio de Janeiro 29.5 (27;32.4) 0.5 (0.5;0.6) 26.9 (23.6;30.4) 0.2 (0.2;0.2) -60.8 (-66.1;-54.6)
Rio Grande do Norte 4 (3.5;4.8) 0.5 (0.4;0.6) 4.9 (4.2;5.6) 0.2 (0.2;0.3) -50.5 (-63.1;-37.1)
Rio Grande do Sul 20.9 (18.9;22.7) 0.6 (0.5;0.6) 19.8 (17.5;22.6) 0.2 (0.2;0.3) -60.7 (-65.8;-54.1)
Rondônia 6.9 (6.1;7.8) 3.9 (3.5;4.4) 9.6 (7.9;11.6) 1.4 (1.1;1.7) -64.8 (-72.1;-56.2)
Roraima 0.1 (0.1;0.1) 0.3 (0.2;0.3) 0.2 (0.1;0.2) 0.1 (0.1;0.1) -63 (-72.2;-52)
Santa Catarina 4.6 (4.1;5.1) 0.4 (0.3;0.4) 5.1 (4.5;6) 0.1 (0.1;0.1) -65 (-70;-58.7)
São Paulo 614.1 (583.5;644.5) 5.4 (5.1;5.6) 593.9 (544.1;650.2) 2 (1.9;2.2) -61.9 (-65.3;-58.1)
Sergipe 3.6 (3.1;4.2) 0.8 (0.7;0.9) 4.1 (3.6;4.7) 0.3 (0.3;0.4) -55.9 (-63.5;-43)
Tocantins 14.5 (11.6;19) 7.9 (6.5;10.2) 21.7 (18.6;25.7) 3.2 (2.8;3.8) -59 (-70;-46.2)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 188

- Correlação entre o índice sociodemográfico (SDI) e a taxa de mortalidade padronizada por idade por cardiomiopatia e miocardite, por 100 mil habitantes, Brasil, 1990 e 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

- Taxa de DALYs atribuíveis a cardiomiopatia e miocardite padronizada por idade (por 100 mil habitantes) no Brasil e regiões brasileiras, de 1990 a 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

- Taxa de mortalidade padronizada por idade atribuível a doença de Chagas no Brasil de 1990 a 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

- Correlação entre o índice sociodemográfico (SDI) em 1990 e a variação percentual das taxas de mortalidade padronizadas por idade por doença de Chagas, por 100 mil habitantes, 2017/1990. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 188

- Distribuição espacial da taxa de mortalidade média relacionada a doença de Chagas (por 100 mil habitantes) com base em causa múltipla de morte, por município, Brasil, 1999–2007. Fonte: Martins-Melo et al. 161

- Taxa de mortalidade padronizada por doença de Chagas no Brasil de acordo com grupo etário e ano de ocorrência, de 2000 a 2010. Fonte: Nóbrega et al. 159

- Taxa de DALYs (por população de 100 mil) padronizada por idade por doença de Chagas em 2016. Fonte: Martins-Melo et al. 166

- Tendências da mortalidade por insuficiência cardíaca de 2007 a 2016 no Brasil (BR), no Rio Grande do Sul (RS) e em Porto Alegre (POA). Fonte: Nicolao et al. 183

– Número de DALYs, taxas de DALYs padronizadas por idade (por 100 mil) e variação percentual das taxas, por grupo cardiovascular de causa de morte, no Brasil e suas unidades federativas, 1990 e 2017
Causa de morte e localização 1990 2007 Variação percentual (II 95%)
Número (II 95%) Taxa (II 95%) Número (II 95%) Taxa (II 95%)
B.2.1- Doença cardíaca reumática
Acre 460.8 (410.3;524.6) 127.1 (114.1;144.3) 671 (557.8;816.4) 79.5 (67.1;95.5) -37.5 (-43.8;-30.7)
Alagoas 3143.3 (2600.7;3851.6) 125 (105.1;149.3) 2632.8 (2168.9;3233.3) 73.8 (61.1;90.1) -40.9 (-50;-30.9)
Amapá 204.8 (173.1;242.1) 91.4 (78.4;106.6) 551.5 (440.6;687.6) 71.1 (57.7;87.5) -22.2 (-29.7;-14.4)
Amazonas 1528 (1267.3;1848.2) 85.2 (71.4;102.2) 2460.5 (1938.2;3170.4) 62.1 (49.5;78.9) -27.1 (-33.3;-20.8)
Bahia 12095.4 (10485.4;13973.7) 103.7 (90.3;120.3) 11460 (9428.5;14129.4) 70.5 (58.1;86.8) -32.1 (-38.7;-24.8)
Brasil 163388 (144922.3;186177.2) 118.9 (106.1;134.7) 162013.6 (134153.5;198443.9) 71.2 (59;87.2) -40.1 (-45.4;-34.6)
Ceará 5090.4 (4101.6;6158.3) 81.2 (65.9;98.4) 5664.1 (4357.1;7338.2) 56.4 (43.5;72.8) -30.6 (-39.8;-20.8)
Distrito Federal 2073.5 (1853.8;2341.2) 151.6 (137.6;168.9) 2439.1 (2023.3;2978.4) 78.8 (65.8;94.9) -48 (-53.7;-42)
Espírito Santo 2628.8 (2295.3;3051.6) 109.2 (96.1;125.8) 2974.6 (2426.3;3661.6) 70.1 (57.1;86.3) -35.8 (-42;-29.9)
Goiás 4735.6 (4205.1;5429.8) 128 (114.7;145.2) 5840.8 (4903.6;7144.8) 79.8 (67.3;97.3) -37.7 (-43.5;-31.5)
Maranhão 7473 (5921.2;9327.9) 142.1 (116.4;171.6) 4842.9 (3887.8;6116.6) 63.2 (51;79.3) -55.6 (-64.4;-46.3)
Mato Grosso 1828.6 (1579.2;2132.2) 101.6 (88.5;117.3) 2466 (1996.8;3072) 66.9 (54.5;82.8) -34.2 (-40.9;-27.8)
Mato Grosso do Sul 1669 (1402.1;1974.2) 104.5 (90.1;121.8) 2109.8 (1733.1;2612.1) 71.2 (58.6;87.9) -31.8 (-38.6;-24.4)
Minas Gerais 19249.1 (17181.8;21938.6) 130.8 (117.6;148) 18154.8 (15183.7;21952.5) 76.5 (63.5;92.8) -41.5 (-47.4;-35.5)
Pará 3950.3 (3349.3;4663.4) 91.5 (78.6;107.5) 5808.4 (4645;7300.4) 65.9 (53.3;82) -27.9 (-34.8;-20.8)
Paraíba 3916.4 (3288.8;4699.1) 125.1 (106.1;147.5) 3123.4 (2541.7;3837.2) 70.6 (57.5;86.9) -43.5 (-52;-34.8)
Paraná 10399.6 (9331.5;11680) 136.1 (123.1;152.3) 10256.3 (8682.8;12479.2) 81.7 (68.6;99.4) -40 (-45.5;-33.8)
Pernambuco 7748.4 (6752.1;8887.8) 110.2 (95.9;126.4) 8150.9 (6836.5;9867.3) 78.7 (66.2;95.3) -28.5 (-34.6;-22.1)
Piauí 2106.2 (1603.1;2601.3) 83.8 (66;103.3) 2139 (1699.7;2745.7) 58.6 (46.7;75.1) -30.1 (-40.3;-17.3)
Rio de Janeiro 14806.5 (13066.6;16943.4) 113.9 (100.9;129.8) 13785.8 (11373.1;17049.6) 70.7 (58;88) -37.9 (-43.9;-31.8)
Rio Grande do Norte 2163 (1817.4;2559.8) 94.3 (79.8;111.1) 2852.8 (2365.9;3507.2) 75.4 (62.7;92.4) -20.1 (-28.4;-10.9)
Rio Grande do Sul 8371.7 (7163.3;9922.7) 94.4 (81.5;110.9) 7857.9 (6265.8;9956.8) 62 (48.9;78.6) -34.4 (-40.8;-27.9)
Rondônia 1066 (924.3;1232.7) 113.4 (100;129.4) 1317 (1055;1625.9) 73 (58.9;89.6) -35.7 (-43.4;-28.3)
Roraima 153.9 (127.6;187.4) 88.8 (75.3;105.5) 335.3 (262.1;430.8) 61.7 (48.9;77.9) -30.5 (-38.5;-22.8)
Santa Catarina 4413.5 (3816.7;5148.1) 108.6 (95.7;125) 5283.7 (4296.7;6556.9) 68.4 (55.6;85) -37 (-43.4;-30.6)
São Paulo 39592.8 (35476.3;45103.4) 134.5 (121.5;151.7) 35783 (29557.6;44123.8) 70.9 (58.2;87.7) -47.3 (-53.3;-41.3)
Sergipe 1627.5 (1401.2;1913.6) 114.8 (100.3;133) 1870.6 (1561.8;2277.1) 77 (64.6;93.1) -33 (-40.2;-26.3)
Tocantins 891.8 (595.4;1118.1) 109.4 (80.7;133.7) 1181.6 (973.8;1459.3) 72.9 (60.4;89.7) -33.3 (-44.6;-15.9)
B.2.5- Doença valvar do coração não reumática
Acre 76.6 (68.6;89.8) 34.6 (31.1;41) 231.2 (202.9;258.1) 34.9 (30.4;39) 1.1 (-16.5;14.5)
Alagoas 435.5 (385.3;565.4) 27.1 (24;35.1) 1122.2 (1002.4;1359.9) 34.4 (30.7;41.5) 26.9 (7.9;43.8)
Amapá 60 (41.1;66.2) 43.9 (31;48.5) 276 (187.7;307.7) 48.3 (32.6;53.9) 10 (-7.8;24.5)
Amazonas 383.1 (320.1;430.5) 35.8 (30.9;40.2) 1120.8 (942.5;1248.8) 36.4 (30.5;40.4) 1.7 (-10.3;14)
Bahia 2839.9 (2502.2;3279.7) 35.1 (31.1;40.7) 4949.5 (4486.8;6140.9) 30.8 (28;38.3) -12.2 (-22.2;12)
Brasil 45589.2 (38652.3;48617.4) 42.9 (36.6;45.8) 89684.3 (75761.8;95891.8) 39.4 (33.2;42.2) -8 (-15.6;-4)
Ceará 979.5 (757.8;1644.8) 21.4 (16.6;36) 2601.6 (2333.2;3343) 26.2 (23.5;33.6) 22.2 (-13.9;51.7)
Distrito Federal 475.3 (369.5;517.4) 53 (41.8;57.3) 1026.2 (904.4;1164.8) 40.2 (35.3;45.4) -24.1 (-32.1;-7.6)
Espírito Santo 954.5 (637.9;1049.7) 53.2 (36.8;58.2) 1994.2 (1441.6;2200) 46.7 (33.9;51.6) -12.2 (-19.7;-3.4)
Goiás 1044.4 (870.5;1136.7) 40.3 (34;43.8) 2513.9 (2156.8;2780.7) 36.3 (31.4;40.2) -10 (-17;-1)
Maranhão 841.7 (638.4;1353.6) 27.4 (21;44.5) 1646 (1410.8;2450.2) 24.5 (21;36.5) -10.4 (-24;7.8)
Mato Grosso 448.3 (391.9;502.9) 39.1 (34.6;43.8) 1235 (1068.3;1378.4) 37.4 (32.3;41.7) -4.3 (-15.6;7.1)
Mato Grosso do Sul 518 (401.4;571.5) 45.4 (35.9;49.7) 1237.3 (960.8;1368.1) 43.2 (33.7;47.7) -4.9 (-15.2;6.1)
Minas Gerais 4805.1 (4079.6;5198.5) 41.1 (35.6;44.6) 9545.6 (7991.5;10392.3) 38 (31.9;41.5) -7.7 (-17.5;-0.1)
Pará 871.1 (775.6;1053.9) 31.3 (28.2;38.5) 2471.2 (2222.8;2874.6) 33.9 (30.5;39.6) 8.3 (-6.6;20.6)
Paraíba 485 (382.9;858.3) 19.9 (15.8;34.8) 978.9 (818.3;1667.4) 21.5 (17.9;36.6) 8.1 (-11.5;28.3)
Paraná 3211.1 (2218.8;3517.2) 54.6 (38.2;59.6) 6327.7 (4281.6;6982.9) 49.8 (33.6;55) -8.8 (-18.1;-1.4)
Pernambuco 2014.5 (1698.1;2212.9) 38.6 (33.3;42.7) 4112.2 (3493.4;4518.3) 41 (34.7;44.9) 6.1 (-4.3;16.3)
Piauí 381.9 (291.7;687.1) 23.2 (18.1;41) 879.2 (770.3;1289.3) 24.2 (21.2;35.5) 4.3 (-18.9;27.5)
Rio de Janeiro 4639.3 (4053.3;5965.9) 41.8 (37.1;54.1) 7855.6 (7028.2;9622.4) 37.1 (33.3;45.6) -11.2 (-18.7;-3.6)
Rio Grande do Norte 446.7 (374.6;658.4) 25.3 (21.2;37) 1205.9 (1082.5;1495.1) 31.9 (28.6;39.6) 26.3 (-7.3;51.8)
Rio Grande do Sul 4017.2 (2844.8;4352.4) 53.9 (38.7;58.5) 7588.9 (4941.1;8430.1) 51.9 (34.2;57.5) -3.7 (-19.7;5.2)
Rondônia 221.1 (193.3;264.1) 39.1 (34.9;46.8) 524.4 (452.9;662.3) 33.5 (29;41.7) -14.5 (-25.9;-1.6)
Roraima 32 (27.8;41.7) 35.3 (30.8;48.9) 120.3 (104;161.8) 31.5 (27.3;41) -10.9 (-28.3;7.3)
Santa Catarina 1766.7 (1153.7;1937.8) 58.3 (37.4;63.9) 3758.7 (2515;4171.6) 49.2 (32.4;54.7) -15.6 (-22.8;-7.7)
São Paulo 13252 (9281.2;14232.8) 54.6 (39;58.4) 23226.5 (18142.4;25116.5) 44.9 (35.1;48.6) -17.7 (-24.1;-10.8)
Sergipe 218.2 (184.3;330.5) 22.6 (19.1;34.2) 615.9 (541.8;879.7) 27.4 (24.2;39.1) 21.2 (1.3;39)
Tocantins 170.7 (124.4;233.6) 33.3 (26.2;46.2) 519.5 (455.3;586.8) 35.4 (31.1;40) 6.4 (-24;35.7)
B.2.5.1- Doença valvar aórtica calcífica não reumática
Acre 40.5 (30;46.2) 19.1 (14.6;21.7) 133.9 (112.7;168.1) 20.8 (17.7;25.7) 9 (-10.8;51.7)
Alagoas 189.8 (160.5;241.4) 12.2 (10.4;15.3) 625.7 (549.3;827.4) 19.4 (17.1;25.3) 58.6 (33.4;93.9)
Amapá 32.1 (18.2;37) 24.9 (14.5;28.3) 161.6 (122.6;192) 29.4 (21.7;34.5) 17.8 (-0.4;68.2)
Amazonas 231.6 (136.2;266.9) 22.4 (13.8;25.4) 739.3 (617.9;840) 24.4 (20.1;27.5) 9.1 (-6.7;58.5)
Bahia 1658.3 (1011.9;1940.1) 20.9 (13.1;24.3) 3000.9 (2707.6;3816.1) 18.8 (16.9;23.9) -10.4 (-27;61.2)
Brasil 26502.4 (19395.6;28697.2) 25.4 (19.1;27.4) 56930.9 (50545.9;65681.9) 25.1 (22.1;28.7) -1.2 (-9.1;24.2)
Ceará 429.8 (315.7;695.5) 9.6 (7.1;15.5) 1451.9 (1234;2158.8) 14.7 (12.5;21.7) 52.5 (18.4;95)
Distrito Federal 271.8 (234.1;332.2) 32.1 (27.4;38.2) 655.9 (552.3;920.4) 26.3 (22.3;36.6) -18.1 (-30.1;8.5)
Espírito Santo 488.7 (313.1;557) 28.5 (18.8;32.2) 1182.1 (959.5;1371.1) 27.8 (22.4;32) -2.4 (-15.2;28.3)
Goiás 589.3 (415.1;674) 23.7 (17;26.7) 1582.9 (1418.5;1838.7) 23 (20.6;26.6) -3 (-15.7;29.8)
Maranhão 377.9 (295.1;491.2) 12.6 (10;16.7) 951.9 (812.4;1361.8) 14.3 (12.2;20.4) 13.4 (-5.9;44.1)
Mato Grosso 243.7 (182.5;280.4) 22.4 (17.3;25.6) 749.8 (666.3;912.9) 23 (20.5;27.7) 2.6 (-12.2;37)
Mato Grosso do Sul 302.3 (199.2;348.4) 27.5 (18.3;31.2) 806 (658.2;903.3) 28.3 (23;31.6) 2.8 (-12;39)
Minas Gerais 2808.8 (1974.5;3167.3) 24.5 (17.8;27.4) 6005.2 (5096.3;6815.2) 23.9 (20.4;27.2) -2.5 (-13.6;22.8)
Pará 423.2 (333.3;485.2) 16 (13;18.4) 1351.8 (1171.1;1746.7) 19 (16.5;24.4) 18.6 (1.6;53.1)
Paraíba 206.3 (155.1;396.3) 8.6 (6.5;16.2) 547.1 (426.1;1049) 12 (9.3;23.1) 40.1 (11.5;73.1)
Paraná 1874.7 (1154.1;2123.9) 32.9 (20.9;36.9) 4232.1 (3003.5;4719) 33.4 (23.7;37.2) 1.4 (-9;23.8)
Pernambuco 965.9 (746.3;1081.1) 19 (15.1;21.3) 2374.9 (2111.6;2875.8) 23.8 (21.2;28.7) 25.5 (9.4;53.7)
Piauí 152.4 (113.5;255.6) 9.6 (7.3;16.1) 449.8 (369.5;734.1) 12.4 (10.2;20.3) 29.1 (2.6;69.1)
Rio de Janeiro 2651.5 (2230.2;3550.9) 24.2 (20.8;33) 5140.9 (4615.8;7109.1) 24.2 (21.8;33.6) 0 (-10.3;18.3)
Rio Grande do Norte 241.5 (194.2;300.7) 13.8 (11.2;17.3) 750.5 (657;955.2) 19.9 (17.4;25.4) 43.9 (15.2;93.5)
Rio Grande do Sul 2457.2 (1619.1;2728) 33.6 (22.2;37.2) 5106.1 (3487.4;5690.3) 34.8 (23.9;38.6) 3.8 (-6.2;22.4)
Rondônia 121.9 (90.7;143.3) 22.8 (17.7;26.2) 317.1 (262.3;435) 20.6 (17.2;27.3) -9.8 (-28;26.9)
Roraima 20.4 (14.5;23.9) 23.2 (17.5;26.6) 82.2 (68.4;107.1) 22.1 (18.7;27.4) -4.7 (-23.2;36.4)
Santa Catarina 1071.1 (587;1233.8) 36.6 (19.9;41.7) 2571.3 (1727.2;2869.9) 33.9 (22.4;37.9) -7.3 (-17.4;18.6)
São Paulo 8484.5 (5317.1;9384.8) 35.5 (23.3;39.1) 15357.3 (13142.4;17600.3) 29.7 (25.2;33.9) -16.2 (-26;10.5)
Sergipe 93.2 (75.2;149.4) 9.9 (8;15.8) 324.7 (258.7;557.4) 14.6 (11.7;24.7) 47.2 (20.2;81.9)
Tocantins 74 (53.8;103.7) 15.3 (11.9;21) 278.2 (234.9;375.9) 19.2 (16.3;25.7) 25.8 (-2.9;66.6)
B.2.5.2- Doença valvar mitral degenerativa não reumática
Acre 30 (25.2;46) 13.1 (10.9;20.6) 75.1 (60.5;90.7) 11.2 (8.9;13.4) -14.8 (-45.7;3.5)
Alagoas 220.5 (183.7;311.8) 13.5 (11.2;19) 444.4 (356.2;522.7) 13.4 (10.8;15.8) -0.1 (-29.4;20.1)
Amapá 23.8 (19.6;30.9) 16.6 (14;21.9) 91.8 (53.3;112.4) 15.6 (9.2;19) -6 (-44.1;13.9)
Amazonas 136 (113;215.8) 12.2 (10.1;19.4) 331.9 (263.6;401.4) 10.6 (8.4;12.7) -13.3 (-43;4.9)
Bahia 1104.1 (905.1;1731.5) 13.3 (10.9;21.1) 1828.7 (1488.1;2227.1) 11.3 (9.2;13.8) -14.9 (-42.1;2.9)
Brasil 17936 (15500.4;22621.4) 16.4 (14.4;20.8) 30580.8 (20064.3;34729.6) 13.4 (8.8;15.2) -18.7 (-43.4;-9.3)
Ceará 493.4 (278.6;898.4) 10.7 (6.1;19.1) 1052.9 (767.3;1230.3) 10.6 (7.7;12.4) -1.2 (-43.9;35.8)
Distrito Federal 190.7 (115.1;218.4) 19.7 (12.4;22.5) 339.3 (159.2;421.1) 12.8 (6.2;15.9) -35.1 (-59.2;-22.7)
Espírito Santo 443.7 (279.5;557.8) 23.6 (15.4;29.7) 762.6 (387;901.9) 17.7 (9.1;21) -24.9 (-45.7;-13.2)
Goiás 424.4 (369.9;542.4) 15.6 (13.6;20) 855.1 (613.7;989.7) 12.2 (8.9;14.2) -21.6 (-43.6;-8.5)
Maranhão 385.9 (203.6;833) 12.5 (6.8;26.7) 582.5 (380.8;1068.8) 8.6 (5.7;15.7) -31 (-45.2;-11)
Mato Grosso 190.4 (160.8;242.1) 15.7 (13.3;20.6) 447.5 (286.6;524.3) 13.3 (8.7;15.7) -14.8 (-44.4;3.3)
Mato Grosso do Sul 204.1 (169.1;260.1) 17 (14.4;21.8) 406.4 (251.7;480.2) 14.1 (8.8;16.6) -17.4 (-46;-0.6)
Minas Gerais 1890.6 (1645.4;2507.9) 15.8 (13.9;21.1) 3353.1 (2245.4;3860.9) 13.3 (9;15.3) -15.7 (-44.4;-0.2)
Pará 404.9 (333.3;563.2) 14 (11.7;19.8) 983 (706.3;1136.6) 13.3 (9.6;15.4) -5.5 (-35.3;12.4)
Paraíba 237.4 (142.8;443.7) 9.7 (5.9;17.8) 370 (265.7;569.3) 8.1 (5.8;12.5) -16.5 (-38.4;3.1)
Paraná 1268 (887.1;1627.5) 20.6 (14.9;26.9) 1968.9 (1084.3;2414.3) 15.4 (8.5;18.9) -25.5 (-48;-13.3)
Pernambuco 999.8 (786.7;1162.9) 18.8 (15.1;22) 1641.1 (1077;1887.1) 16.2 (10.7;18.7) -13.7 (-34;-1.5)
Piauí 195.7 (108.4;388.3) 11.8 (6.8;22.7) 376.3 (274.4;508.7) 10.3 (7.5;14) -12.3 (-42.4;17.5)
Rio de Janeiro 1909.1 (1454.4;2345.8) 16.9 (13;20.8) 2593.4 (1731.6;3056.8) 12.3 (8.2;14.5) -27.2 (-47.3;-16.1)
Rio Grande do Norte 183.1 (118.7;339.9) 10.3 (6.7;18.9) 401.6 (333.7;489.9) 10.6 (8.8;12.9) 3 (-38.3;45.6)
Rio Grande do Sul 1483.2 (1058.6;1927.1) 19.4 (13.9;25.2) 2354.6 (1214.6;2951.9) 16.1 (8.4;20.2) -16.7 (-46.7;-2.1)
Rondônia 87 (71.6;132.9) 14.6 (12.1;22.1) 172.4 (133;219) 10.9 (8.5;13.5) -25.6 (-47.3;-7.7)
Roraima 9.1 (6.4;21.2) 10 (7.1;23) 27 (19.8;52.4) 7 (5.2;12.6) -30.3 (-53.4;-10)
Santa Catarina 664.1 (474.2;931.5) 20.8 (14.7;29.9) 1126.1 (625.8;1436.1) 14.5 (8.2;18.8) -30.2 (-50.8;-18.5)
São Paulo 4562.6 (3474.3;6176.4) 18.3 (14.3;24.5) 7528.5 (4049.6;8857.7) 14.5 (7.8;17) -20.8 (-50.7;-5.8)
Sergipe 111.2 (75.5;172) 11.4 (7.8;17.5) 256 (187.3;305.8) 11.3 (8.3;13.7) -0.9 (-32.9;20.8)
Tocantins 83.2 (52.6;126.5) 15.7 (10.1;24) 210.5 (142.8;246.4) 14.2 (9.7;16.6) -9.5 (-49.6;31)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 236

- A: Taxas de prevalência padronizadas por idade de doença cardíaca reumática no Brasil em 1990-2017. B: Taxa bruta de prevalências de doença cardíaca reumática no Brasil em 1990-2017. C: Prevalência proporcional de doença cardíaca reumática na população brasileira em 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- A: Taxas de prevalência padronizadas por idade de doença valvar do coração não reumática no Brasil em 1990-2017. B: Taxa bruta de prevalência de doença valvar do coração não reumática no Brasil em 1990-2017. C: Prevalência proporcional de doença valvar do coração não reumática na população brasileira em 1990-2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- A: Taxas de mortalidade padronizadas por idade atribuíveis a doença cardíaca reumática no Brasil em 1990–2017. B: Taxa bruta de mortalidade atribuível a doença cardíaca reumática no Brasil em 1990–2017. C: Mortalidade proporcional atribuível a doença cardíaca reumática na população brasileira em 1990–2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- Correlação entre o Índice Sociodemográfico (SDI) e a variação percentual nas taxas de mortalidade padronizadas por idade atribuíveis a doença cardíaca reumática nas unidades federativas brasileiras em 1990. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- A: Taxas de mortalidade padronizadas por idade atribuíveis a doença valvar do coração não reumática no Brasil em 1990–2017. B: Taxas brutas de mortalidade atribuíveis a doença valvar do coração não reumática no Brasil em 1990–2017. C: Mortalidade proporcional atribuível a doença valvar do coração não reumática na população brasileira em 1990–2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- Correlação entre as taxas de mortalidade padronizadas por idade atribuíveis a doença valvar aórtica calcífica e o Índice Sociodemográfico (SDI) nas unidades federativas brasileiras em 1990 e 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- A: Taxas de DALYs padronizadas por idade atribuíveis a doença cardíaca reumática no Brasil e cada região em 1990–2017. B: Proporção de DALYs atribuíveis a doença cardíaca reumática no Brasil e cada região em 1990–2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- Correlação entre a variação percentual nas taxas de DALYs atribuíveis a doença cardíaca reumática em 1990 – 2017 e o Índice Sociodemográfico (SDI) nas unidades federativas brasileiras em 1990 e 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- A: Taxas de DALYs padronizadas por idade atribuíveis a doença valvar do coração não reumática no Brasil e cada região em 1990–2017. B: Proporção de DALYs atribuíveis a doença valvar do coração não reumática no Brasil e cada região em 1990–2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

- Correlação entre as taxas de DALYs padronizadas por idade atribuíveis a doença valvar do coração não reumática e o Índice Sociodemográfico (SDI) nas unidades federativas brasileiras em 1990 e 2017. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 236

– Número de casos prevalentes e prevalência padronizada por idade de fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, em 1990 e 2017, com variação percentual, para ambos os sexos e para mulheres e homens, no Brasil e suas unidades federativas
Ambos os sexos Mulheres Homens
Brasil e unidades federativas 1990 (II 95%) 2017 (II 95%) Variação percentual (II 95%) 1990 (II 95%) 2017 (II 95%) Variação percentual (II 95%) 1990 (II 95%) 2017 (II 95%) Variação percentual (II 95%)
Acre 585.2 (482.8;692.5) 600.8 (493.1;714.2) 2.7 (7.1;-2) 487.9 (408.1;569.3) 508.3 (427;596.5) 4.2 (10.3;-2.2) 669.8 (540.1;806.8) 697.2 (555;849.8) 4.1 (10.6;-2.5)
Alagoas 426.1 (308.3;568) 428.7 (312.2;556.5) 0.6 (5.9;-5) 320.2 (221.7;432.7) 322.5 (225.4;434.5) 0.7 (7.5;-6.3) 546.6 (398.9;735.7) 562.5 (421.5;734.3) 2.9 (10.7;-5.3)
Amapá 673.7 (580.9;766.1) 696.7 (600.5;800.2) 3.4 (7.3;-0.5) 538.9 (464;616.7) 559.2 (483.3;643.2) 3.8 (8.8;-1.3) 816.7 (703.6;936.5) 848.1 (726.9;976.7) 3.8 (10.1;-1.8)
Amazonas 482.5 (375.5;610.5) 503 (385.7;636.4) 4.3 (9.9;-0.4) 349.6 (257.3;461.3) 360.5 (264.6;476.8) 3.1 (9.9;-3.1) 620 (490.9;766.8) 655.3 (510;813) 5.7 (13;-0.7)
Bahia 447.3 (332.2;579.6) 469.7 (346.1;606.8) 5 (10.1;0.1) 336.9 (242.4;445.2) 359.7 (258.1;475.1) 6.8 (13.6;-0.5) 574.2 (436.2;733.4) 605.7 (454;772.5) 5.5 (14;-1.6)
Brasil 619 (515.5;727.6) 640.9 (537;751) 3.5 (5.3;1.7) 499.3 (417.9;586.5) 522.1 (439.9;610.1) 4.6 (7;2.3) 758.9 (630;893.1) 786.9 (656.6;925) 3.7 (5.9;1.4)
Ceará 470.1 (361.8;598.3) 481.7 (368.6;612.8) 2.5 (7.1;-1.9) 338.8 (242.3;450.9) 348.8 (250.2;463.5) 2.9 (9.6;-3.7) 618.3 (486.1;767.3) 645.7 (505.6;803.7) 4.4 (10.7;-2.2)
Distrito Federal 649.2 (560.8;745.1) 665.2 (569.5;769.2) 2.5 (7.2;-1.6) 528.1 (456.8;602.9) 547.3 (468.8;629.1) 3.6 (9.8;-1.9) 796.8 (686.4;920.9) 824.8 (698.9;968.1) 3.5 (10.7;-2.1)
Espírito Santo 483.6 (371.6;608.6) 505 (386.6;644.5) 4.4 (9.4;-0.7) 381 (295.8;478.9) 401.9 (311.9;509.7) 5.5 (13.1;-0.8) 597 (453;756.4) 629.5 (479.9;809) 5.4 (12.5;-0.9)
Goiás 487.3 (378.1;605.3) 511.8 (397.7;643.5) 5 (10.8;-0.1) 438.8 (359.7;524.3) 461.1 (377.2;557.3) 5.1 (12;-1.8) 533.3 (381.5;695.6) 568.7 (412.3;754.8) 6.6 (14.8;-1.1)
Maranhão 377.7 (251.2;546.2) 351.4 (234.6;502) -7 (-1.9;-13.4) 300.6 (197.9;439.7) 281.1 (185.6;398.6) -6.5 (0.1;-14.7) 467.9 (312.4;676.6) 432.4 (290.1;621.1) -7.6 (0.1;-16)
Mato Grosso 537.9 (432.1;652) 558.1 (443.3;686) 3.8 (8.6;-1.1) 456.4 (381.1;543.6) 477.2 (393.2;572.4) 4.6 (11.2;-1.6) 607.2 (471.4;759.2) 637.4 (491.4;812.9) 5 (11.6;-1.8)
Mato Grosso do Sul 678.5 (588.7;774.3) 690.4 (594.9;796.2) 1.8 (6.6;-2.3) 532.6 (459.2;608.8) 551.4 (477.8;631.7) 3.5 (9.7;-1.9) 815.8 (706.7;938.3) 845.2 (719.9;986) 3.6 (10.2;-2.2)
Minas Gerais 716.3 (620.7;815.9) 732.2 (646.8;820.9) 2.2 (7.8;-2.6) 554.1 (476.8;635) 565.7 (498.8;638.4) 2.1 (9;-3.9) 907.1 (783.5;1034.5) 930.7 (822.7;1040.7) 2.6 (9;-2.9)
Pará 426.2 (310.8;561) 434.7 (314;575.1) 2 (7.4;-3.1) 312 (218.4;434.1) 309.5 (215.6;429.8) -0.8 (6.5;-7.7) 549.8 (406.6;719.6) 569.2 (416;743) 3.5 (9.7;-3.5)
Paraíba 507.8 (405.5;622) 527.4 (418.9;650.3) 3.9 (8.1;-0.2) 417.8 (341.3;505.7) 438.5 (352.9;531.2) 5 (11;-1.2) 610.3 (472.6;762.7) 640.1 (498.3;810.1) 4.9 (11.5;-1.8)
Paraná 588.3 (488.1;692.4) 607.7 (502.3;721.1) 3.3 (7.6;-0.9) 493.9 (418.7;573.1) 514.7 (434.7;602.9) 4.2 (10;-2) 686.9 (554.8;827.8) 719 (576.4;870.9) 4.7 (12.5;-1)
Pernambuco 422.7 (304.4;559.1) 442 (317.7;588.2) 4.6 (10.1;-0.4) 335.9 (238.6;447.7) 354.9 (255.2;473.6) 5.7 (14;-1.6) 528.9 (379.7;703.9) 558.1 (400.4;750.7) 5.5 (11.9;-1.7)
Piauí 429.2 (311.3;569) 437.6 (318.1;577.5) 2 (7.4;-2.4) 322 (227.4;434.3) 327.8 (229.5;439.6) 1.8 (9.4;-5.2) 550.2 (408.1;719.3) 568.7 (417.2;750.2) 3.4 (9.7;-2.6)
Rio de Janeiro 723.3 (626.3;827) 742.4 (646.8;845.8) 2.6 (6.6;-1.4) 567.3 (487;652.3) 585 (506.3;671.8) 3.1 (8.3;-2.2) 934.3 (812;1071.9) 956.7 (831.5;1094.2) 2.4 (8.2;-3.3)
Rio Grande do Norte 458.2 (345.8;587) 467.1 (346.5;603.8) 1.9 (7.6;-3.1) 337.9 (242.7;446.4) 347.7 (247;466.6) 2.9 (11.2;-4.7) 592.8 (458.7;744.5) 617 (468.6;789.3) 4.1 (11;-3)
Rio Grande do Sul 509.1 (399;629.9) 534.9 (418.9;668) 5.1 (9.5;0.3) 435.5 (351.1;526.3) 456.5 (367.2;558.1) 4.8 (11.9;-1.6) 604.9 (449;773) 635.8 (476.4;823.5) 5.1 (11.8;-0.9)
Rondônia 515.5 (408.2;637) 529.1 (416;655) 2.6 (7.3;-2.3) 436.6 (357.1;521.5) 455.1 (371.5;547.6) 4.2 (11.1;-2.2) 580.5 (446;741.2) 601.5 (453.1;767.6) 3.6 (10.8;-3)
Roraima 702.9 (609.8;804.9) 741.4 (646.1;844.4) 5.5 (9.5;1.6) 523.1 (451.2;603.1) 562.9 (488.7;641.4) 7.6 (13.8;2) 843.5 (728.4;969) 909.8 (793.3;1039.6) 7.9 (13.4;2.4)
Santa Catarina 617.1 (516.7;722.4) 641.9 (539.1;754.4) 4 (8.5;-0.2) 561.6 (482.9;640.9) 582.5 (504;667.2) 3.7 (9.4;-2.4) 679.5 (544.4;820.5) 711.7 (566.7;873) 4.7 (11.1;-1.6)
São Paulo 849.8 (736.7;972.7) 865.6 (753.4;984.3) 1.9 (6.1;-1.9) 702.6 (605.4;807.1) 726.4 (629.4;832.9) 3.4 (9.7;-1.6) 1028.3 (890.9;1176.3) 1042.9 (903.6;1190.2) 1.4 (6.8;-4.1)
Sergipe 518.5 (419.8;629.8) 536.3 (436.6;654.6) 3.4 (8.5;-1.3) 390.7 (312.6;481.3) 408.3 (322.8;515.6) 4.5 (11.9;-2.6) 669.2 (543.8;805.3) 699.4 (570.4;847.3) 4.5 (10.9;-1.6)
Tocantins 613.3 (518.7;713.7) 632.8 (532.1;743) 3.2 (8.2;-1.6) 448.1 (372.1;527.4) 465.7 (385.1;557.3) 3.9 (9.7;-1.4) 765.1 (651.1;890.6) 794.5 (668.7;927.2) 3.8 (10.3;-2.9)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de mortes e taxa de mortalidade padronizada por idade por fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%) Variação percentual (II 95%)
Acre 4 (4;5) 4.9 (4.5;5.5) 22 (20;24) 4.5 (4.1;4.8) -8.6 (-18.4;-0.9)
Alagoas 35 (33;41) 3.5 (3.3;4.1) 119 (112;135) 4.1 (3.8;4.7) 16.1 (4.2;26.2)
Amapá 3 (3;3) 5.8 (5.4;6.5) 18 (16;19) 5.3 (4.7;5.6) -9.6 (-20.2;-2.2)
Amazonas 19 (17;22) 3.9 (3.7;4.7) 87 (82;96) 4 (3.8;4.5) 3.2 (-11.6;13)
Bahia 236 (219;265) 4.2 (3.9;4.8) 719 (675;798) 4.3 (4.1;4.8) 2.3 (-6.1;10.2)
Brasil 2649 (2428;2836) 4.7 (4.4;5.1) 10059 (9390;10698) 4.8 (4.5;5.2) 2.5 (-2.9;7.3)
Ceará 128 (117;149) 3.5 (3.2;4.1) 404 (380;443) 3.9 (3.6;4.3) 10.9 (-1.7;21.9)
Distrito Federal 13 (12;14) 6.4 (6.1;7) 97 (88;108) 7.6 (6.8;8.4) 19.8 (5.5;32.9)
Espírito Santo 41 (37;44) 6.2 (5.7;6.7) 169 (157;188) 4.5 (4.1;5) -28.3 (-33.7;-21)
Goiás 43 (38;46) 4.9 (4.5;5.2) 226 (206;246) 4.3 (3.9;4.6) -13.7 (-20.1;-5.6)
Maranhão 85 (55;101) 4.9 (3;5.8) 305 (219;342) 5.1 (3.6;5.7) 4.1 (-6.7;26.3)
Mato Grosso 18 (16;21) 4.1 (3.8;5.1) 99 (92;111) 4.4 (4.1;4.9) 5.6 (-8.3;16.1)
Mato Grosso do Sul 24 (22;26) 5.1 (4.7;5.5) 110 (103;122) 4.8 (4.5;5.3) -6.6 (-13.3;2.2)
Minas Gerais 279 (253;294) 5.2 (4.7;5.4) 1144 (1058;1223) 4.6 (4.3;4.9) -11.5 (-17.2;-4.6)
Pará 63 (59;71) 4.5 (4.2;5) 258 (232;279) 4.6 (4.1;5) 2.5 (-8.3;11.9)
Paraíba 74 (69;85) 3.8 (3.5;4.3) 196 (179;222) 3.9 (3.6;4.5) 4.1 (-8.4;16.3)
Paraná 123 (115;137) 5.4 (5.1;5.9) 516 (487;575) 4.9 (4.6;5.5) -8.3 (-14.2;-2)
Pernambuco 135 (127;151) 4.7 (4.5;5.3) 402 (377;446) 4.3 (4;4.8) -9 (-15.1;-2.3)
Piaui 43 (39;51) 4.1 (3.7;5) 138 (129;157) 3.8 (3.5;4.3) -9.1 (-20.7;0.5)
Rio de Janeiro 290 (266;306) 5.3 (4.9;5.6) 1052 (972;1124) 5.2 (4.8;5.6) -0.2 (-6.7;6.5)
Rio Grande do Norte 60 (54;67) 4.1 (3.7;4.6) 169 (158;188) 4.2 (3.9;4.6) 1.5 (-8.4;12.4)
Rio Grande do Sul 183 (168;195) 4.9 (4.5;5.2) 698 (655;761) 4.9 (4.6;5.3) 0.5 (-6.6;7.6)
Rondônia 5 (5;6) 4.5 (4.2;5) 45 (41;52) 4.3 (3.8;4.9) -5.4 (-16.1;6.2)
Roraima 1 (1;2) 7.7 (7;9.2) 11 (10;13) 6.6 (5.8;7.4) -14.5 (-30.2;-1.2)
São Paulo 637 (571;670) 5.8 (5.2;6.1) 2605 (2372;2755) 5.8 (5.3;6.2) 1.2 (-6.3;8.4)
Santa Catarina 69 (64;74) 5.2 (4.8;5.6) 312 (293;340) 5.1 (4.8;5.6) -1.3 (-8.7;6.5)
Sergipe 27 (25;31) 3.6 (3.4;4.1) 81 (75;87) 4 (3.7;4.4) 11.4 (-0.8;21.6)
Tocantins 10 (9;12) 7.1 (6.4;8.3) 55 (50;60) 4.4 (4;4.8) -37.4 (-46.5;-30.2)
Fonte: Estudo Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de mortes e taxa de mortalidade padronizada por idade por fibrilação atrial e flutter, por 100 mil habitantes, para homens, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%) Variação percentual (II 95%)
Acre 2.4 (2;2.9) 5.2 (4.5;6.3) 9.9 (7.4;11) 4.3 (3.2;4.7) -18.5 (-36;-6.3)
Alagoas 16.8 (14.9;21.8) 3.9 (3.5;5.1) 43.9 (36;51) 3.6 (3;4.2) -6.8 (-25.1;7.4)
Amapá 1.4 (1.2;1.7) 5.3 (4.7;6.9) 8 (5.9;8.9) 5.7 (4.2;6.3) 7.2 (-22.4;24.4)
Amazonas 9 (8;12.5) 4.1 (3.7;5.9) 37.1 (31.5;44.3) 3.8 (3.2;4.5) -8.9 (-31.4;6.1)
Bahia 106.6 (93.5;133.7) 4.5 (3.9;5.6) 300.3 (246.4;345.5) 4.5 (3.7;5.2) 2 (-12.8;14.6)
Brasil 1134.1 (952.8;1309.1) 4.7 (4.1;5.6) 3773.7 (3076.2;4312) 4.6 (3.8;5.2) -3.5 (-12.9;1.8)
Ceará 60.8 (52.3;85.1) 3.7 (3.2;5.2) 150.3 (124.7;172.3) 3.6 (3;4.1) -3.7 (-27.5;14.2)
Distrito Federal 5.1 (4.4;6.3) 5.8 (5;6.9) 33.1 (27.6;44.6) 6.5 (5.5;8.3) 12.6 (-5.3;28.7)
Espírito Santo 18.7 (15.5;21.5) 6 (5;7.1) 68.3 (59.6;85.4) 4.5 (3.9;5.6) -25.5 (-35.5;-12.6)
Goiás 19.6 (15.7;22.2) 3.6 (2.8;4) 104.4 (86.7;121.5) 4.3 (3.6;5.1) 20.7 (5.6;36.8)
Maranhão 37.7 (28.4;47.6) 6 (4.1;7.9) 152.5 (121.6;180.5) 6.1 (4.8;7.2) 0.5 (-17.7;21.6)
Mato Grosso 9.7 (8.6;13.3) 4.5 (3.9;6.5) 45.7 (39.9;56.6) 4 (3.5;4.9) -12.1 (-31.4;2)
Mato Grosso do Sul 12 (10;13.7) 4.8 (3.9;5.4) 46.7 (37.9;53) 4.5 (3.7;5.2) -4.6 (-15;4.9)
Minas Gerais 117.9 (91.5;129.6) 4.9 (3.8;5.3) 448.6 (360.9;504.4) 4.4 (3.6;5) -8.8 (-18.3;5.3)
Pará 27.4 (24.5;34.2) 4.4 (3.9;5.6) 118.4 (98.2;138.8) 4.7 (3.8;5.5) 6.5 (-11.5;21.6)
Paraíba 34.5 (30.2;43.6) 3.7 (3.2;4.6) 73.6 (58.5;86.4) 3.7 (3;4.4) 1.3 (-16.8;20)
Paraná 56.9 (48.1;67.9) 5.1 (4.3;6.1) 207 (179.8;248.3) 4.7 (4.1;5.6) -7.7 (-19.6;2.2)
Pernambuco 60.6 (51.5;72.6) 5 (4.2;5.9) 146.5 (118.1;165.8) 4 (3.2;4.5) -19.1 (-30.3;-10.8)
Piauí 21.7 (18.5;31.3) 5.2 (4.4;7.7) 51.5 (41.7;59.5) 3.3 (2.7;3.8) -36.2 (-55.3;-22.8)
Rio de Janeiro 111.5 (86.2;124.2) 5.4 (4.3;6.1) 348.2 (286.2;400.2) 4.9 (4.1;5.7) -9.5 (-20.4;2.3)
Rio Grande do Norte 28.1 (25.1;36.5) 4.4 (3.9;5.6) 64.6 (52.2;74.5) 4 (3.2;4.6) -7.7 (-27.1;6.6)
Rio Grande do Sul 72.6 (59.1;83.3) 5.2 (4.2;6) 244.4 (205.8;288.7) 4.8 (4;5.6) -8 (-20.4;2.1)
Rondônia 3.1 (2.7;3.7) 4.9 (4.1;5.7) 21.6 (18;25.5) 4 (3.3;4.7) -18.7 (-32.2;-4.5)
Roraima 0.7 (0.6;0.9) 7.4 (6.4;10.2) 5.2 (3.5;6.1) 5.6 (3.7;6.6) -24.1 (-55.7;-2.4)
Santa Catarina 29 (23.2;33.3) 4.9 (3.9;5.6) 111.5 (95.9;136.1) 4.6 (3.9;5.5) -6.4 (-21.3;9.3)
São Paulo 253.3 (189.4;278.3) 5.4 (4.1;6) 877.3 (668.2;969.6) 5.2 (4;5.8) -4.1 (-16.6;9.7)
Sergipe 12.1 (10.9;15.6) 3.8 (3.4;4.8) 29.6 (24;33.9) 3.7 (3;4.3) -1.3 (-19.8;13.2)
Tocantins 5 (4.3;7) 6.7 (5.6;10.1) 25.5 (19.7;28.6) 4.1 (3.1;4.5) -39.9 (-59.5;-25)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de mortes e taxa de mortalidade padronizada por idade por fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, para mulheres, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de mortes (II 95%) Taxa de mortalidade (II 95%) Número de mortes (II 95%) Taxa de mortalidade (II 95%) Variação percentual (II 95%)
Acre 2.1 (1.9;2.2) 4.7 (4.3;5) 12.1 (11;13.8) 4.7 (4.3;5.4) 0.1 (-12.3;20.5)
Alagoas 18.6 (17.2;20.4) 3.3 (3;3.6) 74.9 (68.7;87) 4.4 (4;5.1) 33.7 (18.1;51.9)
Amapá 1.8 (1.6;1.9) 6.2 (5.7;6.6) 9.8 (8.9;10.9) 5 (4.6;5.6) -19.1 (-28.5;-6.7)
Amazonas 9.5 (8.8;10.3) 3.8 (3.5;4) 50.3 (46.4;55.1) 4.2 (3.9;4.7) 13 (1.5;26.5)
Bahia 129.5 (119;141.4) 4.1 (3.8;4.5) 419 (386.8;470) 4.1 (3.8;4.6) 1 (-10.1;14.6)
Brasil 1515 (1453.7;1558) 4.7 (4.5;4.9) 6285.3 (6014.2;6615.7) 5 (4.8;5.2) 5.4 (0;12.3)
Ceará 67.3 (55.6;76.4) 3.4 (2.8;3.8) 253.8 (235.8;280.5) 4.1 (3.8;4.5) 21.2 (2.5;55.8)
Distrito Federal 7.9 (7.4;8.5) 6.8 (6.3;7.5) 64.3 (55.9;72) 8 (6.9;9) 17.8 (-4.1;36.2)
Espírito Santo 22.2 (21.1;23.4) 6.3 (5.9;6.6) 100.3 (91.8;109.2) 4.4 (4;4.8) -29.8 (-36.4;-22.7)
Goiás 23.4 (21.9;24.8) 6.4 (6;6.8) 121.8 (112.8;132.6) 4.2 (3.9;4.6) -34.1 (-39.9;-27.8)
Maranhão 47.5 (19.2;62) 4.6 (1.8;6) 152.1 (84.2;183) 4.5 (2.5;5.4) -2.7 (-16.2;44.7)
Mato Grosso 7.9 (7.1;8.8) 3.8 (3.4;4.2) 53 (48.6;58.4) 4.7 (4.3;5.2) 23.7 (7;43.6)
Mato Grosso do Sul 12.3 (11.7;13) 5.4 (5.1;5.7) 63.5 (58.3;71.8) 5 (4.5;5.6) -8.2 (-16.6;3.4)
Minas Gerais 161 (153.7;169.7) 5.3 (5.1;5.6) 695.6 (644.5;746.7) 4.7 (4.3;5) -12.6 (-19.7;-5.3)
Pará 35.7 (33;38.6) 4.5 (4.2;4.8) 139.2 (126.4;151.5) 4.5 (4.1;4.9) -0.5 (-10.9;10.8)
Paraíba 40 (36.6;44) 3.9 (3.5;4.2) 122.3 (108.1;146.1) 4.1 (3.6;4.8) 5.2 (-10.7;27.9)
Paraná 66 (62.6;70.3) 5.6 (5.3;6) 309.3 (287.2;338.3) 5 (4.7;5.5) -10 (-16.8;-2)
Pernambuco 74.4 (69.4;82.4) 4.6 (4.3;5) 255.8 (234.3;293.1) 4.5 (4.1;5.1) -2.1 (-10.7;9)
Piauí 21.2 (17.8;24.3) 3.5 (3;4.1) 86.9 (80.1;99) 4 (3.7;4.6) 14.2 (-2.7;46.6)
Rio de Janeiro 178.9 (169.9;190.3) 5.2 (4.9;5.5) 703.5 (652;753.2) 5.3 (5;5.7) 3.5 (-4.7;12.5)
Rio Grande do Norte 31.7 (27.6;35.2) 4 (3.4;4.4) 104.6 (95.4;119) 4.2 (3.8;4.8) 7.2 (-7.4;35.9)
Rio Grande do Sul 110 (104.6;115.1) 4.7 (4.5;5) 454 (421.1;488) 4.9 (4.6;5.3) 3.6 (-4.2;12)
Rondônia 2 (1.8;2.2) 4.1 (3.8;4.5) 23.7 (20.5;28.3) 4.5 (3.9;5.4) 9.7 (-6.2;28.3)
Roraima 0.5 (0.5;0.6) 7.8 (7.1;8.7) 6.1 (5.1;7.7) 7.3 (6.1;9.2) -6.5 (-26.1;18.5)
Santa Catarina 39.8 (37.7;42.4) 5.4 (5.1;5.7) 200.6 (185.2;217.9) 5.4 (5;5.9) 0.7 (-8;10.2)
São Paulo 384 (366;404.7) 5.9 (5.6;6.2) 1728 (1597.3;1849.2) 6.1 (5.7;6.6) 3.3 (-4.6;11.7)
Sergipe 14.7 (13.6;16) 3.5 (3.2;3.8) 51 (46.9;55.6) 4.2 (3.9;4.6) 20 (5.5;34.7)
Tocantins 5 (4.2;5.6) 7.3 (6;8.4) 29.9 (27.3;33.6) 4.8 (4.4;5.4) -34.3 (-44.6;-13.8)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de DALYs e taxas de DALYs padronizadas por idade por fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de DALYs (II 95%) Taxa de DALYs (II 95%) Número de DALYs (II 95%) Taxa de DALYs (II 95%) Variação percentual (II 95%)
Acre 140.3 (113.7;174.5) 95.2 (79;115.3) 542.9 (445.2;660.8) 99.2 (82.4;119.4) 4.2 (-2.5;9.6)
Alagoas 909.3 (730.5;1123.5) 72.4 (59.1;88.5) 2456 (2031.2;2952.7) 82.7 (68.8;99.8) 14.3 (5.6;21.9)
Amapá 93.7 (76;114.6) 108.7 (91.2;129.2) 499.4 (411.6;598.4) 114.8 (96.3;135.5) 5.6 (-0.8;10.9)
Amazonas 560.7 (445.6;698.8) 80.3 (65.3;98.1) 2138.5 (1735.6;2644.7) 86 (70.9;104.7) 7 (-2.3;13.8)
Bahia 5285.8 (4366.4;6397.1) 81.3 (67.7;97.7) 13791.8 (11451.4;16610.3) 87.7 (72.8;105.1) 7.9 (1.8;14.3)
Brasil 79208.5 (64514;96525.8) 99 (82.3;118.9) 226809.7 (187976.8;272166.3) 103.6 (86.3;123.8) 4.6 (1.7;7.2)
Ceará 3014.4 (2422;3741.1) 75.8 (61.3;93.5) 8054.1 (6619.6;9756.6) 81.9 (67.2;99.4) 8.1 (0.8;15.1)
Distrito Federal 543.8 (441.9;662.7) 115.2 (98.8;135.3) 2469.3 (2043.2;2968.8) 121.7 (104.3;143.6) 5.6 (-0.4;12.4)
Espírito Santo 1099.3 (895.3;1344.2) 92 (77.3;109.3) 3570.3 (2938.2;4327.6) 88 (73;106.3) -4.3 (-9.7;2)
Goiás 1394.8 (1125.9;1736.9) 88.5 (74.3;106.4) 5412.9 (4410.7;6618) 87.9 (72.8;106.9) -0.7 (-6;4.2)
Maranhão 1889.2 (1401.3;2435) 82.3 (59.9;105.9) 5041.4 (3929.4;6224.5) 82.1 (63.9;101) -0.3 (-8.1;9.3)
Mato Grosso 598.8 (479.5;750) 88.1 (72.5;107.8) 2612.4 (2125.1;3202.6) 93.2 (76.9;113.4) 5.7 (-1.8;12.3)
Mato Grosso do Sul 826.2 (672.8;1002.9) 106.5 (89.4;126.4) 2822.2 (2306.6;3401.7) 107.2 (88.5;128.2) 0.7 (-4.2;5.9)
Minas Gerais 9413 (7638.3;11547.3) 108.3 (90.1;129.8) 27059.3 (22340.6;32657.7) 108.2 (89.5;130.4) -0.1 (-5;4.7)
Pará 1539.4 (1262.2;1889.2) 81.5 (67.9;98.9) 5393.3 (4478.1;6529.9) 87.8 (73.5;105.3) 7.7 (-0.5;15.3)
Paraíba 1821.5 (1468.3;2223.4) 80.9 (65.7;98.4) 4007.5 (3263.1;4821.6) 86.5 (70.3;104.3) 6.9 (-0.9;14.3)
Paraná 3979.9 (3220;4841.8) 99.3 (83.5;118.5) 12001.8 (9814.5;14534.6) 99.9 (82.5;120) 0.6 (-4.5;5.2)
Pernambuco 3220.7 (2629.5;3992.3) 80.7 (67.7;97.7) 7977.1 (6643;9724) 83.5 (69.8;101.6) 3.5 (-2.1;8.8)
Piauí 1028.8 (830.3;1272.4) 78.1 (63.8;95.4) 2789.9 (2291.5;3412.7) 77.8 (64;95) -0.4 (-9.6;6.5)
Rio de Janeiro 9520.4 (7787.9;11658.2) 111.4 (93.3;133.4) 24316.8 (20202.2;29195.3) 115 (95.9;137.6) 3.2 (-1.1;7.7)
Rio Grande do Norte 1263.4 (1031.4;1535.4) 80.1 (65.7;96.9) 3165.6 (2620.9;3796.6) 84.7 (70.1;101.5) 5.8 (-1;13)
Rio Grande do Sul 5078.4 (4134.3;6186.3) 89.5 (74.8;107.2) 13838.5 (11505.8;16723.4) 93.9 (78.3;113) 5 (-0.4;10.1)
Rondônia 253.4 (200.9;317.6) 90.3 (75.1;109.6) 1179 (948.7;1453.8) 89.7 (73.1;108.8) -0.7 (-9.2;6.7)
Roraima 56.1 (44.6;69.3) 126.8 (106.6;149.8) 348.9 (280.1;430.2) 121.6 (100.7;145.4) -4.1 (-14.3;4.4)
Santa Catarina 2181.6 (1779.3;2657.9) 102 (85.4;121.3) 7392.7 (6024.1;8973) 103.4 (85.4;123.9) 1.3 (-4.1;6.7)
São Paulo 22477.6 (18132.5;27717.9) 126.9 (105.3;152.6) 64766.7 (53494.2;78258.7) 129.7 (107.8;155.7) 2.2 (-1.9;6.8)
Sergipe 669 (542.7;814.8) 81.1 (66.1;98.5) 1828.2 (1484.9;2230) 88.9 (72.8;108.1) 9.6 (2;16.3)
Tocantins 349.1 (280.8;431.7) 109.5 (92.1;130.9) 1333.2 (1097.2;1609.2) 100.5 (83.2;120.9) -8.2 (-17.2;-1.2)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de DALYs e taxas de DALYs padronizadas por idade por fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, para homens, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de DALYs (II 95%) Taxa de DALYs (II 95%) Número de DALYs (II 95%) Taxa de DALYs (II 95%) Variação percentual (II 95%)
Acre 82.4 (64.8;104.4) 103.4 (83.4;127.4) 285.5 (225.7;358.6) 105.6 (83.6;130.8) 2.1 (-9.8;11)
Alagoas 499.5 (389.5;638.7) 85 (67.3;107.9) 1190.5 (947.6;1474.1) 90.7 (72.7;112.3) 6.7 (-5.5;16.7)
Amapá 51.1 (40;63.7) 118 (95.2;144.5) 271.4 (214;333.8) 130.5 (104.5;157) 10.6 (-3;20.7)
Amazonas 329.6 (252.8;421.6) 94 (74.1;118) 1188.9 (930.8;1511.3) 97.5 (77.3;121.8) 3.7 (-9.4;13)
Bahia 2825.4 (2259;3508.4) 93.6 (75.8;114.9) 7090.6 (5714.9;8706.2) 103.8 (83.9;126.9) 10.8 (0.8;20.6)
Brasil 41514.9 (32715.2;51721.2) 111.1 (89.5;136.9) 110643.1 (88439.8;136579.6) 115.1 (92.9;141.4) 3.6 (-1.4;6.8)
Ceará 1685.5 (1306.6;2141) 90 (70.3;113.6) 4062.6 (3213.5;5079.7) 94.3 (74.8;117.5) 4.8 (-9.7;15.1)
Distrito Federal 279.4 (219.3;350.7) 121.6 (100;148) 1168.9 (907.8;1460.2) 129.5 (104.1;159.2) 6.5 (-3.6;16.9)
Espírito Santo 599.5 (468.5;752.8) 102.1 (82.7;126.1) 1800.5 (1424.3;2230.4) 99.9 (79.9;123) -2.1 (-9.8;6.8)
Goiás 751.4 (581.6;960.7) 85.2 (67.9;107.5) 2773.6 (2210.3;3516.4) 95.5 (77.1;119.9) 12.1 (3.3;20.3)
Maranhão 1002.8 (794.7;1292) 97.2 (76.4;124.3) 2672.9 (2147.4;3307.8) 95.8 (77.1;117.9) -1.4 (-12.1;9.3)
Mato Grosso 361.1 (280.9;464.2) 97.1 (77.2;122.4) 1416.9 (1121.4;1780.2) 98 (78;122.3) 0.9 (-10.9;10.3)
Mato Grosso do Sul 481.8 (382.6;600.1) 116.5 (94.2;143.5) 1485.7 (1183.7;1835.7) 118.9 (95.7;145.8) 2 (-5;8.3)
Minas Gerais 5075.7 (3941.5;6388.2) 123.2 (98.4;152.2) 13931.2 (11083.4;17144.6) 124.9 (100.2;152.9) 1.4 (-5.6;8.7)
Pará 848 (666.8;1072.3) 92 (73.9;114.8) 3030.6 (2434.6;3752.2) 102.1 (83.5;125.9) 11 (-0.9;21.2)
Paraíba 959.6 (751.8;1199.7) 89.6 (70.4;112.2) 1908.7 (1508.1;2391.4) 96.4 (76.2;120.1) 7.6 (-3.9;19.3)
Paraná 2155.1 (1663;2723.3) 106.1 (85.2;131) 5923.6 (4690.3;7392.9) 109.3 (87.5;134.3) 3 (-4.7;10.2)
Pernambuco 1666.7 (1313.2;2134) 92.1 (74.4;115.9) 3745.8 (2945.1;4730.6) 92.8 (73.4;117.1) 0.8 (-8.9;8.4)
Piauí 576.9 (446.6;737.6) 95.2 (74.8;122.4) 1384.7 (1098.5;1744.7) 85.8 (68.1;107.6) -9.9 (-26.6;0.8)
Rio de Janeiro 4817.5 (3787.4;6124) 130.7 (106;161.9) 11413.5 (9010.4;14162.3) 132.1 (105.6;162.3) 1.1 (-6.1;7.9)
Rio Grande do Norte 693 (547.8;864.6) 93.1 (74.1;115.7) 1566.9 (1250.7;1936.6) 97.1 (77.6;119.6) 4.3 (-9.9;14.5)
Rio Grande do Sul 2490.2 (1952.9;3132) 100.7 (81.3;123.8) 6341.6 (5040.4;7933.5) 103.5 (83.6;128.3) 2.8 (-6;10)
Rondônia 162 (126.2;207.2) 99.7 (81.4;123.1) 641.9 (500.4;812.1) 94.9 (75.2;118.3) -4.9 (-14.9;5)
Roraima 37.3 (29;46.7) 140.1 (113.5;170.8) 206.6 (161.2;261.9) 132.4 (105.1;163.7) -5.5 (-24.5;7.6)
Santa Catarina 1083.7 (847.3;1362.7) 106.2 (85.8;130.2) 3431.7 (2674.2;4328.4) 107 (85.2;133.9) 0.8 (-8.3;9.9)
São Paulo 11426.4 (8857.6;14374.4) 139.5 (111.1;173.2) 30035.6 (23857;37379.4) 140.2 (112.5;172.2) 0.5 (-6.5;7.5)
Sergipe 360.2 (280.2;450.3) 95.4 (74.6;119) 913.8 (721.5;1145.2) 101.8 (81.3;126.9) 6.7 (-4.6;16.1)
Tocantins 213.1 (162.9;269.7) 120.8 (96.4;150) 758.9 (602.2;940.5) 111.6 (89.1;137.6) -7.6 (-24.8;3.3)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

– Número de DALYs e taxas de DALYs padronizadas por idade por fibrilação atrial e <italic>flutter</italic> , por 100 mil habitantes, para mulheres, em 1990 e 2017, com variação percentual, no Brasil e suas unidades federativas
1990 2017
Número de DALYs (II 95%) Taxa de DALYs (II 95%) Número de DALYs (II 95%) Taxa de DALYs (II 95%) Variação percentual (II 95%)
Acre 57.9 (47.4;70.5) 86.1 (72.7;102.9) 257.4 (215.1;306.5) 92.9 (77.9;110.2) 7.9 (-0.3;18.8)
Alagoas 409.8 (338.1;497) 61.8 (51.4;75) 1265.4 (1065.7;1512.4) 76 (64.2;90.7) 23 (11;37.8)
Amapá 42.6 (35.6;51.1) 99.4 (85;116.6) 227.9 (189.3;270.1) 101.1 (84.9;118.6) 1.6 (-6.7;11.1)
Amazonas 231.1 (189.1;286.3) 67.1 (56.5;81.1) 949.6 (793.8;1139.7) 74.8 (62.7;88.8) 11.4 (2.8;20.8)
Bahia 2460.4 (2058.7;2986.8) 70.7 (59.5;85.1) 6701.3 (5667.8;8010.2) 74.7 (62.9;89.5) 5.6 (-2.8;15)
Brasil 37693.5 (31770.2;45054.9) 88.6 (76.2;103.9) 116166.6 (98895.8;135791.7) 93.7 (79.8;109.5) 5.8 (2.4;9.7)
Ceará 1329 (1065.5;1653.3) 63.3 (51;78.8) 3991.4 (3369.5;4733.9) 71.4 (60.1;85.2) 12.8 (0.7;31.8)
Distrito Federal 264.4 (221.2;315.2) 109.1 (94.7;125) 1300.4 (1089.6;1554.4) 113.9 (96.7;132.4) 4.4 (-7.5;15.1)
Espírito Santo 499.9 (418.4;598.1) 82.4 (71.3;96.2) 1769.9 (1488;2115) 78 (65.7;93) -5.3 (-11.9;1.5)
Goiás 643.3 (529.2;783.9) 92.3 (80.3;107) 2639.3 (2200.5;3167.7) 81.1 (68.2;96.8) -12.2 (-18.5;-5.6)
Maranhão 886.4 (483.4;1176.4) 72.3 (38.6;96) 2368.5 (1549.5;2987.1) 71.1 (46.4;89.5) -1.8 (-12.9;25)
Mato Grosso 237.7 (192.1;291.2) 78.2 (64.8;94.1) 1195.4 (994.5;1433.5) 88.1 (74.1;103.9) 12.7 (3.3;24)
Mato Grosso do Sul 344.4 (290.2;410.1) 95.3 (82.6;111.1) 1336.5 (1121.2;1582.5) 96.4 (81.4;113.9) 1.2 (-5.8;9.8)
Minas Gerais 4337.2 (3603.5;5206.8) 95 (81.1;111.6) 13128.1 (11052.7;15567.4) 93.7 (78.7;111.3) -1.3 (-7.3;4.6)
Pará 691.4 (579.5;847.2) 71.2 (60.2;85.5) 2362.7 (2004;2820.5) 74.2 (63.4;87.9) 4.2 (-4.6;13.7)
Paraíba 861.9 (711.9;1040.7) 73.2 (61.1;87.8) 2098.8 (1736.5;2506.6) 78.4 (64.5;94) 7.1 (-4;21.5)
Paraná 1824.7 (1515.5;2188.5) 92.4 (79.6;107.7) 6078.2 (5072;7195.1) 91.6 (76.9;107.9) -0.9 (-6.8;5.3)
Pernambuco 1554 (1305.2;1877.1) 71.4 (61;84.8) 4231.3 (3587.3;5077.2) 76.1 (64.6;91) 6.6 (-0.4;14.6)
Piauí 451.9 (362.3;565.1) 64.6 (52.1;80.5) 1405.3 (1184.9;1674.4) 70.6 (59.4;84.4) 9.2 (-2.9;28)
Rio de Janeiro 4703 (3930;5630.4) 97 (82.5;114.7) 12903.3 (10976.9;15227.6) 101.6 (86.2;120) 4.7 (-1.2;11)
Rio Grande do Norte 570.4 (472.9;691.2) 68.7 (57;82.9) 1598.7 (1346;1893.9) 74.5 (62.2;88.8) 8.4 (-3.2;27.5)
Rio Grande do Sul 2588.2 (2156.8;3097.6) 81.1 (69.1;95.9) 7496.9 (6386.8;8904.7) 86 (72.8;102.1) 5.9 (0;12.8)
Rondônia 91.4 (72.4;113.5) 79.2 (66.7;94.3) 537.1 (434.2;655.1) 84.2 (68.9;101.2) 6.3 (-4.1;18.8)
Roraima 18.8 (15.1;22.9) 108.9 (92.8;126.8) 142.3 (114.4;173.6) 108.9 (89.6;130.4) 0 (-14.6;17.9)
Santa Catarina 1097.9 (912.9;1328.2) 97.8 (83.5;116.1) 3961 (3331.6;4682.9) 99.3 (83.9;116.5) 1.5 (-4.6;8.4)
São Paulo 11051.2 (9167;13335.7) 115.9 (98;137.3) 34731.2 (29277.5;41069.7) 120.4 (101.6;142.3) 3.9 (-1.4;9.9)
Sergipe 308.8 (258.3;371.5) 69 (58;82.6) 914.3 (770.8;1097.2) 78.3 (65.9;93.7) 13.3 (4.5;23.3)
Tocantins 136 (110.1;166.5) 96.4 (80.4;114.7) 574.3 (479.9;679.9) 89 (74.9;105.6) -7.7 (-18.2;8.4)
Fonte: Estudo Global Burden of Disease 2017, Institute for Health Metrics and Evaluation. 285

- Número de casos prevalentes de fibrilação atrial e flutter entre 1990 e 2017, por sexo no Brasil. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 285

- Correlação entre o Índice Sociodemográfico (SDI) e a taxa de mortalidade padronizada por idade por fibrilação atrial e flutter, por 100 mil habitantes. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 285

- Correlação entre o Índice Sociodemográfico (SDI) e a taxa de DALYs padronizada por idade por fibrilação atrial e flutter, por 100 mil habitantes. Dados derivados do Estudo Global Burden of Disease 2017 (GBD 2017). 285

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Incidence of stroke and acute renal failure in patients of postoperative atrial fibrillation after myocardial revascularization. Rev Bras Cir Cardiovasc. 2013;28(4):442-8. doi: 10.5935/1678-9741.20130073. Barbieri LR Sobral MLP Gerônimo GMS Santos GG Sbaraíni E Dorfman FK Stolf NA Incidence of stroke and acute renal failure in patients of postoperative atrial fibrillation after myocardial revascularization Rev Bras Cir Cardiovasc 2013 28 4 442 448 10.5935/1678-9741.20130073 265. Bohatch MS Jr, Matkovski PD, Di Giovanni FJ, Fenili R, Varella EL, Dietrich A. Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting. Braz J Cardiovasc Surg. 2015;30(3):316-24. doi: 10.5935/1678-9741.20150040. Bohatch MS Jr Matkovski PD Di Giovanni FJ Fenili R Varella EL Dietrich A Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting Braz J Cardiovasc Surg 2015 30 3 316 324 10.5935/1678-9741.20150040 266. Pivatto F Jr, Teixeira Filho GF, Sant’Anna JR, Py PM, Prates PR, Nesralla IA, Kalil RAK. [Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement]. Rev Bras Cir Cardiovasc. 2014;29(1):45-50. Portuguese. doi: 10.5935/1678-9741.20140010. Pivatto F Jr Teixeira GF Filho Sant’Anna JR Py PM Prates PR Nesralla IA Kalil RAK Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement] Rev Bras Cir Cardiovasc 2014 29 1 45 50 Portuguese 10.5935/1678-9741.20140010 267. Sá MP, Sá MV, Albuquerque AC, Silva BB, Siqueira JW, Brito PR, Ferraz PE, Lima RC. Predicting risk of atrial fibrillation after heart valve surgery: evaluation of a Brazilian risk score. Rev Bras Cir Cardiovasc. 2012;27(1):117-22. doi: 10.5935/1678-9741.20120017. Sá MP Sá MV Albuquerque AC Silva BB Siqueira JW Brito PR Ferraz PE Lima RC Predicting risk of atrial fibrillation after heart valve surgery: evaluation of a Brazilian risk score Rev Bras Cir Cardiovasc 2012 27 1 117 122 10.5935/1678-9741.20120017 268. Folla CO, Melo CC, Silva RC. Predictive factors of atrial fibrillation after coronary artery bypass grafting. Einstein (Sao Paulo). 2016;14(4):480-5. doi: 10.1590/S1679-45082016AO3673. Folla CO Melo CC Silva RC Predictive factors of atrial fibrillation after coronary artery bypass grafting Einstein (Sao Paulo) 2016 14 4 480 485 10.1590/S1679-45082016AO3673 269. Souza PFP, Pine RCD, Ramos FLP, Pinto AYDN. Atrial fibrillation in acute Chagas disease acquired via oral transmission: a case report. Rev Soc Bras Med Trop. 2018;51(3):397-400. doi: 10.1590/0037-8682-0296-2017. Souza PFP Pine RCD Ramos FLP Pinto AYDN Atrial fibrillation in acute Chagas disease acquired via oral transmission: a case report Rev Soc Bras Med Trop 2018 51 3 397 400 10.1590/0037-8682-0296-2017 270. Marcolino MS, Palhares DM, Ferreira LR, Ribeiro ALP. Electrocardiogram and Chagas disease a large population database of primary care patients. Glob Heart. 2015;10(3):167-72. doi: 10.1016/j.gheart.2015.07.001. Marcolino MS Palhares DM Ferreira LR Ribeiro ALP Electrocardiogram and Chagas disease a large population database of primary care patients Glob Heart 2015 10 3 167 172 10.1016/j.gheart.2015.07.001 271. Cardoso CS, Sabino EC, Oliveira CD, Oliveira LC, Ferreira AM, Cunha-Neto E, Bierrenbach AL, Ferreira JE, Haikal DS, Reingold AL, Ribeiro ALP. Longitudinal study of patients with chronic Chagas cardiomyopathy in Brazil (SaMi-Trop project): a cohort profile. BMJ Open. 2016;6(5):e011181. doi: 10.1136/bmjopen-2016-011181. Cardoso CS Sabino EC Oliveira CD Oliveira LC Ferreira AM Cunha E Neto Bierrenbach AL Ferreira JE Haikal DS Reingold AL Ribeiro ALP Longitudinal study of patients with chronic Chagas cardiomyopathy in Brazil (SaMi-Trop project): a cohort profile BMJ Open 2016 6 5 e011181 10.1136/bmjopen-2016-011181 272. Rojas LZ, Glisic M, Pletsch-Borba L, Echeverria LE, Bramer WM, Bano A, Stringa N, Zaciragic A, Kraja B, Asllanaj E, Chowdhury R, Morillo CA, Rueda-Ochoa OL, Franco OH, Muka T. Electrocardiographic abnormalities in Chagas disease in the general population: a systematic review and meta-analysis. PLoS Negl Trop Dis. 2018;12(6):e0006567. doi: 10.1371/journal.pntd.0006567. Rojas LZ Glisic M Pletsch-Borba L Echeverria LE Bramer WM Bano A Stringa N Zaciragic A Kraja B Asllanaj E Chowdhury R Morillo CA Rueda-Ochoa OL Franco OH Muka T Electrocardiographic abnormalities in Chagas disease in the general population: a systematic review and meta-analysis PLoS Negl Trop Dis 2018 12 6 e0006567 10.1371/journal.pntd.0006567 273. Rassi A Jr, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi AG, Hasslocher-Moreno A, Sousa AS, Scanavacca MI. Development and validation of a risk score for predicting death in Chagas’ heart disease. N Engl J Med. 2006;355(8):799-808. doi: 10.1056/NEJMoa053241. Rassi A Jr Rassi A Little WC Xavier SS Rassi SG Rassi AG Hasslocher-Moreno A Sousa AS Scanavacca MI Development and validation of a risk score for predicting death in Chagas’ heart disease N Engl J Med 2006 355 8 799 808 10.1056/NEJMoa053241 274. Nunes MCP, Kreuser LJ, Ribeiro ALP, Sousa GR, Costa HS, Botoni FA, de Souza AC, Gomes Marques VE, Fernandez AB, Teixeira AL, da Costa Rocha MO. Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease. Glob Heart. 2015;10(3):151-7. doi: 10.1016/j.gheart.2015.07.006. Nunes MCP Kreuser LJ Ribeiro ALP Sousa GR Costa HS Botoni FA Souza AC Gomes Marques VE Fernandez AB Teixeira AL Costa Rocha MO Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease Glob Heart 2015 10 3 151 157 10.1016/j.gheart.2015.07.006 275. Vinereanu D, Lopes RD, Bahit MC, Xavier D, Jiang J, Al-Khalidi HR, He W, Xian Y, Ciobanu AO, Kamath DY, Fox KA, Rao MP, Pokorney SD, Berwanger O, Tajer C, Silva PGMB, Roettig ML, Huo Y, Granger CB; IMPACT-AF investigators. A multifaceted Intervention to Improve Treatment With Oral Anticoagulants in Atrial Fibrillation (IMPACT-AF): an international, cluster-randomised trial. Lancet. 2017;390(10104):1737-46. doi: 10.1016/S0140-6736(17)32165-7. Vinereanu D Lopes RD Bahit MC Xavier D Jiang J Al-Khalidi HR He W Xian Y Ciobanu AO Kamath DY Fox KA Rao MP Pokorney SD Berwanger O Tajer C Silva PGMB Roettig ML Huo Y Granger CB IMPACT-AF investigators A multifaceted Intervention to Improve Treatment With Oral Anticoagulants in Atrial Fibrillation (IMPACT-AF): an international, cluster-randomised trial Lancet 2017 390 10104 1737 1746 10.1016/S0140-6736(17)32165-7 276. Bartholomay E, Polli I, Borges AP, Kalil C, Arroque A, Kohler I, Danzmann LC. Prevalence of oral anticoagulation in atrial fibrillation. Clinics (Sao Paulo). 2014;69(9):615-20. doi: 10.6061/clinics/2014(09)07. Bartholomay E Polli I Borges AP Kalil C Arroque A Kohler I Danzmann LC Prevalence of oral anticoagulation in atrial fibrillation Clinics (Sao Paulo) 2014 69 9 615 620 10.6061/clinics/2014(09)07 277. Martins MAP, Costa JM, Mambrini JVM, Ribeiro ALP, Benjamin EJ, Brant LCC, Paasche-Orlow MK, Magnani JW. Health literacy and warfarin therapy at two anticoagulation clinics in Brazil. Heart. 2017;103(14):1089-95. doi: 10.1136/heartjnl-2016-310699. Martins MAP Costa JM Mambrini JVM Ribeiro ALP Benjamin EJ Brant LCC Paasche-Orlow MK Magnani JW Health literacy and warfarin therapy at two anticoagulation clinics in Brazil Heart 2017 103 14 1089 1095 10.1136/heartjnl-2016-310699 278. Marcatto LR, Sacilotto L, Darrieux FCC, Hachul DT, Scanavacca MI, Krieger JE, Pereira AC, Santos PC. Age is associated with time in therapeutic range for warfarin therapy in patients with atrial fibrillation. Oncotarget. 2016;7(34):54194-99. doi: 10.18632/oncotarget.10944. Marcatto LR Sacilotto L Darrieux FCC Hachul DT Scanavacca MI Krieger JE Pereira AC Santos PC Age is associated with time in therapeutic range for warfarin therapy in patients with atrial fibrillation Oncotarget 2016 7 34 54194 54199 10.18632/oncotarget.10944 279. Silva RGDL, Bertollo CM, Ferreira IG, Brant LCC, Martins MAP. Assessment of oral anticoagulation control at two pharmacist-managed clinics in Brazil. Int J Clin Pharm. 2017;39(6):1157-1161. doi: 10.1007/s11096-017-0511-x. Silva RGDL Bertollo CM Ferreira IG Brant LCC Martins MAP Assessment of oral anticoagulation control at two pharmacist-managed clinics in Brazil Int J Clin Pharm 2017 39 6 1157 1161 10.1007/s11096-017-0511-x 280. Oliveira LH, Mallmann FB, Botelho FN, Paul LC, Gianotto M, Abt RB, Silva NJ, Luize CM, Nogueira FL, Carvalho RS, Paola AA, Cirenza C. Cross-sectional study of treatment strategies on atrial fibrillation. Arq Bras Cardiol. 2012;98(3):195-202. doi: 10.1590/s0066-782x2012005000020. Oliveira LH Mallmann FB Botelho FN Paul LC Gianotto M Abt RB Silva NJ Luize CM Nogueira FL Carvalho RS Paola AA Cirenza C Cross-sectional study of treatment strategies on atrial fibrillation Arq Bras Cardiol 2012 98 3 195 202 10.1590/s0066-782x2012005000020 281. van der Sand CR, Leiria TLL, Kalil RAK. Assessment of the adherence of cardiologists to guidelines for the treatment of atrial fibrillation. Arq Bras Cardiol. 2013;101(2):127-33. doi: 10.5935/abc.20130148. van der Sand CR Leiria TLL Kalil RAK Assessment of the adherence of cardiologists to guidelines for the treatment of atrial fibrillation Arq Bras Cardiol 2013 101 2 127 133 10.5935/abc.20130148 282. Keegan R, Aguinaga L, Fenelon G, Uribe W, Diez GR, Scanavacca M, Patete M, Carhuaz RZ, Labadet C, de Zuloaga C, Pozzer D, Scazzuso F; SOLAECE registry investigators. The first Latin American Catheter Ablation Registry. Europace. 2015;17(5):794-800. doi: 10.1093/europace/euu322. Keegan R Aguinaga L Fenelon G Uribe W Diez GR Scanavacca M Patete M Carhuaz RZ Labadet C Zuloaga C Pozzer D Scazzuso F SOLAECE registry investigators The first Latin American Catheter Ablation Registry Europace 2015 17 5 794 800 10.1093/europace/euu322 283. Odozynski G, Forno ARJD, Lewandowski A, Nascimento HG, D’Avila A. Paroxysmal atrial fibrillation in females: understanding gender diferences. Arq Bras Cardiol. 2018;110(5):449-54. doi: 10.5935/abc.20180069. Odozynski G Forno ARJD Lewandowski A Nascimento HG D’Avila A Paroxysmal atrial fibrillation in females: understanding gender diferences Arq Bras Cardiol 2018 110 5 449 454 10.5935/abc.20180069 284. Lopes RD, de Paola AAV, Lorga Filho AM, Consolim-Colombo FM, Andrade J, Piva e Mattos LA, Bernardez-Pereira S, Berwanger O, de Oliveira Figueiredo MJ; RECALL Steering Committee and Investigators. Rationale and design of the First Brazilian Cardiovascular Registry of Atrial Fibrillation: the RECALL study. Am Heart J. 2016;176:10-6. doi: 10.1016/j.ahj.2016.03.001. Lopes RD Paola AAV Lorga AM Filho Consolim-Colombo FM Andrade J Piva e Mattos LA Bernardez-Pereira S Berwanger O Oliveira Figueiredo MJ RECALL Steering Committee and Investigators Rationale and design of the First Brazilian Cardiovascular Registry of Atrial Fibrillation: the RECALL study Am Heart J 2016 176 10 16 10.1016/j.ahj.2016.03.001 285. Global Burden of Disease Study 2017 (GBD 2017) results. Global Health Data Exchange website. Seattle, WA: Institute for Health Metrics and Evaluation (IHME), University of Washington; 2017. Available from: http://ghdx.healthdata.org/gbd-results-tool . Accessed Feb 10, 2020. Global Burden of Disease Study 2017 (GBD 2017) results Global Health Data Exchange website Seattle, WA Institute for Health Metrics and Evaluation (IHME), University of Washington 2017 http://ghdx.healthdata.org/gbd-results-tool Accessed Feb 10, 2020

Vinculação Acadêmica

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Fontes de Financiamento

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 Special Article Cardiovascular Statistics – Brazil 2020 0000-0002-6306-1279 Oliveira Gláucia Maria Moraes de 1 2 0000-0002-7317-1367 Brant Luisa Campos Caldeira 3 4 0000-0002-2447-2577 Polanczyk Carisi Anne 5 6 7 0000-0002-8579-4158 Biolo Andreia 5 6 7 0000-0002-5586-774X Nascimento Bruno Ramos 3 4 0000-0002-8214-5734 Malta Deborah Carvalho 8 0000-0003-3287-9163 Souza Maria de Fatima Marinho de 8 9 0000-0002-7058-799X Soares Gabriel Porto 1 10 0000-0001-5190-3523 Xavier Gesner Francisco Junior 11 0000-0003-1840-4372 Machline-Carrion M. Julia 12 0000-0002-3711-1754 Bittencourt Marcio Sommer 13 14 0000-0003-0317-843X Pontes Octavio M. Neto 15 0000-0002-5538-7455 Silvestre Odilson Marcos 16 Teixeira Renato Azeredo 8 0000-0001-6524-9614 Sampaio Roney Orismar 17 18 19 0000-0002-5985-345X Gaziano Thomaz A. 20 21 Roth Gregory A. 22 23 0000-0002-2740-0042 Ribeiro Antonio Luiz Pinho 3 4 Brazil Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brazil Brazil Disciplina de Cardiologia, Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brazil Brazil Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG – Brazil Brazil Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG – Brazil Brazil Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre, RS – Brazil Brazil Serviço de Cardiologia do Hospital Moinhos de Vento, Porto Alegre, RS – Brazil Brazil Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS – Brazil Brazil Programa de Pós-Graduação em Saúde Pública da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG – Brazil USA Organização Vital Strategies, Nova York – USA Brazil Curso de Medicina da Universidade de Vassouras, Vassouras, RJ – Brazil Brazil Biblioteca da Faculdade de Medicina Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG – Brazil Brazil ePHealth Primary Care Solutions, Santo Antônio, SC – Brazil Brazil Divisão de Clínica Médica do Hospital Universitário da Universidade de São Paulo, São Paulo, SP – Brazil Brazil Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP – Brazil Brazil Serviço de Neurologia Vascular e Emergências Neurológicas, Divisão de Neurologia, Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (USP), São Paulo, SP – Brazil Brazil Universidade Federal do Acre (UFAC), Rio Branco, AC – Brazil Brazil Departamento de Cardiopneumologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil Brazil Programa de Pós-Graduação da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil Brazil Unidade Clínica de Cardiopatias Valvares do Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brazil USA Brigham and Women’s Hospital, Boston – USA USA Department of Medicine, Cardiovascular, Harvard Medical School, Boston – USA USA Global Health and Health Metrics Sciences at the Institute for Health Metrics and Evaluation (IHME), Washington – USA USA Division of Cardiology at the University of Washington School of Medicine, Washington – USA Mailing Address: Gláucia Maria Moraes de Oliveira and Antonio Luiz Pinho Ribeiro • Universidade Federal do Rio de Janeiro – R. Prof. Rodolpho P. Rocco, 255 – 8°. Andar – Sala 6, UFRJ. Postal Code 21941-913, Cidade Universitária, RJ – Brazil E-mail: glauciam@cardiol.br , glauciamoraesoliveira@gmail.com ; tom1963br@yahoo.com.br

Author Contributions

Conception and design of the research; Acquisition of data; Analysis and interpretation of the data, Statistical analysis; Writing of the manuscript; Critical revision of the manuscript for intellectual content: Oliveira GMM, Brant LCC, Polanczyk CA, Biolo A, Nascimento BR, Malta DC, Souza MFM, Soares GP, Xavier Junior GF, Machline-Carrion MJ, Bittencourt MS, Pontes-neto OM, Silvestre OM, Teixeira RA, Sampaio RO, Gaziano TA, Roth GA, Ribeiro ALP. Supervision / as the major investigador: Oliveira GMM, Ribeiro ALP.

Potential Conflict of Interest

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

 Cardiovascular Diseases Coronary Disease Cardiomyopathies. Heart Failure Heart Valve Diseases Atrial Fibrillation Atrial Flutter Statistics Brazil About these Statistics

Abbreviations Used in this Introduction
CVD Cardiovascular Disease
DALY Disability-Adjusted Life Year
FU Federative Unit
GBD Global Burden of Disease
GDP Gross Domestic Product
IBGE Brazilian Institute of Geography and Statistics (in Portuguese, Instituto Brasileiro de Geografia e Estatística )
ICD International Statistical Classification of Diseases and Related Health Problems
IHME Institute for Health Metrics and Evaluation
Int$ International dollars
IPCA Brazilian Consumer Price Index (in Portuguese, Índice de Preços ao Consumidor Amplo )
PNS National Health Survey (in Portuguese, Pesquisa Nacional de Saúde )
PPP Purchasing Power Parity
R$ Reais, Brazilian currency
SBC Brazilian Society of Cardiology (in Portuguese, Sociedade Brasileira de Cardiologia )
SIH Brazilian Hospital Information System (in Portuguese, Sistema de Informações Hospitalares )
SIM Brazilian Mortality Information System (in Portuguese, Sistema de Informações sobre Mortalidade )
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde )
US$ US dollars
YLL Year of Life Lost
YLD Year Lived with Disability

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, Brazil ranks among the 10 countries with the highest Gini index, a measurement of inequality in income distribution ( https://data.worldbank.org/indicator/SI.POV.GINI ). Brazil has one of the largest public health systems with universal coverage, the SUS, which covers the whole Brazilian population, estimated at 210 million inhabitants in 2019 ( https://www.ibge.gov.br/estatisticas/sociais/populacao.html ), the year in which SUS was the exclusive health system for 76% of that population ( http://www.ans.gov.br ). Indeed, SUS co-exists with a private health system that includes health plans and insurance, and private health professionals. Established by the Brazilian Constitution of 1988, the implementation and expansion of SUS have 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 3 decades.1 , 2 The Family Health Program, 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 2015.3However, despite its successes, the analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and issues related to access to care and its quality.1 , 2

Cardiovascular disease has been the leading cause of mortality since the 1960s and has accounted for a substantial burden of disease in Brazil.2 , 4 Considerable data relevant to cardiovascular health are now available from government health surveillance and administrative databases, as well as 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.2In recent years, the GBD project, led by the IHME of the University of Washington, began working with a Brazilian GBD network to release subnational estimates of the burden of disease by the Brazilian FUs, including for cardiovascular causes.11 - 14

This report, the Cardiovascular Statistics – Brazil 2020 , incorporates official statistics provided by the Brazilian Ministry of Health and other government agencies, as well as data generated by other sources and scientific studies on heart disease, stroke, and other CVDs, including data from GBD/IHME. The aim of this project is to continuously monitor and evaluate data sources on heart disease and stroke in Brazil, 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 15methodology, and is supported by the SBC, the GBD Brazil network, and an International Committee. The Cardiovascular Statistics – Brazil 2020 document is the product of effort of 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 general public, and others who seek comprehensive national data on heart disease and stroke. The first edition was restricted to a limited number of clinical conditions, listed below:

Total Cardiovascular Diseases

Cerebrovascular Disease

Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris

Cardiomyopathy and Heart Failure

Valvular Diseases including Rheumatic Heart Disease

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 Research. In the following editions, we intend to cover the clinical cardiac conditions more comprehensively, as well as the cardiovascular risk factors, life habits, quality of care, and other aspects that are relevant to the study of CVDs.

The emphasis of this document is on updated epidemiological data. It neither focuses on pathophysiological mechanisms or the merits of specific clinical treatments nor makes treatment recommendations. In addition, it is neither a position paper nor a comprehensive review, but tries to present the newest and best health-related metrics of CVD statistics for the Brazilian population. Moreover, it is not intended to cover other countries and regions, being restricted to Brazil, its regions, and FUs.

For the present document, we mostly used 3 sources of data: (a) the Brazilian mortality and health information systems, provided by the government; (b) GBD 2017 estimates; (c) systematic review of the literature with emphasis on what was published in the last 10 years. The metrics from the 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. The 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 the IBGE definition, i.e., white, black, brown, yellow (oriental) or Indian (native American).

Herein, we present a summary of our data sources and the methodology used to assess healthcare utilization.

 Brazilian Mortality and Health Information Systems

For the present version of the Cardiovascular Statistics – Brazil 2020 document, the major Brazilian data sources were the Brazilian Health Information Systems, comprising the Brazilian Mortality Information System and the Brazilian Hospital Information System, periodic health surveys, such as the National Health Survey, and official population estimates.

Brazilian Mortality Information System (SIM): In Brazil, the SIM, created in 1975 by the Brazilian Ministry of Health, is responsible for collecting, storing, managing, and disseminating national mortality data. This health information system represented a major advance in the country’s epidemiological surveillance, since its main task is to record all deaths occurring in the Brazilian territory. The Ministry of Health implemented a Standard Certificate of Death model, a document for collecting information on death that uses the ICD to code the causes of death; in addition, a flow of collection, processing, and distribution of death information was implemented in all 5570 municipalities across the country.16 , 17 The quality of the statistics on causes of death in Brazil significantly improved in the last 2 decades, but data from the beginning of the 2000 decade are still of low quality, specifically in some parts of the country.18Knowing the heterogeneity of these indicators in Brazil, the Cardiovascular Statistics – Brazil 2020 report treated data to estimate information closer to real, by correcting for underreporting and redistribution of ill-defined causes of death. More details can be found in the article by Malta et al. (In press).

Brazilian Hospital Information System (SIH): The aim of the SIH database is to register all hospitalizations funded by the SUS. The SIH-SUS compiles the hospitalizations at the municipal level through the ‘Hospital Admission Authorization’, which has information about the diseases leading to hospitalization (using ICD-10), length of stay, procedures, and costs.19The SIH-SUS information allows the development of methodologies and the definition of indicators to identify geographical disparities related to hospital resources.20

National Health Survey (PNS): Although it was not in the scope of this year’s document to describe the statistics for cardiovascular risk factors, some chapters cite the metrics for some risk factors in the context of the specified disease. In such cases, a preference for the PNS was made. The PNS is a household-based epidemiological survey, representative of Brazil, its large regions, FUs, metropolitan regions, capitals, and other municipalities in each FU. The PNS 2013 sample was composed of 64 348 households. The survey was carried out by IBGE in partnership with the Ministry of Health. Most health topics were included, such as noncommunicable diseases, renal function, elderly, women, children, use of health services, health inequalities, anthropometric features, laboratory tests, and blood pressure measurements.21The PNS data are used by the GBD in its estimates for Brazil.

For population estimates, the most updated population estimates generated by the IBGE (www.ibge.gov.br) were used in the denominator. For the hospitalizations and cost analyses, the resident population estimated for the National Audit Office yearly, from 2008 to 2018, was used.

 GBD 2017

The GBD Study (http://www.healthdata.org/gbd) is the most comprehensive worldwide observational epidemiological study to date. It describes mortality and morbidity from major diseases, injuries, and risk factors at global, national, and regional levels. Examining trends from 1990 to the present and making comparisons across populations enable the understanding of the changing health challenges faced by people across the world in the 21st century. The GBD 2017 is the latest publicly available dataset.22 - 25 The GBD Brazil network has been collaborating with the IHME, from the University of Washington, that leads the project in the world, in the identification and provision of datasets, revision of models and estimates, validation and publication of the results for Brazil.13 , 14 Details on how the estimates are calculated can be obtained in the capstone papers of the GBD Study22 - 25 and in the IHME website (http://www.healthdata.org/acting-data/what-we-measure-and-why). We summarize below the main estimates used in this document:

Estimates of deaths and causes of deaths. The main source of information is the SIM, a database from the Brazilian Ministry of Health, adjusted to other national and international sources. The IHME used methods for correcting for underreporting of deaths and “garbage code” deaths according to previously published algorithms,26updated in the newer versions of the study ( http://www.healthdata.org/acting-data/determining-causes-death-how-we-reclassify-miscoded-deaths ).

YLLs are years lost due to premature mortality. The YLLs are calculated by subtracting the age at death from the longest possible life expectancy for a person at that age. For example, if the longest life expectancy for men in a given country is 75 years, but a man dies of cancer at 65, this would be 10 years of life lost due to cancer.

YLDs, years lived with disability, can also be described as years lived in less than ideal health. This includes conditions such as influenza, which may last for only a few days, or epilepsy, which can last a lifetime. It is measured by taking the prevalence of the condition multiplied by the disability weight for that condition. Disability weights reflect the severity of different conditions and are developed through surveys of the general public.

DALY is a universal metric that allows researchers and policymakers to compare quite different populations and health conditions across time. The DALYs equal the sum of YLLs and YLDs. One DALY equals one lost year of healthy life. DALYs allow us to estimate the total number of years lost due to specific causes and risk factors at the country, regional, and global levels.

 Systematic Review of the Literature

Descriptors for the elaboration of search strategies were selected in MeSH and DeCS, the controlled vocabularies from MEDLINE and LILACS, respectively. Embase’s plan was designed with Emtree descriptors associated with MeSH. Free terms were also used, that is, significant keywords and their synonyms, spelling variations, and acronyms that are essential for searching in the searched domain, but are not controlled descriptors (or are not in the synonym list of these descriptors). Importantly, to maintain search uniformity, the same descriptors were used in all search strategies. However, search strategies were customized according to the specifics of each database. It is also noteworthy that the group of terms related to “Brazil” was generally searched in all fields of research (subject, author, title, institutional affiliation, journal name, etc.).

The selected bases for research were MEDLINE via PubMed, Embase, LILACS, CINAHL, Cochrane Library Scopus, and Web of Science. The following bibliographic research filters and limits were used: period of publication (2004-2019); languages: Portuguese, English and Spanish; type of study/publication: Review, Meta-Analysis, Clinical Trial, Randomized Controlled Trial, Comparative Study, Practice Guideline, Guideline, Systematic Review, Evaluation Studies, Government Publications, and Multicenter Study. All references were managed using EndNote Web. From the search, articles were included if the studies were population- or community-based; nation- or state-wide studies were preferred. Moreover, articles set at health services or hospitals were included if the study was multicenter and had an adequate sample size (> 200 participants was the suggested cut-off), preferably. In addition to the articles identified by the systematic search, authors could include other studies found in the references of the searched articles or other articles they were aware of in their area of expertise, if the studies fulfilled the criteria above mentioned. Finally, which studies should be described in each chapter was mostly a decision of the experts commissioned to the specific theme.

 Healthcare Utilization

Healthcare costing studies have expressive methodologic variability and, thus, need to be carefully interpreted. In the present document, most of the cost data were gathered from reimbursement tables from the Public Health System from 2008 to 2018. During this period, adjustment for inflation was performed neither regularly nor homogeneously across the CVD groups or procedures. The Brazilian inflation rate (based on the IPCA) from 2008 to 2018 was 76.3%, and the mean inflation for cardiovascular procedures was 43.5%. For some procedure codes, the adjustment was minimal; for coronary stenting, for example, it was 8.7%. Other procedures, however, were adjusted above the inflation rate, such as the treatment of arrhythmias (83.4%).

To minimize biases in reporting and interpreting cost data, a systematic approach was applied to all chapters. Overall costing studies were described in original currency (Reais or US dollars in a specific year) and international dollars. International dollars were converted to PPP adjusted to 2018 US dollars (2018 Int$) using the Campbell and Cochrane Economics Methods Group Evidence for Policy and Practice Information and Coordination Centre cost converter ( https://eppi.ioe.ac.uk/costconversion/default.aspx) . A two-stage approach is applied in this method. First, it adjusts the original estimate of cost from the original price-year to a target price-year, using a GDP deflator index (GDPD values). Second, it converts the price-year adjusted cost estimate in the original currency to a target currency, using conversion rates based on PPP for GDP (PPP values).27For original economic studies, when the base year of the currency was not reported or could not be inferred from the manuscript (e.g., the last year of data collection), the recommendation was to assume the year before the publication of the paper.

 1. TOTAL CARDIOVASCULAR DISEASES ICD-9 390 to 459; ICD-10 I00 to I99.

See Tables 1-1 through 1-9 and Charts 1-1 through 1-16

Abbreviations Used in Chapter 1
ACS Acute Coronary Syndrome
AHA American Heart Association
AMI Acute Myocardial Infarction
CABG Coronary Artery Bypass Grafting
CI Confidence Interval
CVD Cardiovascular Disease
DALY Disability-Adjusted Life Year
DATASUS Brazilian Unified Health System Database
ELSA-Brasil Brazilian Longitudinal Study of Adult Health
ELSI-Brasil Brazilian Longitudinal Study of the Elderly Health and Wellness
FHP Family Health Program
FU Federative Unit
GBD Global Burden of Disease
GDP Gross Domestic Product
HDI Human Development Index
HDIm Municipal Human Development Index
HF Heart Failure
IBGE Brazilian Institute of Geography and Statistics
ICD International Statistical Classification of Diseases and Related Health Problems
IHD Ischemic Heart Disease
NCD Noncommunicable Chronic Disease
NHS National Health System
OR Odds Ratio
PAR Population Attributable Risks
RR Relative Risk
SDI Sociodemographic Index
SIDRA IBGE Automated Retrieval System (in Portuguese, Sistema IBGE de Recuperação Automática )
SIH Brazilian Hospital Information System (in Portuguese, Sistema de Informações Hospitalares )
SIM Brazilian Mortality Information System (in Portuguese, Sistema de Informações sobre Mortalidade )
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde )
UI Uncertainty Interval
– Age-standardized prevalence rates of CVD per 100 000 inhabitants, by sex, in Brazil, 1990 and 2017, and percent change
Federative Units Both sexes Female Male
1990 2017 Percent change 1990 2017 Percent change 1990 2017 Percent change
Brazil 6290 (6048.3;6548.9) 6025 (5785.8;6274.8) -4.2 (-3.2;-5.1) 5939.5 (5694.8;6205.5) 5612.9 (5366.3;5856.6) -5.5 (-4.2;-6.7) 6697.3 (6433.7;6961.9) 6536.8 (6282.7;6806.6) -2.4 (-1.3;-3.4)
Acre 6011.6 (5762.4;6272.3) 5814.9 (5568.2;6071.4) -3.3 (-1.4;-5.3) 5595.5 (5340.7;5865.5) 5350.3 (5101.6;5618.9) -4.4 (-1.5;-7.2) 6361.8 (6076.6;6659.2) 6299 (6033;6583.4) -1 (1.8;-3.9)
Alagoas 5960.7 (5700.5;6233.7) 5790.1 (5543.7;6044.7) -2.9 (-0.8;-4.8) 5603.9 (5346;5888.2) 5381 (5123;5659.8) -4 (-1;-6.9) 6360 (6070.2;6651.8) 6307.2 (6024.2;6580.8) -0.8 (2;-3.5)
Amapá 6219.5 (5950.1;6490.2) 6185.3 (5922.8;6478.7) -0.5 (1.5;-2.7) 5945.1 (5646.7;6260.9) 5817.8 (5542.5;6137.7) -2.1 (1.3;-5.4) 6515.4 (6227.7;6811.6) 6587.8 (6304.5;6889.1) 1.1 (3.8;-1.6)
Amazonas 5728.7 (5485.7;5987.5) 5701.6 (5455.9;5955) -0.5 (1.8;-2.6) 5367.7 (5112.8;5643.3) 5244.5 (4984.1;5506.4) -2.3 (0.8;-5.5) 6092 (5823.9;6361.4) 6183.2 (5892.3;6475.4) 1.5 (4.5;-1.3)
Bahia 5760.9 (5521.5;6019.9) 5685.9 (5433.9;5942.7) -1.3 (0.9;-3.4) 5420.2 (5164;5706.9) 5247 (4989.7;5508.9) -3.2 (-0.2;-6) 6147.9 (5863.3;6431.4) 6225 (5936.4;6513.3) 1.3 (4.3;-1.6)
Ceará 5860.4 (5600.4;6118.9) 5943.7 (5668.7;6231.8) 1.4 (3.8;-0.9) 5545.9 (5270.6;5820.4) 5541.3 (5256.3;5850.7) -0.1 (3.2;-3.3) 6211.7 (5923.9;6506.7) 6448.9 (6145.4;6775.2) 3.8 (7.1;0.7)
Distrito Federal 5798.5 (5563.4;6037.2) 5529.8 (5303.6;5752.8) -4.6 (-2.7;-6.5) 5461.1 (5211.3;5732.7) 5144.9 (4908.1;5382.3) -5.8 (-3;-8.7) 6209.3 (5957.1;6458.7) 6061.9 (5797;6321.5) -2.4 (0.3;-4.9)
Espírito Santo 6214.8 (5957;6478.6) 5748.2 (5490.1;5998.6) -7.5 (-5.6;-9.5) 5868.6 (5600.7;6137.1) 5341.6 (5086.6;5596.6) -9 (-6.1;-11.8) 6591.9 (6320.7;6883.9) 6240.1 (5950.8;6518.6) -5.3 (-2.8;-7.8)
Goiás 5642.8 (5395.9;5901.5) 5527.3 (5295.5;5762.8) -2 (0.1;-4.2) 5318.3 (5037.2;5601.6) 5136.8 (4890.8;5398.2) -3.4 (0;-6.6) 5947.9 (5701.8;6217.5) 5969.3 (5701.1;6245.8) 0.4 (3.2;-2.6)
Maranhão 5596.3 (5341.3;5857.4) 5592.5 (5348.5;5844.7) -0.1 (2;-2.1) 5196.3 (4944.4;5463.5) 5174.8 (4941.4;5424) -0.4 (2.6;-3.3) 6026.1 (5740.7;6311.6) 6065.4 (5785.2;6348.3) 0.7 (3.5;-2.2)
Mato Grosso 5995.6 (5727.7;6258.6) 5869.7 (5612.3;6121.4) -2.1 (0.2;-4.1) 5622 (5350.5;5896.6) 5441.8 (5189.2;5704.2) -3.2 (-0.1;-6) 6297.7 (6001.6;6588.6) 6285.3 (5998.3;6582.1) -0.2 (2.8;-3)
Mato Grosso do Sul 6168.4 (5915.1;6427.7) 5964.9 (5727.2;6210.6) -3.3 (-1.3;-5.3) 5730.5 (5467.9;5987.4) 5472.6 (5219.8;5732.1) -4.5 (-1.6;-7.4) 6571.7 (6308.5;6860.6) 6512.2 (6248.7;6790.3) -0.9 (1.8;-3.7)
Minas Gerais 6269 (5985.9;6552.4) 6031.6 (5768.1;6308.7) -3.8 (-1.4;-5.9) 5902 (5602;6201.4) 5614.5 (5333.5;5907.9) -4.9 (-1.8;-7.9) 6699.1 (6401.3;6989.1) 6532.8 (6246.7;6839) -2.5 (0.2;-5)
Pará 5842.4 (5588.6;6111.7) 5751 (5495.1;6017.5) -1.6 (0.6;-3.6) 5511.2 (5245.2;5786.3) 5291.5 (5022.7;5567.5) -4 (-0.7;-7.2) 6191.5 (5918.1;6485.6) 6236.9 (5947.8;6540.6) 0.7 (3.7;-2)
Paraíba 5802.6 (5546.1;6053.4) 5755.9 (5515.6;6004.5) -0.8 (1.4;-3) 5477.7 (5212.5;5728.9) 5371 (5114.4;5651.9) -1.9 (1.3;-5) 6170.5 (5892.1;6456.2) 6253.3 (5978.4;6539.4) 1.3 (4.1;-1.5)
Paraná 6350.3 (6083.3;6621.1) 5998 (5747.6;6250.1) -5.5 (-3.5;-7.6) 5947.5 (5671;6238.5) 5549.2 (5289.1;5808) -6.7 (-3.8;-9.5) 6765.8 (6472.5;7054) 6538.5 (6262.5;6813.3) -3.4 (-0.5;-6)
Pernambuco 5864.3 (5618.3;6114.8) 5642.3 (5399.5;5887.5) -3.8 (-1.7;-5.9) 5544.4 (5296;5814.4) 5239.5 (4986.3;5490.8) -5.5 (-2.5;-8.3) 6252.9 (5972.2;6545.7) 6184.6 (5912.5;6459.7) -1.1 (1.7;-3.9)
Piauí 5511.3 (5276.3;5755.1) 5545.1 (5314.7;5786.3) 0.6 (2.8;-1.4) 5145.2 (4900.4;5394.3) 5131.4 (4894.1;5385.3) -0.3 (2.8;-3.3) 5911.2 (5642.8;6176.5) 6034.4 (5776.8;6317.2) 2.1 (4.8;-0.6)
Rio de Janeiro 6714.2 (6446.8;7008.6) 6230.8 (5980.5;6490.7) -7.2 (-5.3;-9.2) 6350.5 (6067.4;6659.1) 5820 (5546.8;6108.8) -8.4 (-5.6;-11.1) 7208.1 (6917.8;7498.2) 6800.2 (6527.3;7073.1) -5.7 (-3.1;-8.1)
Rio Grande do Norte 5701.2 (5452.1;5951.2) 5672.5 (5438;5939.2) -0.5 (1.6;-2.4) 5393 (5131.9;5659.9) 5280.7 (5029.7;5550.9) -2.1 (0.8;-5) 6041.8 (5780.8;6327.3) 6170.4 (5892.3;6466.5) 2.1 (5.1;-0.6)
Rio Grande do Sul 6600.3 (6315.3;6880.9) 6182.1 (5906.1;6460.9) -6.3 (-4.4;-8.3) 6322.7 (6028.2;6645.2) 5828.4 (5536.3;6116.6) -7.8 (-4.9;-10.6) 6961.6 (6661.6;7269.6) 6639.1 (6336.7;6946.7) -4.6 (-2;-7.3)
Rondônia 5985.6 (5731;6240.1) 5705.1 (5457.5;5949.3) -4.7 (-2.4;-6.8) 5599.4 (5348.2;5868.1) 5285.8 (5041.4;5543.5) -5.6 (-2.6;-8.6) 6276.9 (5998.5;6564.3) 6111.8 (5837.6;6398.4) -2.6 (0.4;-5.3)
Roraima 6064.1 (5818.4;6308.8) 5814.1 (5583.7;6060.7) -4.1 (-2.1;-6) 5617 (5371;5884) 5317.9 (5070;5562.2) -5.3 (-2.4;-8.1) 6407.7 (6148.3;6694.1) 6269.6 (6021.5;6541.3) -2.2 (0.4;-4.9)
Santa Catarina 6679.1 (6397.8;6964.3) 6217 (5941.2;6488.4) -6.9 (-5;-8.8) 6375.3 (6069.7;6674.6) 5844.5 (5564.4;6133.5) -8.3 (-5.4;-11.1) 7026.3 (6731;7339.3) 6667 (6373.5;6959.6) -5.1 (-2.3;-7.8)
São Paulo 6801.7 (6517.3;7096.7) 6423.9 (6151.9;6705.8) -5.6 (-3.4;-7.5) 6406.6 (6114.7;6715.3) 6000.7 (5715;6302.4) -6.3 (-3.1;-9.3) 7284.4 (6975.5;7612.3) 6975.7 (6661.7;7268.7) -4.2 (-1.4;-6.8)
Sergipe 5922.8 (5667.3;6171.5) 5851.4 (5597.1;6110.4) -1.2 (1.2;-3.4) 5582.1 (5328.1;5864.7) 5442.8 (5194.8;5717) -2.5 (0.7;-5.3) 6324.1 (6036.1;6611.2) 6374.1 (6091.1;6662.7) 0.8 (3.9;-1.8)
Tocantins 5849.3 (5606.1;6103.5) 5849.2 (5606.6;6094.9) 0 (2.1;-2.1) 5387.1 (5153.3;5644.6) 5307.1 (5065.3;5571.5) -1.5 (1.5;-4.3) 6261.9 (5993.8;6548.1) 6368.8 (6094;6643.8) 1.7 (4.6;-1)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.66 – Number of cases and age-standardized incidence rates (per 100 000) of CVD, in Brazil and its Federative Units, 1990 and 2017, and percent change
Brazilian Federative Units 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 723595.1 (700074.3;750549.6) 755.6 (731.6;783) 1550188.5 (1495647.3;1607115.8) 687.5 (663.4;712.4) -9 (-9.9;-8.2)
Acre 1400.9 (1352.7;1453.7) 701.5 (675.5;730.5) 4219.8 (4070.7;4381.3) 673.9 (648.3;700.9) -3.9 (-5.4;-2.4)
Alagoas 10692.8 (10301.7;11114.3) 715.2 (688;744.7) 21304 (20503.3;22148.2) 675.8 (649.9;702.9) -5.5 (-7;-4)
Amapá 845.7 (817.2;875.8) 697.3 (672.7;723.9) 3589.8 (3464.8;3720.7) 680.8 (655.6;706.2) -2.4 (-3.9;-0.9)
Amazonas 6580.8 (6356.7;6809.1) 683.2 (658.2;709.5) 19228.5 (18527.4;19964.4) 667.3 (643.2;695.3) -2.3 (-3.7;-0.9)
Bahia 53499.5 (51571.2;55573.5) 715.2 (689.1;744.7) 108386.9 (104426.4;112633.4) 686 (660.4;713) -4.1 (-5.6;-2.5)
Ceará 29391.6 (28364.7;30541.6) 668.4 (644.1;695.3) 64457.4 (61963.2;67082.7) 657.3 (631.5;684.4) -1.7 (-3.2;-0.1)
Distrito Federal 5460.4 (5280.9;5656.2) 735.9 (711.2;762.2) 17461 (16845.3;18144.4) 681 (657.1;706.6) -7.5 (-8.8;-6.1)
Espírito Santo 12056.9 (11646.4;12504.3) 761.1 (733.7;789.4) 28206.7 (27136.4;29299.3) 669.3 (644.8;695.5) -12.1 (-13.6;-10.6)
Goiás 16069.6 (15492.1;16700.6) 721.2 (695.6;749.2) 44756.7 (43051.4;46526.6) 667.8 (643.2;694.3) -7.4 (-8.8;-6.1)
Maranhão 19179.5 (18453.2;19975.2) 668.8 (642.1;698.5) 42991.2 (41329.7;44766) 660.5 (634.6;689.6) -1.3 (-2.8;0.3)
Mato Grosso 6719.6 (6494.8;6965.5) 704 (679.9;731.2) 21357.5 (20543;22189.1) 675.9 (649.6;702.9) -4 (-5.4;-2.4)
Mato Grosso do Sul 7537.2 (7281.1;7807.5) 744.2 (717.8;772.7) 19409.2 (18668.4;20188) 693.7 (667.6;721.3) -6.8 (-8.1;-5.4)
Minas Gerais 80523.3 (77820.9;83428.5) 768.2 (742;795.2) 171252.6 (164841.8;177705.6) 685.1 (660.4;709.9) -10.8 (-12.3;-9.4)
Pará 17011.1 (16426.2;17625.4) 688.6 (662.5;716.5) 45519.2 (43870.8;47258) 661.7 (637.2;688.8) -3.9 (-5.4;-2.5)
Paraíba 16176.5 (15565.7;16826.5) 667.2 (642.6;693.4) 29872.4 (28740.8;31073.8) 657.2 (632.5;684.2) -1.5 (-3;0)
Paraná 41419.6 (40008.6;42968.7) 800.3 (773;830.5) 87883.8 (84611.7;91450.2) 695.9 (670.7;722.7) -13 (-14.5;-11.6)
Pernambuco 35110.1 (33804.7;36547.8) 732.2 (705.7;761.9) 66763.4 (64155.4;69477.8) 675.2 (649.1;703) -7.8 (-9.3;-6.2)
Piauí 10631.7 (10240.3;11034.3) 670.2 (644.4;697.2) 23550.9 (22654.2;24486.5) 655.2 (629.6;681.5) -2.2 (-3.7;-0.7)
Rio de Janeiro 81868.9 (78983.8;85145.6) 821.9 (793.4;852.5) 150842.8 (145276.6;156396.1) 709 (683.9;734.5) -13.7 (-15.1;-12.3)
Rio Grande do Norte 11276.8 (10853;11708.8) 654.7 (629.9;680.7) 24101.3 (23205;25082.8) 646.6 (621.9;674.4) -1.2 (-2.6;0.3)
Rio Grande do Sul 53751.8 (51853.1;55798.7) 788.9 (761.7;817.8) 101785.9 (97835;105973.3) 695.5 (669.9;722.4) -11.8 (-13.3;-10.3)
Rondônia 3371.8 (3252.6;3505) 720.6 (695.4;749.2) 9991.1 (9629.9;10396.4) 668.7 (643.9;697) -7.2 (-8.7;-5.7)
Roraima 568.1 (548.3;589.3) 720.4 (694.8;748.1) 2537.1 (2444.2;2635) 677 (651.8;703.1) -6 (-7.4;-4.7)
Santa Catarina 21007.9 (20283;21746.3) 763.1 (736.1;790.2) 52679.6 (50763.8;54847.6) 685.8 (661.2;712.9) -10.1 (-11.6;-8.7)
São Paulo 171665.5 (165924.5;178117.1) 803.6 (775.3;833.8) 364049.8 (350776.2;377905.8) 707.2 (681.6;733.4) -12 (-13.4;-10.6)
Sergipe 6408.5 (6185.3;6643.9) 693.3 (667.4;720.5) 14467 (13942.5;15036.2) 667.5 (642.1;694.7) -3.7 (-5.2;-2.2)
Tocantins 3369.1 (3254.2;3500) 711.8 (686.8;739.6) 9522.9 (9187.6;9895.5) 676.5 (652.2;704) -5 (-6.5;-3.5)
UI: uncertainty interval; Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.66 – Number of deaths and age-standardized mortality rates (per 100 000) due to CVD, in Brazil and its Federative Units, 1990 and 2017, and percent change
1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 266957.7 (264384.5;269670.5) 341.8 (338.7;345.2) 388268.1 (383814.8;392697.7) 178 (175.9;180) -47.9 (-48.5;-47.2)
Acre 398.2 (388.1;407.4) 276.3 (269.5;282.7) 860.3 (827.9;893.3) 158.5 (152.2;164.7) -42.6 (-45.5;-39.5)
Alagoas 4053.8 (3962.9;4148.6) 312.4 (306.1;318.9) 6330.3 (6126.2;6536.9) 211.9 (204.9;218.9) -32.2 (-34.8;-29.5)
Amapá 204.7 (199.9;209.6) 252.5 (246.8;258.8) 668.5 (646.7;691.1) 157.2 (152.2;162.6) -37.8 (-40.2;-35.1)
Amazonas 1671.4 (1607.3;1730) 248.9 (239.5;257.4) 3566.2 (3452.4;3679.5) 147 (142.3;151.9) -40.9 (-43.7;-37.8)
Bahia 16748.2 (15951.3;17572.4) 252.2 (240.6;264.6) 25924.4 (25261.1;26649.5) 162.9 (158.6;167.6) -35.4 (-38.8;-31.7)
Ceará 8157.7 (7634.1;8698.6) 200.3 (187.1;213.5) 15199.6 (14788.3;15643.8) 152.4 (148.2;156.9) -24 (-28.8;-18.3)
Distrito Federal 1564 (1530.6;1593.1) 347.4 (340.8;353.3) 3196.5 (3061;3340.7) 175.4 (168;183.2) -49.5 (-51.8;-47)
Espírito Santo 4547.7 (4479.3;4621.1) 409.1 (403.1;415.6) 6692 (6473.6;6899.1) 165.8 (160.3;171) -59.5 (-60.9;-58.1)
Goiás 5034.5 (4904.9;5160.8) 326.3 (317.6;334.9) 10071.3 (9753.2;10423.5) 163.9 (158.7;169.5) -49.8 (-51.4;-48)
Maranhão 6355.1 (5965.1;6814.3) 250.6 (234.1;269) 11471.5 (11001.2;11997) 184.6 (177;193.1) -26.3 (-30.8;-22)
Mato Grosso 1969.9 (1862.5;2089.6) 288.6 (274.1;305) 4470.8 (4292.6;4648.3) 162.8 (156.5;169.3) -43.6 (-47.1;-39.8)
Mato Grosso do Sul 2619.6 (2546.5;2676.5) 351.7 (344.2;358.2) 5149.6 (4987.1;5336) 198.6 (192.5;205.5) -43.5 (-45.6;-41.2)
Minas Gerais 29369 (28899.2;29849.4) 357.1 (351.8;362.5) 38721.8 (37782;39823.5) 154.5 (150.8;159) -56.7 (-58;-55.3)
Pará 5266.9 (5055.8;5475) 280 (269.1;290.5) 10353.6 (9971.8;10725.7) 168.6 (162.5;174.7) -39.8 (-43.2;-36.4)
Paraíba 5718.5 (5474.8;5964.4) 254.9 (244.2;265.8) 8984.7 (8426.7;9582.7) 190.9 (179;203.9) -25.1 (-30.9;-18.6)
Paraná 16504.7 (16270.4;16731.9) 445.3 (438.8;451.5) 22160.3 (21559.6;22775.3) 188.3 (183.3;193.6) -57.7 (-59.1;-56.4)
Pernambuco 14360.8 (14092.9;14607.3) 364.9 (358.4;371) 20620.7 (20029;21264.3) 214.6 (208.3;221.3) -41.2 (-43;-39.3)
Piauí 3514.8 (3300.4;3730.5) 262.9 (247.1;279.1) 6327.5 (6132.3;6535.5) 175.1 (169.7;181) -33.4 (-37.3;-28.8)
Rio de Janeiro 37561.8 (37050.8;38028.3) 456.7 (450.5;462.1) 43858 (42710.9;45057.9) 207.7 (202.4;213.3) -54.5 (-55.8;-53.2)
Rio Grande do Norte 3386.4 (3206.1;3566.2) 213.3 (202;224.8) 6068 (5855.2;6289.3) 159.2 (153.6;165.1) -25.4 (-30;-19.9)
Rio Grande do Sul 20393.7 (20091.6;20681.9) 378.1 (372.6;383.2) 25992.2 (25243.6;26731.3) 177.2 (172.1;182.3) -53.1 (-54.6;-51.6)
Rondônia 1006.4 (941.1;1071.3) 368.1 (347.8;387.7) 2351.5 (2146.6;2592.9) 184.8 (169.6;202.6) -49.8 (-54.8;-44.5)
Roraima 146.8 (135.1;159.4) 373.6 (349.4;399.7) 495.4 (447.4;549.9) 196.3 (178.6;216) -47.5 (-53.5;-41.2)
Santa Catarina 7674.7 (7557;7795.4) 389.1 (383.2;395.1) 11764.8 (11388.8;12125) 170.2 (164.9;175.2) -56.3 (-57.8;-54.7)
São Paulo 65661.8 (64717.7;66544.9) 401.2 (395.5;406.2) 91136 (88785.8;93412.4) 185.6 (180.7;190.2) -53.8 (-55;-52.5)
Sergipe 2100.9 (2048.7;2155) 252.8 (246.6;259.1) 3529.6 (3404.6;3655.8) 171.6 (165.6;177.7) -32.1 (-35;-29.2)
Tocantins 965.7 (864.4;1053.9) 329.1 (304.8;353.4) 2302.8 (2183.2;2429) 173.9 (165.1;183.1) -47.2 (-51.4;-42.2)
UI: uncertainty interval; Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.66 – Proportional mortality from cardiovascular diseases (CVD), ischemic heart diseases (IHD) and stroke, by Brazilian region and Federative Unit, and in Brazil, 2017
Region Federative Unit CVD/Total % IHD/CVD % Stroke/CVD %
North 22.9 30.6 33.4
Rondônia 24.2 33.0 27.7
Acre 22.3 27.6 32.4
Amazonas 18.1 27.7 36.9
Roraima 21.3 24.8 30.3
Pará 23.4 31.4 35.1
Amapá 19.6 32.3 34.2
Tocantins 30.8 31.0 27.7
Northeast 27.2 32.2 30.3
Maranhão 30.8 33.0 33.2
Piauí 32.5 30.0 33.1
Ceará 26.3 31.4 31.7
Rio Grande do Norte 25.8 38.9 24.0
Paraíba 29.2 35.4 26.1
Pernambuco 28.1 37.8 28.2
Alagoas 30.2 29.6 30.2
Sergipe 23.5 29.5 31.5
Bahia 24.0 26.4 31.8
Southeast 28.3 32.4 25.7
Minas Gerais 25.4 24.4 28.4
Espírito Santo 28.8 36.8 28.0
Rio de Janeiro 27.9 32.9 25.1
São Paulo 29.8 34.9 24.8
South 27.2 31.1 30.2
Paraná 28.3 29.4 29.5
Santa Catarina 27.4 32.4 25.7
Rio Grande do Sul 26.2 32.1 32.9
West-Central 26.4 33.0 28.4
Mato Grosso do Sul 28.6 37.9 29.3
Mato Grosso 24.3 31.2 27.6
Goiás 26.2 31.8 26.3
Distrito Federal 26.7 32.2 35.1
BRAZIL 27.3 32.1 28.2
Source: Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade – SIM/DATASUS).56 – Procedure codes included in each group of conditions for cost analysis
Type Disease Group Code Code Description
Surgical Atrial Fibrillation Ablation 0406050074 Estudo Eletrofisiológico Terapêutico II (Ablação de Fibrilação atrial)
Surgical Coronary Angioplasty 0406030073 Angioplastia em Enxerto Coronariano (c/ Implante de Stent)
Surgical Coronary Angioplasty 0406030014 Angioplastia Coronariana
Surgical Coronary Angioplasty 0406030065 Angioplastia em Enxerto Coronariano
Surgical Coronary Angioplasty 0406030022 Angioplastia Coronariana c/ Implante de dois Stents
Surgical Coronary Angioplasty 0406030030 Angioplastia Coronariana c/ Implante de Stent
Surgical Coronary Artery Bypass Graft Surgery 0406010927 Revascularização Miocárdica c/ uso de Extracorpórea
Surgical Coronary Artery Bypass Graft Surgery 0406010935 Revascularização Miocárdica c/ uso de Extracorpórea (c/ 2 ou mais enxertos)
Surgical Coronary Artery Bypass Graft Surgery 0406010943 Revascularização Miocárdica s/ uso de Extracorpórea
Surgical Coronary Artery Bypass Graft Surgery 0406010951 Revascularização Miocárdica s/ uso de Extracorpórea (c/ 2 ou mais enxertos)
Surgical Valvular Surgery 0406010811 Plástica valvar c/ Revascularização Miocárdica
Surgical Valvular Surgery 0406010340 Correção de Insuficiência da Válvula Tricúspide
Surgical Valvular Surgery 0406010692 Implante de Prótese Valvar
Surgical Valvular Surgery 0406010021 Abertura de estenose Aórtica Valvar
Surgical Valvular Surgery 0406010803 Plástica Valvar
Surgical Valvular Surgery 0406010030 Abertura de Estenose Pulmonar Valvar
Surgical Cardiomyopathies 0406011397 Correção de Hipertrofia Septal Assimétrica (criança e adolescente)
Surgical Valvular Surgery 0406011206 Troca valvar c/ Revascularização Miocárdica
Surgical Primary Angioplasty 0406030049 Angioplastia Coronariana Primária
Surgical Cardiomyopathies 0406011397 Correção de Hipertrofia Septal Assimétrica (criança e adolescente)
Surgical Other Valvuloplasties 0406030146 Valvuloplastia Tricúspide Percutânea
Surgical Other Valvuloplasties 0406030138 Valvuloplastia Pulmonar Percutânea
Surgical Other Valvuloplasties 0406030111 Valvuloplastia Aórtica Percutânea
Surgical Mitral Valvuloplasties 0406030120 Valvuloplastia Mitral Percutânea
Clinical Chronic Ischemic Heart Disease 0303060042 Tratamento de Cardiopatia Isquêmica Crônica
Clinical Stroke 0303040149 Tratamento de Acidente Vascular Cerebral - AVC (isquêmico ou hemorrágico agudo)
Clinical Stroke 0303040076 Tratamento Conservador da Hemorragia Cerebral
Clinical Stroke 0303040300 Tratamento do Acidente Vascular Cerebral Isquêmico Agudo com uso de Trombolítico
Clinical Valve Diseases 0303060123 Tratamento de Doença Reumática s/ Cardite
Clinical Valve Diseases 0303060115 Tratamento de Doença Reumática c/ Comprometimento Cardíaco
Clinical Atrial Fibrillation 0303060026 Tratamento de Arritmias*
Clinical Myocardial Infarction – Clinical Treatment 0303060190 Tratamento de Infarto Agudo do Miocárdio
Clinical Heart Failure 0303060131 Tratamento de Edema Agudo de Pulmão
Clinical Heart Failure 0303060212 Tratamento de Insuficiência Cardíaca
Clinical Cardiomyopathies 0303060239 Tratamento de Miocardiopatias
Clinical Cardiomyopathies 0303060034 Tratamento de Cardiopatia Hipertrófica
Clinical Acute Coronary Syndromes 0303060280 Tratamento de Síndrome Coronariana Aguda

*If ICD 10 I48

Source: Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade – SIM/DATASUS).56 – Procedures paid by the SUS from 2008 to 2018, by group of procedures
Group of Procedures Number of procedures paid by the SUS
Cardiomyopathies and Heart Failure
Heart Failure 2 862 739
Cardiomyopathies 24 964
Ischemic Heart Disease
Chronic, Clinical Tx 87 894
Myocardial Infarction, Clinical Tx 676 467
Primary Angioplasty 85 664
Acute Coronary Syndrome, Clinical Tx 784 921
Coronary Angioplasty 669 893
CABG 244 105
Stroke 2 042 195
Valve Disease
Clinical Tx 32 795
Surgeries 139 131
Mitral Valvuloplasty 4204
Other Valvuloplasties 5087
Atrial Fibrillation 321 866
Atrial Fibrillation Ablation 1250

CABG: Coronary Artery Bypass Grafting; Tx: Treatment.

Source: Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade – SIM/DATASUS).56

– Annual absolute number and rates of procedures paid by the SUS, from 2008 to 2018, by disease groups*
Procedure code 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000 N per 100 000
Cardiomyopathies and Heart Failure
Heart Failure 298,474 157.41 297,763 155.48 289,11 151.58 284,844 148.06 264,469 136.34 254,285 126.47 243,913 120.27 240,832 117.78 236,358 114.67 230,297 110.90 222,394 106.67
Cardiomyopathies 2,092 1.10 2,363 1.23 2,459 1.29 2,302 1.20 2,357 1.22 2,293 1.14 2,370 1.17 2,230 1.09 2,250 1.09 1,997 0.96 2,251 1.08
Ischemic Heart Disease
Chronic, Clinical Tx 12,393 6.54 9,743 5.09 9,300 4.88 8,497 4.42 8 4.12 7,197 3.58 7,581 3.74 6,403 3.13 6,317 3.06 6,171 2.97 6,292 3.02
Myocardial Infarction, Clinical Tx 47,358 24.98 50,987 26.62 55,513 29.11 58,194 30.25 59,562 30.71 58,552 29.12 62,809 30.97 66,647 32.59 70,441 34.18 71,835 34.59 74,569 35.77
Primary Angioplasty 7,648 4.03 6,362 3.32 6,262 3.28 6,033 3.14 5,865 3.02 6,055 3.01 7,135 3.52 8,524 4.17 10,195 4.95 10,774 5.19 10,811 5.19
Acute Coronary Syndrome, Clinical Tx 63,300 33.38 68,833 35.94 72,912 38.23 71,523 37.18 75,734 39.04 73,432 36.52 76,945 37.94 72,686 35.55 70,430 34.17 70,713 34.05 68,413 32.81
Coronary Angioplasty 38,635 20.38 45,648 23.84 49,492 25.95 55,931 29.07 60,959 31.43 63,838 31.75 66,492 32.79 66,55 32.55 69,802 33.87 73,971 35.62 78,575 37.69
CABG 20,515 10.82 22,077 11.53 21,225 11.13 23,187 12.05 23,9 12.32 23,249 11.56 22,997 11.34 22,559 11.03 22,248 10.79 21,474 10.34 20,674 9.92
Stroke 159,545 84.14 176,047 91.93 181,035 94.92 184,751 96.03 182,065 93.86 183,043 91.04 187,110 92.26 191,678 93.74 195,787 94.99 198,068 95.38 203,066 97.40
Valve Diseases
Clinical Tx 3,237 1.71 4,156 2.17 3,526 1.85 3,637 1.89 3,285 1.69 2,996 1.49 2,753 1.36 2,400 1.17 2,244 1.09 2,231 1.07 2,330 1.12
Surgeries 12,201 6.43 12,664 6.61 12,169 6.38 13,181 6.85 13,435 6.93 13,067 6.50 12,993 6.41 12,624 6.17 12,432 6.03 12,277 5.91 12,088 5.80
Mitral Valvuloplasty 477 0.25 551 0.29 478 0.25 473 0.25 403 0.21 431 0.21 408 0.20 341 0.17 206 0.10 236 0.11 200 0.10
Other Valvuloplasties 451 0.24 477 0.25 445 0.23 486 0.25 456 0.24 527 0.26 515 0.25 513 0.25 399 0.19 427 0.21 391 0.19
Atrial Fibrillation
AF 29,034 15.31 28,174 14.71 28,382 14.88 28,583 14.86 28,760 14.83 28,268 14.06 29,799 14.69 29,754 14.55 29,889 14.50 30,265 14.57 30,958 14.85
AF Ablation 68 0.04 72 0.04 90 0.05 85 0.04 123 0.06 139 0.07 143 0.07 161 0.08 124 0.06 120 0.06 125 0.06

* Disease groups according to the procedure codes of Table 1-5.

AF: atrial fibrillation, CABG: Coronary Artery Bypass Grafting, Tx: treatment.

Source: Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade – SIM/DATASUS).56

– Total unadjusted and adjusted for 2018Int$ reimbursement values of clinical cardiovascular admissions by the Brazilian Unified Health System (SUS) from 2008 to 2018. Data expressed in thousands (1,000)
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 TOTAL
R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ R$ + IPCA 10 ANOS Int$ 2018
Chronic Ischemic Heart Disease 7,799 7,519 6,861 6,167 6,593 5,465 6,251 4,781 5,690 4,031 5,248 3,460 6,214 3,798 5,141 2,921 5,327 2,800 5,532 2,811 5,672 2,797 66,328 125,224 46,550
Stroke 142,062 136,975 188,450 169,388 198,813 164,774 205,448 157,139 218,628 154,902 228,141 150,393 242,664 148,315 252,441 143,442 263,771 138,669 272,140 138,253 286,293 141,170 2,498,850 4,717,691 1,643,419
Valvular Diseases 1,052 1,014 1,589 1,428 1,439 1,193 1,607 1,229 1,509 1,069 1,510 995 1,584 968 1,672 950 1,675 881 1,679 853 2,043 1,008 17,361 32,776 11,590
Atrial Fibrillation 13,791 13,297 17,396 15,636 18,537 15,363 18,858 14,424 20,371 14,433 19,969 13,164 22,637 13,835 23,330 13,256 23,929 12,580 26,061 13,239 26,971 13,300 231,850 437,720 152,529
Myocardial Infarction (Clinical) 65,020 62,691 84,308 75,780 92,969 77,051 97,324 74,439 104,898 74,328 106,246 70,040 119,583 73,088 128,724 73,143 134,912 70,925 136,438 69,313 143,349 70,685 1,213,077 2,291,532 791,479
Heart Failure 272,281 262,532 322,849 290,192 327,914 271,771 330,492 252,781 317,586 225,015 321,712 212,077 326,141 199,336 337,610 191,834 345,566 181,670 346,841 176,203 348,832 172,008 3,598,825 6,792,495 2,435,420
Cardiomyopathy 1,288 1,242 1,902 1,709 2,144 1,777 1,900 1,453 2,110 1,495 2,302 1,517 2,696 1,648 2,682 1,524 3,065 1,611 2,556 1,299 3,120 1,538 25,764 48,641 16,813
Acute Coronary Syndromes 44,711 43,110 57,922 52,063 64,612 53,550 65,586 50,165 75,210 53,288 74,619 49,190 83,607 51,100 82,095 46,648 80,185 42,155 82,072 41,694 80,037 39,466 790,657 1,492,716 522,427
Total 548,001 528,381 681,277 612,364 713,021 590,944 727,466 556,412 746,003 528,555 759,747 500,835 805,126 492,089 833,695 473,719 858,430 451,291 873,320 443,665 896,319 441,972 8,442,405 15,938,795 5,620,226
Source: Brazilian Hospital Information System (Sistema de Informações Hospitalares – SIH/DATASUS).29

– Total unadjusted and adjusted for 2018Int$ reimbursement values of interventional cardiovascular admissions by the Brazilian Unified Health System (SUS) from 2008 to 2018. Data expressed in thousands (1,000)
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 TOTAL
R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ Int$ 2018 R$ R$ + IPCA Int$ 2018
Atrial Fibrilation Ablation 360 348 378 339 471 390 457 349 690 489 788 520 771 471 906 515 707 372 691 351 732 361 6,951 11,430 5,636
Coronary angioplasty 210,529 202,991 266,654 239,681 295,641 245,024 337,972 258,502 372,063 263,613 388,920 256,381 411,252 251,355 412,073 234,147 433,590 227,946 466,696 237,091 495,885 244,519 4,091,276 6,728,694 3,317,896
Coronary Artery Bypass Graft Surgery 176,032 169,730 208,585 187,486 214,484 177,762 287,851 220,167 297,844 211,027 290,541 191,528 294,854 180,213 289,638 164,577 286,160 150,439 282,175 143,351 275,110 135,656 2,903,274 4,774,145 2,354,114
Valvular Surgery 125,954 121,445 140,684 126,453 142,383 118,006 179,111 136,995 183,271 129,851 178,564 117,711 180,088 110,069 176,814 100,469 175,319 92,168 176,134 89,481 177,584 87,566 1,835,908 3,018,967 1,488,643
Primary Angioplasty 45,267 43,647 37,888 34,055 37,113 30,759 35,577 27,211 35,545 25,185 37,288 24,581 45,883 28,044 56,101 31,877 66,515 34,968 71,624 36,387 73,429 36,208 542,231 891,645 439,667
Cardiomyopaathies 168,993 163 545 490 192 159 326 249 436 309 354 233 306 187 298 169 527 277 452 230 426 210 4,031 6,623 3,266
Other Valvoplasties 1,519 1,464 1,662 1,493 1,718 1,423 1,919 1,468 1,871 1,325 2,052 1,352 2,128 1,301 2,086 1,185 1,594 838 1,889 960 1,690 833 20,126 33,095 16,319
Mitral Valvoplasty 3,115 3,004 3,585 3,223 3,147 2,608 3,228 2,469 2,718 1,926 2,970 1,958 2,809 1,717 2,394 1,360 1,378 724 1,721 874 1,462 721 28,525 46,907 23,130
Total 562,946 542,790 659,980 593,221 695,149 576,132 846,441 647,411 894,438 633,724 901,476 594,265 938,091 573,356 940,309 534,300 965,790 507,732 1,001,383 508,723 1,026,318 506,074 9,432,322 15,510,510 7,648,180
Source: Brazilian Hospital Information System (Sistema de Informações Hospitalares – SIH/DATASUS).29 – Number of deaths and age-standardized mortality rates (per 100 000) for intracerebral hemorrhage and subarachnoid hemorrhage in Brazil and Brazilian Federative Units, 1990 and 2017, and percent change
Cause of death and location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.3.2 - Intracerebral hemorrhage
Acre 76 (72;80) 48,6 (46;51) 169 (157;181) 30,8 (28,4;33) -36,7 (-42,1;-31,1)
Alagoas 892 (840;948) 66,8 (63;70,9) 1220 (1147;1292) 40,7 (38,3;43,2) -39 (-43,7;-34,4)
Amapá 37 (34;39) 40,5 (37,7;42,7) 130 (120;140) 29,4 (27;31,7) -27,3 (-33,1;-20,8)
Amazonas 362 (336;383) 48,7 (45,2;51,4) 761 (711;806) 30,8 (28,8;32,7) -36,8 (-41,7;-31,4)
Bahia 3297 (3089;3521) 47,9 (44,9;51,1) 4782 (4521;5060) 30,4 (28,6;32,2) -36,6 (-41,6;-31,4)
Brazil 50247 (49123;51383) 58,6 (57,3;59,9) 61518 (59874;63290) 27,9 (27,1;28,7) -52,4 (-53,8;-51,1)
Ceará 1646 (1506;1782) 40,2 (36,6;43,6) 2649 (2491;2795) 26,9 (25,3;28,4) -33,1 (-39,2;-26,5)
Distrito Federal 302 (288;322) 56,1 (53,6;59,1) 498 (463;537) 25,4 (23,6;27,3) -54,8 (-58,3;-50,7)
Espírito Santo 1035 (996;1079) 79,5 (76,3;82,6) 1124 (1059;1194) 27,6 (26;29,2) -65,3 (-67,5;-63)
Goiás 1078 (1027;1143) 59,9 (57,1;63,4) 1543 (1447;1638) 24,6 (23;26,1) -59 (-61,9;-56,1)
Maranhão 1396 (1276;1520) 53,2 (48,5;58,2) 2198 (2042;2416) 35,3 (32,8;38,8) -33,7 (-39,7;-26,9)
Mato Grosso 325 (300;351) 43,3 (39,9;46,5) 733 (686;785) 25,7 (24,1;27,6) -40,6 (-46,1;-33,8)
Mato Grosso do Sul 516 (492;540) 60,6 (57,8;63,3) 831 (781;883) 31,3 (29,5;33,3) -48,2 (-52;-44,6)
Minas Gerais 5752 (5521;6069) 60,5 (58,1;63,3) 6361 (6029;6729) 25,3 (23,9;26,8) -58,3 (-61,1;-55,5)
Pará 1060 (979;1128) 52,1 (48,1;55,6) 2025 (1888;2161) 32,6 (30,4;34,7) -37,5 (-43;-31,5)
Paraíba 1008 (938;1082) 44,1 (41;47,2) 1419 (1306;1550) 30,6 (28,1;33,4) -30,6 (-38,1;-22,5)
Paraná 3442 (3301;3597) 80,3 (76,8;83,8) 3538 (3335;3750) 29,3 (27,7;31,1) -63,4 (-65,9;-60,8)
Pernambuco 3010 (2866;3154) 70,7 (67,5;74,1) 3459 (3259;3659) 35,8 (33,7;37,9) -49,4 (-52,5;-45,9)
Piaui 746 (682;809) 53,5 (48,8;57,9) 1156 (1085;1276) 32,2 (30,1;35,5) -39,9 (-45,1;-33,8)
Rio de Janeiro 7389 (7096;7680) 79,6 (76,6;82,8) 6678 (6329;7056) 31,2 (29,5;32,9) -60,8 (-63,4;-58,1)
Rio Grande do Norte 515 (477;553) 31,9 (29,5;34,2) 842 (783;908) 22,5 (20,9;24,3) -29,4 (-36,1;-21,3)
Rio Grande do Sul 3471 (3287;3636) 56,9 (53,9;59,7) 4291 (4020;4547) 28,9 (27,1;30,7) -49,2 (-52,4;-45,5)
Rondônia 225 (208;243) 69,2 (64;74,6) 394 (352;442) 30 (26,9;33,6) -56,7 (-61,7;-50,8)
Roraima 28 (25;31) 58,4 (53,7;63,5) 80 (70;91) 29,5 (26;33,4) -49,5 (-56,8;-41,3)
São Paulo 10472 (10014;10931) 55,4 (52,9;57,9) 11829 (11219;12484) 23,6 (22,3;24,9) -57,5 (-60,1;-54,3)
Santa Catarina 1508 (1438;1573) 68 (64,8;71) 1727 (1613;1825) 24,4 (22,9;25,9) -64,1 (-66,6;-61,5)
Sergipe 453 (428;476) 53,7 (50,8;56,5) 677 (638;716) 32,9 (31;34,9) -38,7 (-43,1;-33,8)
Tocantins 206 (181;230) 58 (52,1;63,5) 404 (373;439) 30,2 (27,9;32,9) -47,9 (-53,5;-40,8)
B.2.3.3 - Subarachnoid hemorrhage
Acre 19 (18;20) 8,7 (8,1;9,4) 38 (35;41) 6 (5,5;6,6) -30,8 (-38,1;-23,1)
Alagoas 168 (147;186) 10 (8,8;11) 215 (197;239) 6,7 (6,1;7,5) -33 (-42,5;-19,3)
Amapá 8 (7;9) 6,4 (5,9;7,5) 29 (26;33) 5,4 (4,9;6,1) -15,8 (-24,5;-6,4)
Amazonas 70 (64;76) 6,9 (6,4;7,8) 154 (142;169) 5,3 (4,9;5,9) -23 (-30,9;-14,5)
Bahia 641 (591;706) 8 (7,3;8,9) 968 (899;1065) 6 (5,6;6,7) -24,2 (-32;-16)
Brazil 9809 (8917;10192) 9,6 (8,8;9,9) 13811 (13189;14611) 6,1 (5,8;6,4) -36,5 (-39,8;-32,2)
Ceará 340 (294;402) 7,1 (6,2;8,3) 530 (489;573) 5,4 (4,9;5,8) -24,1 (-37,1;-13,3)
Distrito Federal 81 (70;87) 10,2 (8,8;10,9) 139 (121;153) 5,8 (4,9;6,4) -43,8 (-49,1;-36,8)
Espírito Santo 191 (155;204) 11,8 (9,6;12,6) 254 (232;274) 5,9 (5,5;6,4) -49,7 (-54,5;-38,7)
Goiás 219 (202;234) 9,3 (8,6;9,9) 378 (348;416) 5,5 (5,1;6,1) -40,2 (-45,4;-33,2)
Maranhão 354 (286;418) 10,5 (8,2;12,7) 482 (423;527) 7,3 (6,4;8) -30,6 (-41,4;-18,5)
Mato Grosso 85 (78;93) 8 (7,3;8,8) 181 (167;199) 5,6 (5,2;6,2) -29,8 (-37,3;-21,9)
Mato Grosso do Sul 103 (93;111) 9,7 (8,9;10,4) 180 (165;197) 6,3 (5,8;6,9) -34,8 (-41,1;-27,3)
Minas Gerais 1130 (977;1203) 10,1 (8,9;10,7) 1529 (1402;1639) 6,1 (5,5;6,5) -40 (-45,2;-33,5)
Pará 191 (175;211) 7,2 (6,7;8,1) 416 (381;459) 5,9 (5,4;6,6) -17,9 (-25,6;-8,7)
Paraíba 209 (179;243) 8,5 (7,2;9,9) 274 (247;305) 6 (5,4;6,7) -29,7 (-42,5;-15,7)
Paraná 624 (516;667) 11,7 (9,7;12,5) 810 (739;871) 6,4 (5,8;6,9) -45,2 (-50,2;-37,7)
Pernambuco 438 (410;487) 8,9 (8,3;10) 665 (615;733) 6,7 (6,2;7,3) -25,6 (-32,9;-18,1)
Piaui 153 (128;179) 9,1 (7,6;10,7) 216 (200;235) 6 (5,5;6,5) -34 (-43,5;-21,9)
Rio de Janeiro 1375 (1099;1473) 12,9 (10,4;13,8) 1452 (1314;1571) 6,8 (6,2;7,3) -47,4 (-52,3;-38,2)
Rio Grande do Norte 100 (88;125) 5,5 (4,8;7,1) 163 (149;212) 4,3 (3,9;5,6) -21,3 (-32,2;-9,9)
Rio Grande do Sul 593 (554;667) 8,4 (7,8;9,5) 835 (768;922) 5,7 (5,2;6,3) -32,1 (-38,5;-25,1)
Rondônia 49 (45;53) 9,6 (8,8;10,6) 88 (77;101) 5,8 (5,1;6,6) -40 (-48,2;-30,3)
Roraima 7 (7;8) 9,1 (8,1;10,9) 19 (17;24) 5,6 (4,9;6,6) -38,6 (-48,5;-27,7)
São Paulo 2259 (2009;2403) 9,6 (8,8;10,3) 3190 (2945;3415) 6,1 (5,7;6,6) -36,3 (-42,3;-30)
Santa Catarina 275 (251;292) 9,8 (8,9;10,5) 392 (362;439) 5,2 (4,8;5,8) -47,4 (-52,3;-40,2)
Sergipe 77 (71;85) 7,8 (7,2;8,7) 125 (115;138) 5,7 (5,2;6,3) -27,4 (-36,2;-17,9)
Tocantins 48 (38;57) 9,6 (7,9;11,3) 90 (82;99) 6,2 (5,7;6,8) -35,2 (-46,1;-21,6)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109 – Age-standardized stroke prevalence rates (per 100 000) for both sexes and for males and females, in Brazil and its Federative Units, 1990 and 2017, and percent change
Both sexes Female Male
1990 2017 Percent change 1990 2017 Percent change 1990 2017 Percent change
Brazil 6290 (6048.3;6548.9) 6025 (5785.8;6274.8) -4.2 (-3.2;-5.1) 5939.5 (5694.8;6205.5) 5612.9 (5366.3;5856.6) -5.5 (-4.2;-6.7) 6697.3 (6433.7;6961.9) 6536.8 (6282.7;6806.6) -2.4 (-1.3;-3.4)
Acre 6011.6 (5762.4;6272.3) 5814.9 (5568.2;6071.4) -3.3 (-1.4;-5.3) 5595.5 (5340.7;5865.5) 5350.3 (5101.6;5618.9) -4.4 (-1.5;-7.2) 6361.8 (6076.6;6659.2) 6299 (6033;6583.4) -1 (1.8;-3.9)
Alagoas 5960.7 (5700.5;6233.7) 5790.1 (5543.7;6044.7) -2.9 (-0.8;-4.8) 5603.9 (5346;5888.2) 5381 (5123;5659.8) -4 (-1;-6.9) 6360 (6070.2;6651.8) 6307.2 (6024.2;6580.8) -0.8 (2;-3.5)
Amapá 6219.5 (5950.1;6490.2) 6185.3 (5922.8;6478.7) -0.5 (1.5;-2.7) 5945.1 (5646.7;6260.9) 5817.8 (5542.5;6137.7) -2.1 (1.3;-5.4) 6515.4 (6227.7;6811.6) 6587.8 (6304.5;6889.1) 1.1 (3.8;-1.6)
Amazonas 5728.7 (5485.7;5987.5) 5701.6 (5455.9;5955) -0.5 (1.8;-2.6) 5367.7 (5112.8;5643.3) 5244.5 (4984.1;5506.4) -2.3 (0.8;-5.5) 6092 (5823.9;6361.4) 6183.2 (5892.3;6475.4) 1.5 (4.5;-1.3)
Bahia 5760.9 (5521.5;6019.9) 5685.9 (5433.9;5942.7) -1.3 (0.9;-3.4) 5420.2 (5164;5706.9) 5247 (4989.7;5508.9) -3.2 (-0.2;-6) 6147.9 (5863.3;6431.4) 6225 (5936.4;6513.3) 1.3 (4.3;-1.6)
Ceará 5860.4 (5600.4;6118.9) 5943.7 (5668.7;6231.8) 1.4 (3.8;-0.9) 5545.9 (5270.6;5820.4) 5541.3 (5256.3;5850.7) -0.1 (3.2;-3.3) 6211.7 (5923.9;6506.7) 6448.9 (6145.4;6775.2) 3.8 (7.1;0.7)
Distrito Federal 5798.5 (5563.4;6037.2) 5529.8 (5303.6;5752.8) -4.6 (-2.7;-6.5) 5461.1 (5211.3;5732.7) 5144.9 (4908.1;5382.3) -5.8 (-3;-8.7) 6209.3 (5957.1;6458.7) 6061.9 (5797;6321.5) -2.4 (0.3;-4.9)
Espírito Santo 6214.8 (5957;6478.6) 5748.2 (5490.1;5998.6) -7.5 (-5.6;-9.5) 5868.6 (5600.7;6137.1) 5341.6 (5086.6;5596.6) -9 (-6.1;-11.8) 6591.9 (6320.7;6883.9) 6240.1 (5950.8;6518.6) -5.3 (-2.8;-7.8)
Goiás 5642.8 (5395.9;5901.5) 5527.3 (5295.5;5762.8) -2 (0.1;-4.2) 5318.3 (5037.2;5601.6) 5136.8 (4890.8;5398.2) -3.4 (0;-6.6) 5947.9 (5701.8;6217.5) 5969.3 (5701.1;6245.8) 0.4 (3.2;-2.6)
Maranhão 5596.3 (5341.3;5857.4) 5592.5 (5348.5;5844.7) -0.1 (2;-2.1) 5196.3 (4944.4;5463.5) 5174.8 (4941.4;5424) -0.4 (2.6;-3.3) 6026.1 (5740.7;6311.6) 6065.4 (5785.2;6348.3) 0.7 (3.5;-2.2)
Mato Grosso 5995.6 (5727.7;6258.6) 5869.7 (5612.3;6121.4) -2.1 (0.2;-4.1) 5622 (5350.5;5896.6) 5441.8 (5189.2;5704.2) -3.2 (-0.1;-6) 6297.7 (6001.6;6588.6) 6285.3 (5998.3;6582.1) -0.2 (2.8;-3)
Mato Grosso do Sul 6168.4 (5915.1;6427.7) 5964.9 (5727.2;6210.6) -3.3 (-1.3;-5.3) 5730.5 (5467.9;5987.4) 5472.6 (5219.8;5732.1) -4.5 (-1.6;-7.4) 6571.7 (6308.5;6860.6) 6512.2 (6248.7;6790.3) -0.9 (1.8;-3.7)
Minas Gerais 6269 (5985.9;6552.4) 6031.6 (5768.1;6308.7) -3.8 (-1.4;-5.9) 5902 (5602;6201.4) 5614.5 (5333.5;5907.9) -4.9 (-1.8;-7.9) 6699.1 (6401.3;6989.1) 6532.8 (6246.7;6839) -2.5 (0.2;-5)
Pará 5842.4 (5588.6;6111.7) 5751 (5495.1;6017.5) -1.6 (0.6;-3.6) 5511.2 (5245.2;5786.3) 5291.5 (5022.7;5567.5) -4 (-0.7;-7.2) 6191.5 (5918.1;6485.6) 6236.9 (5947.8;6540.6) 0.7 (3.7;-2)
Paraíba 5802.6 (5546.1;6053.4) 5755.9 (5515.6;6004.5) -0.8 (1.4;-3) 5477.7 (5212.5;5728.9) 5371 (5114.4;5651.9) -1.9 (1.3;-5) 6170.5 (5892.1;6456.2) 6253.3 (5978.4;6539.4) 1.3 (4.1;-1.5)
Paraná 6350.3 (6083.3;6621.1) 5998 (5747.6;6250.1) -5.5 (-3.5;-7.6) 5947.5 (5671;6238.5) 5549.2 (5289.1;5808) -6.7 (-3.8;-9.5) 6765.8 (6472.5;7054) 6538.5 (6262.5;6813.3) -3.4 (-0.5;-6)
Pernambuco 5864.3 (5618.3;6114.8) 5642.3 (5399.5;5887.5) -3.8 (-1.7;-5.9) 5544.4 (5296;5814.4) 5239.5 (4986.3;5490.8) -5.5 (-2.5;-8.3) 6252.9 (5972.2;6545.7) 6184.6 (5912.5;6459.7) -1.1 (1.7;-3.9)
Piauí 5511.3 (5276.3;5755.1) 5545.1 (5314.7;5786.3) 0.6 (2.8;-1.4) 5145.2 (4900.4;5394.3) 5131.4 (4894.1;5385.3) -0.3 (2.8;-3.3) 5911.2 (5642.8;6176.5) 6034.4 (5776.8;6317.2) 2.1 (4.8;-0.6)
Rio de Janeiro 6714.2 (6446.8;7008.6) 6230.8 (5980.5;6490.7) -7.2 (-5.3;-9.2) 6350.5 (6067.4;6659.1) 5820 (5546.8;6108.8) -8.4 (-5.6;-11.1) 7208.1 (6917.8;7498.2) 6800.2 (6527.3;7073.1) -5.7 (-3.1;-8.1)
Rio Grande do Norte 5701.2 (5452.1;5951.2) 5672.5 (5438;5939.2) -0.5 (1.6;-2.4) 5393 (5131.9;5659.9) 5280.7 (5029.7;5550.9) -2.1 (0.8;-5) 6041.8 (5780.8;6327.3) 6170.4 (5892.3;6466.5) 2.1 (5.1;-0.6)
Rio Grande do Sul 6600.3 (6315.3;6880.9) 6182.1 (5906.1;6460.9) -6.3 (-4.4;-8.3) 6322.7 (6028.2;6645.2) 5828.4 (5536.3;6116.6) -7.8 (-4.9;-10.6) 6961.6 (6661.6;7269.6) 6639.1 (6336.7;6946.7) -4.6 (-2;-7.3)
Rondônia 5985.6 (5731;6240.1) 5705.1 (5457.5;5949.3) -4.7 (-2.4;-6.8) 5599.4 (5348.2;5868.1) 5285.8 (5041.4;5543.5) -5.6 (-2.6;-8.6) 6276.9 (5998.5;6564.3) 6111.8 (5837.6;6398.4) -2.6 (0.4;-5.3)
Roraima 6064.1 (5818.4;6308.8) 5814.1 (5583.7;6060.7) -4.1 (-2.1;-6) 5617 (5371;5884) 5317.9 (5070;5562.2) -5.3 (-2.4;-8.1) 6407.7 (6148.3;6694.1) 6269.6 (6021.5;6541.3) -2.2 (0.4;-4.9)
Santa Catarina 6679.1 (6397.8;6964.3) 6217 (5941.2;6488.4) -6.9 (-5;-8.8) 6375.3 (6069.7;6674.6) 5844.5 (5564.4;6133.5) -8.3 (-5.4;-11.1) 7026.3 (6731;7339.3) 6667 (6373.5;6959.6) -5.1 (-2.3;-7.8)
São Paulo 6801.7 (6517.3;7096.7) 6423.9 (6151.9;6705.8) -5.6 (-3.4;-7.5) 6406.6 (6114.7;6715.3) 6000.7 (5715;6302.4) -6.3 (-3.1;-9.3) 7284.4 (6975.5;7612.3) 6975.7 (6661.7;7268.7) -4.2 (-1.4;-6.8)
Sergipe 5922.8 (5667.3;6171.5) 5851.4 (5597.1;6110.4) -1.2 (1.2;-3.4) 5582.1 (5328.1;5864.7) 5442.8 (5194.8;5717) -2.5 (0.7;-5.3) 6324.1 (6036.1;6611.2) 6374.1 (6091.1;6662.7) 0.8 (3.9;-1.8)
Tocantins 5849.3 (5606.1;6103.5) 5849.2 (5606.6;6094.9) 0 (2.1;-2.1) 5387.1 (5153.3;5644.6) 5307.1 (5065.3;5571.5) -1.5 (1.5;-4.3) 6261.9 (5993.8;6548.1) 6368.8 (6094;6643.8) 1.7 (4.6;-1)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109 – Number of DALYs, age-standardized DALY rates (per 100 000) and percent change of rates for stroke and stroke subtypes, in Brazil and its Federative Units, 1990 and 2017
Cause of death and location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.3- Stroke
Acre 3953.6 (3783.3;4122.2) 1979.4 (1889.4;2059) 7266.7 (6834.2;7705) 1186.3 (1115.8;1257.3) -40.1 (-43.8;-36.1)
Alagoas 43233.8 (40973.6;45710.8) 2817.5 (2696.9;2939.7) 50039.4 (47688.1;52560.1) 1603.7 (1528;1685.4) -43.1 (-46.4;-39.8)
Amapá 1920.5 (1817.3;2003.4) 1670.5 (1572;1744.3) 6037.8 (5631.2;6387.6) 1177.4 (1098.1;1246.7) -29.5 (-33.8;-25.2)
Amazonas 17676.9 (16548.2;18641.9) 1941.3 (1817.2;2042.1) 31700.8 (29773.6;33426.1) 1140 (1076.7;1203.3) -41.3 (-44.6;-37.3)
Bahia 156852.9 (148273.2;166581.9) 2060 (1952.1;2187.7) 195170.9 (186401.1;204704.4) 1235.6 (1179.1;1295.2) -40 (-43.7;-36.1)
Brazil 2448379.5 (2393632.7;2503724.8) 2511.9 (2457.3;2567.6) 2594661.6 (2510573.1;2684848.2) 1145.3 (1107.8;1185.3) -54.4 (-55.5;-53.2)
Ceará 77492.6 (71681.9;83089.4) 1703.7 (1591.4;1819.1) 103566.8 (98110.9;108379.4) 1057.1 (1000.6;1107) -38 (-42.2;-33.4)
Distrito Federal 16605 (15926.8;17311.1) 2251.3 (2165.6;2333.6) 22403.1 (21031.9;23843.1) 920.1 (864.6;978.9) -59.1 (-61.8;-56.6)
Espírito Santo 48506.9 (47021.8;49978.7) 3107.9 (3018.3;3201) 46467.9 (44131.5;48868.8) 1096.7 (1041.8;1153.2) -64.7 (-66.5;-62.8)
Goiás 53132.8 (51019.6;55603.8) 2378.7 (2290.8;2484.2) 67110 (63427;71058) 992.6 (937.7;1051.6) -58.3 (-60.4;-56.1)
Maranhão 75263.4 (68906.4;82104.3) 2388.4 (2215.7;2565.2) 91064 (85853.5;96952.9) 1402.6 (1322.8;1493.3) -41.3 (-46;-36.2)
Mato Grosso 18394.3 (17193.1;19706.7) 1921.2 (1795;2051.7) 33309.4 (31413.2;35286.5) 1053.1 (994.2;1114.2) -45.2 (-49.3;-40.3)
Mato Grosso do Sul 24999.9 (23740.6;26097.7) 2462.2 (2369.6;2564.2) 34030.3 (32246.1;35981.7) 1208.7 (1146.7;1277.8) -50.9 (-53.7;-48)
Minas Gerais 285548.6 (275818.9;297328.5) 2638.6 (2555.4;2738.7) 271355.2 (257504.2;284521) 1075.3 (1020.5;1128.8) -59.2 (-61.3;-57)
Pará 53548.4 (50133.8;56655) 2253.4 (2113.7;2377) 88611.2 (83452.1;93804) 1314.4 (1238.6;1389.9) -41.7 (-45.7;-37.3)
Paraíba 45144.4 (42515.4;47988.9) 1858.6 (1751.2;1976.6) 54910.4 (50876.5;59063.6) 1206.4 (1118.5;1299.4) -35.1 (-40.9;-29.1)
Paraná 161625.7 (156492.6;166651.6) 3179.7 (3077;3274.8) 151291.7 (143947.2;158892.6) 1197.3 (1140.6;1255.3) -62.3 (-64.2;-60.3)
Pernambuco 130872.4 (125974.8;135596) 2751.6 (2651.9;2849.7) 136137.9 (129804.7;142784.5) 1375 (1311.6;1441) -50 (-52.3;-47.6)
Piauí 34432.1 (31750.1;37132.4) 2154.9 (1999.1;2316.3) 44933.5 (42457;48250.5) 1250.2 (1181.4;1343.6) -42 (-46.3;-37.4)
Rio de Janeiro 347453.9 (334592.7;357975.7) 3346.4 (3230.9;3445.4) 273760.5 (261736;286898.1) 1271.2 (1214.1;1331.4) -62 (-63.9;-60.1)
Rio Grande do Norte 25680.8 (24130.7;27242.4) 1487.2 (1395.3;1582.5) 34501.8 (32491.3;36566.5) 927.5 (872.6;983.7) -37.6 (-42.5;-32.5)
Rio Grande do Sul 172339.3 (165146.5;178677.8) 2524.5 (2421.8;2615.5) 170330.5 (160060.7;179998.5) 1150.9 (1082.3;1214.1) -54.4 (-56.8;-52)
Rondônia 12073.7 (11218.4;12924.2) 2741.2 (2563.3;2929.9) 17322.9 (15670.4;19262) 1178.2 (1069.9;1308.7) -57 (-61.6;-51.8)
Roraima 1569.1 (1426.3;1728.5) 2172.9 (2005;2364.6) 3644.2 (3249.6;4101.8) 1057.5 (946.3;1182.6) -51.3 (-57.5;-44.5)
Santa Catarina 69910.9 (67055.5;72514.6) 2666.7 (2559.3;2763.6) 71975.6 (67852.1;76213.3) 950.5 (898.1;1006.1) -64.4 (-66.2;-62.4)
São Paulo 539524.3 (519316.5;557948.6) 2449 (2360.9;2532.4) 542703.5 (515509.8;569546.5) 1043.5 (993.5;1094.6) -57.4 (-59.5;-55.2)
Sergipe 20033.1 (19174.8;20849.7) 2166.3 (2075.3;2253.8) 27552 (26196.3;28951.2) 1282.7 (1220.2;1347.5) -40.8 (-44;-37.2)
Tocantins 10590 (8966.2;11793.5) 2245 (1990.4;2461.4) 17463.5 (16283.5;18745.7) 1235.7 (1153.4;1326.5) -45 (-50.5;-37.6)
B.2.3.1- Ischemic stroke
Acre 1063.5 (996.8;1132.3) 667.8 (626.7;707.7) 2076 (1893.9;2264.6) 383.1 (351;417.7) -42.6 (-47.4;-37.9)
Alagoas 13197.8 (12462.3;14030.4) 985.2 (929.6;1045.1) 15974 (14833.8;17114.8) 542.2 (503.3;580.4) -45 (-48.8;-40.7)
Amapá 587.7 (545;627.3) 640.8 (595.3;680.4) 1748.6 (1589.7;1898.5) 402.8 (368.8;435.9) -37.1 (-41.9;-32.4)
Amazonas 5084.6 (4695.8;5429.5) 688.6 (637.7;735) 9130.4 (8393.2;9894.1) 375.1 (345.4;405.2) -45.5 (-49.4;-41)
Bahia 46074.5 (43055.7;49389.4) 671.6 (627.8;719.8) 60202.2 (56130.2;64836.4) 388.2 (361.5;418.2) -42.2 (-46.8;-37.5)
Brazil 731917.9 (704484.3;760431.9) 871.4 (841.1;902.4) 846622.4 (794644.5;900331.8) 387.3 (363.8;411.5) -55.6 (-57.3;-53.8)
Ceará 22421 (20485.5;24419.3) 546.3 (497.9;596.2) 35205.6 (32642.9;37754.2) 361.7 (335.2;388.2) -33.8 (-40.2;-27.1)
Distrito Federal 3906.4 (3644.7;4163.9) 766.5 (721.7;813) 6593.1 (5992;7230) 325.9 (298.5;356.9) -57.5 (-61.1;-53.7)
Espírito Santo 14282 (13533.3;15095.1) 1098.2 (1045.3;1153.6) 14731.1 (13585.4;15935.6) 363.2 (335.4;393.2) -66.9 (-69.2;-64.5)
Goiás 13916.2 (12991.6;14820.9) 800.2 (752;844.9) 19898.4 (18199.2;21777) 320.9 (293.9;350) -59.9 (-62.8;-56.7)
Maranhão 17377 (15585.8;19607.3) 660 (586.2;752.6) 27215.8 (24986.8;29637.2) 439.9 (404.1;479) -33.3 (-40;-26)
Mato Grosso 5212.7 (4803.6;5633.7) 705.7 (650.9;759.9) 10002 (9113.3;10867.5) 356.6 (326.3;386.9) -49.5 (-54.1;-44.5)
Mato Grosso do Sul 6723.6 (6322.8;7131.6) 813.8 (767.3;859.5) 10101.1 (9292.6;10911.3) 384.6 (354.4;414.8) -52.7 (-56.5;-48.9)
Minas Gerais 81390.3 (76723.4;86023.9) 881.5 (836.4;927.8) 86497.3 (79441.7;93590) 346.9 (318.9;375.4) -60.6 (-63.5;-57.6)
Pará 18296.6 (16994.5;19445.1) 906.6 (843.3;962.1) 28488.5 (26185.1;30787) 465.3 (428.2;501.5) -48.7 (-53;-44.3)
Paraíba 14128.8 (12998.2;15518.4) 609.2 (560.5;666.9) 18006.3 (16468.6;19631.7) 392.4 (358.4;427.9) -35.6 (-42.9;-27.8)
Paraná 51172.4 (48539.5;53822.5) 1204 (1146.1;1259.9) 55096.3 (51203.8;59213.8) 455.8 (424.5;489.8) -62.1 (-64.8;-59.4)
Pernambuco 41435.4 (39396.4;43702.5) 970.5 (925.1;1020.6) 41014.9 (38043.8;44085.7) 431.5 (400.1;463.9) -55.5 (-58.6;-52.1)
Piauí 9568.2 (8668;10635.1) 687.6 (623.1;765.2) 14673.1 (13540.8;15959.7) 411.7 (379.6;448) -40.1 (-45.6;-34)
Rio de Janeiro 95808.8 (90420.4;100946.9) 1069 (1012.6;1122.6) 83858 (77688.3;90710.3) 394.7 (366.4;426.8) -63.1 (-65.9;-60.3)
Rio Grande do Norte 9503.9 (8745.6;10253.4) 584.6 (538.8;631.1) 11733.2 (10776.4;12756) 319.1 (292.9;346.8) -45.4 (-50.7;-39.9)
Rio Grande do Sul 60826.8 (57517.2;64097.9) 1027.2 (972.9;1078) 61657.7 (56558.6;66642) 417.5 (382.7;451.1) -59.4 (-62.2;-56.3)
Rondônia 3034.7 (2783.7;3293.1) 970.7 (899.5;1042.4) 5412.4 (4855.6;6020.7) 415.3 (373.7;461) -57.2 (-61.8;-51.9)
Roraima 372.6 (336.5;412.4) 795.4 (729;867.3) 1055.5 (934.1;1183.6) 379.8 (337.7;421.7) -52.2 (-58.4;-45.5)
Santa Catarina 22415.1 (21207.6;23730.7) 1029.7 (974;1083.9) 25161.9 (23015.1;27290.2) 354.4 (325.4;383.2) -65.6 (-68;-62.8)
São Paulo 164767.5 (155579.3;173984.4) 890.4 (843.4;938) 186699.6 (171816.4;201713.6) 372 (342.1;401.3) -58.2 (-61;-55.2)
Sergipe 6658.2 (6265.3;7056.5) 781.8 (736.7;828.1) 8987.9 (8329;9671) 443.8 (411.4;476.9) -43.2 (-47.3;-38.6)
Tocantins 2692 (2368.4;3009.9) 750 (674.7;828.6) 5401.9 (4954.1;5885.6) 408.6 (374.8;444.9) -45.5 (-51.5;-38.7)
B.2.3.2- Intracerebral hemorrhage
Acre 2042.4 (1946.7;2151.3) 1021.1 (972.1;1070.2) 3907 (3628.3;4180.9) 625.6 (581;667.5) -38.7 (-43.7;-33.5)
Alagoas 22644.7 (21077;24235.6) 1476.9 (1388.9;1567.2) 27097.9 (25636;28599.9) 855.7 (809.8;904.3) -42.1 (-46.4;-37.8)
Amapá 1000.2 (936.5;1047.5) 829.7 (774.6;869.6) 3256.8 (2973.7;3497.4) 613.2 (561;657.1) -26.1 (-31.8;-19.8)
Amazonas 9657.5 (8944.9;10226.1) 1033.8 (957;1093.8) 17298.4 (16028.8;18370.1) 607.4 (564.8;644.9) -41.2 (-45.5;-36.3)
Bahia 84377.2 (79355.7;90141) 1108.1 (1040.1;1183.5) 104105.8 (98385.8;110053.4) 656.6 (620.6;694) -40.7 (-45.3;-35.8)
Brazil 1334369 (1303152.8;1373801.4) 1322.1 (1291.8;1358.2) 1326910.8 (1288958.3;1368112.2) 576.9 (560.7;594.9) -56.4 (-57.8;-55.1)
Ceará 40070.2 (36879.4;43154.2) 893.2 (817;960.7) 52333.9 (49236;55146.4) 533.9 (501.6;562.5) -40.2 (-45.3;-34.6)
Distrito Federal 9370.1 (8908.1;10046.1) 1179 (1125.2;1252.5) 11358.7 (10528;12284.1) 443.7 (413.3;477.7) -62.4 (-65;-59.3)
Espírito Santo 27092.1 (26043.2;28443.7) 1651.2 (1587.7;1725.3) 23985.1 (22605.5;25435.7) 557 (525.7;591.2) -66.3 (-68.3;-64.1)
Goiás 30618.2 (29152.7;32584.3) 1291.1 (1232.1;1366.3) 35332.4 (33203.1;37574) 509.5 (478.7;541.7) -60.5 (-63;-57.8)
Maranhão 40946.2 (36530.2;45483) 1334.4 (1213.3;1456.3) 48119.1 (44681.6;52607.1) 738.8 (686.2;810.1) -44.6 (-50.9;-37.9)
Mato Grosso 9481.7 (8758.9;10235.2) 952.6 (879.1;1027.3) 17317.5 (16178.9;18505.5) 529.8 (495.5;566.5) -44.4 (-49.2;-38.3)
Mato Grosso do Sul 14326.7 (13580.5;15036) 1346.6 (1285.1;1408.5) 18396.2 (17315.1;19515.4) 639.5 (601.6;678.8) -52.5 (-55.9;-49.1)
Minas Gerais 160746.7 (153946.9;171975.7) 1422.7 (1364.4;1509) 139119.5 (131593;146724) 546.2 (516.9;575.9) -61.6 (-64.2;-58.9)
Pará 27317.6 (25130.3;29082.4) 1111.4 (1017.5;1182.7) 46066.2 (42810.4;49272.9) 668.3 (622.2;712.9) -39.9 (-45;-34.3)
Paraíba 23051.3 (21538.9;24766) 954 (892.6;1024.9) 28591.1 (26253.3;30997.8) 629.8 (578.8;682.3) -34 (-40.8;-26.8)
Paraná 88216.4 (84443;91983) 1633.9 (1570.7;1702) 72564.6 (68483;76843.2) 561.1 (530.1;593.1) -65.7 (-67.9;-63.3)
Pernambuco 73380.8 (69895.3;76702.7) 1499.7 (1430.9;1568.9) 74615.6 (70543.1;78768.3) 744.4 (703.9;786.5) -50.4 (-53.4;-47.5)
Piauí 18501.1 (16948.8;20251.5) 1160.3 (1060.5;1264) 23443.1 (22029.8;25610) 651 (611.5;710.8) -43.9 (-48.8;-38.6)
Rio de Janeiro 201658.8 (193417.1;211873.7) 1858 (1782.2;1943.7) 147613.4 (140085.6;156033.4) 676.3 (641.5;713.3) -63.6 (-66;-61.1)
Rio Grande do Norte 12099.4 (11196.2;12951.9) 706.5 (651.7;757.1) 17465.8 (16141.3;18793.4) 468.6 (433.9;504.3) -33.7 (-39.7;-26.6)
Rio Grande do Sul 90116 (85634.7;94313.2) 1235.2 (1173.1;1292.4) 85329.9 (79196.9;90723.5) 570.3 (529.1;605.5) -53.8 (-56.9;-50.3)
Rondônia 6920.4 (6371.4;7465.9) 1469.9 (1361.9;1583.8) 8998.9 (8019.1;10137.8) 592.7 (529.6;666.4) -59.7 (-64.6;-53.9)
Roraima 868.7 (786;962.9) 1116.5 (1020.8;1223.5) 1914.8 (1686.6;2190.9) 527.6 (464.5;599.3) -52.7 (-59.7;-45.1)
Santa Catarina 37531.6 (35812;39073.7) 1347.1 (1285.7;1402.4) 35160.6 (32444.1;37333.3) 451.6 (418.2;478.8) -66.5 (-68.8;-64.1)
São Paulo 286216.8 (273648.3;299941.9) 1235.3 (1182.4;1289) 259904.1 (245650.4;275069.5) 490.6 (464.5;518.7) -60.3 (-62.8;-57.4)
Sergipe 10290.6 (9777.3;10791) 1120.9 (1062.3;1176.2) 14532.9 (13755.7;15333.1) 666.3 (631.3;703.4) -40.6 (-44.7;-35.7)
Tocantins 5825.5 (4890.2;6575) 1189.3 (1037.1;1325.3) 9081.5 (8410.7;9866.8) 633.5 (587.1;688.8) -46.7 (-52.9;-38.2)
B.2.3.3- Subarachnoid hemorrhage
Acre 847.7 (773.2;919.3) 290.6 (269.9;311.1) 1283.8 (1183.9;1391) 177.6 (164.1;193.1) -38.9 (-44.9;-32.4)
Alagoas 7391.3 (6373.7;8529.4) 355.3 (311.7;397.2) 6967.4 (6414.6;7757.1) 205.9 (189.4;228.9) -42.1 (-50.3;-29.8)
Amapá 332.7 (309.9;365) 200.1 (186;223.5) 1032.5 (948.2;1149) 161.5 (148.4;179.7) -19.3 (-26.7;-10.9)
Amazonas 2934.8 (2699.5;3205.7) 218.9 (203.2;238.9) 5271.9 (4852.8;5795.8) 157.6 (145.2;173.4) -28 (-34.4;-20.6)
Bahia 26401.2 (23947.3;28838.7) 280.2 (256.7;306.5) 30862.9 (28723;33700.7) 190.8 (177.6;208.7) -31.9 (-38.9;-24.6)
Brazil 382092.5 (341738.8;399795.1) 318.4 (287;332.2) 421128.4 (402202.4;445263.2) 181 (173.1;191) -43.1 (-46.3;-37.2)
Ceará 15001.4 (12391.2;18119.3) 264.2 (225.1;311.9) 16027.3 (14761.6;17474.1) 161.5 (148.7;176) -38.9 (-49.2;-28.2)
Distrito Federal 3328.5 (2921.2;3564.8) 305.8 (267.9;326.7) 4451.2 (3996.2;4855.6) 150.5 (134.4;164.3) -50.8 (-55.3;-45.2)
Espírito Santo 7132.8 (5899.9;7604.3) 358.5 (294.5;382.4) 7751.8 (7128.6;8367.7) 176.5 (162.5;190) -50.8 (-55.4;-39.5)
Goiás 8598.4 (7989.3;9184.5) 287.4 (265.6;307) 11879.3 (10974.1;13114.1) 162.2 (150.1;178.6) -43.6 (-48.6;-36.8)
Maranhão 16940.2 (13560.2;20200.9) 394 (321;459.7) 15729.1 (14113.5;17089.8) 223.9 (199;243.2) -43.2 (-50.9;-32.3)
Mato Grosso 3699.9 (3386.4;4012) 262.9 (241.4;287.3) 5989.9 (5522;6551.1) 166.7 (154.3;182) -36.6 (-43.1;-29.6)
Mato Grosso do Sul 3949.6 (3524;4259.3) 301.8 (272.8;324.2) 5533 (5124.3;6033) 184.7 (171.2;201.1) -38.8 (-45.1;-31.2)
Minas Gerais 43411.7 (36926.5;46441.3) 334.4 (286;356.7) 45738.5 (42358.9;49050.9) 182.2 (169;195.2) -45.5 (-50.4;-37.9)
Pará 7934.2 (7204.8;8740.1) 235.4 (216.8;259.9) 14056.5 (12883.9;15453.7) 180.9 (166.2;198.4) -23.2 (-30.1;-15.8)
Paraíba 7964.3 (6876.5;9209) 295.5 (255.4;339.2) 8313 (7521.9;9221.7) 184.2 (166.7;204.3) -37.7 (-48.2;-25.5)
Paraná 22236.9 (18814.4;23684.3) 341.8 (287.1;364.5) 23630.8 (21760.6;25484.3) 180.4 (166.5;194) -47.2 (-52.1;-39.6)
Pernambuco 16056.3 (14930.2;17673.3) 281.4 (262.2;311.8) 20507.5 (19042.9;22982.6) 199.2 (185;222.9) -29.2 (-35.8;-22.5)
Piauí 6362.7 (5250.5;7430) 307 (258.7;356.2) 6817.4 (6299.7;7358.7) 187.4 (173.4;202.5) -39 (-47.3;-28.2)
Rio de Janeiro 49986.3 (39896.5;53598.5) 419.4 (335.1;449.1) 42289.2 (38909;45633.2) 200.1 (184.6;215.2) -52.3 (-56.7;-41.4)
Rio Grande do Norte 4077.6 (3612.7;4762.8) 196.1 (174.2;236.3) 5302.8 (4835.1;6667.4) 139.8 (127.7;175.3) -28.7 (-37.7;-18.9)
Rio Grande do Sul 21396.6 (19895.4;23508.5) 262.1 (244.7;290.7) 23342.9 (21439;25660.3) 163.1 (150.5;178.8) -37.8 (-43.1;-31.4)
Rondônia 2118.6 (1933.7;2303) 300.6 (275.8;327.4) 2911.6 (2578.8;3318.4) 170.2 (151;193.1) -43.4 (-51;-34.1)
Roraima 327.8 (294;368.6) 261.1 (234.8;298.9) 673.8 (592.6;805.6) 150.1 (132.2;178.6) -42.5 (-50.8;-32.5)
Santa Catarina 9964.3 (9246.9;10542.8) 289.9 (267.1;306.6) 11653.1 (10732.6;13019.9) 144.5 (133.5;160.9) -50.2 (-54.8;-43)
São Paulo 88540 (77303.1;94399.5) 323.3 (286.2;343.1) 96099.9 (89106.8;103155.3) 181 (168.3;194.1) -44 (-49.1;-36.7)
Sergipe 3084.4 (2757.9;3439.9) 263.6 (241.5;290.9) 4031.2 (3725.2;4445.7) 172.6 (159.7;190.2) -34.5 (-42.1;-26.6)
Tocantins 2072.4 (1546;2522.9) 305.7 (242.4;363.9) 2980.1 (2699;3279) 193.6 (175.8;212.5) -36.7 (-47.4;-21.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109 – Age-standardized mortality rates (per 100 000) for all strokes, ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, in Brazil, 1990 and 2017, and percent change
Cause of death and age group 1990 2017 Percent change (95% UI)
B.2.3 - Stroke
15-49 years 17.8 (17.3;18.3) 8.3 (8.1;8.6) -53.4 (-55.2;-51.6)
50-69 years 215.8 (210.8;220.9) 95 (92.4;97.6) -56 (-57.5;-54.5)
5-14 years 0.9 (0.8;1) 0.4 (0.3;0.4) -57.4 (-61.8;-51.7)
70+ years 1145.5 (1119.4;1166) 639.5 (622.2;655.6) -44.2 (-45.6;-42.7)
Age-standardized 122.9 (120.6;125) 56.6 (55.2;57.8) -54 (-55.1;-53)
All Ages 65 (63.8;66.1) 58 (56.6;59.2) -10.8 (-13;-8.8)
Under 5 4.3 (3.5;5.4) 0.7 (0.6;0.8) -84.1 (-88.7;-78)
B.2.3.1 - Ischemic stroke
15-49 years 2.2 (2.1;2.4) 0.9 (0.8;0.9) -59.7 (-64.2;-56.7)
50-69 years 58 (56;60.2) 21.1 (20.1;21.9) -63.7 (-65.8;-61.6)
5-14 years 0.1 (0;0.1) 0 (0;0) -71.6 (-76.9;-65.9)
70+ years 618.1 (603.3;632.5) 319.7 (309.7;328.7) -48.3 (-49.9;-46.5)
Age-standardized 54.8 (53.6;55.9) 22.6 (21.9;23.2) -58.7 (-60;-57.4)
All Ages 24.8 (24.2;25.4) 22.4 (21.7;23) -9.6 (-12.6;-6.8)
Under 5 0.2 (0.2;0.3) 0 (0;0) -89.7 (-94.3;-82.2)
B.2.3.2 - Intracerebral hemorrhage
15-49 years 11.2 (10.9;11.9) 4.8 (4.5;5) -57.6 (-60.9;-55.4)
50-69 years 133.4 (129.6;137.1) 58.3 (56.4;60.3) -56.3 (-58;-54.5)
5-14 years 0.3 (0.2;0.3) 0.1 (0.1;0.1) -59.6 (-66.9;-51.7)
70+ years 482.2 (468.2;494.2) 281 (272.2;289.9) -41.7 (-43.8;-39.6)
Age-standardized 58.6 (57.3;59.9) 27.9 (27.1;28.7) -52.4 (-53.8;-51.1)
All Ages 33.6 (32.9;34.4) 29 (28.3;29.9) -13.6 (-16.2;-11.1)
Under 5 1 (0.6;1.6) 0.1 (0.1;0.1) -89 (-94.1;-79.7)
B.2.3.3 - Subarachnoid hemorrhage
15-49 years 4.4 (3.8;4.5) 2.6 (2.5;2.9) -39.4 (-43.6;-29.4)
50-69 years 24.4 (22;25.6) 15.6 (14.8;16.6) -36 (-40.2;-29.6)
5-14 years 0.6 (0.5;0.6) 0.3 (0.2;0.3) -54.9 (-59.2;-47.8)
70+ years 45.3 (43.2;49.1) 38.8 (35.8;41) -14.2 (-22.7;-8.1)
Age-standardized 9.6 (8.8;9.9) 6.1 (5.8;6.4) -36.5 (-39.8;-32.2)
All Ages 6.6 (6;6.8) 6.5 (6.2;6.9) -0.7 (-6;7.4)
Under 5 3 (2.4;3.6) 0.5 (0.5;0.6) -82 (-86.4;-74.1)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109 – Age-standardized DALY rates (per 100 000) for stroke and stroke subtypes, for women, in Brazil, 1990 and 2017, and percent change
Cause of death and age group 1990 2017 Percent change (95% UI)
B.2.3- Stroke
15-49 years 817.7 (790.3;848.7) 421.7 (400.5;440) -48.4 (-51.1;-45.8)
50-69 years 5185 (4992.7;5389.2) 2392.8 (2276.5;2511) -53.9 (-56;-51.8)
5-14 years 69.9 (60.4;76.3) 32.7 (29.4;36.3) -53.2 (-57.8;-47.5)
70+ years 13838.3 (13364.1;14288.7) 7055.4 (6735.7;7403.1) -49 (-51;-46.9)
Age-standardized 2162.9 (2095.1;2225.5) 990.7 (947.7;1034.7) -54.2 (-55.9;-52.7)
All Ages 1466.3 (1419.5;1509.1) 1134.6 (1085.5;1185.3) -22.6 (-25.6;-20)
Under 5 337.3 (257.9;439) 49.3 (41.5;60.4) -85.4 (-89.9;-78.1)
B.2.3.1- Ischemic stroke
15-49 years 104.9 (97.4;113.8) 55.1 (48.1;62.3) -47.5 (-53.4;-42.3)
50-69 years 1382.3 (1287.6;1474.6) 571.4 (514.2;629.2) -58.7 (-61.7;-55.6)
5-14 years 7.5 (6.2;9.1) 4.3 (3.2;5.5) -43 (-49.6;-36.6)
70+ years 7472.4 (7131.5;7787.8) 3643.1 (3416.1;3892) -51.2 (-53.8;-48.8)
Age-standardized 747.7 (713.7;780.1) 326.3 (302.2;351.8) -56.4 (-58.8;-54.1)
All Ages 439.5 (418.8;460.3) 371.1 (343.5;400.1) -15.5 (-20.3;-11.3)
Under 5 18.4 (13;29.6) 2.4 (1.9;3) -87 (-93.1;-79.5)
B.2.3.2- Intracerebral hemorrhage
15-49 years 460.3 (440.4;483.1) 207 (194.5;220.2) -55 (-58.2;-51.4)
50-69 years 2968.9 (2849.9;3089.3) 1272.5 (1215.6;1335.2) -57.1 (-59.8;-54.7)
5-14 years 20.3 (17.3;22.7) 9.4 (8.1;10.8) -53.5 (-60.8;-45.8)
70+ years 5659.7 (5417.6;5890.7) 2879.7 (2743.7;3027.5) -49.1 (-52;-46.1)
Age-standardized 1070.2 (1035.3;1106.6) 465.2 (445;485.9) -56.5 (-58.7;-54.5)
All Ages 746.6 (722;774) 535.7 (512.6;559.7) -28.2 (-31.8;-24.9)
Under 5 69.4 (45.1;118.1) 7.9 (5.9;10.3) -88.6 (-94.6;-79.9)
B.2.3.3- Subarachnoid hemorrhage
15-49 years 252.5 (238.8;265.9) 159.6 (149.6;169.8) -36.8 (-41.6;-31.8)
50-69 years 833.8 (780.9;891.9) 548.9 (513;588.7) -34.2 (-39.3;-29.1)
5-14 years 42.1 (35.8;46.5) 19 (17;21.3) -54.8 (-59.7;-48.2)
70+ years 706.2 (661.2;794.7) 532.6 (494.2;573.3) -24.6 (-32.3;-18.3)
Age-standardized 345.1 (324.7;363.2) 199.2 (187.4;210.1) -42.3 (-46.1;-39)
All Ages 280.2 (263.7;293.7) 227.8 (214.2;240.8) -18.7 (-24.1;-13.6)
Under 5 249.5 (190.9;317.3) 39 (32.9;48.1) -84.4 (-89.1;-77.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109 1 – Age-standardized prevalence rates (per 100 000 inhabitants) of coronary heart disease in Brazil and its Federative Units, for both sexes, and for males and females, 1990 and 2017, and percent changes of rates
Federative Units Both sexes Females Males
1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI)
Acre 1640.6 (1532.9;1756.6) 1483.4 (1387.7;1581.8) -9.6 (-6.5;-12.8) 1083.4 (1008.2;1165.6) 923.1 (852.4;993.5) -14.8 (-10.9;-18.5) 2120.8 (1978.5;2276.6) 2063.9 (1928.2;2201.2) -2.7 (1.7;-7.1)
Alagoas 1671.2 (1568;1784.7) 1506.8 (1412.5;1611.2) -9.8 (-6.8;-12.5) 1150.1 (1070.1;1235.1) 969.9 (901.4;1043.3) -15.7 (-11.8;-19.4) 2251.6 (2099.8;2410.2) 2164.3 (2031.8;2318.6) -3.9 (0.8;-7.7)
Amapá 1450.7 (1353.6;1551) 1435.3 (1340.1;1536.3) -1.1 (2.6;-4.4) 991.2 (916;1066.2) 903.8 (837.3;975.3) -8.8 (-4.6;-13.2) 1927.9 (1798.7;2058.4) 2003 (1862.3;2143.5) 3.9 (8.8;-0.4)
Amazonas 1411.5 (1316.1;1512.7) 1407.8 (1315.6;1504.9) -0.3 (3.5;-3.7) 956.9 (888.2;1034.4) 879.4 (815.1;947.3) -8.1 (-4.1;-12.2) 1865.3 (1737.9;2002.7) 1958.7 (1823.7;2096.5) 5 (9.8;0.5)
Bahia 1644.7 (1540.7;1753.3) 1558.9 (1459.5;1659.1) -5.2 (-2;-8.4) 1132.7 (1049.9;1215.3) 1001 (922;1077.6) -11.6 (-7.4;-15.8) 2218.2 (2076.7;2364.7) 2223.4 (2085;2372.7) 0.2 (4.8;-3.9)
Brazil 1674.5 (1573.5;1784) 1563.7 (1465.6;1669.4) -6.6 (-5.2;-7.8) 1159.3 (1082.7;1238.5) 1008 (938.1;1080.6) -13.1 (-11.4;-14.7) 2259.7 (2126.8;2403.2) 2229.4 (2098.2;2372.8) -1.3 (0.4;-2.9)
Ceará 1455.2 (1356.6;1559.7) 1452 (1350.5;1561.1) -0.2 (3.2;-3.8) 1009.3 (931.1;1092.2) 938.9 (860.1;1021.8) -7 (-2.1;-11.6) 1955.1 (1824;2091.9) 2066.7 (1922.7;2221.3) 5.7 (10.6;0.6)
Distrito Federal 1474.8 (1386;1569.3) 1404.4 (1315.5;1499.5) -4.8 (-1.8;-7.8) 1025.9 (952.7;1100.2) 915.8 (849.4;988.1) -10.7 (-6.8;-14.6) 2009.9 (1885;2147.1) 2046.6 (1914.8;2184.4) 1.8 (6.4;-2.4)
Espírito Santo 1563.5 (1462.6;1663.4) 1473.9 (1378.5;1573.3) -5.7 (-2.5;-8.7) 1072.1 (991.1;1153) 942 (867.7;1015.4) -12.1 (-7.8;-16.1) 2091.3 (1954.6;2229.9) 2094.4 (1960.9;2243.1) 0.1 (4.4;-4)
Goiás 1663.5 (1563.6;1775.3) 1596.3 (1498.4;1700.3) -4 (-0.5;-7.4) 1115.1 (1037.1;1195.5) 1006.6 (934.1;1083.7) -9.7 (-5.3;-14) 2184.7 (2051;2333.6) 2249.7 (2117.6;2405.1) 3 (7.9;-1.4)
Maranhão 1604.3 (1501;1714.3) 1491.9 (1391.9;1600.2) -7 (-3.8;-10.1) 1104.3 (1022.7;1183.9) 949.8 (877.8;1025.4) -14 (-9.9;-17.8) 2138.3 (1994.2;2294.4) 2095.5 (1953.1;2255) -2 (2.8;-6.7)
Mato Grosso 1633.2 (1524.5;1746.9) 1528.7 (1428.2;1637.1) -6.4 (-3.4;-9.5) 1072.6 (997.6;1154.4) 941.6 (873.1;1012.4) -12.2 (-8.2;-16.2) 2097.9 (1955.3;2247.1) 2099.9 (1963.9;2250.9) 0.1 (4.1;-4.3)
Mato Grosso do Sul 1671.6 (1569.6;1787.9) 1602.8 (1501.1;1711.9) -4.1 (-0.6;-7.2) 1114.7 (1034.9;1194.8) 1008 (931.9;1089.9) -9.6 (-5.3;-13.5) 2190.1 (2052.1;2342.3) 2253.6 (2104.9;2408.3) 2.9 (7.8;-1.7)
Minas Gerais 1635 (1533.4;1743.3) 1571.7 (1473.5;1676.6) -3.9 (-0.9;-6.9) 1130.7 (1054.5;1213.7) 1005 (931.7;1084.4) -11.1 (-7.2;-15.1) 2209.6 (2062.1;2361.5) 2230 (2092.6;2384.2) 0.9 (4.9;-3.1)
Pará 1494.5 (1393.7;1598.9) 1461.5 (1363.1;1567.8) -2.2 (1.3;-5.4) 1018.3 (939.5;1099.9) 914.1 (844.1;996.3) -10.2 (-5.8;-14.6) 1981.7 (1840.9;2123.7) 2031.3 (1893.8;2172.4) 2.5 (7.5;-1.7)
Paraíba 1580.3 (1473.9;1688.4) 1483.4 (1382.1;1589.2) -6.1 (-3;-9) 1093.7 (1010.1;1178.4) 958 (888.5;1032.7) -12.4 (-8.2;-16.4) 2137.4 (1994.7;2291.2) 2133.3 (1989.7;2288.1) -0.2 (4.4;-4.5)
Paraná 1751.9 (1639.3;1864.8) 1612.4 (1508;1723.5) -8 (-4.5;-10.9) 1193.9 (1111;1282.8) 1033.6 (959.7;1111.8) -13.4 (-9.4;-17.2) 2327.5 (2172.7;2484.7) 2290.6 (2147.7;2451.6) -1.6 (3.1;-6)
Pernambuco 1623.1 (1514.3;1734.5) 1523.7 (1426.1;1629.4) -6.1 (-2.8;-9.1) 1132.6 (1047.6;1214.9) 992.2 (916.5;1067) -12.4 (-8.1;-16.5) 2210.5 (2065.8;2374.7) 2206.4 (2064.2;2362.1) -0.2 (4.3;-4.6)
Piauí 1485.8 (1389.6;1590.6) 1446 (1348.2;1549) -2.7 (0.7;-5.8) 1021.5 (945.7;1100.5) 922.3 (853;992.7) -9.7 (-5.5;-13.8) 1992.1 (1858.4;2134.9) 2052.7 (1910.4;2199.7) 3 (7.7;-1.2)
Rio de Janeiro 1686.3 (1576;1809) 1572.3 (1471.2;1676.3) -6.8 (-3.7;-10) 1182.7 (1093.6;1286.2) 1027.8 (948.9;1110.8) -13.1 (-9;-17.2) 2341.8 (2186.6;2513.1) 2288.8 (2129;2438.1) -2.3 (2.1;-6.5)
Rio Grande do Norte 1458.3 (1361.9;1562.6) 1471.1 (1371.1;1572.6) 0.9 (4.4;-2.6) 1011.9 (935.3;1092.3) 953.8 (876.8;1029.9) -5.7 (-1.2;-10.1) 1954.9 (1823.4;2096.9) 2097.1 (1956.4;2244.8) 7.3 (12.2;2.3)
Rio Grande do Sul 1793.9 (1676.8;1914.8) 1641.5 (1532.1;1756.2) -8.5 (-5.4;-11.4) 1254.7 (1160.7;1358.6) 1064.5 (981.2;1149.1) -15.2 (-11.1;-19.1) 2457.9 (2294.2;2621.4) 2349.8 (2195.1;2513.4) -4.4 (-0.1;-8.3)
Rondônia 1648.7 (1539.6;1757.9) 1485.5 (1387.3;1588.9) -9.9 (-6.6;-13.3) 1072.2 (993.2;1153.8) 914.5 (842.3;990.6) -14.7 (-10.6;-18.4) 2101 (1957.3;2246.4) 2041.5 (1905;2179.1) -2.8 (1.8;-7.4)
Roraima 1583.8 (1480.2;1691.3) 1418.8 (1330.3;1512.8) -10.4 (-7.4;-13.5) 1021.1 (948.7;1092.6) 862.9 (798.2;925.9) -15.5 (-11.6;-19.1) 2010.7 (1870.7;2154) 1935.6 (1810.6;2075) -3.7 (0.5;-7.9)
Santa Catarina 1770.3 (1655.4;1892.5) 1651.5 (1547.2;1753.9) -6.7 (-3.5;-9.5) 1219 (1129.9;1317.9) 1054.9 (977.2;1138.7) -13.5 (-9.3;-17.2) 2383.9 (2230.9;2553.1) 2346.6 (2193.4;2503.1) -1.6 (2.6;-5.3)
São Paulo 1802.7 (1689.6;1922.7) 1617.6 (1515.9;1730.3) -10.3 (-7.3;-13) 1251.7 (1162.4;1346.3) 1051.7 (973.2;1132.7) -16 (-11.9;-19.8) 2455.1 (2298.6;2620) 2324 (2176.2;2488.7) -5.3 (-1.1;-9.1)
Sergipe 1497.6 (1400.5;1600.2) 1419.8 (1327.5;1520.9) -5.2 (-1.8;-8.3) 1041.2 (966.2;1120.6) 918.5 (844;988.3) -11.8 (-7.3;-16.1) 2024.6 (1889.5;2175) 2038.2 (1905.1;2188.1) 0.7 (5.2;-3.5)
Tocantins 1621 (1515.9;1725.6) 1553.5 (1450;1661.8) -4.2 (-0.7;-7.4) 1074.3 (1000.6;1152.9) 953.2 (878.9;1032.1) -11.3 (-6.8;-15.1) 2110.4 (1972.8;2257.3) 2133.4 (1993;2284.5) 1.1 (5.9;-3.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.151 – Number of deaths and age-standardized mortality rates (per 100 000 inhabitants) due to ischemic heart disease, in Brazil and its Federative Units, 1990 and 2017, and percent changes of rates
Federative Units 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Acre 189.4 (182.1;196.3) 136.6 (131.4;141.7) 357.5 (333;378.2) 65.8 (61.2;69.6) -51.8 (-55.6;-48.2)
Alagoas 1651.4 (1570;1736.9) 130.1 (123.8;136.9) 2673 (2560.9;2792.4) 88.9 (85;93.1) -31.7 (-36.7;-26.7)
Amapá 98 (93.9;101.6) 125.3 (119.8;130) 272.6 (254;287.1) 64.1 (59.8;67.4) -48.9 (-51.9;-45.6)
Amazonas 759.2 (710.6;793.9) 119.1 (111.3;124.4) 1437.4 (1353.9;1501.7) 59.3 (56;62.1) -50.2 (-53.2;-47)
Bahia 7454.5 (7013;7908) 114.8 (108.1;121.6) 10948.6 (10506.6;11402.3) 68.9 (66;71.8) -40 (-44.1;-35.8)
Brazil 129011.3 (126506.8;131646) 169.1 (165.8;172.5) 175791.5 (171318.3;179410.1) 80 (77.9;81.7) -52.7 (-53.9;-51.4)
Ceará 3476.7 (3149.9;3838) 88 (79.8;97) 6852.5 (6528.4;7135.3) 68.7 (65.3;71.5) -22 (-30.1;-12.5)
Distrito Federal 693.4 (670.8;723.3) 163.8 (159.2;169) 1255 (1188.1;1334.8) 68.1 (64.3;72.4) -58.4 (-61;-55.5)
Espírito Santo 1962.9 (1903.6;2020.5) 184 (178.6;189.5) 2849 (2723.4;2991.5) 70.1 (67;73.5) -61.9 (-63.7;-60.2)
Goiás 2187.7 (2095.2;2284.9) 148.7 (142.7;155.3) 4608.3 (4418.6;4837.6) 73.8 (70.8;77.3) -50.3 (-52.7;-47.9)
Maranhão 2681.4 (2413.1;2998.8) 109.5 (98.6;122.8) 5059.4 (4771.1;5411.4) 81.3 (76.6;87) -25.8 (-31.9;-18.4)
Mato Grosso 1038.9 (971.1;1108.6) 157 (147.1;166.7) 2001.7 (1905.6;2108) 71.9 (68.5;75.7) -54.2 (-57.6;-50.4)
Mato Grosso do Sul 1279 (1236.9;1322.1) 178 (172.7;183.3) 2417 (2305.2;2535.9) 92.1 (87.8;96.5) -48.3 (-51.1;-45.2)
Minas Gerais 13676.9 (13229;14143.9) 174.9 (169.3;180.2) 16472.4 (15831.1;17142.3) 65.4 (62.8;68) -62.6 (-64.5;-60.6)
Pará 2429.1 (2281.2;2555) 132.1 (124;138.8) 4475.8 (4255.9;4707.2) 72.4 (68.9;76.1) -45.2 (-49;-41.4)
Paraíba 2656.4 (2457.3;2857.9) 119.5 (110.8;128.7) 4347.9 (4037.2;4662.3) 92.4 (85.8;99.2) -22.7 (-30.6;-12.9)
Paraná 7635.2 (7436.3;7844.1) 213.6 (208.1;218.8) 10022.2 (9595.8;10414) 83.9 (80.3;87.2) -60.7 (-62.5;-59)
Pernambuco 6654.6 (6472.6;6840.5) 172 (167;176.9) 9894.9 (9459.7;10308.8) 102.5 (97.8;106.9) -40.4 (-43.4;-37.4)
Piauí 1454.4 (1315.5;1623.6) 110.5 (100.2;123.7) 2657.7 (2534.2;2880.6) 73.5 (70;79.6) -33.5 (-39.4;-26.8)
Rio de Janeiro 19105.3 (18615.3;19589.5) 237.3 (231.6;242.9) 21214.7 (20296.2;22025.8) 99.8 (95.4;103.5) -58 (-59.7;-56.2)
Rio Grande do Norte 1678.9 (1569.7;1800.4) 107.4 (100.4;115.1) 3054.6 (2909.4;3207.9) 80.2 (76.3;84.4) -25.3 (-32;-17.8)
Rio Grande do Sul 10753.7 (10391.3;11026.2) 200.1 (193;205.2) 11915.8 (11240.8;12411.3) 80.6 (76.1;84.1) -59.7 (-61.5;-57.9)
Rondônia 483.1 (449.2;518.8) 183.3 (172.6;193.6) 1115.8 (1002.5;1234.4) 86.9 (78.3;95.9) -52.6 (-57.9;-47.2)
Roraima 67.3 (61.3;74) 180.3 (167.7;194) 207.7 (184.9;232.6) 82 (73.6;91.2) -54.5 (-60.4;-48)
Santa Catarina 3677.2 (3564.2;3771.3) 189.9 (183.9;195) 5461 (5194.3;5690.8) 77.7 (74;80.9) -59.1 (-61.1;-57.2)
São Paulo 33956.3 (33066.3;34860.2) 216.3 (210.7;221.3) 41732.9 (40054.1;43206.1) 84.2 (80.8;87.2) -61.1 (-62.6;-59.5)
Sergipe 882.9 (837.6;933.2) 108.6 (103.1;114.7) 1509.1 (1440.4;1579.9) 72.8 (69.5;76.3) -32.9 (-37.1;-28.4)
Tocantins 427.5 (379.8;475.3) 153.9 (139.6;169.6) 977 (912.6;1047.3) 73.4 (68.6;78.6) -52.3 (-57.4;-46.8)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.151 – Number of DALYs and age-standardized DALY rates (per 100 000 inhabitants) due to ischemic heart disease, in Brazil and its Federative Units, 1990 and 2017, and percent changes of rates
Federative Units 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Acre 4490.5 (4309.4;4679.4) 2481.7 (2383.9;2581.2) 7971 (7417;8477.2) 1295.1 (1208;1374.4) -47.8 (-51.7;-44.2)
Alagoas 38381.3 (36257.4;40572.7) 2644.8 (2506.1;2789.1) 58660.8 (55937.2;61544.4) 1852.2 (1766.3;1942.7) -30 (-35.3;-25.1)
Amapá 2256.8 (2161.6;2349.2) 2139.7 (2042.8;2217.4) 6578.5 (6114.7;6944.1) 1275.9 (1188.4;1345.7) -40.4 (-44;-36.6)
Amazonas 17148.9 (16081.9;18005.8) 2072.2 (1942.7;2171.1) 31464.8 (29293.6;33102.3) 1136.6 (1066.1;1192.7) -45.1 (-48.5;-41.7)
Bahia 166604.8 (156031.4;177498) 2294.4 (2154;2441) 231348.2 (220711.5;241597.1) 1457.6 (1390.2;1521.1) -36.5 (-41.1;-31.4)
Brazil 2959511 (2894436.2;3033217.1) 3159.1 (3091.6;3233.5) 3678315.8 (3579145.9;3768782) 1602.4 (1559.2;1641.9) -49.3 (-50.7;-47.8)
Ceará 71384.3 (64483.4;79273.1) 1691.4 (1530.8;1874.3) 128192.5 (121929.7;134050.4) 1307.4 (1243.4;1368.7) -22.7 (-30.6;-13.7)
Distrito Federal 19308.3 (18564.4;20275.2) 2845.7 (2756.4;2962.1) 27808.1 (26221.3;29618.7) 1121.3 (1059.8;1190.4) -60.6 (-62.8;-58.2)
Espírito Santo 44177 (42688.1;45695) 2975.1 (2882.6;3065.8) 59450.4 (56507.8;62558.7) 1381.9 (1314.9;1451.2) -53.6 (-55.8;-51.3)
Goiás 55914.3 (53327.6;58557.6) 2636.3 (2522.6;2754.3) 105343.2 (100500;110380.6) 1523.3 (1454.2;1595.6) -42.2 (-45.2;-39.3)
Maranhão 73066.2 (65836.5;81337.6) 2557 (2305.8;2845.1) 109267.8 (103121.4;115769.7) 1680.2 (1586.4;1780.6) -34.3 (-39.8;-27.3)
Mato Grosso 26946.1 (25171.5;28837) 3010.9 (2820.1;3213.2) 46202.4 (43768.5;48781) 1433.9 (1363;1510.9) -52.4 (-56.1;-48.3)
Mato Grosso do Sul 30871.7 (29551.5;32110.1) 3216 (3102.7;3326.8) 52574.5 (50174.7;55121.4) 1835.5 (1754.7;1923.1) -42.9 (-46.1;-39.5)
Minas Gerais 313998.9 (302102.3;326795.2) 3087.6 (2980.2;3202.3) 343731.3 (329343.3;358925.5) 1346.9 (1290.4;1406.4) -56.4 (-58.7;-53.9)
Pará 54735.8 (51421.7;57718.5) 2415.2 (2272.2;2540.5) 100381.7 (95156.5;105848.4) 1469.8 (1395.9;1547.3) -39.1 (-43.1;-35.1)
Paraíba 54949.7 (50451.8;59641.8) 2344.6 (2160.6;2543.5) 82981 (77060.1;89538.2) 1821.8 (1692;1966.4) -22.3 (-30.7;-12.1)
Paraná 174525.4 (169345.9;179809.9) 3561.7 (3464.6;3661) 206379.1 (196027.1;215789.4) 1595.2 (1516.5;1666.7) -55.2 (-57.4;-53.1)
Pernambuco 144001.4 (139657.6;148414.6) 3110.2 (3018.9;3200.9) 207666.8 (198225.5;216500.9) 2076.1 (1982.5;2164.9) -33.2 (-36.7;-29.9)
Piauí 33224.1 (29689.6;37114.1) 2189.2 (1970.8;2442.1) 54215.2 (51650.7;57900) 1502.3 (1430.9;1604.2) -31.4 (-37.5;-24.5)
Rio de Janeiro 454987.3 (442500.6;467807.1) 4481.1 (4365.5;4597) 450050 (429870;467261.3) 2063.8 (1970.8;2142.5) -53.9 (-55.9;-52)
Rio Grande do Norte 32424.2 (30203.4;34875.9) 1972.3 (1838.5;2120.1) 60710.1 (57559.4;64019.8) 1623.5 (1539.9;1712.6) -17.7 (-25.2;-9.2)
Rio Grande do Sul 242410.1 (233975.5;249439.7) 3573.4 (3449.5;3665.5) 231413.1 (216004.4;242521.6) 1542.5 (1439.4;1617.4) -56.8 (-59;-54.6)
Rondônia 14130.4 (13109.8;15219.2) 3388.7 (3169.3;3608.1) 24830 (22172.1;27619.4) 1657 (1487.6;1836.9) -51.1 (-57;-44.9)
Roraima 1916.4 (1730.6;2127) 2919.1 (2687.8;3186.5) 4797.3 (4262.1;5419.4) 1374.5 (1225;1539.8) -52.9 (-59.4;-45.6)
Santa Catarina 82034.2 (79539.6;84426.2) 3208.9 (3105;3295.8) 112363.3 (106011.6;117727.3) 1436.9 (1357.2;1503.9) -55.2 (-57.5;-53)
São Paulo 777221.4 (755207.8;800862.7) 3746.1 (3646.7;3850.3) 880339.1 (842359;915273) 1669.2 (1598.4;1735) -55.4 (-57.2;-53.5)
Sergipe 17580.3 (16558.7;18785.1) 2012.2 (1900.5;2143.3) 32232.2 (30675;33873.9) 1474.5 (1403.3;1547) -26.7 (-31.9;-21.1)
Tocantins 10821.1 (9291.9;12213.6) 2516.2 (2233.5;2791.5) 21363.6 (19891.7;22878) 1503.1 (1400.6;1606.9) -40.3 (-47.2;-32.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.151 – Age-standardized prevalence rates of cardiomyopathy and myocarditis, per 100 000 inhabitants, and percent change of rates, for both sexes, and for males and females, in Brazil and its Federative Units, 1990 and 2017
Both sexes Female Male
1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI)
Brazil 102.8 (82.5;125.7) 112.4 (92.2;134.2) 9.4 (15.3;4.1) 107.7 (86.2;131.2) 115 (95;137.4) 6.9 (14.2;0.2) 97.1 (77.5;119) 109 (88.3;131.7) 12.3 (20;5.4)
Acre 61 (49.2;75.6) 65.9 (53.2;81.1) 8 (21.6;-4.5) 63.8 (50.7;79.9) 66.3 (51.7;81.8) 3.9 (26.6;-13.3) 58.6 (46;74.4) 65.5 (51.5;82.3) 11.8 (32.5;-5.6)
Alagoas 84 (65.4;105.2) 103.3 (82.9;126.8) 23.1 (38.9;8.9) 86.6 (67.4;109.4) 101.4 (80.5;125.5) 17.1 (37.4;-0.5) 80.8 (60.5;104) 105.7 (82.7;133.3) 30.8 (56.3;9.4)
Amapá 104.9 (84.8;128.4) 106.4 (86.4;130.8) 1.4 (13.8;-9.1) 102.7 (83.2;126.6) 103.6 (82.8;128.4) 0.9 (19.5;-15) 107.1 (84.7;133.7) 108.9 (86.4;135.3) 1.6 (19.9;-12.4)
Amazonas 95.3 (76.7;117.9) 98.7 (78.8;120.6) 3.5 (15.3;-7.7) 94.3 (75.1;116.1) 95.7 (75.9;118) 1.5 (17.7;-13.2) 96.1 (74.8;120.2) 101.6 (79.7;126.8) 5.7 (24.6;-10.1)
Bahia 67.2 (51.5;84.9) 74.1 (58.9;91.2) 10.4 (25.4;-2.3) 70.4 (53.8;89.7) 73.8 (58.2;91.7) 4.7 (24.1;-11.1) 63.6 (47.9;82.5) 74.7 (58.6;95.4) 17.5 (41.8;-1.9)
Ceará 105.6 (83.9;128.9) 130.2 (105.9;157.5) 23.2 (37.7;10) 96.8 (76.9;119.8) 116.9 (92.7;142.9) 20.7 (41.8;2.5) 115.4 (90.2;145.4) 146.4 (117.2;181.7) 26.8 (49;9.5)
Distrito Federal 125.6 (92.7;161.3) 144 (113;179.2) 14.6 (32.7;1.3) 134.7 (98.8;171.7) 148.5 (116.4;183.6) 10.2 (33.1;-5.9) 116 (82.6;156.4) 138.9 (104.8;177.4) 19.8 (48.5;-0.3)
Espírito Santo 104.2 (83.5;127.5) 104 (84.4;126.2) -0.1 (10.8;-11.7 95.8 (76.3;120.3) 94.2 (75.1;115.8) -1.7 (15;-15.7) 112.9 (88.7;139.5) 115.2 (91.7;143) 2 (18.3;-11.9)
Goiás 99.1 (71.5;130.5) 125.9 (97.2;160.3) 27.1 (49.3;10.8) 116.1 (81;154.9) 141.2 (109.2;179.2) 21.6 (51.5;1.9) 83 (58.9;111.8) 108.7 (82.5;142.4) 31 (63.1;8.5)
Maranhão 61.3 (48.3;75.9) 76.7 (61.9;94.2) 25.2 (41.6;10.8) 58.7 (46;73.9) 69.1 (54.3;86.4) 17.6 (41.1;-1.4) 63.8 (48.5;81.1) 85.1 (67.2;106.1) 33.5 (60.4;12.1)
Mato Grosso 92.9 (74;115.1) 100.5 (80.4;123.5) 8.2 (21.7;-3.1) 100.3 (79.3;124.1) 106.4 (84.1;132.4) 6.1 (22.8;-8.4) 86.3 (65.6;109.5) 94.5 (73.9;118.4) 9.6 (30.4;-7.3)
Mato Grosso do Sul 126.2 (100.6;155.9) 141.5 (113.6;172.9) 12.1 (26.2;0.5) 131.9 (105;162.7) 140.3 (113;174) 6.4 (23.2;-9.8) 120.5 (91.5;154.7) 142.4 (112.8;175.3) 18.1 (40.9;0.6)
Minas Gerais 110.7 (85.9;139.6) 123.7 (98;152) 11.7 (27.3;-0.9) 123.3 (95.2;155.8) 132.4 (105.3;163.8) 7.3 (28;-7.5) 95.8 (70.1;124.4) 113 (87.8;142.4) 17.9 (42.6;-0.7)
Pará 72.9 (59;88.7) 74.8 (60.4;92.1) 2.6 (15.9;-9.4) 73.1 (57.6;90.4) 72.6 (58.3;91.3) -0.7 (16.4;-16.5 72.8 (57.8;90.9) 77.1 (60.5;95.1) 5.8 (25.4;-10.7)
Paraíba 116.2 (92.8;142.4) 138.3 (112.3;168.2) 19 (34.8;7) 118.5 (94.5;145.7) 140.4 (112.6;172.9) 18.5 (39.6;1.2) 113.5 (89.8;142.8) 135.7 (107.6;167.8) 19.6 (40.3;1.7)
Paraná 90.4 (71.4;111.4) 97 (77.5;118.8) 7.3 (21.1;-4.3) 95.8 (74.8;119.6) 99.5 (79.5;123) 3.8 (21.9;-11.1) 84.7 (64.6;106.9) 93.7 (73.7;117) 10.7 (32.5;-7.3)
Pernambuco 81.8 (64.8;101.5) 85.3 (68.5;104) 4.3 (17.8;-7.4) 80.5 (62.3;100.8) 81.9 (64.1;102.3) 1.8 (20.4;-14.8) 83.6 (64.2;106) 89.9 (70.6;112.4) 7.6 (29.5;-9.2)
Piauí 64.6 (50.1;80.1) 75.4 (60.2;92.7) 16.8 (33.1;3.5) 65.9 (51.4;82.2) 74.5 (58.7;92.7) 13.1 (34.9;-3.7) 63.1 (47.5;81.5) 76.4 (59.5;96.4) 21 (45.6;0.3)
Rio de Janeiro 117.3 (94.5;144.3) 113.9 (92.7;138.1) -2.9 (8.7;-12.7) 115.9 (92.9;145) 112.8 (91.5;137.7) -2.7 (12.4;-15.7 119.3 (93;149) 115.6 (91.9;142.1) -3.1 (13.9;-16.3)
Rio Grande do Norte 75.9 (60.8;95.4) 83.6 (67.4;102.5) 10.1 (23.8;-1.8) 68 (53.4;85.4) 74.7 (59.2;93.7) 9.8 (30.5;-6.9) 84.6 (67.8;107.3) 94.9 (75.6;116.7) 12.1 (32;-4.2)
Rio Grande do Sul 75.2 (59.7;93.4) 74.7 (60;91.3) -0.7 (12.1;-11.7 73.1 (57.3;92.8) 72.1 (57.7;89.4) -1.4 (17.2;-16.8 77 (60;96.4) 76.9 (60.5;95.5) 0 (18.5;-15.9)
Rondônia 69.9 (54.3;87.9) 76.3 (62;94.4) 9.2 (25.4;-3.8) 74.1 (57.7;94.9) 78.7 (63.2;98.4) 6.1 (25.9;-10.5) 66.2 (49.8;84.5) 74 (57.8;92.9) 11.7 (34.3;-7)
Roraima 141.5 (114.4;172.9) 145 (118.1;174.6) 2.5 (14.5;-7.8) 137.9 (111;168.4) 140.3 (111.4;171.8) 1.7 (18.3;-12.1) 143.8 (113.8;177.9) 149.2 (118.5;183.1) 3.7 (21.1;-10.2)
Santa Catarina 107.2 (86.6;131.2) 106.7 (86.6;130) -0.5 (10.2;-10.9 109.7 (88.8;135.7) 108.4 (86.2;133.7) -1.2 (14;-15.3) 103.5 (81.8;129) 103.6 (82.4;127.7) 0.1 (17.4;-14.5)
São Paulo 138.4 (108.2;171.2) 147.7 (120.7;178) 6.7 (21.3;-4.4) 152.1 (118.7;187.1) 158 (128;193.1) 3.8 (21.1;-10.7) 121.3 (92.5;156) 134.1 (105.8;164.7) 10.5 (29;-6.6)
Sergipe 100.2 (80.6;123.9) 115.3 (93.9;141.5) 15.2 (29.1;3.3) 102.5 (81.7;128.8) 115 (92.6;141.2) 12.2 (31.1;-3.9) 97.3 (75.4;120.9) 115.2 (91.3;142.9) 18.4 (39.4;2.2)
Tocantins 71.3 (53.8;89.6) 88.8 (70.6;109.2) 24.6 (43.3;9.2) 71.1 (54.4;91.9) 85.2 (67.3;106.3) 19.9 (45.4;0.7) 71.6 (53;92.1) 92.3 (71.6;116.4) 28.9 (59;7.9)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Incidence rates of cardiomyopathy and myocarditis per 100 000 inhabitants, and percent change of rates, by age and sex, Brazil, 1990 and 2017
Age group 1990 2017 Percent change (95% UI)
Both sexes
Age-standardized 46.3 (41.5;52.1) 46.7 (41.8;52.6) 0.8 (-0.3;1.8)
Under 5 11.2 (8.9;13.9) 11.3 (9;14.1) 1.1 (-0.8;3.5)
5-14 years 16.5 (12;22.2) 16.7 (12.3;22.6) 1.1 (-1.4;3.6)
15-49 years 32.8 (27.1;39) 34.2 (28.2;40.6) 4.2 (0.4;8.2)
50-69 years 82.4 (67.1;102) 83.4 (67.5;103.2) 1.2 (-1;3.5)
70+ years 203.1 (165.4;252.3) 214.8 (176.5;263.2) 5.8 (2.2;10.1)
All Ages 36.5 (32.5;41) 49 (43.7;55.4) 34.4 (29;39.9)
Male
Age-standardized 46 (41.1;51.8) 45.5 (40.7;51.5) -1 (-2.5;0.5)
Under 5 11.2 (8.8;13.8) 11 (8.7;13.7) -1.3 (-4.1;2.5)
5-14 years 16.5 (11.9;22.2) 16.2 (11.9;22) -1.5 (-5.1;2.7)
15-49 years 32.6 (26.9;38.7) 33.2 (27.4;39.5) 1.9 (-2.5;5.9)
50-69 years 81.6 (65.9;100.9) 81.6 (66;101.9) 0 (-3.2;2.9)
70+ years 198.9 (161.2;247.1) 205.6 (167.7;253.2) 3.4 (-0.4;7.7)
All Ages 35.4 (31.4;39.9) 45.7 (40.6;51.9) 29.1 (23.9;34.9)
Female
Age-standardized 46.6 (41.6;52.4) 47.7 (42.7;53.8) 2.3 (0.8;3.8)
Under 5 11.3 (9;14) 11.7 (9.4;14.6) 3.7 (0.8;7.2)
5-14 years 16.6 (12.2;22.2) 17.2 (12.7;23.1) 3.7 (0.3;7.1)
15-49 years 33 (27.2;39.4) 35.2 (29;41.8) 6.4 (2.1;11)
50-69 years 83.2 (67.6;103) 85.1 (69.1;105.6) 2.3 (-1;5.3)
70+ years 206.5 (168.6;257.1) 221.6 (182.6;270.7) 7.3 (2.9;12.4)
All Ages 37.6 (33.4;42.3) 52.3 (46.6;59) 39.1 (33.3;45.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Number of deaths and age-standardized mortality rates (per 100 000) due to cardiomyopathy and myocarditis, and percent change of rates, in Brazil and its Federative Units, 1990 and 2017
Location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 9734 (8417;10163) 10.9 (9.6;11.4) 18812 (17885;21745) 8.6 (8.2;9.9) -21.2 (-26.8;-2.6)
Acre 11 (10;15) 5.7 (5.2;7.9) 29 (25;45) 4.8 (4.1;7.6) -15.2 (-28;26.1)
Alagoas 172 (137;194) 10.6 (8.4;11.9) 262 (239;289) 8.4 (7.7;9.3) -20.7 (-32.3;1.9)
Amapá 7 (6;9) 6.7 (6;8.4) 32 (28;42) 6.7 (5.9;8.7) -0.1 (-13.5;36)
Amazonas 55 (50;69) 6.3 (5.8;8) 135 (118;210) 4.9 (4.3;7.7) -22.4 (-33.1;18.6)
Bahia 581 (503;639) 7.9 (6.6;8.8) 892 (800;1189) 5.6 (5;7.5) -28.9 (-39.9;10.5)
Ceará 362 (296;425) 7.4 (5.9;8.7) 642 (592;704) 6.5 (6;7.1) -11.8 (-27.5;15.6)
Distrito Federal 95 (71;103) 16.2 (12.5;17.5) 268 (221;299) 13.1 (10.8;14.5) -19.4 (-28.2;-5)
Espírito Santo 138 (121;147) 10.5 (9.3;11.3) 261 (236;355) 6.4 (5.8;8.7) -39.7 (-47.2;-13.5)
Goiás 345 (246;378) 20.1 (14.7;22.2) 730 (609;792) 11.8 (9.8;12.8) -41.2 (-47.9;-24.8)
Maranhão 232 (193;286) 6.2 (5;8.1) 303 (268;458) 4.6 (4.1;7.1) -25.7 (-41.7;3.6)
Mato Grosso 75 (68;83) 8.7 (7.8;9.7) 202 (182;277) 7.1 (6.3;9.5) -18.5 (-29;14)
Mato Grosso do Sul 122 (89;133) 14.5 (10.6;15.9) 261 (236;293) 10 (9.1;11.2) -30.8 (-39.9;2.9)
Minas Gerais 1238 (962;1334) 13.1 (10.3;14) 2059 (1903;2288) 8.4 (7.7;9.3) -36 (-42.8;-16.7)
Pará 114 (102;162) 4.9 (4.5;7) 314 (274;482) 4.8 (4.2;7.3) -3.6 (-15.2;29.3)
Paraíba 279 (220;318) 11.3 (8.9;12.9) 456 (392;515) 9.8 (8.4;11.1) -12.9 (-27.5;8)
Paraná 567 (479;605) 13 (11;13.9) 769 (685;1168) 6.6 (5.9;9.9) -49.2 (-56.2;-19.1)
Pernambuco 330 (306;367) 7.1 (6.6;8) 775 (700;884) 7.9 (7.1;9.1) 11.3 (-2.9;26.3)
Piaui 124 (102;146) 7.3 (5.9;8.9) 183 (165;233) 5.1 (4.6;6.5) -30.7 (-43.4;3.1)
Rio de Janeiro 830 (749;1076) 8.9 (8.2;11.5) 2749 (2069;2994) 13.1 (10;14.2) 46.2 (12.6;63.3)
Rio Grande do Norte 92 (80;119) 5.1 (4.4;6.8) 176 (153;256) 4.6 (4;6.8) -8.8 (-25.2;34.4)
Rio Grande do Sul 298 (268;487) 4.8 (4.3;7.8) 709 (617;1221) 4.9 (4.3;8.5) 2.7 (-7;14.1)
Rondônia 30 (27;36) 7.8 (7.1;9.3) 83 (70;120) 6.1 (5.2;8.8) -22.6 (-34.2;4.1)
Roraima 10 (7;11) 17.1 (12.1;19.4) 40 (33;47) 13.5 (11.2;16.1) -20.9 (-36.3;12.7)
São Paulo 3260 (2466;3519) 17.6 (13.5;19) 5766 (4987;6355) 11.8 (10.3;12.9) -33.1 (-39.7;-16.4)
Santa Catarina 246 (229;264) 10.9 (10;11.8) 493 (449;681) 7 (6.3;9.5) -36.3 (-43.8;-14.8)
Sergipe 82 (73;90) 8.7 (7.7;9.7) 139 (125;173) 6.5 (5.9;8.1) -24.6 (-35.6;2)
Tocantins 41 (31;49) 10.2 (8.1;12.4) 87 (77;113) 6.3 (5.5;8.3) -38.5 (-51.3;-5.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Mortality rates (per 100 000 inhabitants) due to cardiomyopathy and myocarditis, and percent change of rates, per age and sex, Brazil, 1990-2017
1990 2017 Percent change (95% UI)
Both sexes
Age-standardized 10.9 (9.6;11.4) 8.6 (8.2;9.9) -21.2 (-26.8;-2.6)
Under 5 4.8 (4;5.6) 2.5 (2.2;2.8) -47.1 (-56.4;-31.1)
5-14 years 0.4 (0.4;0.5) 0.4 (0.3;0.4) -11.3 (-22.3;2.2)
15-49 years 2.4 (2;2.6) 2.5 (2.2;2.7) 1.4 (-6.7;21.7)
50-69 years 21.2 (17.7;22.5) 16.5 (15.3;19.3) -22.4 (-29.3;-0.2)
70+ years 84.2 (74.2;89.1) 76.6 (72.1;90) -9 (-16.8;14.7)
All Ages 6.5 (5.6;6.8) 8.9 (8.4;10.3) 36.3 (26.6;68.8)
Male
Age-standardized 12.8 (10;13.7) 11.3 (10.5;14.4) -12.1 (-20.9;28.2)
Under 5 4.8 (3.3;5.7) 2.7 (2.3;3.2) -43 (-57.1;-3.5)
5-14 years 0.4 (0.4;0.5) 0.4 (0.4;0.5) -3.9 (-20;15.3)
15-49 years 3.3 (2.5;3.6) 3.6 (3.2;4.2) 9.5 (-1;43.7)
50-69 years 26.2 (19.1;28.4) 23.6 (21.4;29.7) -10.1 (-20.9;31.7)
70+ years 91.6 (69.7;99.7) 89.3 (81.2;119.5) -2.5 (-15.1;53.7)
All Ages 7.4 (5.6;7.9) 10.7 (10;13.6) 44.8 (30.7;109.6)
Female
Age-standardized 9.2 (8.8;9.6) 6.3 (6;6.6) -31.3 (-35.5;-26.2)
Under 5 4.7 (3.9;5.9) 2.3 (2;2.6) -51.5 (-64.1;-37.5)
5-14 years 0.4 (0.3;0.5) 0.3 (0.3;0.4) -19.9 (-31.7;-4.4)
15-49 years 1.6 (1.5;1.6) 1.3 (1.2;1.4) -15.9 (-23.1;-7.1)
50-69 years 16.6 (15.6;17.6) 10.2 (9.5;11) -38.6 (-43.7;-32.3)
70+ years 78.3 (73.7;83.3) 67.4 (63.2;71.9) -13.9 (-21.1;-5.9)
All Ages 5.7 (5.4;5.9) 7.1 (6.8;7.5) 26.3 (18.6;35.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Number of DALYs and age-standardized DALY rates (per 100 000) due to cardiomyopathy and myocarditis, and percent change of rates, in Brazil and its Federative Units, 1990 and 2017
Location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 328636.2 (283325;346745.9) 286.3 (246.7;300.6) 490571.8 (465903.3;556885.7) 222.3 (211.1;250.9) -22.4 (-27.6;-7)
Acre 497.4 (436.2;639.6) 160.9 (145;211.8) 892.9 (770.2;1353.6) 128.3 (110.6;194.8) -20.3 (-32.5;10.3)
Alagoas 7445.3 (5810.9;8943.2) 325.1 (260.1;373.1) 7889.4 (7045.9;8603.6) 238.4 (215;260) -26.7 (-37.3;-12.9)
Amapá 260.3 (235.6;324.2) 162.7 (147.6;202.1) 1030.8 (926.3;1349.3) 172.1 (154.9;223) 5.8 (-6.7;41)
Amazonas 2178.8 (1943.2;2658.8) 162.5 (148;203.1) 4500.2 (3953.1;6675.2) 137.2 (120.4;205.4) -15.6 (-25.7;19.1)
Bahia 19212.5 (17344.2;21147.3) 212.7 (188;232.3) 27181.1 (24338.5;33355.6) 175.2 (156.2;214.1) -17.6 (-29.2;10.8)
Ceará 16413.7 (13000.4;20157.3) 260.6 (210.1;309.8) 18369.4 (16682.7;20144.2) 188.2 (170.6;206.9) -27.8 (-41.3;-10.1)
Distrito Federal 3658.3 (2766.2;3988) 376.3 (286.8;405.1) 7351.8 (6159.1;8113.1) 276.6 (233.7;305.7) -26.5 (-33;-14.2)
Espírito Santo 4540.9 (4041.7;4871.1) 241 (213.7;258.1) 7341.7 (6712.8;9314.8) 177 (161.6;223.8) -26.5 (-34.9;-2.3)
Goiás 11003.3 (8024.8;12004.6) 428.7 (312.4;467.9) 18299.6 (15675.5;19752.8) 272.9 (234.7;293.9) -36.3 (-43;-16)
Maranhão 13001.5 (10067.9;16807.4) 242.9 (200.7;299.4) 10003.6 (8755.1;13529.3) 137.8 (121.5;190.6) -43.3 (-56.7;-23.3)
Mato Grosso 3073.7 (2771.1;3438.3) 229.1 (209.1;254.1) 5796.7 (5242.4;7786.8) 177.7 (161.1;236.5) -22.4 (-31.3;2.3)
Mato Grosso do Sul 3865.2 (2943.9;4262.8) 329.7 (247;361.6) 6710.7 (6101.4;7492.7) 242 (221.4;268.6) -26.6 (-35.7;6.5)
Minas Gerais 39564.4 (30507.2;42826) 327.1 (253.6;352.7) 51182.3 (47035.5;56511.4) 216.8 (198.6;238.8) -33.7 (-40.5;-13.2)
Pará 4344.5 (3801.9;5889.4) 129.8 (116.4;180.3) 9977.8 (8660.1;14959.6) 132.8 (115.4;198.5) 2.3 (-9.4;25.4)
Paraíba 10241.9 (8039.5;12095.6) 341.3 (272.3;396.2) 11470.6 (9717.3;12811.3) 257.1 (217.9;287.7) -24.7 (-36.3;-9.2)
Paraná 17321.6 (15163;18438.9) 292.2 (250.6;309.9) 19045.2 (16983.3;28587.7) 160.6 (142.8;234.4) -45 (-52.3;-14.1)
Pernambuco 11872 (10716.4;13371.5) 200.8 (184.9;220.9) 21914.4 (19857.6;24316.1) 218.9 (198.9;243.3) 9 (-3.7;22.2)
Piauí 5486.8 (4473.4;6582.1) 227.8 (188.3;269.8) 5211.8 (4701.4;6542.5) 145.4 (130.7;182.9) -36.2 (-48;-13)
Rio de Janeiro 28335.5 (24866.7;35902.2) 249.5 (221.8;316.3) 68879.7 (50970.5;75152.9) 334.9 (253.6;363.3) 34.2 (2.5;48.6)
Rio Grande do Norte 3445.5 (2978.7;4084.9) 153.8 (134.2;188.6) 5076.1 (4420.6;6901.5) 137.6 (119.9;186.8) -10.6 (-24.8;18.6)
Rio Grande do Sul 9946.1 (8932.6;15081.7) 128.4 (115.3;197.2) 16836.2 (14705.4;28348.6) 124.5 (109.3;204.3) -3.1 (-11.8;8.7)
Rondônia 1298.7 (1165.9;1533.3) 197.3 (178.5;234.3) 2395.2 (2053.6;3399.5) 153.1 (132.1;214.9) -22.4 (-33.3;0.6)
Roraima 435.5 (314.2;500.3) 376.2 (264.9;423.8) 1242.6 (1054;1445.5) 296.9 (253.9;344.2) -21.1 (-35.7;10)
Santa Catarina 7573.9 (7109.4;8246.8) 244.7 (229.3;262.6) 12498.4 (11367.3;16891.4) 168.5 (153.3;225.2) -31.2 (-38.2;-12.2)
São Paulo 98920.7 (75875.1;106392.2) 410.9 (316.9;441.8) 142836.1 (123464.2;155246.1) 288.1 (253.2;311.2) -29.9 (-36;-15)
Sergipe 2898.6 (2556.6;3238.8) 237.8 (211.1;262.1) 4042.2 (3652.6;4946.7) 180.8 (163.1;219.5) -24 (-34.8;-0.4)
Tocantins 1799.9 (1350.9;2222.4) 255.1 (199.3;307.4) 2595.3 (2275.4;3210.4) 174.4 (152.9;216.8) -31.6 (-45.1;-1.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – DALY rates due to cardiomyopathy and myocarditis, per 100 000 inhabitants, and percent change of rates, by age and sex, Brazil, 1990 and 2017
Age groups 1990 2017 Percent change (95% UI)
All
Age-standardized 286.3 (246.7;300.6) 222.3 (211.1;250.9) -22.4 (-27.6;-7)
Under 5 414 (345.2;487) 219.9 (195.5;246.4) -46.9 (-56.3;-30.9)
5-14 years 35.3 (29.9;39.3) 31.3 (28.2;34.5) -11.3 (-21.8;1.5)
15-49 years 126.4 (107.3;133.9) 125.6 (115.7;139.5) -0.7 (-8.1;19.3)
50-69 years 624 (522.3;660.5) 492.5 (458.8;569.8) -21.1 (-27.9;-0.2)
70+ years 1165 (1027.8;1237.6) 957.2 (888.7;1110.9) -17.8 (-24.6;2.9)
All Ages 219.9 (189.6;232.1) 231.6 (220;262.9) 5.3 (-2;24.8)
Male
Age-standardized 343.1 (262.8;365.7) 299 (279.9;363.4) -12.8 (-21;17.6)
Under 5 419.5 (287.2;498.1) 239.9 (202.9;283.3) -42.8 (-57;-3.3)
5-14 years 36.9 (30.7;41.7) 35.3 (30.6;41.1) -4.5 (-19.7;13.8)
15-49 years 172.3 (132.9;185.4) 184.3 (164.1;213) 7 (-3.2;40.7)
50-69 years 769.4 (565.3;832.5) 699.1 (634.3;864) -9.1 (-19.9;30.9)
70+ years 1293.3 (990.1;1415.9) 1165 (1058.4;1512.1) -9.9 (-21.7;39.8)
All Ages 258.5 (198.1;276.9) 302.3 (282.1;367.3) 16.9 (5.5;55.7)
Female
Age-standardized 233.8 (222.7;247.3) 153.5 (145.5;161.5) -34.3 (-38.6;-30)
Under 5 408.3 (336.9;516.1) 199 (171.3;225) -51.3 (-63.9;-37.2)
5-14 years 33.6 (28.6;37.5) 27.2 (23.5;30.4) -19.1 (-30.3;-4.4)
15-49 years 82 (77.2;87) 68.4 (64.2;73) -16.6 (-23.2;-8.8)
50-69 years 489.8 (460.6;520) 309.6 (288.2;332.4) -36.8 (-41.7;-30.8)
70+ years 1061.9 (993.3;1138.6) 806.3 (749.9;868.8) -24.1 (-30.4;-17.1)
All Ages 182.2 (172.3;194.9) 164 (155.3;172.6) -10 (-16.9;-3.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Number of deaths and age-standardized mortality rate due to Chagas disease, per 100 000 inhabitants, for females, in 1990 and 2017, and percent change of rates, in Brazil and its Federative Units
Location 1990 2017 Percent change (95% UI)
Number of deaths (95% UI) Mortality Rate (95% UI) Number of deaths (95% UI) Mortality Rate (95% UI)
Acre 0.4 (0.4;0.5) 0.5 (0.5;0.6) 0.6 (0.5;0.7) 0.2 (0.2;0.2) -58.7 (-65.8;-49.8)
Alagoas 25.8 (20.2;30.7) 3.5 (2.7;4.2) 33.4 (28.8;38.2) 1.9 (1.7;2.2) -44.4 (-57.5;-24.8)
Amapá 0.2 (0.1;0.2) 0.3 (0.3;0.3) 0.3 (0.3;0.4) 0.1 (0.1;0.1) -58.5 (-67;-49.9)
Amazonas 0.9 (0.8;1) 0.2 (0.2;0.2) 1.3 (1.2;1.6) 0.1 (0.1;0.1) -56.4 (-63.1;-46.9)
Bahia 232.2 (210.6;255.3) 6.1 (5.5;6.7) 276.5 (253.1;304.8) 3.2 (2.9;3.5) -47.8 (-54.4;-40)
Brazil 2638.1 (2545.4;2737.8) 5.3 (5.1;5.5) 2399.2 (2255.9;2597.1) 1.9 (1.8;2.1) -63.7 (-66.3;-60.7)
Ceará 14.1 (11.5;18) 0.6 (0.5;0.8) 19.3 (17;22.2) 0.4 (0.3;0.4) -44.4 (-59.3;-27.6)
Distrito Federal 98.7 (91.8;106.5) 29.2 (27.3;31.3) 103 (91.5;121.4) 8.5 (7.6;10.1) -70.9 (-74.4;-66.1)
Espírito Santo 3.2 (2.9;3.5) 0.4 (0.4;0.5) 3.3 (2.9;3.9) 0.1 (0.1;0.2) -67.3 (-72.1;-61.3)
Goiás 447.5 (419.6;480.6) 50.1 (46.8;54.1) 362 (329.1;407.7) 11.1 (10.1;12.5) -77.9 (-80;-75.4)
Maranhão 4.3 (3;6.8) 0.3 (0.2;0.5) 5.6 (4.9;6.8) 0.2 (0.1;0.2) -47.1 (-64.2;-23.3)
Mato Grosso 12.6 (11;14.5) 3.2 (2.8;3.6) 21 (18.4;25.5) 1.4 (1.3;1.7) -55.4 (-62.5;-45.2)
Mato Grosso do Sul 16.1 (14.6;17.8) 3.6 (3.3;4) 19.5 (17;22.6) 1.4 (1.2;1.6) -62.8 (-68.3;-56.2)
Minas Gerais 853.2 (809.6;904.2) 15.9 (15.1;16.8) 646 (593.4;706.5) 4.6 (4.3;5.1) -70.8 (-73.7;-67.6)
Pará 6.8 (6;7.6) 0.6 (0.5;0.7) 8.3 (7.2;10) 0.2 (0.2;0.3) -58.6 (-65.5;-49.1)
Paraíba 13.3 (9.7;15.6) 1.1 (0.8;1.3) 15.3 (12.9;17.7) 0.6 (0.5;0.7) -45.9 (-58.7;-22.1)
Paraná 131.4 (122;140.3) 5.3 (4.9;5.6) 111.6 (100.4;125.1) 1.7 (1.5;1.9) -68.8 (-72.3;-64.8)
Pernambuco 60.3 (53.4;66.2) 2.4 (2.2;2.7) 59.7 (52.8;67.5) 1.1 (0.9;1.2) -56.4 (-62.7;-47)
Piauí 19 (15.4;24.5) 2.5 (2;3.2) 26.3 (23.1;30.8) 1.3 (1.2;1.6) -46.1 (-59.2;-30)
Rio de Janeiro 29.5 (27;32.4) 0.5 (0.5;0.6) 26.9 (23.6;30.4) 0.2 (0.2;0.2) -60.8 (-66.1;-54.6)
Rio Grande do Norte 4 (3.5;4.8) 0.5 (0.4;0.6) 4.9 (4.2;5.6) 0.2 (0.2;0.3) -50.5 (-63.1;-37.1)
Rio Grande do Sul 20.9 (18.9;22.7) 0.6 (0.5;0.6) 19.8 (17.5;22.6) 0.2 (0.2;0.3) -60.7 (-65.8;-54.1)
Rondônia 6.9 (6.1;7.8) 3.9 (3.5;4.4) 9.6 (7.9;11.6) 1.4 (1.1;1.7) -64.8 (-72.1;-56.2)
Roraima 0.1 (0.1;0.1) 0.3 (0.2;0.3) 0.2 (0.1;0.2) 0.1 (0.1;0.1) -63 (-72.2;-52)
Santa Catarina 4.6 (4.1;5.1) 0.4 (0.3;0.4) 5.1 (4.5;6) 0.1 (0.1;0.1) -65 (-70;-58.7)
São Paulo 614.1 (583.5;644.5) 5.4 (5.1;5.6) 593.9 (544.1;650.2) 2 (1.9;2.2) -61.9 (-65.3;-58.1)
Sergipe 3.6 (3.1;4.2) 0.8 (0.7;0.9) 4.1 (3.6;4.7) 0.3 (0.3;0.4) -55.9 (-63.5;-43)
Tocantins 14.5 (11.6;19) 7.9 (6.5;10.2) 21.7 (18.6;25.7) 3.2 (2.8;3.8) -59 (-70;-46.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Prevalence number and age-standardized prevalence rate of heart failure impairment for all causes (per 100 000 inhabitants) and percent change of rates, 1990 and 2017, in Brazil and its Federative Units
Location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 670194.8 (589952.6;753672.6) 818.1 (718.1;922.8) 1686320.1 (1478563.8;1890537.3) 777.2 (680;874.8) -5 (-7.1;-3)
Acre 1235.9 (1083.5;1395.6) 764.3 (668.5;869) 4025.6 (3559.4;4534.9) 728.8 (638.1;830.1) -4.6 (-10.1;1.8)
Alagoas 9783 (8509.2;11210.5) 752.5 (654.5;861.9) 22691.5 (19784.3;25922) 764.8 (664.4;879.3) 1.6 (-5.7;8.3)
Amapá 748.2 (662;841.1) 779.1 (680.7;889.6) 3278.9 (2865.5;3672.3) 749.3 (651.9;845.2) -3.8 (-9.5;2.6)
Amazonas 6097.6 (5376.6;6855.3) 809.8 (709.1;919) 19459.2 (17131;21872.1) 775.9 (678.8;884.1) -4.2 (-10.2;1.9)
Bahia 52840.3 (46323.4;60082) 783.5 (685.2;893) 118062.7 (103361.3;134066.1) 753.3 (656.9;857.9) -3.8 (-9.6;2.5)
Ceará 30093.8 (26385.1;34137.4) 739.5 (648;842.1) 77144.8 (67097.6;87800.2) 785.5 (682.6;896) 6.2 (-0.8;14.2)
Distrito Federal 4256.7 (3710.8;4838.9) 813.3 (701.7;932) 16100.7 (13996.8;18333.4) 753.5 (654.5;850.2) -7.4 (-13.1;-0.6)
Espírito Santo 11320.9 (9847.7;12942.2) 841.5 (730.3;961.6) 31391.5 (27390.7;35566.7) 782.7 (680;889.7) -7 (-13.2;-0.6)
Goiás 14142 (12371.7;16150.6) 800.7 (703.5;912.7) 46168.1 (40298.2;52244.1) 753 (655.9;854) -6 (-12.9;1)
Maranhão 18235.7 (15857.1;20802.4) 747.2 (650.9;852.8) 49180.9 (43277;55993.9) 795.1 (697.6;907.8) 6.4 (0.2;13.5)
Mato Grosso 5774.8 (5067;6502.3) 819.3 (712.6;938) 21845.3 (19017.4;24622) 789.4 (688;895.4) -3.7 (-9.6;3)
Mato Grosso do Sul 6795.1 (5934.8;7652) 846.4 (740.2;961.2) 21183 (18418.4;24002) 816 (710.9;922.6) -3.6 (-9.3;3.4)
Minas Gerais 74411.2 (64608;84527.1) 826.9 (722;940.5) 187809.8 (163412.5;214570.5) 759.5 (659.4;867) -8.1 (-14.2;-1.6)
Pará 16002.3 (14153.8;18014.5) 789.4 (694.3;893.2) 46324.1 (40809.4;52186.1) 746.6 (652.1;844.8) -5.4 (-11.3;0.9)
Paraíba 17922.4 (15619.1;20442.3) 772 (675.4;881) 36827.2 (32186.6;41911.1) 794.6 (693.4;902.5) 2.9 (-3.6;10.2)
Paraná 35843.5 (31360.3;40661.2) 834.4 (726.6;948.5) 93386.5 (81689;106563.6) 779.7 (684;892.6) -6.6 (-12.2;0.1)
Pernambuco 34084.1 (29826.4;39017.2) 793.9 (695;908.1) 72004 (62756.3;81953.9) 753.9 (655.5;862.9) -5 (-11.2;1.3)
Piauí 11016.2 (9596.9;12503.6) 803.5 (698.9;912.6) 29097.2 (25425.9;33105.2) 812.7 (708.9;927) 1.1 (-5.6;8.5)
Rio de Janeiro 72976.8 (63619.5;83192) 850.4 (744;970.5) 162697.6 (140265.7;185508.6) 778.9 (674.2;887.1) -8.4 (-14.1;-1.7)
Rio Grande do Norte 13462.3 (11756.9;15396.2) 827 (720.5;948.1) 31332.8 (27529.6;35470.6) 839 (734;955.6) 1.5 (-4.9;8.1)
Rio Grande do Sul 51590.7 (45263.1;58166.6) 862.8 (754.1;980) 115132.9 (100064.2;130860) 787.4 (685.2;894.6) -8.7 (-14.7;-2.9)
Rondônia 2451.8 (2150.6;2766.5) 813.4 (710.9;925.4) 9980.6 (8742.3;11325) 766 (669.2;872.1) -5.8 (-11.9;1)
Roraima 419.1 (368.5;471.8) 809.3 (706.3;925) 2297.9 (2000.3;2611) 774.6 (674.4;884.7) -4.3 (-10.5;2)
Santa Catarina 19387.5 (16978;21842.4) 847 (741.4;957.7) 55662.9 (48893.1;63470.8) 779.6 (685.4;894.9) -8 (-13.7;-2)
São Paulo 150009 (131202;169778.7) 842.8 (734.6;959.2) 387169.5 (336629;442688.8) 787.9 (685;899.2) -6.5 (-12.8;-0.4)
Sergipe 6409.8 (5592.5;7302.6) 754.4 (657.2;860.7) 15587.4 (13661.6;17664.6) 763.8 (668.4;870.4) 1.2 (-4.7;8.8)
Tocantins 2884.2 (2501.8;3284.4) 789.5 (691.7;906.1) 10477.4 (9147.4;11899) 796.5 (692.4;907.9) 0.9 (-5.9;8.5)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Prevalence rates of heart failure, per 100 000 inhabitants, and percent change of rates, by sex and age groups, Brazil, 1990 and 2017
Age group 1990 2017 Percent change (95% UI)
Prevalence Prevalence
Age-standardized 818.1 (718.1;922.8) 777.2 (680;874.8) -5 (-7.1;-3)
Under 5 46.3 (32;63.8) 45 (30.8;61.9) -2.9 (-5.5;-0.1)
5-14 years 34.7 (24.2;47.2) 34.1 (23.6;46.7) -1.6 (-4.5;1.3)
15-49 years 107.1 (90.7;124.8) 119 (100.2;139.3) 11.1 (5.5;15.6)
50-69 years 1391.6 (1172.1;1627.5) 1330.4 (1125.6;1570.4) -4.4 (-6.9;-1.8)
70+ years 8249.1 (6918.9;9752.5) 8530.2 (7265.9;9922.9) 3.4 (-1;8)
All Ages 448.5 (394.8;504.4) 796.1 (698.1;892.6) 77.5 (72.3;82.4)
Male
Age-standardized 811.8 (714;916.9) 750.6 (656.2;845) -7.5 (-10.2;-4.8)
Under 5 46.8 (32.2;64.5) 45.2 (31;62.1) -3.6 (-7.2;0.4)
5-14 years 34.3 (23.7;46.9) 33.4 (23.1;45.9) -2.5 (-6.6;1.7)
15-49 years 105.3 (89;122.4) 114.2 (95.6;134.7) 8.5 (0.5;14.2)
50-69 years 1386.9 (1164.2;1643.5) 1311.3 (1102.4;1555.5) -5.4 (-9.1;-1.5)
70+ years 8083.9 (6784.9;9549.3) 7926.1 (6721.2;9286.2) -2 (-6.4;2.9)
All Ages 415.6 (367.7;466.8) 685 (602.9;770) 64.8 (59.3;70.4)
Female
Age-standardized 820.9 (721;933.2) 794.7 (694.4;900.6) -3.2 (-6.5;-0.1)
Under 5 45.8 (31.6;63.3) 44.8 (30.7;63.3) -2.1 (-5.7;2.2)
5-14 years 35.1 (24.7;47.9) 34.9 (24.3;47.2) -0.7 (-4.6;3.1)
15-49 years 109 (91.7;126.6) 123.7 (103.9;144) 13.5 (8.8;18.3)
50-69 years 1395.9 (1183.9;1632.2) 1347.3 (1137.1;1586.4) -3.5 (-6.9;0.3)
70+ years 8381.9 (7012.1;9982.4) 8968.9 (7622.9;10482.3) 7 (1.1;12.8)
All Ages 480.8 (422.3;544.4) 902.3 (790.2;1020.9) 87.7 (81;94.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Number of YLDs and age-standardized rates of YLDs (per 100 000 inhabitants) due to heart failure from all causes, and percent change of rates, 1990 and 2017, in Brazil and its Federative Units
Location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 88114.2 (64078.1;112623.9) 112.2 (82.8;141.2) 234168.9 (174338.9;291187.7) 108.8 (81.4;134.5) -3 (-6.7;0.3)
Acre 188.7 (140.7;234.7) 123.8 (95.3;148.9) 636.8 (490.6;767.6) 119.8 (93.4;142.4) -3.2 (-9.6;5.2)
Alagoas 1230.4 (880.5;1587.3) 97.7 (70.9;124.1) 2951 (2189.4;3685.1) 101 (75;125.8) 3.3 (-5.8;12)
Amapá 100.2 (73.7;127.2) 112.2 (84.5;139.2) 451.5 (337.3;558.9) 108.9 (83.4;132.6) -3 (-9.5;5)
Amazonas 810.4 (592.2;1020.8) 115.9 (87.9;141.5) 2702.1 (2050;3305.1) 112.2 (86.1;135.8) -3.1 (-10;3.9)
Bahia 6684.8 (4893.5;8540.9) 101.7 (75.5;129) 15736.9 (11812.7;19456) 100.8 (75.3;125.3) -0.8 (-7.7;7.9)
Ceará 3969.6 (2897.9;5084.5) 99.2 (72.8;126.2) 10451.4 (7838.4;12882.6) 106.6 (79.8;132) 7.4 (-1.3;17)
Distrito Federal 431.1 (298.6;581.8) 97.6 (70.8;128.8) 1940.3 (1366.1;2560) 96.9 (69.9;125.4) -0.8 (-8.1;9.2)
Espírito Santo 1462.1 (1054.4;1878.9) 113.4 (84.3;143.6) 4162.7 (3063.9;5243.2) 104.9 (77.5;131.9) -7.5 (-14.4;0.1)
Goiás 1592.7 (1128;2094.6) 103.8 (76.7;132.4) 6291.2 (4685;7868.1) 106.1 (79.5;131.7) 2.2 (-6.5;11.5)
Maranhão 2190.7 (1560.1;2873.3) 92 (66.4;119.5) 5992.2 (4402.4;7553.5) 97.8 (72;122.9) 6.3 (-1.6;15.9)
Mato Grosso 725.4 (526.7;941) 113.1 (83.9;142.3) 3003 (2248.2;3728.7) 112 (84.7;137.3) -0.9 (-8.1;7.7)
Mato Grosso do Sul 850.1 (609.1;1106.8) 113.3 (83.8;142.8) 2829.1 (2072.2;3549.4) 110.8 (82.1;137.7) -2.2 (-9.5;6.5)
Minas Gerais 9477.1 (6808.4;12335.3) 110.9 (82.3;141.3) 25557 (18974.8;31992.6) 103.6 (77.2;129.4) -6.5 (-14.4;1.6)
Pará 2221.3 (1651.1;2795.8) 115.7 (88.1;142.8) 6624.9 (5036.2;8052.8) 109.8 (84.8;132.1) -5.2 (-12.2;2.3)
Paraíba 2298.3 (1666.9;2947.6) 99.5 (72.4;126.3) 4808 (3560.3;5995.7) 103.4 (76.3;129.4) 4 (-4.2;12.5)
Paraná 4964.3 (3563.3;6413.6) 123.5 (92.3;154.2) 13883.5 (10128.6;17249.1) 117 (86.8;144.4) -5.2 (-12.7;3.3)
Pernambuco 4627.4 (3326;5865.3) 110.9 (81.9;137.8) 10375.1 (7650.4;12784) 109.6 (81;134.6) -1.2 (-9;7.3)
Piauí 1230.3 (866.5;1647.8) 92.1 (65.6;122) 3402.3 (2478.9;4365.3) 95.1 (69.4;122.2) 3.3 (-5;11.9)
Rio de Janeiro 9922.7 (7229.9;12662.8) 119.7 (88.6;150.3) 22953.2 (16743.8;28786) 110 (81.3;137.7) -8.1 (-14.7;-0.4)
Rio Grande do Norte 1606.1 (1145.6;2057.5) 99.5 (71.8;126.6) 3856.8 (2838.4;4879.3) 103.5 (75.7;132) 4 (-3.9;12)
Rio Grande do Sul 8134 (5994.6;10280.5) 140.5 (106.7;171.9) 18696.6 (14241.9;22612.8) 126.9 (97;152.5) -9.7 (-16.6;-2.5)
Rondônia 300.3 (209.4;397.4) 117.4 (86.9;145.5) 1408.5 (1062.2;1750.7) 111.9 (85.8;137) -4.7 (-11.7;4.4)
Roraima 46.3 (32.4;62.3) 101.5 (74.8;130.8) 276.8 (197.7;358.6) 98.7 (72.2;125.2) -2.8 (-9.7;5)
Santa Catarina 2880 (2095.3;3688.1) 133.3 (99.4;165.6) 8433.4 (6334.3;10482.5) 119.7 (90.8;147.4) -10.2 (-16.8;-3.4)
São Paulo 18988.5 (13523.4;24849.5) 112.8 (81.9;144.5) 53360.6 (38622.8;68602.6) 109.6 (80.1;140.1) -2.9 (-10.6;5.1)
Sergipe 853.9 (627.3;1082.5) 102.4 (75.6;129) 2085.5 (1551.2;2578.3) 103.7 (77.4;127.2) 1.3 (-6.3;9.9)
Tocantins 327.5 (226.3;438.8) 96.4 (69.6;126.2) 1298.6 (952.1;1635.1) 100.3 (73.9;125.9) 4 (-4.3;14.5)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188 – Rates of YLDs due to heart failure (per 100 000 inhabitants) and percent change of rates, by age and sex, Brazil, 1990 and 2017
Age group 1990 2017 Percent Change (95% UI)
Both sexes
Age-standardized 112.2 (82.8;141.2) 108.8 (81.4;134.5) -3 (-6.7;0.3)
Under 5 4.5 (2.7;7) 4.3 (2.6;6.8) -3.4 (-6;-0.6)
5-14 years 3.2 (1.9;5.1) 3.2 (1.9;5) -1.4 (-4.4;1.5)
15-49 years 8.7 (5.7;12.6) 10.4 (6.8;14.8) 18.7 (12.3;25.5)
50-69 years 165.8 (112.7;226.8) 166.4 (115.3;228.9) 0.3 (-3.8;5.5)
70+ years 1263.1 (919.3;1599.5) 1308.3 (988.6;1586) 3.6 (-3.2;10.2)
All Ages 59 (42.9;75.4) 110.6 (82.3;137.5) 87.5 (78.8;96.2)
Male
Age-standardized 112.9 (86.9;137.4) 105.2 (81.6;127.1) -6.8 (-10.9;-2.6)
Under 5 4.5 (2.7;7.1) 4.3 (2.6;6.8) -4.2 (-7.8;-0.2)
5-14 years 3.2 (1.9;5) 3.1 (1.8;4.9) -2.2 (-6.4;2)
15-49 years 7.9 (5.1;11.6) 9.5 (6.1;13.8) 19.8 (10.2;29.3)
50-69 years 165.5 (111.9;230.9) 165.8 (113.5;229.4) 0.2 (-5.9;6.8)
70+ years 1282.5 (973.9;1555.8) 1225.7 (980;1439.6) -4.4 (-11.1;3.4)
All Ages 55 (40.6;68.5) 94.5 (72.6;115.7) 71.9 (63.1;81.5)
Female
Age-standardized 111.2 (79.9;145) 110.9 (80.1;140.6) -0.3 (-4.9;4.2)
Under 5 4.4 (2.7;7) 4.3 (2.6;6.7) -2.6 (-6.3;1.7)
5-14 years 3.2 (1.9;5.2) 3.2 (1.9;5.1) -0.6 (-4.5;3.2)
15-49 years 9.5 (6.3;13.4) 11.2 (7.4;15.9) 17.9 (10.5;26.4)
50-69 years 166.1 (112.5;225.8) 166.9 (116.6;228.9) 0.5 (-5;6.7)
70+ years 1247.5 (876.2;1659.2) 1368.3 (992.5;1714.5) 9.7 (0.6;17.6)
All Ages 62.9 (44.1;82.5) 125.9 (90.9;159.5) 100.2 (88.8;111.5)

Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188

– Age-standardized prevalence rates of valvular heart disease per 100 000, for both sexes and for males and females, in Brazil and its Federative Units, 1990 and 2017, and percent change of rates
Cause of death and age group Both sexes Female Male
1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI)
B.2.1 - Rheumatic heart disease
Acre 703.8 (665.8;739.9) 729.7 (693.1;768.5) 3.7 (7.7;-0.3) 775 (730.9;820.8) 815.5 (768.6;865.4) 5.2 (11.2;0.2) 637.6 (602;673.8) 643.2 (608.9;683.8) 0.9 (6.3;-4.6)
Alagoas 716 (680.1;754.7) 742.7 (704.3;784.6) 3.7 (8.3;-0.2) 792.6 (748;840.8) 831.5 (783;883.6) 4.9 (11.4;-0.9) 633.3 (596;671.4) 644.2 (604.8;683.5) 1.7 (8.5;-4.2)
Amapá 717.6 (682.8;756.8) 738.1 (699;779.4) 2.9 (7;-1.2) 788 (746;835.3) 825.5 (778.8;872.7) 4.8 (10.6;-0.4) 647.3 (612.4;686.3) 649.1 (611.5;689.5) 0.3 (6;-5.3)
Amazonas 725.7 (690.9;766) 745.4 (701.9;787.1) 2.7 (6.6;-1.4) 806.5 (761.8;856.7) 837.9 (785.6;893.9) 3.9 (9.7;-2.3) 646.3 (609.2;688.4) 652.9 (614.4;690.3) 1 (7.2;-5.6)
Bahia 698.3 (664.2;739.1) 726.2 (689.5;765.3) 4 (7.7;-0.1) 764.8 (722.7;814.7) 809.5 (763.4;859.3) 5.8 (11;0.6) 627.7 (589.6;669.6) 637.3 (602.1;676.4) 1.5 (7.7;-4.5)
Brazil 721.4 (688.7;754.5) 743.2 (709;778.6) 3 (4.3;1.6) 797 (758.9;835.7) 832.2 (793.3;871.2) 4.4 (6.1;2.6) 641.9 (611.4;672.8) 648.9 (619;682.4) 1.1 (2.8;-0.7)
Ceará 721.8 (682.3;759.9) 747.5 (708.2;785.5) 3.6 (7.4;0) 798.7 (753;847.5) 838 (787.6;887.3) 4.9 (10.2;-1) 636.7 (596.7;676) 649.9 (611.1;688.1) 2.1 (7.8;-3.5)
Distrito Federal 727.1 (689.8;767.7) 744.2 (705.1;781.2) 2.3 (6.5;-1.6) 802.3 (758.5;851.6) 831.2 (783.8;881.5) 3.6 (9.6;-1.8) 643.2 (607.9;683.5) 646.7 (609.8;685.7) 0.5 (6.4;-5.4)
Espírito Santo 723.1 (686.9;761.9) 743.5 (705.8;783.6) 2.8 (7.2;-1.2) 802.6 (759.6;849.1) 834.1 (785;885.2) 3.9 (9.9;-1.8) 642.2 (602.5;682.4) 648.9 (611;692.3) 1 (7.6;-4.8)
Goiás 712.2 (676.2;749.8) 731.3 (695.6;769.8) 2.7 (6.3;-1.3) 785 (744.4;829.9) 818.3 (772.2;869.3) 4.2 (10.6;-1.6) 640.6 (605.3;678.1) 641.7 (605.2;680.2) 0.2 (6;-5.5)
Maranhão 697.8 (662.7;735.1) 723.3 (686.3;761.1) 3.7 (8.2;0.2) 763.4 (720.7;810.6) 808.1 (761.7;855.2) 5.9 (13;0.7) 629.9 (594.6;666.9) 634.3 (598.3;671.6) 0.7 (6.9;-5.1)
Mato Grosso 718.2 (679.8;759.1) 741.6 (703.4;783) 3.3 (7.8;-1.2) 803.2 (754.4;856.1) 835.7 (789.3;887) 4 (10.1;-2.3) 642.9 (604;683.2) 650.5 (613.5;691.9) 1.2 (7.8;-4.9)
Mato Grosso do Sul 721.6 (682.2;762.9) 743.9 (707;786.6) 3.1 (7.1;-1) 801.8 (755.3;852.3) 836.1 (787.1;887.1) 4.3 (10.1;-1.4) 644.1 (604.1;685.3) 649.6 (613.7;693) 0.9 (7.1;-5.4)
Minas Gerais 724.4 (685;763.2) 746.6 (707;789.2) 3.1 (7.3;-0.8) 801.8 (752.5;848.6) 838 (791;889.4) 4.5 (10.1;-0.9) 643.6 (607;682.9) 651.3 (611.4;692.4) 1.2 (7.5;-5.5)
Pará 697.5 (659.7;733.9) 725.6 (687.9;766.2) 4 (7.8;0.4) 764.8 (718.8;811.3) 812.4 (764.3;861.1) 6.2 (13.1;0.3) 632 (596.3;670.2) 638.8 (601.1;676.1) 1.1 (6.7;-4.3)
Paraíba 722.5 (685.6;764.3) 745.9 (708;784.5) 3.2 (7.7;-0.7) 798.1 (752.6;848.6) 835.4 (788.5;885.1) 4.7 (11.6;-0.4) 637.5 (601.1;676.8) 648.6 (608.5;687.3) 1.7 (7.7;-3.9)
Paraná 726.1 (688.1;765.9) 749 (710.7;789) 3.2 (7.1;-0.8) 805.2 (761.2;853.1) 839.6 (789.9;892.7) 4.3 (10.3;-1.9) 645.8 (608.5;686.5) 653.7 (616.8;695.5) 1.2 (7;-4.8)
Pernambuco 698 (662.3;735) 725.4 (688.9;764.7) 3.9 (8.4;0.2) 765.2 (722.9;809.1) 807.6 (762;853.5) 5.6 (11.7;0) 622.3 (583.7;661.9) 634.3 (597.7;673.3) 1.9 (7.9;-3.3)
Piauí 695.7 (660.7;733) 728.9 (691.5;769.8) 4.8 (9.2;0.6) 760.9 (719.6;805.7) 812.4 (765.2;862.7) 6.8 (13.6;0.6) 625.6 (591.2;663.8) 639.7 (605.1;678.2) 2.3 (8.4;-3.5)
Rio de Janeiro 724 (687.3;761.5) 744.2 (706;786.6) 2.8 (6.7;-1.2) 798.6 (752.6;845.5) 832.1 (784.7;881) 4.2 (10.3;-2.1) 641 (605.8;678.1) 647.6 (609.7;690.4) 1 (7.3;-5.1)
Rio Grande do Norte 728.2 (691.7;770.1) 748.7 (710;789.2) 2.8 (7;-1.5) 807.1 (762.2;859.6) 840.3 (789.7;889.8) 4.1 (10.7;-2.5) 641.6 (603;682.9) 650.7 (611.7;691.2) 1.4 (7.9;-4.9)
Rio Grande do Sul 736 (696.2;776.3) 751.4 (711.4;791) 2.1 (6.2;-2.1) 814.7 (768.3;865.5) 842.7 (791.8;893.9) 3.4 (10.5;-2.6) 652.1 (609.9;690.5) 654.9 (615.9;693.4) 0.4 (6.3;-5.9)
Rondônia 715.4 (677.7;753.8) 739.2 (700.9;778.6) 3.3 (7.5;-0.1) 801.5 (755.8;853.8) 833 (785.4;884.3) 3.9 (10.5;-2) 640.7 (601.2;677.1) 647.5 (608.9;685.7) 1.1 (6.9;-4.3)
Roraima 708.8 (672.4;748.4) 737.8 (697.7;780.1) 4.1 (8.6;0) 798.3 (751.2;847.9) 831.4 (782.3;881.2) 4.1 (11;-2.3) 641.5 (604.8;680.2) 648.6 (610.6;689.5) 1.1 (7.1;-4.4)
Santa Catarina 738 (700.8;775.2) 756.4 (714.4;799.4) 2.5 (6.3;-0.9) 819.4 (771.8;869.5) 849.2 (797.9;900.5) 3.6 (9.8;-1.9) 655.2 (616;694.9) 661.3 (623.1;702.9) 0.9 (7.2;-4.3)
São Paulo 733.8 (694.9;775.3) 753.5 (713;794.1) 2.7 (6.6;-1.4) 813.1 (765.5;864.3) 844.5 (793.5;897.4) 3.9 (9.9;-1.9) 650.5 (611.9;690) 656.5 (615.6;697.4) 0.9 (7.4;-5)
Sergipe 709.6 (673;747.4) 733.5 (695.4;772.8) 3.4 (7.9;-1.2) 776.6 (733.6;822) 816 (769.1;870.3) 5.1 (11.1;-0.7) 636.9 (599.1;673.6) 642.7 (606.2;680.8) 0.9 (7.8;-5.4)
Tocantins 694.9 (660.5;733.7) 726.2 (688.6;767.1) 4.5 (8.4;0.7) 763.1 (720.4;810.2) 813.3 (767.8;861.3) 6.6 (12.5;1.4) 631.9 (596.2;668.5) 640.4 (600.7;679.6) 1.4 (6.8;-3.8)
B.2.5 - Non-rheumatic valvular heart disease
Acre 205.7 (195;216.6) 224.6 (212.8;236.5) 9.2 (15.3;3.5) 204.6 (191.3;218.3) 222.1 (207.8;236) 8.6 (17.7;0.3) 206.4 (192.7;219.8) 227.3 (212.2;242.4) 10.2 (18.6;2.2)
Alagoas 196.1 (185.1;207.4) 217.3 (205.8;228.9) 10.8 (17.5;4.6) 196.3 (183;210.4) 215 (200.9;228.9) 9.5 (18.8;1.4) 196.1 (181.9;211.2) 220.6 (205.6;236.6) 12.5 (22.1;3.6)
Amapá 215 (204.2;227) 232 (218.9;243.8) 7.9 (13.9;2.2) 213.9 (200.3;228.3) 228.1 (213.2;242.2) 6.7 (15.1;-1.6) 216.6 (202.3;232) 236.6 (220.5;252.2) 9.3 (18.6;1)
Amazonas 212.8 (201.5;223.1) 231.9 (219.4;244.2) 9 (15.1;3) 210.1 (196.7;223.6) 227.8 (212.6;242.9) 8.4 (17.1;0.2) 215.8 (201.1;229.7) 236.5 (219.9;252.6) 9.6 (18.2;1.5)
Bahia 203.9 (192.4;214.8) 221.9 (210;234.1) 8.9 (15.5;2.6) 202.4 (187.9;216.5) 219 (204.8;234.2) 8.2 (17.9;-0.8) 205.7 (191.5;219.8) 226 (211;241.8) 9.9 (18.8;1.7)
Brazil 216.2 (207.9;224.6) 233.9 (224.6;243.2) 8.2 (10.5;6.2) 214.2 (205.6;222.8) 231 (221.7;240.5) 7.8 (10.8;5.1) 218.7 (209.3;228.2) 238.1 (227.4;249.1) 8.9 (12.1;5.8)
Ceará 199.9 (188.5;211.5) 220.7 (208.5;232.9) 10.4 (17.2;4.2) 200 (187;213.9) 219.1 (205;233.9) 9.5 (19.2;1.3) 199.9 (184.7;215.4) 223.3 (207.3;237.7) 11.7 (21.3;2.9)
Distrito Federal 240.9 (227.1;253.5) 258.6 (245.2;271.6) 7.3 (13.1;1.7) 237.1 (221.3;252.1) 254.1 (237.7;270.7) 7.2 (15.7;-0.9) 245.8 (228.3;263.5) 265.5 (248;282.5) 8 (16.6;0.2)
Espírito Santo 220.3 (209.2;233) 236.8 (225.2;250) 7.5 (13.5;1.8) 218 (204.7;233) 233.5 (218.6;248.8) 7.1 (16.2;-1.2) 222.9 (209.1;238.9) 241.2 (225.8;257.4) 8.2 (16.8;0)
Goiás 212.7 (201.9;224.4) 229.7 (217.4;242) 8 (14.4;2.2) 212.7 (197.9;227.3) 227.2 (212.7;241.9) 6.8 (15.8;-1.3) 212.6 (198.6;227.5) 232.8 (216.2;248.7) 9.5 (18.5;1.1)
Maranhão 195.1 (184.6;205.8) 214.5 (202.2;227.9) 9.9 (16.4;3.9) 194.9 (182.5;208.7) 211.6 (197;225.9) 8.6 (17.4;0.3) 195.7 (181.7;209) 218.1 (203.1;233.7) 11.4 (21.2;2.3)
Mato Grosso 214.7 (203.5;226) 233.1 (220.6;245.6) 8.6 (15.4;2.5) 212.6 (198.1;226.8) 229.7 (215;245) 8.1 (17.4;-0.4) 216.3 (202.2;231.3) 236.5 (220.9;252.5) 9.3 (18.2;1.2)
Mato Grosso do Sul 216.7 (204.9;228.2) 233.5 (220.7;246) 7.8 (14.1;1.8) 214 (199.5;227.8) 229.7 (214.8;244.4) 7.4 (16.6;-0.6) 219.1 (203.9;233.4) 238 (222.4;255.5) 8.6 (17.5;0.1)
Minas Gerais 214.7 (203.5;226.9) 232 (220.1;244.2) 8 (14.2;2.1) 212.3 (199.1;227) 228.8 (214.3;243.2) 7.8 (16.3;-0.6) 217.9 (203.8;233.2) 236.2 (220.7;253.4) 8.4 (17;0.1)
Pará 201.6 (191;213) 221.3 (209.1;233.7) 9.8 (16;3.7) 200.7 (187.3;215.1) 218 (202.3;232.6) 8.7 (17.9;0.4) 202.9 (189.7;217.7) 225 (210.3;240.2) 10.9 (19.4;2.5)
Paraíba 199.4 (188.2;210.9) 219.5 (207.7;231.3) 10.1 (16.1;4) 197.7 (183.8;211.4) 217.2 (203.3;232) 9.8 (19.2;1.6) 201.2 (186.2;216.6) 222.9 (207;238.5) 10.8 (19.7;2.8)
Paraná 223.8 (211.7;236.2) 239.7 (228;253) 7.1 (13.1;1.3) 220.7 (207.1;235.2) 236.4 (222;251.8) 7.1 (16.1;-0.8) 227.1 (212.7;243) 244.1 (228.7;261.2) 7.5 (15.9;-0.7)
Pernambuco 204.2 (193.4;215.1) 223 (209.8;235.2) 9.2 (15.5;3.2) 203.7 (190.6;217.2) 221.1 (206.2;236.5) 8.5 (17.1;0.3) 205 (191.8;220.3) 226.3 (210.5;241.5) 10.4 (20.1;2.5)
Piauí 197.2 (186.5;208) 215.7 (204.1;228) 9.4 (16;3) 196.4 (183.2;208.8) 213.2 (199.2;227.8) 8.5 (16.9;0.4) 198.3 (184;212.8) 219 (204.6;235.2) 10.5 (20.3;1.6)
Rio de Janeiro 220.5 (209.3;232.1) 238.3 (224.6;250.7) 8.1 (14.4;2) 219 (204.4;233.4) 235.5 (219.4;250.4) 7.5 (16.6;-1.2) 223.5 (209.1;239) 243.1 (227.6;261) 8.8 (17.2;0.8)
Rio Grande do Norte 203.5 (193;214.7) 223.7 (211.6;235.9) 9.9 (16.1;3.6) 202.9 (188.7;216.4) 221.3 (206;235.7) 9.1 (18.1;0.7) 204.2 (190.3;218.4) 227.3 (212.4;243.5) 11.3 (20.2;3.2)
Rio Grande do Sul 227.5 (215.2;239.3) 241.9 (229.2;254.8) 6.3 (12.6;0.6) 224.4 (208.7;239.5) 237.8 (223;253.3) 6 (14.5;-2) 232.2 (216.5;247.3) 247.8 (231.7;265.4) 6.7 (15.7;-0.9)
Rondônia 209.2 (197.9;220.7) 227.1 (215;239.8) 8.6 (15.4;2.6) 205 (190.9;219) 223.9 (208.6;239.1) 9.2 (18.7;0.9) 212.3 (197.7;226.5) 230.2 (214.3;246.5) 8.4 (17.7;0.1)
Roraima 212 (200;223.9) 229.5 (217;242.8) 8.3 (14.4;2.4) 212.3 (198.8;227.8) 226.9 (211.8;242.6) 6.9 (15.5;-1.2) 211.9 (197.6;226.9) 231.9 (216.3;247.8) 9.4 (18.6;1.3)
Santa Catarina 228.3 (215.6;240.1) 242.5 (229.2;256.5) 6.2 (11.8;0.5) 225.6 (210.8;239.8) 238.7 (223.3;255.3) 5.8 (14.4;-1.9) 231.7 (216.6;248.1) 247.8 (230.8;264.6) 6.9 (15.7;-1.1)
São Paulo 229.8 (217.3;241.6) 244.9 (232.6;258.6) 6.6 (12.6;1.1) 226.1 (211;239.7) 241.7 (225.7;257.7) 6.9 (15.2;-0.9) 234.9 (219.1;251.4) 250 (232.9;267.1) 6.4 (15.1;-1.3)
Sergipe 201.1 (190.2;212.8) 223.1 (210.6;235.4) 11 (17.7;5) 201.1 (187.9;215.2) 220.7 (205.4;235.6) 9.7 (18.3;1.2) 201.2 (187.4;215.7) 226.7 (211.9;242.3) 12.6 (21.7;3.9)
Tocantins 206.2 (194.6;217) 223.1 (210.7;236) 8.2 (14.6;2) 204.3 (190.8;218.4) 219.4 (203.7;234.3) 7.4 (16.5;-1.2) 207.8 (193.3;221.3) 226.6 (210.1;242.4) 9 (17.8;1.2)
B.2.5.1 - Non-rheumatic calcific aortic valve disease
Acre 49.8 (44.5;55.8) 61.3 (54.1;68.9) 23.1 (31.2;16) 40.7 (36;45.6) 51.9 (45.5;58.4) 27.5 (38.3;18.7) 57.6 (51.3;64.6) 71.1 (62.4;80.2) 23.4 (34.1;14)
Alagoas 43.4 (38.7;49.1) 58.1 (51;66.2) 34 (42.5;26.3) 36.7 (32.4;41.7) 50 (44.1;57.1) 36.2 (46.5;26.7) 50.9 (45;57.6) 68.2 (59.6;77.9) 34 (46.2;23.8)
Amapá 54.6 (48.7;61.6) 65.6 (58.2;74.2) 20 (27.4;13.1) 45.3 (40.3;51.1) 54.7 (48.1;61.5) 20.7 (30.6;12.2) 64.6 (57.1;72.7) 77.6 (68.8;87.9) 20.2 (30.1;11.4)
Amazonas 51.3 (45.9;58) 63.9 (56.7;72) 24.5 (32.1;17.2) 41 (36.3;46.4) 53.1 (46.5;60.3) 29.4 (39.9;20.2) 62 (55.2;70.2) 75.4 (66.5;85.8) 21.7 (31.1;12.9)
Bahia 48.3 (43.1;54.2) 59 (52.4;67) 22.4 (30.1;15.3) 40.4 (35.8;45.5) 50.1 (43.8;57) 24.2 (35;16) 57.3 (50.9;65.1) 70 (61.5;79.3) 22.2 (31.7;13.3)
Brazil 53.5 (48.1;59.9) 64.4 (57.2;72.5) 20.4 (25.4;16) 44.2 (39.8;49.6) 54.9 (48.7;62) 24.2 (29.7;19.1) 64.3 (57.5;72) 76.2 (67.3;85.6) 18.5 (24.2;13.7)
Ceará 46 (40.9;52.2) 59.6 (52.5;67.7) 29.4 (37;22.2) 38.7 (33.9;44.3) 51 (44.8;58) 31.6 (40.6;22.4) 54.3 (47.8;62) 70.2 (61;80.2) 29.3 (39.1;19.6)
Distrito Federal 63.1 (56.5;70.5) 73.3 (64.7;82.1) 16.2 (23.5;9.5) 51.3 (45.7;58) 62.5 (55;70.6) 21.8 (32;12.6) 77.4 (68.7;87.1) 88.2 (77.6;99.8) 13.9 (22.5;5.8)
Espírito Santo 55.5 (49.5;61.9) 64.9 (57.5;73.3) 17.1 (23.9;10.8) 45.5 (40.4;51.3) 55 (48.4;62.4) 20.7 (29.8;12.5) 66.3 (58.9;74.6) 76.9 (67.6;86.9) 16 (24.5;7.8)
Goiás 52.9 (46.9;59.3) 62.4 (55;70.1) 18.1 (25.3;11.4) 44.8 (39.7;50.6) 52.9 (46.6;59.4) 18.2 (27.4;10.7) 60.5 (53.5;67.8) 73.1 (64.3;83) 20.8 (30.4;11.5)
Maranhão 43.9 (38.9;49.6) 57 (50.1;64.9) 29.9 (37.2;22.8) 36.9 (32.3;42.1) 48.5 (42.5;55.5) 31.3 (41.2;22.2) 51.8 (45.9;58.7) 66.8 (58.8;76.5) 29 (38.5;19.4)
Mato Grosso 52.4 (46.7;58.7) 64.1 (56.6;72.4) 22.4 (30;15.2) 41.8 (37.4;47.1) 53.8 (47.6;61) 28.6 (38.8;19.9) 61.3 (54.3;68.9) 74.3 (65.2;84.3) 21.2 (31.3;11.9)
Mato Grosso do Sul 55.3 (49.5;62) 65.6 (58.3;74.3) 18.7 (26.3;11.8) 45.4 (40.4;51.1) 55.4 (48.6;62.5) 21.9 (31;13.7) 64.5 (57.2;72.6) 77 (67.9;87.4) 19.4 (29.9;9.9)
Minas Gerais 51.9 (46.5;58.3) 63.1 (55.9;71.4) 21.6 (29.2;14.7) 42.7 (38.1;48.1) 53.5 (47.2;60.6) 25.4 (34.1;18) 62.7 (55.9;70.9) 74.7 (65.7;84.8) 19 (28.9;9.5)
Pará 46.9 (41.7;53) 60 (53.2;67.4) 27.8 (35.1;20.3) 38.8 (34.1;44) 50.2 (43.9;57.3) 29.4 (39.6;20.8) 55.7 (49.5;63.2) 70.4 (62;79.3) 26.4 (35.8;16.2)
Paraíba 46.3 (40.4;52.6) 58.8 (51.8;66.9) 26.9 (33.9;21) 38.2 (33.8;43.5) 50.2 (43.8;57.5) 31.2 (41.8;21.7) 55.5 (47.5;63.8) 69.8 (60.8;79.5) 25.7 (36.4;16.8)
Paraná 58.8 (52.7;66.1) 67.9 (59.9;76.5) 15.5 (23.5;8.6) 48.4 (42.9;54.4) 57.7 (50.5;65.4) 19.4 (28.9;10.9) 69.6 (62.3;78.2) 80.1 (70.3;90.4) 15.1 (25.8;6.7)
Pernambuco 47 (41.9;53.1) 60.2 (53;68) 28.2 (35.5;20.8) 39.2 (34.7;44.1) 51.9 (45.4;58.5) 32.2 (42.2;22.9) 56.5 (50.1;63.9) 71.4 (62.5;80.8) 26.5 (36.8;16.7)
Piauí 45.8 (40.5;51.5) 57.8 (51;66) 26.2 (34.8;18.5) 38.1 (33.2;43.4) 49.1 (43;56.1) 28.9 (38.8;20.1) 54.5 (48.4;61.4) 68.2 (59.9;78) 25.1 (36.2;15.5)
Rio de Janeiro 53.1 (47.6;59.6) 64.6 (57.1;72.9) 21.6 (29;14.8) 44.3 (39.5;49.6) 55.5 (48.9;62.9) 25.4 (34.9;16.2) 65.2 (57.8;73.7) 77.1 (67.7;87.3) 18.2 (29;8.7)
Rio Grande do Norte 47.8 (42.7;53.9) 61.4 (54.2;69.4) 28.3 (35.9;21.6) 39.6 (35.1;45) 52.3 (45.9;59.4) 31.9 (42.5;23) 57 (50.5;64.3) 72.8 (64.1;82.2) 27.7 (36.8;18.8)
Rio Grande do Sul 60.4 (54;67.4) 68.6 (60.3;77.2) 13.5 (21.4;6.7) 50.2 (44.6;56.4) 58.5 (51.3;66.5) 16.6 (26.8;7.5) 73.6 (65.3;82.2) 81.6 (71.7;92.5) 10.8 (20.8;2.1)
Rondônia 51.4 (45.7;57.8) 62.6 (55.5;70.1) 21.9 (29.6;14.9) 40 (35.4;45.4) 52.2 (45.7;59) 30.4 (40.4;20.9) 60.4 (53.7;67.8) 72.8 (64.3;81.9) 20.4 (30.1;11.2)
Roraima 53.5 (47.5;59.9) 63.7 (56.3;71.7) 19.1 (26.6;12.4) 45.4 (40.2;51.2) 54.4 (47.7;61.5) 19.7 (29.3;10.8) 59.7 (52.8;67.2) 72.3 (63.9;81.6) 21.2 (30.9;12.1)
Santa Catarina 61.1 (54.5;68.6) 69 (60.8;77.5) 13.1 (20.6;6.4) 50.9 (44.9;57.7) 58.8 (51.3;66.5) 15.5 (26.3;6.6) 72.7 (64.4;82.2) 81.5 (71.7;92) 12.2 (21.6;4.5)
São Paulo 60.2 (53.8;67.5) 68.8 (60.9;77.4) 14.3 (22.1;7.9) 49.1 (43.6;55.2) 58.7 (51.8;66.3) 19.7 (28.7;11) 73.7 (65;83.2) 82 (72.5;92.5) 11.2 (20.4;3.3)
Sergipe 44.7 (39.3;50.9) 59.2 (52.1;67.4) 32.5 (40;25.8) 37.5 (32.7;43) 50.6 (44.6;58.2) 34.8 (45.1;26.2) 53.1 (46.5;60.8) 70.1 (61.2;80.1) 32 (42.5;23.5)
Tocantins 49.8 (44.3;56) 61.4 (54.7;69.2) 23.3 (30.7;16.4) 40.6 (35.6;46.1) 51.2 (45.4;57.8) 26.2 (36.3;18) 58.2 (51.7;65.8) 71.2 (62.5;80.6) 22.2 (31.6;13.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.236 – Death and DALY rates per 100 000 and percent change of rates, by age and cause of death, in Brazil, 1990 and 2017
Cause of death and age group 1990 2017 Percent change (95% UI) 1990 2017 Percent change (95% UI)
Death (age-standardized) DALY (age-standardized)
B.2.1- Rheumatic heart disease
15-49 years 1.4 (1.3;1.4) 0.6 (0.6;0.6) -56.5 (-59.3;-52.9) 121.8 (104.9;143.4) 79.3 (62.4;101.4) -34.9 (-41.7;-28.1)
50-69 years 4.8 (4.6;5) 2.6 (2.5;2.8) -45.1 (-48.2;-41.2) 179.7 (164.5;198.4) 117.5 (102.8;136.9) -34.6 (-39;-30.1)
5-14 years 0.7 (0.6;0.8) 0.2 (0.2;0.2) -69.8 (-72.4;-65.6) 71.3 (61.1;80.6) 34.7 (28;43.5) -51.4 (-58;-43.6)
70+ years 11.4 (11;11.7) 7.5 (7.2;7.8) -33.9 (-37.1;-30.3) 174.2 (165.3;184.2) 113.8 (105.3;123.7) -34.7 (-38.1;-31.1)
Age-standardized 2.4 (2.3;2.5) 1.2 (1.1;1.2) -50.3 (-52.4;-47.5) 118.9 (106.1;134.7) 71.2 (59;87.2) -40.1 (-45.4;-34.6)
All ages 1.8 (1.7;1.8) 1.3 (1.2;1.3) -28.5 (-31.7;-24.3) 109.3 (97;124.6) 76.5 (63.3;93.7) -30 (-36.3;-23.9)
Under 5 0.6 (0.5;0.8) 0.1 (0.1;0.1) -82.5 (-87.9;-74.4) 52.8 (40.6;68.7) 11 (9.3;13.1) -79.1 (-85.3;-70.4)
B.2.5- Non-rheumatic valvular heart disease
15-49 years 0.5 (0.4;0.5) 0.4 (0.4;0.5) -23.5 (-30;1.2) 27 (21.7;28.8) 20 (18.5;24.3) -26.1 (-32.2;-1.6)
50-69 years 3.5 (2.9;3.7) 3.3 (2.6;3.4) -6.9 (-14.5;-1.6) 104.1 (86.8;111.4) 94.9 (78.6;101.4) -8.9 (-15.4;-3.8)
70+ years 13.1 (11.7;15.1) 19 (14;20.2) 45.6 (10;57.1) 201 (179.1;230.6) 254.6 (194.7;280) 26.7 (1.3;35.5)
Age-standardized 1.7 (1.5;1.9) 1.8 (1.4;1.9) 7.1 (-9.1;13) 42.9 (36.6;45.8) 39.4 (33.2;42.2) -8 (-15.6;-4)
All ages 1 (0.9;1.1) 1.9 (1.5;2) 87.5 (63.5;96.9) 30.5 (25.9;32.5) 42.3 (35.8;45.3) 38.8 (27.5;47.2)
B.2.5.1- Non-rheumatic calcific aortic valve disease
15-49 years 0.3 (0.2;0.3) 0.2 (0.2;0.3) -18.6 (-30.8;37.4) 14.3 (9.8;15.8) 11.3 (10.2;15.3) -21.2 (-32.9;33.7)
50-69 years 2.2 (1.6;2.4) 2.1 (1.9;2.5) -4.1 (-14.1;25.2) 64.6 (47.3;70.3) 60.6 (54.6;71.2) -6.2 (-16;23.2)
70+ years 9.1 (7.5;9.9) 14.4 (11.1;15.6) 57.4 (35.7;73.3) 127.3 (102.9;138.2) 173.9 (136.8;188.7) 36.6 (22.9;52.4)
Age-standardized 1.1 (0.9;1.2) 1.3 (1.1;1.4) 16.3 (9.6;34) 25.4 (19.1;27.4) 25.1 (22.1;28.7) -1.2 (-9.1;24.2)
All ages 0.6 (0.5;0.7) 1.3 (1.1;1.5) 108.3 (94.8;146.2) 17.7 (13;19.2) 26.9 (23.9;31) 51.5 (38.3;94.9)
B.2.5.2- Non-rheumatic degenerative mitral valve disease
15-49 years 0.2 (0.2;0.3) 0.2 (0.1;0.2) -31.4 (-49.9;-22.8) 11.8 (9.8;14.5) 7.8 (5.6;8.7) -33.9 (-51.3;-25.7)
50-69 years 1.2 (1;1.6) 1 (0.6;1.2) -12.7 (-47.4;3) 37.6 (32.6;49.1) 32.4 (19.6;36.8) -14 (-44;-0.2)
70+ years 3.7 (3.3;5.3) 4.3 (2.2;5.2) 17.7 (-42.1;39.2) 70.5 (57.7;92.6) 77.4 (50.2;94.7) 9.8 (-31.8;24.3)
Age-standardized 0.5 (0.5;0.7) 0.5 (0.3;0.5) -10.8 (-47.6;2.4) 16.4 (14.4;20.8) 13.4 (8.8;15.2) -18.7 (-43.4;-9.3)
All ages 0.3 (0.3;0.5) 0.5 (0.3;0.6) 50.1 (-9.7;71.8) 12 (10.4;15.1) 14.4 (9.5;16.4) 20.3 (-15.9;35.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation .236

Overview

Noncommunicable diseases comprise the world’s leading group of causes of death, responsible for premature deaths, loss of quality of life, and adverse economic and social impacts. The NCDs are responsible for approximately 70% of global deaths, equivalent to more than 38 million deaths annually, significantly exceeding deaths from external causes and infectious diseases.28 -31Nearly 45% of all deaths from NCDs worldwide, over 17 million, result from CVDs. The same happens in Brazil, where 72% of deaths result from NCDs, 30% being due to CVDs, 16% to neoplasms, and 6% to respiratory diseases.32 - 34

The definition of CVD may vary according to the study, from including all diseases listed in ICD-10 Chapter IX to just grouping together the 3 main causes (IHD, stroke, and HF). For the GBD, the definition of total CVDs comprises 10 causes: rheumatic heart disease, IHD, cerebrovascular disease, hypertensive heart disease, cardiomyopathy, myocarditis, atrial fibrillation and flutter, aortic aneurysm, peripheral vascular disease, and endocarditis.35

Cardiovascular diseases were the number 1 cause of death in Brazil in 1990 and 2017 (Chart 1-1). According to the GBD Study 2017 estimates, of the CVDs, IHD was the leading cause of death in the country, followed by stroke, in 1990 and 2017 (Chart 1-2). In fact, in 2017, IHD was the leading cause of death in all Brazilian FUs, although, in 1990, stroke was still the number 1 cause of death in the states of Alagoas and Sergipe (Charts 1-3 and 1-4).

 Prevalence

Gonçalves et al. published in 2019 a cross-sectional study that analyzed information from the Brazilian National Health Survey conducted in 2013 on a sample of 60 202 adults aged over 18 years, stratified by sex and 6 age groups, using a hierarchical binary logistic regression model. The self-reported diagnosis of heart disease in Brazil was 4.2% (95% CI: 4.0 – 4.3 ) and was associated with female sex (OR = 1.1; 95% CI: 1.1 – 1.1), individuals 65 years and older, hypertension (OR = 2.4; 95% CI: 2.2 – 2.7), increased cholesterol (OR = 1.6; 95% CI: 1.5 – 1.8), overweight (OR = 1.5; 95% CI: 1.4 – 1.8) or obesity (OR = 2.0; 95% CI: 1.7 – 2.2), sedentary behavior (OR = 1.5; 95% CI: 1.02 – 2.1), and tobacco use (OR = 1.2; 95% CI: 1.03 – 1.3).36

In the ELSA-Brasil, a cohort study that included 15 105 civil servants from 6 universities or research institutes (54% women, 35-74 years, with baseline assessment between 2008 and 2010), the self-reported prevalence was as follows: coronary heart disease, 4.7% (men=5.7%, women=4.0%); HF, 1.5% (men=1.9%, women=1.5%); stroke, 1.3% for both sexes; rheumatic fever, 2.9% (men=2.2%, women=3.4%); and Chagas disease, 0.4%, for both sexes.37

The prevalence of CVDs increases significantly with age. In a longitudinal study in the elderly aged over 60 years, from the state of São Paulo, in 2000, 2006 and 2010, the prevalence of CVDs was defined as the individual’s positive response to the question: “Has a doctor or nurse ever told you that you have had a heart attack, coronary heart disease, angina, congestive disease, or other heart problems?” The CVD prevalence was 17.9%, 22.2% and 22.9% for 2000, 2006 and 2010, respectively. The presence of CVD was associated with older age, smoking history, presence of diabetes, and hypertension.38

According to the GBD Study 2017, the age-standardized prevalence of CVD in Brazil, in 1990, was 6290 (95% UI, 6048-6549) per 100 000 inhabitants, and, in 2017, 6025 (95% UI, 5786-6275) per 100 000 inhabitants, affecting 6% of the population aged ≥ 20 years, with a slight reduction of 4.2% (95% UI, -3.2 to -5.1) from 1990 to 2017. Males had a higher age-standardized prevalence than females from 1990 to 2017 (Charts 1-5 and 1-6), although the percent of change was greater for males -5.5 (-4.2; -6.7) than for females -2.4 (-1.3; -3.4) in that period (Chart 1-6). Considering the total number in 2017, 13 702 303 individuals (95% UI, 13 110 682-14 281 540) had prevalent CVD in Brazil, 6 784 523 men (95% UI, 6 517 523-7 167 162) and 6 917 779 women (6 616 359-7 220 572) (Table 1-1).39

The GBD Study 2017 reveals that the age-standardized prevalence of CVD decreased unevenly in the FUs, with a major reduction in the Southeastern and Southern regions, particularly in the states of Espírito Santo, Rio de Janeiro, Santa Catarina, and Rio Grande do Sul (Table 1-1), which are among the most developed states of the country.

 Incidence

According to the GBD Study 2017, the age-standardized incidence rate of CVD in Brazil in 2017 was 687.5 (95% UI, 663.4-712.4) cases per 100 000 inhabitants, lower than in 1990, when there were 755.6 (95% UI, 731.6-783) cases per 100 000 inhabitants (Table 1-2). Of note, in the whole time series, the GBD incidence rates for total CVDs may be underestimated due to the entrance and exclusion criteria of the models for each specific disease included. The incidence of total CVDs is the aggregate of the incidences of all diseases contained within.39

The FU with the highest incidence rate in 2017 was the state of Rio de Janeiro, with 709 (95% UI, 683.9-734.5)cases per 100 000 inhabitants, and the FU with the lowest incidence rate in 2017 was the state of Rio Grande do Sul, with 646.6 (95% UI, 621.9-674.4) cases per 100 000 inhabitants (Table 1-2).

 Mortality

In Brazil, Mansur and Favarato have shown that the CVD age-standardized mortality rate has declined significantly in recent decades. A 2016 study analyzed CVD mortality rates for the age of 30 years and older, by sex, per 100 000 inhabitants. The annual variations in cardiovascular mortality for the periods 1980-2006 and 2007-2012 were, respectively: for both sexes: -1.5% and -0.8%; for men: -1.4% and -0.6%; for women: -1.7% and -1.0%.40

Baptista et al. have investigated how age composition and age-specific mortality rates are related to the observed difference in deaths from CVD in the adult population, by sex, in Brazilian microregions from 1996 to 2015. They have suggested, after correcting for underreporting of death counts, that there is a decline in the rates of death from CVD over the period studied. However, the main driver of the change in mortality rates was heterogeneous across Brazilian microregions. In general, in the most socioeconomically developed areas, the age structure was more importantly related to the mortality rates, with older populations dying from CVD. Interestingly, there were differences in the main drivers of CVD mortality even within the Brazilian FUs.41

Data from the GBD Study 2017 reveal that, although mortality rates from CVD in Brazil have significantly decreased over the past few years, the total number of deaths due to CVD has increased, probably as a result of population growth and aging. There were 266 958 (95% UI, 264 385-269 671) and 388 268 (95% UI, 383 815-392 698) deaths from CVD in the country in 1990 and 2017, respectively. The age-standardized mortality rate per 100 000 inhabitants was 341.8 (95% UI, 338.7-345.2) in 1990, and 178.0 (95% UI, 175.9-180) in 2017, decreasing -47.9 (95% UI, -48.5 to -47.2) in the period (Chart 1-7). Although age-standardized mortality rates were higher for men throughout the whole period, the percent decrease was similar for both sexes, and the proportional mortality due to CVD was higher for women, exceeding 30% throughout the entire period, while that for men remained always slightly over 25% (Chart 1-8).

Table 1-3 shows the number of deaths, the age-standardized mortality rate per 100 000 inhabitants, and percent change due to CVD, by FU, in Brazil, in 1990-2017. The FUs with the highest percentages of reduction observed between 1990 and 2017 were the states of Espírito Santo, Paraná, Minas Gerais, Santa Catarina, Rio de Janeiro, São Paulo, and Rio Grande do Sul, in that order.

Chart 1-9 shows the geographical distribution of mortality rates per 100 000 inhabitants, standardized by age in the Brazilian FUs, for both sexes, in 2000 and 2017, according to the SIM, and using the IBGE population, the redistribution of ill-defined causes and the correction for underreporting according to the GBD 2017 coefficients. There was a decrease in the standardized mortality rates for both sexes, except for the males from the states of Maranhão and Roraima. Malta et al. have compared a historical series of CVD mortality rates in Brazil using SIM database with and without correction (crude data) and the GBD 2017 estimates between 2000 and 2017. The authors have pointed out that the increase in the age-standardized crude CVD mortality rates from SIM observed in 2017 as compared to 2010 in most Northern and Northeastern FUs was in fact due to improvements in death registration and in the definition of underlying causes of death in recent years. When SIM corrected data or the GBD 2017 estimates were used, the trends from 2010 to 2017 were similar across all Brazilian FUs.42

Brant et al. , analyzing GBD 2015 data, have observed a decrease in age-standardized CVD mortality rate from 429.5 (1990) to 256.0 (2015) per 100 000 inhabitants (40.4%), with marked differences across the FUs. That decrease was more pronounced in the FUs of the Southeastern and Southern regions and the Distrito Federal, regions that concentrate the largest populations and income, and more modest in most Northern and Northeastern states. Importantly, Brant et al. have also emphasized that the annual reduction in CVD mortality rates in Brazil was lower in the final years of the series analyzed (1990-2015). When considering the 1990-2017 period, the GBD 2017 estimates confirm the same trend for males and females. Charts 1-10 and 1-11 show the decline in age-standardized CVD mortality rate from 1990 to 2017, revealing a reduction in the decline in the last 5 years of the series, when the rates achieved a plateau or even increased in some regions.35

Regarding the trend by age group, the largest reductions in the CVD mortality rates per 100 000, between 1990 and 2017, were observed in the ‘under-5’ age group [-65.4 (-71.2; -60)], followed by the ‘5-14 years’ age group [-48.3 (-52.5; -42.1)], the ‘50-69 years’ age group [-46.5 (-47.4; -45.6)], and lastly the ‘>70 years’ age group, revealing a shift in CVD mortality to older individuals.

The FHP coverage was associated with a reduction in hospitalizations and mortality from CVD that were included in the national ambulatory care-sensitive list in Brazil, and its effect increased according to the duration of the FHP implementation in the municipality. Rasella et al. have observed reductions in cerebrovascular disease and heart disease mortalities of 0.82 (95% CI: 0.79 - 0.86) and 0.79 (95% CI: 0.75 - 0.80), respectively, reaching 0.69 (95% CI: 0.66 - 0.73) and 0.64 (95% CI: 0.59 - 0.68), respectively, when the FHP coverage was consolidated during all 8 years studied.43

According to the SIM database, in 2017, CVD corresponded to 27.3% of total deaths, with the highest proportion in the Southeastern region and the lowest in the Northern region. Ischemic heart disease accounted for 32.1% of total deaths from CVD in Brazil, and stroke was responsible for 28.2% of those deaths. The highest proportion of IHD mortality occurred in the states of Mato Grosso do Sul, Pernambuco, and Espírito Santo, while the highest proportion of stroke deaths occurred in the states of Amazonas and Pará, and the Distrito Federal (Table 1-4).

The proportion of deaths due to CVD decreased for men (from 30.1% to 27.6%) and women (31.1% to 29.9%) from 2000-2002 to 2015-2017. Moreover, Lotufo has noted a constant excess of premature male deaths due to CVD during that period, with a male-to-female ratio of 2:1.44

The SDI is an estimate of the socioeconomic level and can be used to assess the association of socioeconomic level with CVD burden. Chart 1-12 shows the correlation between the percent change in age-standardized mortality rate 2017/1990 and the 2017 SDI. It reveals a correlation between the greater reduction in percent change in age-standardized mortality rates from CVD, between 1990 and 2017, and the higher 2017 SDI, suggesting that the decrease in mortality from CVD followed the improvement in the local socioeconomic conditions, as observed in other studies.32 , 45 - 47

Lotufo et al. have compared 3 different household income levels (high, middle, and low) with mortality rates due to CVD, in the city of São Paulo, from 1996 to 2010. The annual percent changes and 95% CI for men living in the high, middle- and low-income areas were -4.1 (95% CI: -4.5 to -3.8), -3.0 (95% CI: -3.5 to -2.6), and -2.5 (95% CI: -2.8 to -2.1), respectively. The trend rates for women living in the high-income areas were -4.4 (95% CI: -4.8 to -3.9), in 1996-2005, and -2.6 (95% CI: -3.8 to -1.4), in 2005-2010. The reduction in deaths due to CVD was most significant for men and women living in the wealthiest neighborhoods, with a declining gradient for risk of death that was greater for people living in the wealthiest areas as compared to people living in more deprived neighborhoods.48

An inverse association between the HDIm and the supplementary health coverage with mortality due to CVD was observed, suggesting a relationship between socioeconomic factors and CVD.45The HDIm increased between 2000 and 2010 in all FUs, being 0.7 or higher in half of the FUs. Supplementary health coverage increased in the country during the study period and was inversely associated with mortality due to CVD between 2004 and 2013.45

Soares et al. have observed a decrease in CVD mortality in the states of Rio de Janeiro, São Paulo, and Rio Grande do Sul that preceded improvement in the socioeconomic index. The evolution of GDP per capita, the decline in child mortality, the higher educational level (represented by the years of schooling of individuals over the age of 25 years), and the HDIm showed a high correlation with the reduction in the CVD mortality rate. A reduction in the mortality rates due to CVD, stroke, and IHD in the state of Rio de Janeiro in recent decades was preceded by an increase in the HDI, with significant numbers, because a 0.1 increment in the HDI correlated with the following reductions in the number of deaths per 100 000 inhabitants: 53.5 for DCV; 30.2 for stroke; and 10.0 for IHD.46 , 47

Baptista and Queiroz have investigated the relationship between crude CVD mortality rate and economic development over time and space, measured by GDP per capita, in Brazilian microregions, from 2001 to 2015. They have used the databases SIM-DATASUS and SIDRA (IBGE). The authors have observed a rapid decline in crude CVD mortality rates in the Southern and Southeastern microregions and a slower decline in the West-Central region. On the other hand, the Northern and Northeastern regions had an increase in crude CVD mortality rates over time, reflecting the later aging of the population in these Brazilian regions, and maybe lower access to healthcare and other socioeconomic factors.49

Silveira et al. , studying the effect of ambient temperature on cardiovascular mortality in 27 Brazilian cities, have observed a higher number of cardiovascular deaths associated with low and high temperatures in most of the Brazilian cities and the West-Central, Northern, Southern, and Southeastern regions. The overall RR for Brazil was 1.26 (95% CI: 1.17–1.35) for the 1stpercentile of temperature and 1.07 (95% CI: 1.01–1.13) for the 99thpercentile of temperature versus the 79thpercentile (27.7 °C), in which RR was the lowest.50

 Burden of Disease

Age-standardized DALY rates in Brazil were 6907 (95% UI, 6783-7039) per 100 000 inhabitants in 1990 and decreased to 3735 (95% UI, 3621-3849) per 100 000 inhabitants in 2017. The Southeastern region had the highest DALY rates, and the Northern and Northeastern regions, the lowest DALY rates (Chart 1-13). The trend in DALY rates between 1990 and 2017 in Brazil is similar to that reported for the age-standardized mortality rate: there was a heterogeneous reduction in all FUs, more expressive in those with better SDI (Chart 1-14 and Table 1-5).

 Healthcare Utilization and Cost (Refer to Tables 1-6 to 1-9)

In Brazil, CVDs have been responsible for the most substantial direct expenses with hospitalizations and indirect costs from reduced productivity due to time off work.51 -53The CVDs and their complications resulted in a US$ 4.18 billion expenditure in the Brazilian economy between 2006 and 2015.54 , 55

From the SIH/SUS database, we evaluated the number of hospitalizations from 2008 to 2018 and their costs based on the procedure codes related to the topics of the present document: stroke; chronic and acute coronary artery disease; cardiomyopathies (including Chagas disease) and HF; valvular diseases; and atrial fibrillation (Table 1-6). Procedures related to congenital heart disease, peripheral artery disease, endocarditis, and arrhythmias other than atrial fibrillation were not included.

Regarding clinical hospitalizations, HF led the admissions for CVDs with 2 862 739 hospitalizations (131 per 100 000 inhabitants), followed by cerebrovascular diseases with 2 042 195 hospitalizations (93 per 100 000 inhabitants), AMI and ACS with 1 461 388 hospitalizations (76 per 100 000 inhabitants), and atrial fibrillation with 321 866 hospitalizations (14.7 per 100 000 inhabitants) (Table 1-7).54The rates (per 100 000 inhabitants) of clinical admissions related to the evaluated procedure codes (324 to 293) showed a 10% decrease from 2008 to 2018, although the absolute numbers had only a slight reduction, from 615 433 in 2008 to 610 273 in 2018.

Of the 1 149 602 cardiovascular surgical/interventional procedures performed under the selected procedure codes (Table 1-6), coronary angioplasty accounted for 66% (755 557), followed by CABG surgery (21%, 244 105), and heart valve surgery (8%, 88 280). The angioplasty/CABG surgery ratio in 2008 was 2.2 and increased to 4.3 in 2018. During the period, there was an increase in the number of procedures related to myocardial infarction and ACS (70%). The surgical hospitalization rates per 100 000 inhabitants related to the evaluated procedure codes from 2008 to 2018 (42 to 59) showed a 29% increase, while the absolute numbers grew from 80 010 in 2008 to 122 890 in 2018 (Table 1-7).

The ELSI-Brasil, a study conducted in 2015–2016 with a nationally representative sample of the Brazilian population aged 50 years and over, has assessed the hospitalizations of 9389 participants (mean age, 63 years; 54% women) and has found that 10.2% of them had been hospitalized in the previous 12 months. The analysis of PAR for hospitalization revealed major contributions from stroke (PAR = 10.7%), CVD (PAR = 10.0%), and cancer (PAR = 8.9%).56 , 57

About half of the health costs in Brazil is funded by the government.54The CVDs account for the highest spending on hospitalizations in the SUS and create the most significant number of disability pensions and higher morbidity burden for patients.58 - 61 In 2015, the estimated direct public sector spending on hospitalizations and consultations for CVD in Brazil was over R$ 5 billion. It is estimated that the cost of temporary or permanent leave for CVD exceeded R$ 380 million.62

According to the AHA,62it is projected that 61% of direct health expenditures for CVD in the United States, between 2012 and 2030, will be attributed to hospital costs. In Brazil, in 2012, the SUS spent US$ 608.9 million in highly complex therapeutic procedures performed during hospitalizations for CVD, 34% of which were associated with coronary angioplasty and 25% were related to CABG surgery.58 , 63 Tables 1-8 and 1-9 show the amount of Reais paid for clinical and surgical procedures, respectively, in Brazil from 2008 to 2018 by the public health system. Stroke and HF were responsible for the highest cumulative values reimbursed for clinical procedures, which totalized R$ 8.4 billion. The total amount paid for surgical procedures was R$ 9.5 billion, and coronary angioplasty and CABG surgery represented the highest values paid.

From 2008 to 2018, the inflation rate in Brazil was 88% (ranging from 76% to 96%), and unadjusted values spent by the SUS increased in a similar proportion for most clinical conditions, doubling their expenses in the period, except for HF hospitalizations, in which total values reimbursed increased only 28%, and chronic IHD, in whose costs there was a 27% reduction. For surgical admissions, all related groups increased the values expended – most of them nearly doubled the values, except for mitral valvuloplasty, which showed a 53% decrease in the amount paid by the SUS in that decade (Tables 1-8 and 1-9). However, when values spent by the SUS are calculated in international dollars, the costs for most of the clinical hospitalization groups changed less than 10%, except for that for HF, whose expenses decreased by 35%, and for myocardial infarction and cardiomyopathies, whose expenses increased by 13% and 23%, respectively. Regarding surgical/interventional procedures, there was a reduction in costs in all groups reported, except for coronary angioplasties, whose costs increased by 20%, and cardiomyopathies, whose costs increased by 30% (Tables 1-8 and 1-9).

 Future Research

The SIM, implemented in 1975, is an essential tool for monitoring mortality statistics in Brazil, because the registration of all deaths is mandatory in the FUs, with 98% coverage of the national territory in 2017, that coverage being lower in the Northern region than in the Southern region. The Northeastern region has the poorest coverage, still under 95%.56Although SIM has improved through specific Ministry of Health projects,64 , 65 problems still persist, such as ill-defined causes (around 6%), garbage codes and underreporting of deaths, which generate biases that may disrupt the metrics presented. As such, further research is needed to promote methodological adjustments for coverage, redistribution of ill-defined causes, especially in the older years of the historical series. On the other hand, the estimates from the GBD Study need additional research to implement models with better distribution of garbage codes adapted to local realities.

It is worth mentioning that there is a lack of primary incidence data (cohorts) in Brazil, requiring research that allows us to understand how to face CVD in states and populations with low socioeconomic indices.

Because of the reduction in the decline trend of age-standardized CVD mortality in the last 5 years, novel strategies to tackle CVD mortality must be studied. Understanding of the drivers of this reduction is essential to implement effective policies, particularly facing population aging, which will increase the number of individuals with CVD in the country.

Most cost data were gathered from reimbursement tables of the Public Health System from 2008 to 2018 and do not capture the true cost related to those conditions. Trustworthy and comprehensive cost information of the delivery of care for cardiovascular conditions are extremely important to better understand the financial impact of those diseases and to further reevaluate prevention and management strategies. In addition, cost data from the supplementary health system, as well as ambulatory care and indirect costs are critical for a comprehensive economical appraisal of CVD in Brazil.

 2. STROKE (CEREBROVASCULAR DISEASES) ICD-9 430 to 438; ICD-10 I60 to I69.

See Tables 2-1 through 2-10 and Charts 2-1 through 2-4

Abbreviations used in Chapter 2
ACEI/ARB Angiotensin-Converting Enzyme Inhibitor/Angiotensin Receptor Blocker
APC Annual Percent Change
CHD Coronary Heart Disease
CI Confidence Interval
CVD Cardiovascular Diseases
DALY Disability-Adjusted Life Year
FHP Family Health Program
FU Federative Unit
GBD Global Burden of Disease
GWTG-Stroke Get With The Guidelines-Stroke
HR Hazard Ratio
HS Hemorrhagic Stroke
IBGE Brazilian Institute of Geography and Statistics
ICD International Statistical Classification of Diseases and Related Health Problems
ICD-9 International Statistical Classification of Diseases and Related Health Problems, 9thRevision
ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10thRevision
ICF International Classification of Functioning, Disability and Health
JCI Joint Commission International
LDL Low-Density Lipoprotein
LV Left Ventricular
NCEP National Cholesterol Education Program Adult Treatment Panel
NIHSS National Institutes of Health Stroke Scale
OR Odds Ratio
PNS National Health Survey (in Portuguese, Pesquisa Nacional de Saúde)
PSC Primary Stroke Center
QALY Quality-Adjusted Life Year
rtPA Recombinant Tissue Plasminogen Activator
SAH Subarachnoid Hemorrhage
SD Standard Deviation
SIH Brazilian Hospital Information System (in Portuguese, Sistema de Informações Hospitalares )
SIM Brazilian Mortality Information System (in Portuguese, Sistema de Informações sobre Mortalidade )
SSQOL Stroke Specific Quality of Life Scale
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde)
TIA Transient Ischemic Attack
UI Uncertainty Interval
WHO World Health Organization

Prevalence

Stroke prevalence estimates may differ slightly between studies because each study selects and recruits a sample of participants to represent the target study population (e.g., state, region, or country).

In a community-based study in Brazil, using a questionnaire applied to 4496 individuals aged over 35 years, living in a deprived neighborhood in the city of São Paulo in 2011, Abe et al. have found 243 individuals initially screening positive for stroke. The age-standardized prevalence rate for men was 4.6% (95% CI, 3.5-5.7) and, for women, 6.5% (95% CI, 5.5-7.5).67

In a population-based cross-sectional study that included 3391 individuals aged 20 years and over, performed in the city of Porto Alegre, Southern Brazil, from July through December 2009, with systematic sampling, Copstein et al. have found 285 individuals who reported diagnosis or symptoms consistent with prior stroke (8.4% of the sample).68

Using a screening tool, the Stroke Symptom Questionnaire, Fernandes et al. have studied stroke prevalence in the town of Coari, in the Brazilian Amazon Basin, and compared stroke prevalence in riverside inhabitants to that in the urban population of the same municipality. Out of 4897 respondents in the urban area and 1028 in the rural area, the authors have found a 6.3% crude prevalence of stroke in the rural area and 3.7% in the urban area, with differences maintained after sex and age adjustment.69

Pereira et al. have conducted a study to estimate the prevalence of stroke among the elderly in the city of Vassouras, state of Rio de Janeiro, Brazil, 2007, using data from the Information System on Primary Care, the population census conducted by the IBGE, and the standardized patient form from the Ministry of Health FHP. The quality of stroke diagnoses in the FHP was analyzed. Out of 4154 elderly screened, the study detected 122 with a history of stroke diagnosis (prevalence, 2.9%; men, 3.2%; women, 2.7%) and a progressive increase with age. The prevalence rate was the same in the rural and urban areas of the municipality (2.9%).70

Using the WHO Stepwise Approach to Stroke Surveillance, Goulart et al. have conducted a study to verify stroke mortality and morbidity rates in an area of São Paulo, Brazil. The questionnaire determining stroke prevalence was activated door-to-door in an FHP neighborhood (Step 3). Out of 3577 subjects over the age of 35 years evaluated at home, 244 cases (6.8%) of stroke survivors were identified via the questionnaire validated by a board-certified neurologist.71

Benseñor et al. have analyzed a community-based epidemiological survey (PNS – 2013) with a Brazilian representative sample to assess the absolute number of stroke and post-stroke disabilities with respective prevalence rates. The authors have estimated 2 231 000 strokes and 568 000 post-stroke severe disabilities. The point prevalence for stroke was 1.6% and 1.4% for men and women, respectively.72

According to the GBD Study 2017, the age-standardized prevalence of stroke decreased 44.2% (95% UI, -41.7 to -46.9) in Brazil from 1810.9 (95% UI, 1530.9-2131.5) in 1990 to 1010.6 (95% UI, 843.2-1197.8) in 2017.7The age-standardized prevalence decreased similarly among males and females, with a higher prevalence of stroke across the whole period in males (Table 2-1). Table 2-1 also depicts the age-standardized prevalence rates by FU in Brazil.

Data from the ELSA-Brasil cohort study, a six-center cohort study of civil servants in Brazil that included 15 105 adults (45.8% men; age range, 35 to 74 years), have shown a stroke prevalence of 1.3% for males and females.73

 Incidence Stroke Subtypes

In a hospital-based study held in the region of Fortaleza, in the Northeast of Brazil, ischemic stroke was the most frequent subtype (72.9%), followed by intracerebral hemorrhage (15.2%), SAH (6.0%), TIA (3.0%), and undetermined stroke (2.9%).74 This distribution is similar to that of the community-based study conducted from 2005 to 2006 in the city of Joinville, in the South of Brazil, in which, of the 759 first-ever strokes, 610 (80.3%) were ischemic strokes, 94 (12.3%) were HS, and 55 (7.2%) were SAH. In Joinville, the annual incidence per 100 000 person-years was 61.8 (95% CI, 57.0-66.9) for ischemic stroke, 9.5 (5% CI, 7.7-11.6) for HS, and 5.6 (95% CI, 4.2-7.3) for SAH. The incidence of stroke, adjusted to the world population, per 1000 inhabitants older than 55 years, was 5.8 (95% CI, 5.4 - 6.2). The incidence of infarction was 4.7 (95% CI, 4.3 - 5.1), of intracerebral hemorrhage, 0.6 (95% CI, 0.5 - 0.8), and of SAH, 0.3 (95% CI, 0.2 - 0.4).75

In a population-based study conducted in Matão (Southeast Brazil) from 2003 to 2004, the crude annual incidence rate per 100 000 per year was 108 (95% CI, 85.7 - 134.1) and the rate adjusted to sex and age using the Segi Standard Population was 137 (95% CI, 112.0 - 166.4) per 100 000 inhabitants per year. Ischemic stroke occurred in 69 (85.2%) subjects, intracerebral hemorrhage in 11 (13.6%), and SAH in 1 (1.2%).76

Data from the Joinville community-based study have shown that, when comparing different time periods (1995, 2005-2006, 2010-2011, and 2012-2013), the stroke incidence has decreased. Over the last 18 years, the overall stroke (e.g., all major stroke types) incidence in Joinville decreased by 37% (95% CI, 32 - 42).75The incidence of first-ever stroke adjusted to the Brazilian population was 86.6 per 100 000 (95% CI, 80.5 - 93.0) in 2005-2006 and 113.46 per 100 000 (95% CI, 101.5 - 126.8) in 1995.77The overall incidence, age-adjusted to world population per 100 000 person-years was 143.7 (95% CI, 128.4 - 160.3) in 1995, fell to 105.4 (95% CI, 98.0 - 113.2) in 2005–2006, and then to 90.9 (95% CI, 85.1 - 96.9) in 2012-2013. The age-standardized incidence of first-ever stroke stratified by gender and age also decreased significantly over time. The reduction was 11% greater in men (42%; 95% CI, 35 - 49) than in women (31%; 95% CI, 23 - 39), and 16% greater in young people (≤ 44 years: 54%; 95% CI, 41 - 66) than in older individuals (> 44 years: 38%; 95% CI, 33 - 43). From 1995 to 2013, the proportion of ischemic stroke increased by 12%, whereas that of HS decreased by 16%. Meanwhile, the proportion of SAH remained relatively stable, ranging from 7.5% in 1995 to 6% in 2012-2013. The weight of the decrease in age-standardized stroke incidence was proportionally higher for HS than for ischemic stroke, whereas that of SAH remained stable. In the last 8 years, the incidences of ischemic stroke and HS had significant absolute reductions of 15% (95% CI, 1.00 - 28.00) and 60% (95% CI, 13.00 - 86.00), respectively. Meanwhile, the incidence of SAH showed a 29% nonsignificant absolute decrease (95% CI, 15.00 - 92.00).78

A study including 213 consecutive patients with Chagas disease cardiomyopathy in Brazil has explored the long-term cumulative risk of stroke and TIA and its relation to LV dysfunction in those patients from June 1999 to January 2007. After a mean 36-month follow-up, the overall incidence of ischemic stroke was 2.67 events per 100 patient/years. Independent risk factors for stroke and TIA included LV ejection fraction (HR 0.95; 95% CI, 0.91 - 0.99, p=0.009) and left atrial volume corrected for body surface area (HR 1.04; 95% CI, 1.01 - 1.07, p=0.007), which persisted after adjustment for anticoagulation use.79

 Mortality

Data from the Joinville Stroke Registry (n=759 first-ever strokes) have shown that the mortality rate adjusted to the Brazilian population in the 2005-2006 period was 20.5 per 100 000 (95% CI, 17.5 - 23.8), and, when adjusted to the world population, 23.9 per 100 000 (95% CI, 20.4 - 27.8), revealing a decreasing trend from 1995 on. There was also a decrease in mortality adjusted to age, although it was much more pronounced in males (48%) than in females (3%). The case-fatality rate was 19.1% (145/759) in the 2005-2006 period, which is also lower than that found in 1995 [26.6% (84/320)]. Therefore, over a span of approximately 10 years, mortality fell by 37%. The 30-day case-fatality rate decreased by 28.2% during the period (from 26.6% to 7.5%).77 ,80

In a population-based study conducted in Matão, in the Southeastern region (n=141), the overall 30-day case-fatality rate was 18.5% (95% CI, 10.7 - 28.7%). Regarding stroke subtypes, the 30-day case-fatality was 13% (95% CI, 6.1 - 23.3%) for ischemic stroke and 45.4% (95% CI, 16.7 - 76.2%; p=0.02) for HS. The overall 1-year case-fatality rate was 30.9% (95% CI, 21.1 - 42.1%). Regarding stroke subtypes, the 1-year case-fatality rate was 24.6% (95% CI, 23.7 - 47.2%) for ischemic stroke and 63.6% (95% CI, 30.7 - 89.0%; p=0.01) for HS.76

Data from the GBD Study 2017 have shown that the age-standardized mortality rates per 100 000 for stroke in 1990 was 122.9 (95% UI, 120.6 - 125) and 56.6 (95% UI, 55.2 - 57.8) in 2017, representing a percent change of -54 (95% UI, -55.1 to -53) (Chart 2-1 and Table 2-4). The highest percent change occurred in the state of Espírito Santo, -68.3 (95% UI, -69.9 to -66.5), and the lowest, in the state of Maranhão, -31.7 (95% UI, -36.6 to -26.6) (Table 2-2). For adults, the highest percent change was observed among people aged between 50 and 69 years, -56 (95% UI, -57.5 to -54.5) (Table 2-4).

Regarding stroke subtypes, data from the GBD Study 2017 have revealed age-standardized ischemic stroke mortality rates per 100 000 of 54.8 (95% UI, 53.6-55.9) in 1990 and of 22.6 (95% UI, 21.9-23.2) in 2017, representing a percent change of -58.7 (95% UI, -60 to -57.4) (Chart 2-2 and Table 2-2). For adults, the highest percent change was observed among people aged between 50 and 69 years, -63.7 (95% UI, -65.8 to -61.6) (Table 2-4).

For intracerebral hemorrhage, the age-standardized mortality rates (GBD Study 2017) per 100 000 were 58.6 (95% UI, 57.3 - 59.9) and 27.9 (95% UI, 27.1 - 28.7) in 1990 and 2017, respectively, representing a percent change of -52.4 (95% UI, -53.8 to -51.1) (Chart 2-3 and Table 2-4). For adults, the highest percent change was observed among people aged between 15 and 49 years, -57.6 (95% UI, -60.9 to -55.4) (Table 2-4).

For SAH, the age-standardized mortality rates (GBD Study 2017) per 100 000 were 9.6 (95% UI, 8.8 - 9.9) and 6.1 (95% UI, 5.0 - 6.7) in 1990 and 2017, respectively, representing a percent change of -36.5 (95% UI, -39.8 to -32.2) (Chart 2-4 and Table 2-4). For adults, the highest percent change was observed among people aged between 15 and 49 years, -39.4 (95% UI, -43.6 to -29.4) (Table 2-4).

Analyzing the estimates from the GBD 2015 in the 27 Brazilian FUs between 1990 and 2015, Lotufo et al. have shown that, despite the increase in the absolute number of deaths due to cerebrovascular disease, the proportion of deaths under the age of 70 years was halved between 1990 and 2015. From 1990 to 2015, the risk of death attributable to stroke decreased for both men (-2.41% per year) and women (-2.51% per year). Nevertheless, the annual reduction in mortality rates adjusted to age, for both sexes, slowed between 2005 and 2015 when compared to the previous period of 1990-2005. States in the lower social development index tertile had less significant reductions (-1.23 and -1.84% per year) as compared to those in the middle tertile (-1.94 and -2.22%) and in the upper tertile (-2.85 and -2.82%), for men and women, respectively. In addition, the years lived with disability decreased among states, but less expressively.81

André et al., using data from the SIM corrected for ill-defined deaths, have shown that the age-standardized stroke mortality rates consistently decreased between 1980-1982 and 2000-2002, from 68.2 to 40.9 per 100 000 inhabitants. During the same period, total cardiovascular mortality rates also declined markedly, from 208.2 to 126.1 per 100 000 inhabitants. The decline in the age-standardized stroke mortality rate was evident in both decades, with the highest decrease observed between 1990-1992 and 2000-2002. Using the 1980 rate as a reference, there was a 30% (95% CI, 30% - 31%) risk reduction in 1990 and a 55% (95% CI, 55% - 56%) risk reduction in 2000 (P<0.001 for both measures). The proportional reduction in stroke mortality was evident for both men and women, although it was more marked among men. In addition, the decrease was observed in all age strata. An interaction between sex and age was detected, with a more marked decline in age-standardized mortality rates in the young male population (up to 45 years) and a steeper decline for women of all other age strata (P<0.001 for all findings). A reduction in age-standardized stroke mortality rates occurred in all geopolitical regions. An interaction between the studied region and the reduction magnitude was detected. The wealthiest regions (South and Southeast) exhibited higher initial rates and more marked reductions during the study period. The findings were confirmed by the Poisson regression model, in which the least marked reduction in standardized stroke mortality rate was found in the Northeastern region, 41% (95% CI, 40% - 42%). The corresponding values for the other regions were as follows: North, 52% (95% CI, 51% - 52%); West-Central, 53% (95% CI, 53% - 54%); South, 57% (95% CI, 56% - 57%); and Southeast, 59% (95% CI, 58% - 59%). The total number of deaths related to stroke in Brazil has, however, steadily increased in the last 3 decades. The mean annual number of deaths attributable to stroke increased from 79 862, in 1980-1982, to 101 625, in 2000-2002. A similar trend was evident for total cardiovascular mortality: 239 876 deaths in 1980-1982 and 311 138 in 2000-2002. This increase mainly reflects the progressive aging of the Brazilian population.82

In another assessment of stroke mortality trends in Brazil from 1979 to 2009, after excluding deaths due to sequelae from stroke for men, the annual percent changes (95% CI) were as follows: 1979-1984, 0.7 (–0.8 to 2.1); 1984-1994, –1.8 (–2.4 to –1.2); 1994-2007, –5.0 (–5.4 to –4.7); and 2007-2009, –0.8 (–7.0 to 5.8). For women, the annual percent changes were as follows: 1979-1994, –1.9 (–2.2 to –1.6); 1994-1997, –7.5 (–14.0 to –0.6); 1997-2007, –4.0 (–4.6 to –3.3); and 2007-2009, 1.6 (–5.5 to 9.2). For the 2006-2009 period, the average annual percent change (95%CI) for all strokes was –3.1 (–3.3 to –2.9) for men and –2.9 (–3.1 to –2.8) for women. For the same period, the average annual percent change of death rates for stroke subtypes were, for men and women, respectively: intracerebral hemorrhage, –4.0 (–4.9 to –3.1) and –2.9 (–3.4 to –2.3); and ischemic stroke, –3.2 (–3.3 to –3.0) and –1.4 (–2.0 to –0.9).83

An assessment considering reallocation of deaths with non-registered sex or age, redistribution of garbage codes and underreporting correction has shown the following stroke mortality rates for 1996 and 2011, adjusted for age, pre- and post-correction, respectively: 1) for men: in 1996, 82.9 and 113.6; and, in 2011, 49.6 and 60.9; and 2) for women: in 1996, 58.2 and 84.4; and, in 2011, 34.7 and 42.3.84

A study assessing regional differences in mortality transition and using data from the SIM from 1990 to 2012 has shown a variation of -48.05% in the mortality coefficient for stroke. Most regions showed a reduction in age-standardized mortality rates: –62% in the Southeast; –55.5% in the South; –26.91% in the West-Central; and –20.8% in the North. Only the Northeast had an increase (13.77%).85

In the city of São Paulo, from 1996 to 2011, 77 848 stroke deaths were confirmed, 51.4% of them among individuals aged 35-74 years. In that period, age-adjusted mortality rates for cerebrovascular diseases decreased by 46.6% in men and by 47.8% in women. For men in high-income neighborhoods, the downward trend was constant; in the middle-income area, there was a sharp decline from 1996 to 2000, followed by a slower pace between 2000 and 2011. In the low-income areas, the APC was higher between 1996 and 2002, with a mild decline in 2002–2011. For women in high income areas, there was a sharp decline from 1996 to 2003, and a lower decrease in the last half of the period; in the low- and middle-income areas, the decline was constant during all periods. For the full period, both sexes and age group of 35–74 years, the decline in age-adjusted rates was more pronounced among those residing in the wealthiest area as compared to those living in the poorest area. This same pattern, but with a magnitude decline, was observed in people aged ≥75 years in all areas as compared to other age groups, for both sexes. Additionally, the temporal evolution of the ratios between the age-adjusted rates of people aged 35–74 years living in low- and high-income areas was as follows: for men, from 1996 to 1998, the rate ratio was 2.03, and, from 2009 to 2011, it was 2.34. For women, in 1996–1998, the rate ratio was 2.09, and, in 2009–2011, it was 2.58. The trend of the ratios between the age-adjusted rates of these areas showed an APC growth of 1.4 (0.5–2.4) for men and of 1.1 (0.1–2.0) for women.86

In a hospital-based study conducted in the Northeastern and Southeastern regions (n=962), overall 10-day and 28-day case-fatality rates were 7.9 (95% CI, 6.2-9.7) and 12.5 (95% CI, 10.4-14.5), respectively. The death rates of HS were higher than those of ischemic stroke at both 10 days (12.3[95% CI, 7.2-14.4] vs. 7.0[95% CI, 5.3-8.8]) and 28 days (19.8[95% CI, 13.6-26.0] vs. 11.1[95% CI, 8.9-13.3]). Other than advanced age, the risk factors for ischemic stroke case-fatality at 28 days were diabetes (OR=1.69; 95% CI, 1.06–2.68) and previous heart disease (OR=1.86; 95% CI, 1.17–2.96) after adjustment for age.87

 Burden of Disease

Data from the GBD Study 2017 have shown that the age-standardized DALY rates for stroke per 100 000 were, in 1990, 2511.9 (95% UI, 2457.3 - 2567.6) and, in 2017, 1145.3 (1107.8 - 1185.3), representing a percent change of -54.4 (95% UI, -55.5 to -53.2) (Table 2-6). For males, the percent change was -54 (95% UI, -55.4 to -52.5) and, for females, -54.2 (95% UI, -55.9 to -52.7) (Tables 2-9 and 2-10). The highest percent change occurred in the state of Espírito Santo, -64.7 (95% UI, -66.5 to -62.8), and the lowest, in the state of Amapá, -29.5 (-33.8 to -25.2) (Table 2-5).

The age-standardized DALY rates for ischemic stroke per 100 000 were 871.4 (95% UI, 841.1 to 902.3) and 387.3 (95% UI, 363.9 to 411.5) in 1990 and 2017, respectively, representing a percent change of -55.6 (95% UI, 55.5 to -53.2) (Table 2-6). For adults, the highest percent change was observed among individuals aged 50-69 years, -58.7 (95% UI, -60.9 to -56.4) (Table 2-6), -58.3 (95% UI, -61.1 to -55.6) for men and -58.7 (95% UI, -61.7 to -55.6) for women (Tables 2-9 and 2-10).

The age-standardized DALY rates per 100 000 for intracerebral hemorrhage was 1322.1 (95% UI, 1291.8 - 1358.2) in 1990 and 576.9 (95% UI, 560.7 - 594.9) in 2017, representing a percent change of -56.4 (95% UI, -57.8 to -55.1) (Table 2-6). For adults, the highest percent change was observed among people aged 15-49 years, -57.9 (95% UI, -61.3 to -55.8) (Table 2-6), -60.1 (95% UI, -64.4 to -57.1) for men and -57.1 (95% UI, -59.8 to -54.7) for women (Tables 2-9 and 2-10).

The age-standardized DALY rates per 100 000 for SAH was 318.4 (95% UI, 287 - 332.2) in 1990 and 181.0 (95% UI, 173.1 - 191.0) in 2017, representing a percent change of -43.1 (95% UI, -46.3 to -37.2) (Table 2-6). For adults, the highest percent change was observed among people aged 15-49 years, -40 (95% UI, -43.9 to -30.9), -44.2 (95% UI, -49.5 to -22.9) for men and -36.8 (95% UI, -41.6 to -31.8) for women (Tables 2-9 and 2-10).

 Complications

Benseñor et al. have analyzed a community-based epidemiological survey (PNS – 2013) with a Brazilian representative sample to assess the absolute number and prevalence rates of stroke and post-stroke disabilities. The authors have estimated 2 231 000 strokes and 568 000 post-stroke severe disabilities. The point prevalence for stroke was 1.6% and 1.4% in men and women, respectively. The prevalence of post-stroke disabilities was 29.5% for men and 21.5% for women. Stroke prevalence rates increased with aging, low education level, among people living in urban areas, and showed no difference according to self-reported race. The degree of post-stroke disability was not statistically different according to sex, race, education level or living area.72

Carvalho-Pinto et al. have conducted a retrospective observational study that collected data from medical records and home visits of post-stroke patients followed in a primary healthcare unit in the city of Belo Horizonte, Brazil, between May 2013 and May 2014. Data included health status, care received following stroke, personal and environmental contextual factors, functioning and disability, organized according to the conceptual ICF framework. Most participants had good self-perception of manual ability (2.39 [SD, 2.29] logits) and limited walking ability (88%), were capable of improving natural gait speed, had a change in balance (51.43%) and functional mobility (54.16%) with risk of falling, and had a negative self-perception of quality of life (average score of 164.21 [SD, 35.16] points in the SSQOL-Brazil).88

According to the GBD study 2016, the highest percentage of deaths due to stroke in general occurred in individuals aged 70 years or over (60.2%; 95% UI, 59.9-60.5%) and in men (52.9%; 95% UI, 52.6-53.2%). Ischemic stroke was the most common type, accounting for 61.8% (95% UI, 61.5-62.1%) of deaths due to stroke in 2016. Most of the epidemiological indicators of stroke in general or of a type of stroke (incidence, prevalence, mortality-to-incidence ratio, mortality, DALYs, years lost due to disability, and years of life lost) were higher in men and in those aged 70 years or over.89

 Healthcare Utilization and Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 through 1-16) Hospital Admissions

Lopes et al. have conducted an ecological study designed with analytical approach and data collected from the SIH on stroke episodes in the 1998-2012 period. All data were stratified by sex and age, creating an indicator for stroke-related hospital admission. The authors have observed a reduction in stroke-related hospital admissions from 37.56/105 inhabitants in 1998-2001 to 10.33/105 inhabitants in 2002-2005, a 73.64% decline. The reduction occurred in both sexes and all age groups.90

Using time-series analysis, Katz et al. have evaluated the relationship between stroke-related unemployment rate and hospital admission in Brazil over a recent 11-year span. Data on monthly hospital admissions due to stroke from March 2002 to December 2013 were extracted from the Brazilian Public Health System Database, revealing 1 581 675 admissions due to stroke in the period. The unemployment rate decreased from 12.9% in 2002 to 4.3% in 2013, while admissions due to stroke increased. However, the adjusted model showed no positive association between unemployment rate and admissions due to stroke (estimated coefficient = 2.40±4.34; p=0.58).91

Using data from the SIH, the SIM, and the IBGE, Adami et al. have analyzed rates of stroke-related mortality and incidence of hospital admissions in Brazilians aged 15-49 years, according to region and age group, between 2008 and 2012. Stroke was defined according to the ICD-10 (I60-I64). Crude and standardized mortality (WHO reference) and incidence of hospital admissions per 100 000 inhabitants, stratified by region and age group, were estimated. The authors have found 131 344 hospital admissions due to stroke in Brazilians aged 15-49 years between 2008 and 2012. During the same time, the rate of hospital admissions stabilized: 24.67 (95% CI, 24.66 - 24.67) in 2008 and 25.11 (95% CI, 25.10 - 25.11) in 2012 (β = 0.09, p = 0.692, r2 = 0.05).92

Dantas et al. have conducted a study to assess public hospitalizations for stroke in Brazil from 2009 to 2016. The authors have selected hospitalization registries according to the stroke diagnosis codes from the ICD-10. From 2009 to 2016, the number of admissions increased from 131 122 to 146 950, and the absolute number of in-hospital deaths increased from 28 731 to 31 937. Younger age and male sex were significantly associated with patient survival. The annual age-adjusted hospitalization and in-hospital mortality rates decreased by 11.8% and 12.6%, respectively, but the case-fatality rate increased for patients older than 70 years.93

 Healthcare Utilization

An analysis of the expansion trends of the FHP coverage and hospitalization for conditions sensitive to primary care in Rio de Janeiro, between 1998 and 2015, has shown a 7.6% decrease in hospitalizations for cerebrovascular diseases.94

A study carried out in the city of Joinville has assessed the impact of a stroke unit, the first established in Brazil, on the acute phase of stroke management as compared to the conventional general ward treatment. The study has assessed 35 and 39 patients allocated in a stroke unit and at a general ward, respectively, in 2000, showing a 10-day mortality in the stroke unit and at the general ward of 8.5% and 12.8%, respectively (p=0.41). For the stroke unit and the general ward treatments, the mortality rates were as follows, respectively: on day 30, 14.2% and 28.2% (p=0.24); on the 3rdmonth, 17.4% and 28.7% (p=0.39); and, on the 6thmonth, 25.7% and 30.7% (p=0.41). The 30-day survival curve showed a non-significant trend towards lower lethality in the stroke unit. In order to save one death in 6 months in the stroke unit, the number needed to treat was 20; to get one more home independent patient, the number needed to treat was 15.95

A study has described the characteristics and provision of care for 148 patients admitted with ischemic stroke to a large, public, academic hospital in São Paulo, at the neurology emergency department and at the neurology ward. The study has shown that ischemic stroke was diagnosed in 79.6% of the CVD patients admitted to the neurology emergency department, and that thrombolysis was provided to 2.7%. The extent of ischemic stroke investigation and management differed significantly between the neurology emergency department and the neurology ward.96

A hospital-based study, evaluating 2407 consecutive patients (mean age, 67.7 ± 14.4 years; 51.8% females) admitted to 19 hospitals in the city of Fortaleza with the diagnosis of stroke or TIA, has shown that ischemic stroke was the most frequent subtype (72.9%), followed by intraparenchymal hemorrhage (15.2%), SAH (6.0%), TIA (3%), and undetermined stroke (2.9%). The median time from symptom onset to hospital admission was 12.9 (3.8-32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2-26.5) hours.74

A study has compared the quality indicators for stroke management from a private tertiary hospital, certified by the JCI as a PSC, with those of the American Heart Association/American Stroke Association “GWTG-Stroke” program: (1) tissue plasminogen activator use in patients who arrived <2 hours from symptom onset; (2) antithrombotic medication use within 48 hours of admission; (3) deep vein thrombosis prophylaxis within 48 hours of admission for non-ambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) measurement of LDL and treatment for LDL > 100 mg/dL in patients meeting the NCEP III guidelines; and (7) counseling for smoking cessation. The study assessed 343 consecutive patients with acute ischemic stroke (70.8%) or TIA (29.2%) from August 2008 to December 2010. Antithrombotic medication within 48 hours was used in 98.5% of the eligible patients, and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 hours from symptom onset, 23 were eligible for intravenous thrombolysis, and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients.97

A study evaluating factors that influence temporal trends in quality indicators for ischemic stroke in a JCI certified PSC has assessed 551 patients discharged with ischemic stroke from a tertiary hospital from January 2009 to December 2013. Median age was 77.0 years (interquartile range, 64.0-84.0), and 58.4% were men. Ten predefined performance measures selected from the GWTG-Stroke program were assessed. The quality indicators that improved with time were the use of cholesterol-lowering therapy (P = 0.02) and stroke education (P = 0.04). The median composite outcome perfect care did not consistently improve throughout the period (P = 0.13). After a multivariable adjustment, only thrombolytic treatment (OR 2.06, P<0.01), dyslipidemia (OR 2.03, P<0.01), and discharge in a JCI visit year (OR 1.8, P<0.01) remained as predictors of a perfect care index of 85% or higher. The quality indicators with worse performance (anticoagulation for atrial fibrillation and cholesterol reduction) were similar in the tertiary and secondary community hospitals. The overall perfect care measure did not improve and was influenced by being discharged in a JCI visit year, having dyslipidemia, and having undergone thrombolytic treatment.98

A study has assessed the Brazilian Ministry of Health key performance indicators for stroke in the stroke units of two centers, including the percentage of patients admitted to the stroke unit, venous thromboembolism prophylaxis in the first 48 hours after admission, pneumonia and hospital mortality due to stroke, and hospital discharge on antithrombotic therapy in patients without cardioembolic mechanism. The analysis has shown that both centers admitted over 80% of the patients in their stroke units. The incidence of venous thromboembolism prophylaxis was > 85% and that of in-hospital pneumonia was <13%. The rate of in-hospital mortality from stroke was <15%, and that of hospital discharge on antithrombotic therapy was > 70%.99

A before and after study has assessed the effect on mortality rates of the implementation of a dedicated cardiovascular and stroke unit in an emergency department of a tertiary public hospital in the city of Porto Alegre. The period prior to that unit implementation (2002 through 2005) included 4164 patients, and the period after that (2007 to 2010) included 6280 patients. Overall, the case-fatality rate for acute vascular conditions decreased from 9% to 7.3% with the vascular unit implementation (p = 0.002). However, the stroke case-fatality rate did not decrease despite improvements in the quality of stroke healthcare indicators.100

A cluster randomized trial has assessed the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for the care of patients with acute ischemic stroke and TIA (including case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster). The study has evaluated 1624 patients from 36 hospitals covering all Brazilian regions. The primary outcome was a composite outcome of score adherence for acute ischemic stroke and TIA performance measures, and the secondary outcomes included an all-or-none composite endpoint of performance measures. The overall mean (SD) composite outcome adherence to the score and the 10 performance measures in the intervention group hospitals as compared to the control group hospitals was 85.3% (20.1%) vs. 77.8% (18.4%) (mean difference, 4.2%; 95% CI, −3.8% to 12.2%). As a secondary endpoint, 402 of 817 patients (49.2%) at the intervention group hospitals received all the therapies they were eligible for vs 203 of 807 (25.2%) in the control group hospitals (OR, 2.59; 95% CI, 1.22-5.53; P = 0.01). The intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with acute ischemic stroke or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies and in improved thrombolysis rates.101

 Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 and 1-16)

From the SUS administrative database, total expenses attributed to cerebrovascular diseases increased from 2008 to 2018, considering the clinical procedures related to hospital admissions. In 2008 and 2018, there were 159 545 and 203 066 hospitalizations due to cerebrovascular diseases, respectively, of a total of 2 042 195 admissions in the period, representing total costs of R$ 142 061 641 (2018 Int$ 136 975 201) in 2008 and R$ 286 293 302 (2018 Int$ 141 170 268) in 2018, a cumulative amount of R$ 2 498 850 166 in the referred period. There was a real increase in total costs attributed to cerebrovascular diseases in the last decade after adjustment for inflation and local currency, probably due to an increase in complexity of the treatment delivered for those conditions.

A cost-effectiveness study assessing thrombolytic drugs in Brazil has reported that, for a one-year result, for men, the cost of the treatment with rtPA was higher than that of the conservative treatment, with the QALY gained being 0.06 for both sexes. This result is mainly directed by the cost of the medication. Part of this additional cost is compensated by the lower cost of rehabilitation and less productivity losses as early as the first 2 years, because the patients treated with rtPA presented fewer sequelae than those who received conservative treatment. After the second post-stroke year, for both sexes, treatment with rtPA (alteplase), considering direct and indirect costs, started to have a lower cost when compared to conservative treatment. From this time horizon onward, the additional cost of the medication starts to be more than compensated by the smaller productivity losses and lower social security and patient rehabilitation costs.102

 Prevention

The Prospective Urban Rural Epidemiological Study has examined rates and predictors of use of evidence-based secondary prevention medications (ACEI/ARB, antiplatelets, statins, and beta-blockers) in patients with CVD, including CHD and stroke, in South American countries, including Brazil. The study has shown that fewer stroke patients received antiplatelets (24.3%), ACEI/ARB (37.6%), and statins (9.8%) as compared with CHD patients (30.1%, 36.0%, and 18.0%, respectively). This underutilization of therapies in stroke patients varied substantially among countries, with the lowest use in Colombia (no prescription of statins). When CHD and stroke patients were combined, the proportion of utilization of antiplatelets was highest in Chile (38.1%) and lowest in Argentina (23.0%). The use of ACEI/ARB and statins was higher in Brazil (46.4% and 26.4%) and lower in Colombia (26.4% and 1.4%), respectively. Among CHD and stroke participants, the use was higher in those with higher education level relative to those with none, primary, or unknown education [35.6% vs. 23.6% for antiplatelets (p = 0.002); 20.6% vs. 10.9% for statins (p = 0.0007)]. Former smokers with CHD or stroke were more likely to receive proven therapies than current smokers or those who had never smoked [35.2% vs. 26.6% and 27.7%, respectively, for antiplatelets (p = 0.039); 19.9% vs. 10.6% and 13.0% for statins (p = 0.004)]. Only 4.1% of the patients received all 4 therapies (antiplatelets, beta-blockers, ACEI/ARB, and statins), with the highest rate in Brazil (5.5%), and the lowest in Colombia (0.5%) (p = 0.02). Moreover, the use of no medication was observed in 30% of Brazilian stroke patients.103

 Awareness, Treatment, Control

Several studies have shown alarming lack of knowledge about stroke risk factors, stroke treatment, and recognition of stroke symptoms as a medical emergency. In a community-based study, Pontes-Neto et al. have interviewed subjects in public places of 4 major cities in Brazil between July 2004 and December 2005, using a structured, open-ended questionnaire in Portuguese, based on a case presentation of a typical patient with acute stroke at home. The authors have found 28 different Portuguese terms to name stroke. Twenty-two percent of the interviewees did not recognize any warning sign of stroke. Only 34.6% of the interviewees answered the correct nationwide emergency telephone number in Brazil (#192). Only 51.4% of the interviewees reported they would call an ambulance for a relative with symptoms of stroke.104

Falavigna et al. have used a closed-ended, self-administered questionnaire to assess the knowledge about stroke among 952 residents of the city of Caxias do Sul, Brazil. Lower income and lower education level were independent predictors of inability to recognize that stroke affects the brain. Lower income and age <50 years were independent predictors of lack of knowledge about stroke risk factors.105

Panicio et al. have interviewed 104 consecutive patients with acute stroke admitted to a tertiary public hospital in São Paulo, Brazil, from March 2012 to December 2012, to evaluate their knowledge about stroke and the impact of lack of stroke awareness on late hospital arrival. Although 66.2% of the patients knew the warning signs of stroke, only 7.8% showed some knowledge about the limited time window for reperfusion therapy. Stroke severity measured by the NIHSS was the only independent predictor of early arrival.106

In a community-based and cross-sectional study, Pitton Rissardo et al. have applied a stroke knowledge survey to a convenience sample of 633 passers-by of a public square from December 2015 to October 2016, in the city of Santa Maria, state of Rio Grande do Sul. Of the respondents, 33% correctly reported the meaning of the acronym “AVC” (in Portuguese, acidente vascular cerebral ), the most recommended term to name stroke in Portuguese by the Brazilian Society of Cerebrovascular Diseases. Around 30% of the subjects incorrectly localized stroke in the heart. Only 50% of the respondents correctly reported a warning sign of stroke. Individuals with a higher level of education were more likely to call an ambulance for a relative with stroke symptoms.107

In recent years, there have been several initiatives to improve public stroke awareness in Brazil, mainly around the World Stroke Day (October 29th) annual campaigns led by the World Stroke Organization. Despite these efforts, only 30–40% of patients with stroke are hospitalized within 4 hours of symptom onset.108

 Future Research

The Brazilian research portfolio in vascular neurology has evolved largely in recent years. Still, there are several opportunities for improvement. The most expressive community studies on stroke prevalence and incidence derive mostly from 2 cities. While both examples represent a major achievement in stroke epidemiology, there is still a need for a broader assessment, comprising a representation of all geographical regions, diverse cultures, income levels, and ethnicities.

Additionally, there are inherent constrains related to studies relying on stroke identification using ICD codes. It is not uncommon for users to apply a broader code on admission, that might not be adjusted during hospital stay, thus not representing the actual stroke subtype (e.g., an ischemic stroke might be coded as non-specified stroke or even as TIA). With the dawn of big data technologies (e.g., text mining), additional clinical information from admission or discharge records could provide a reliable cross-reference source, thus confirming or correcting a given code.

As a worldwide challenge, not restricted to Brazil, health services research using robust methodology, assessing not only the reality of healthcare delivery but also adequately assessing the effectiveness of healthcare policies through randomized trials, needs to become the basis for quality improvement programs at both community and population levels.

 3. ACUTE AND CHRONIC CORONARY HEART DISEASE ICD-9-CM 410 to 414; ICD-10 I10 to I25.

See Tables 3-1 through 3-3 and Charts 3-1 through 3-6

Abbreviations Used in Chapter 3
ACCEPT/SBC Brazilian Registry of Clinical Practice in Acute Coronary Syndromes of the Brazilian Society of Cardiology
ACS Acute Coronary Syndrome
AMI Acute Myocardial Infarction
BRACE Brazilian Registry on Acute Coronary Syndrome
BYPASS Brazilian Registry of Adult Patients Undergoing Cardiovascular Surgery
CABG Coronary Artery Bypass Grafting
CAD Coronary Artery Disease
CHD Coronary Heart Disease
CI Confidence Interval
CVD Cardiovascular Diseases
DALY Disability-Adjusted Life Year
DATASUS Brazilian Unified Health System Database
GBD Global Burden of Disease
GDP Gross Domestic Product
IHD Ischemic Heart Disease
MASS Medicine, Angioplasty, or Surgery Study
MI Myocardial Infarction
PCI Percutaneous Coronary Intervention
PNS National Health Survey (in Portuguese, Pesquisa Nacional de Saúde)
RBSCA Brazilian Registry of Acute Coronary Syndrome
STEMI ST-Elevation Myocardial Infarction
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde)
UI Uncertainty Interval
WHO World Health Organization
YLL Year of Life Lost

Overview and Prevalence

Coronary heart disease, also known as IHD or CAD, comprises a spectrum of symptomatic and asymptomatic clinical conditions typically related to a reduction in blood flow to the heart muscle. The most common cause is atherosclerotic disease in the coronary arteries, a chronic condition with variable presentations, progressing from a long asymptomatic phase to stable angina, MI, and unstable angina. Coronary heart disease is a common cause of heart failure, with reduced or preserved left ventricular ejection fraction, ventricular arrhythmias, and sudden cardiac arrest.

Coronary heart disease was the leading cause of death in Brazil in the last decade, for men and women. Because of its wide range of clinical presentations, the reported CHD prevalence, incidence and mortality vary widely, depending on the population and healthcare setting studied.

 Coronary Heart Disease

According to data from the GBD 2017, the total CHD prevalence was 1.75% in Brazilian adults >20 years. Males had a higher prevalence as compared to females, 2.33% and 1.19%, respectively. For adults aged 15-49 years, the estimated CHD prevalence was 0.53%; for those aged 50-69 years, 4.34%; and for those older than 70 years, 10.99% (Chart 3-1).

The overall age-standardized prevalence of CHD was 1.63% (1564 per 100 000 inhabitants), being 2.35% (2229 per 100 000 inhabitants) in males and 1.05% (1008 per 100 000 inhabitants) in females. This implies that there were at least ~3.3 million people living with CHD in the Brazilian Federative Units in 2017.

There was a difference in the age-standardized prevalence of CHD among the Brazilian regions, with the highest prevalence observed in the Southeastern and Southern regions (state of São Paulo, 1617 per 100 000 inhabitants; state of Rio Grande do Sul, 1642 per 100 000 inhabitants), and the lowest, in the Northern and West-Central regions (state of Amazonas, 1407 per 100 000 inhabitants; Distrito Federal, 1404 per 100 000 inhabitants). The Northeastern region was in an intermediate position, but in a trend towards an increase in CHD prevalence in the last decades (state of Pernambuco, 1523 per 100 000 inhabitants) (Table 3-1).

For the 1990-2017 period, the CHD prevalence increased in both sexes (from 1.08% to 1.75%), and the slope was more prominent in males than in females. This increase was probably due to population aging, because the age-standardized prevalence rates were stable in the last 2 decades (annual change, -0.25%) for both sexes (Chart 3-2).

 Stable Angina

Regional population surveys conducted before 2000, applying the Rose Angina Questionnaire in 2 cities (Ribeirão Preto, in the state of São Paulo, and Pelotas, in the state of Rio Grande do Sul), have reported angina prevalence of 12.3% and 8.2%, respectively, in adults aged ≥ 40 years.110 , 111

The Brazilian Health Survey conducted in 2003 among 5000 subjects has shown a prevalence of self-reported angina of 6.7% in Brazilian adults aged ≥18 years, and of 13% in those > 50 years. Only 72.8% of the individuals had reported adherence to medical therapy within the previous 2 weeks.112

According to the 2013 PNS, an epidemiological home-based, country-wide representative survey, the overall prevalence of class I angina was 7.6% (95% CI, 7.2% - 8.0%), and of class II angina, 4.2% (95% CI, 3.9% - 4.5%).113

Self-reported angina pectoris was more prevalent in females than in males in all studies described.

It is important to note the higher prevalence rates observed in prospective surveys as compared to national statistics. Self-reported assessments of angina are very sensitive, but not specific to CAD, because they require neither confirmatory exams nor health reports. In addition, national statistics might underrepresent the true epidemiology of CHD, considering its asymptomatic nature.

 Incidence

The GBD has estimated an incidence of 84 events of CAD per 100 000 inhabitants in 2017 in Brazil. The age-standardized incidence was 79 per 100 000 inhabitants, and the age-adjusted numbers were higher for males than for females, 104 and 58 per 100 000 inhabitants, respectively. There was an exponential increase in the incidence by age group, from 19 per 100 000 inhabitants for those aged 15-49 years to 198 per 100 000 inhabitants for those aged 59-69 years, and 744 per 100 000 inhabitants for those aged 70 years or older. Temporal changes from 1990 to 2017 were small, 1.03% crude, and -1.29% age-standardized annually.

According to data from the DATASUS, in 2018, there were 142 982 new cases of AMI and ACS.

In a systematic review from public health data in 2009, the rates of ACS and MI per 100 000 inhabitants were 38 and 29.8, respectively.114

 Mortality

According to GBD 2017 estimates, there were 175 791 deaths attributable to CHD, corresponding to 13% of total deaths in Brazil (Chart 3-3).

The crude mortality rate attributable to CHD was 83 per 100 000 inhabitants in 2017 (GBD 2017), higher for males than for females (95 and 72, respectively). As expected, rates were higher for advanced age groups: 161 per 100 000 inhabitants for those aged 50-69 years, and 837 per 100 000 inhabitants for those aged 70 years or older.

The age-standardized mortality rate of IHD from the GBD 2017 was 80 (95% CI, 78 – 82) per 100 000 inhabitants, representing 13% of the causes of death in Brazil. Ischemic heart disease was the number one cause of death in every Federative Unit in 2017.

Regional variations on mortality rates are significant. The lowest death rate was observed in the state of Amazonas (59 per 100 000 inhabitants), while the highest, in the state of Pernambuco (102 per 100 000 inhabitants). In all Brazilian regions, IHD has been the number one cause of death for the last 3 decades.115

According to data submitted to the WHO and World Bank, in 2015, there were 111 849 deaths due to CHD in Brazil, approximately 50 per 100 000 individuals, making CHD the leading cause of mortality from 2010 to 2015.116

According to the 2009 Ministry of Health data, of 962 931 deaths over the age of 30 years, 95 449 were caused by CHD, whereas 193 309 were caused by atherosclerosis.117

Data from the GBD 2017 have shown a decrease in IHD mortality from 1990 to 2017 (Chart 3-4), with unadjusted annual changes of -0.15%, corresponding to a -53% (-54% to -51%) cumulative change during that period. This decrease was observed in all Federative Units, being, though, less expressive in the Northeastern region (state of Ceará, -22%) than in the Southeastern region (state of Minas Gerais, -63%). The age-standardized rate decreased from 169 per 100 000 inhabitants in 1990 to 80 per 100 000 inhabitants in 2017. This trend was similar for both sexes and across age groups (Table 3-2).

The temporal analysis of CVD mortality between 1981 and 2001 has shown that the coefficient of mortality from CHD remained stable for women in the Northern and West-Central regions, whereas decreased in the Southern and Southeastern regions, and increased in the Northeastern region.118For males, there was a trend towards fewer events in the Southern and Southeastern regions.118

An analysis conducted from the DATASUS, from 1990 to 2009, has shown a reduction in deaths due to CHD in Brazil.117The rate reduced from 195 per 100 000 inhabitants to 149 per 100 000 inhabitants for males and from 120 per 100 000 inhabitants to 84 per 100 000 inhabitants for females (Chart 3-5).

The proportion of deaths caused by CHD has remained stable over the last decades, with reports ranging from 26% to 32%, according to the year. An ecologic study in the city of Porto Alegre, including individuals aged 45-64 years, has shown that CVD was responsible for 28.5% of all deaths in 2009. Of those, 40% were related to CHD, whose proportion was higher among individuals with lower socioeconomic status (42.7%) than among those with higher socioeconomic status (26.3%).119

In a national ecologic study including individuals aged 35-64 years, from 1999 to 2001, the rate of death related to CHD was 84 ± 30 per 100 000 inhabitants. In that study, the incidence of events related directly to poverty rate and lower educational attainment.120Importantly, there was wide variability in the results across the 98 participating cities, probably due to data quality.

 Mortality Related to Acute Coronary Syndrome

According to the DATASUS, there were 142 982 hospital admissions due to AMI in 2018, with an in-hospital mortality of 11%.

Several Brazilian ACS registries have reported the outcomes of individuals admitted with ACS. In general, mortality in registries is lower than that reported in the Brazilian Health Information Systems.

Between 2003 and 2008, the RBSCA enrolled 2693 patients, 45% of whom had AMI. The in-hospital mortality for those with unstable angina was 3.1%, whereas, for those with MI, it was 7.7%, leading to an overall mortality of 5.5%.121

Results from a cross-sectional, observational, epidemiological registry of ACS patients (BRACE) published in 2012 showed an overall in-hospital mortality of 5.2% among 1150 patients from 72 hospitals included in that registry.122 , 123

In a retrospective, multicenter study of 3745 patients admitted with ACS between 2010 and 2015 to a hospital in São Paulo, the in-hospital all-cause mortality was 3.3%, and 454 (12.2%) patients experienced at least one major adverse event (reinfarction, shock, bleeding, stroke or death).124

In another hospital-based registry, the ERICO Study, a cohort of ACS individuals admitted to a community regional hospital in the state of São Paulo, the mortality rates at 30 days and 1 year were 4.4% and 12%, respectively.125

The ACCEPT/SBC Registry, conducted from 2010 to 2011 in 47 hospitals, has enrolled 2485 ACS patients, 35% with non-STEMI and 33% with STEMI. All-cause mortality at 30 days was 1.8% for unstable angina, 3.0% for non-STEMI, and 3.4% for STEMI.126

An observational longitudinal study undertaken from 2011 to 2014 in a high-complexity hospital, in the city of Belo Horizonte, including 1129 patients with STEMI and non-STEMI, has reported an in-hospital mortality of 8.7%. Of the STEMI patients, 56% received reperfusion therapy, and 67% were treated in accordance with guideline recommended practices.127

In a study from the Minas Telecardio 2 Project, conducted in 2013 and 2014 in 6 emergency units in the city of Montes Claros, state of Minas Gerais, among 593 patients with ACS, the in-hospital mortality was 9.4%, ranging from 4.9% for unstable angina to 17% for STEMI cases.128In a STEMI care registry in the city of Salvador (RESISST), interconnected through a Regional Integrated Care Network, from January 2011 to June 2013, only 41% of the patients underwent reperfusion therapy, and the 30-day mortality rate was 15.3%.129

Statewide data from the state of Sergipe collected from 2014 to 2017 have identified 707 cases of STEMI, with an in-hospital mortality of 10.9%. There was a significantly higher mortality rate for individuals admitted to public hospitals as compared to those admitted to private ones (11.9% versus 5.9%, respectively), as described in previous studies.129 , 130

A. Mortality related to percutaneous coronary interventions

According to the DATASUS, in 2018, 10 811 primary angioplasties were performed for AMI, with an in-hospital mortality of 6.3%, and mean length of stay of 5.1 days. When all other coronary procedures are considered, 78 575 coronary angioplasties are identified, with an in-hospital mortality of 2.96%, and mean hospital length of stay of 4.5 days.

According to the DATASUS, in a dataset of 3874 individuals, the in-hospital mortality related to PCI was 2.33% between 2005 and 2008.121That rate was lower in the Southeastern region (2.03%) and higher in the Northern region (3.64%) (P<0.001). Procedure volume was not associated with outcomes in those analyses.121

In a cohort study undertaken from 2009 to 2013, assessing 4806 patients undergoing PCI (Brazilian PCI multicenter registry) in 8 tertiary referral medical centers, considering all clinical conditions (69% with recent MI), the in-hospital mortality was 2.6%.131

The ACCEPT/SBC Registry enrolled 2485 ACS patients from 2010 to 2011, mostly in tertiary care centers; more than 90% of them underwent cardiac catheterization and cardiovascular surgery on the site. Among those patients, the revascularization rate was 39% for unstable angina, 54% for non-STEMI, and 78% for STEMI. For the STEMI group, reperfusion therapy was used in 88% of the patients, and most patients (73%) received primary angioplasty. Treatment delay was, on average, 125 ± 90 minutes.126

Another PCI registry, including 1249 consecutive patients in 2009, has shown total mortality of 2.3%, ranging from 0.2% for stable angina patients to 6.1% for those with STEMI.132

In another frame series of PCI in public hospitals from 2005 to 2008, 166 514 procedures were performed in 180 hospitals. Average in-hospital mortality was 2.33%, ranging from 0% to 11.35%. This rate was lower in the Southeastern region (2.03%) and higher in the Northern region (3.64%). The in-hospital mortality rate was 2.33% in high-volume hospitals, accounting for 101 218 (60.8%) of the PCI, 2.29% in medium-volume hospitals, and 2.52% in low-volume hospitals. Mortality was higher in females and among those older than 65 years.133

Most reports originate from public institutions, and data from private hospitals are limited. An analysis of 440 procedures performed between 2013 and 2014 in one public and one private hospital in the city of Rio de Janeiro has shown low mortality (0.5%), with similar rates in both institutions.134

Data on long-term survival rates for patients undergoing PCI are scarce. In an analysis from procedures performed in the state of Rio de Janeiro between 1999 and 2000 in all public hospitals, including 19 263 individuals, one-year survival was 93% and 15-year survival, 57%. In that study, women had a higher survival rate than men within 15 years after PCI.135

 B. Mortality related to surgical revascularization

According to 2017 data from the National Health System, 21 474 CABG were performed in public institutions in Brazil, with an in-hospital mortality of 5.37% and mean hospital length of stay of 12.2 days (Table 1-7).

The BYPASS Project is an ongoing database established in 2015 by the Brazilian Society of Cardiovascular Surgery and involves 17 institutions representing all Brazilian regions. Among 2292 patients enrolled until November 2018, who underwent isolated or combined CABG, the in-hospital mortality was 2.8%, while 5.3% stayed on mechanical ventilation for more than 24 hours, and 1.2% had an in-hospital stroke.136 , 137

The MASS II trial was a single-center randomized clinical trial designed to compare the long-term effects of medical therapy, angioplasty, or surgical strategies for treating multivessel CAD with stable angina and preserved ventricular function, conducted before 2007. The in-hospital mortality rates for PCI and CABG were 2.4% and 2.5%, respectively.138The 10-year survival rates were not significantly different between the groups: 74.9% for CABG, 75.1% for PCI, and 69% for medical therapy (p=0.089).139In another trial (MASS III), similar 10-year survival rates have been described.140

Several other single-center experiences, with both retrospective and prospective analyses, have reported in-hospital mortality for patients who underwent CABG ranging from 1.9% to 8.7%.141 - 143

Burden of Disease

The GBD 2017 has estimated 1736 (95% CI, 1689 – 1779) DALYs lost per 100 000 individuals due to CHD, with lower rates for females (1298; 95% CI, 1340 – 1250) than for males (2194; 95% CI, 2112 – 2258). This loss in DALY corresponded to 6.1% (95% CI, 5.5% – 6.7%) of all DALYs lost. These rates significantly decreased in the last 2 decades in all regions (annual change of -2.51%) (Chart 3-6).

From 1990 to 2017, there was a decline in DALYs lost for both males (-47%) and females (-52%) in all Federative Units. More expressive relative reductions were observed in the Southern and Southeastern states, while smaller reductions were observed in the Northern and Northeastern states (Table 3-3).

The rate of YLLs due to IHD was 1653 per 100 000 individuals (95% CI, 1607 – 1688), with lower rates for females than for males. These YLLs corresponded to 9.7% (95% CI, 9.4% - 9.9%) of all YLLs in the GBD 2017.

 Healthcare Utilization and Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 through 1-16)

Analysis of the administrative database from the SUS has shown that, in 2018, the total amount reimbursed for coronary interventional procedures was R$ 569 314 580 (Int$ 280 727 110), of which, R$ 73 429 322 (13%) (Int$ 36 202 821) were related to primary angioplasties. The mean value paid per patient was R$ 6369 (Int$ 3230). Regarding CABG, the total amount was R$ 275 110 234 (Int$ 135 655 933), corresponding to a median value of R$ 13 307 (Int$ 6561) per surgical hospitalization.

Unadjusted reimbursed values associated with coronary revascularization procedures (codes for angioplasty and CABG) increased significantly from 2008 to 2018, although in different magnitudes. For percutaneous angioplasties, the mean values raised by 16% (from R$ 5437 to R$ 6351), and for CABG, by 46% (from R$ 9192 to R$ 13 140) during that period.

A global modelling approach was performed in 2015 to assess the economic (health system and productivity) impact of four heart conditions in Brazil, providing estimates of the annual cost for the year 2015. The four heart conditions were estimated to affect ˜45.7 million people in Brazil, corresponding to 32.0% of the adult population. Myocardial infarction implied the greatest financial cost, with an estimated prevalence of 0.2% (334 978 cases), health system cost per case of US$ 48 118, and productivity cost of US$ 18 678.115

The annualized cost for an individual with chronic CAD was estimated to be around R$ 2733 ± 2307 by the SUS, with the outpatient cost representing 54% of the total. For private insurance plans, the cost was estimated to be R$ 6788 ± 7842, of which, 69% related to inpatient costs. For outpatient costs, medications were responsible for R$ 1154, representing, for public and private payers, 77% and 55% of the outpatient costs, respectively, and 42% and 17% of the total cost, respectively.144

Another registry from a IHD clinic of a public hospital has shown a mean annual cost of outpatient management of US$ 1521 per patient (2015 currency). The mean cost per hospitalization was US$ 1976, and the expenses were higher in the first and last years of follow-up. Unstable angina, revascularization procedures, diabetes, hypertension, and obesity were predictors of higher hospitalization costs.145

The annual healthcare costs of individuals with CVD are three times higher than those for individuals without CVD in the public healthcare system (R$ 4626 vs. R$ 1312). In the private healthcare sector, the difference is even higher (R$ 13 453 vs. R$ 1789 – adjusted to 2014).146

According to data from DATASUS, from 2008 to 2014, 4 653 884 cardiac diagnostic procedures were performed in Brazil, including 3 015 993 ECGs, 862 627 invasive angiographies, and 669 969 nuclear studies, leading to an overall cost of US$ 271 million. In this national geospatial evaluation of health access, CHD mortality was associated with lower income, and performance of fewer nuclear tests and of more exercise ECG tests and cardiac catheterization procedures.147

According to administrative claims data from the SUS, in the last decade, there was a 40% increase in the absolute number of primary angioplasties for AMI management, from 7648 in 2008 (4.03 per 100 000 inhabitants) to 10 811 (5.19 per 100 000 inhabitants) in 2018. A similar trend was observed for hospital admissions due to CHD. The number of coronary angioplasties almost doubled during that period, while the number of CABG remained stable.

Regarding the angioplasties not classified as primary by the administrative claims of the SUS (procedure codes: 0406030073, 0406030014, 0406030065, 0406030022, 0406030030), the proportion of those procedures that occurred in the context of a hospitalization for MI increased from 2008 to 2018 (12% to 31%, respectively). Moreover, coronary angioplasties performed during hospitalizations for AMI increased by 518%, while for chronic CAD, they increased only by 70%, revealing a change in the profile of patients submitted to coronary interventions, following the current guidelines recommendations, in which angioplasties are more extensively recommended for acute instead of chronic CAD. In fact, in 2018, 70% of all angioplasties assigned a procedure code from those cited above occurred in the context of acute CAD.

A cost analysis of 101 patients undergoing PCI in 2014 and 2015 has shown a median cost of R$ 6705 ± 3116 per patient. Those costs were lower for elective PCI, R$ 5085 ± 16, than those for ACS, R$ 6854 ± 3396.148

A quantitative, descriptive and cross-sectional study carried out in a philanthropic hospital of São Paulo, assessing 1913 consecutive patients who underwent CABG in 2012, has reported an average total cost per patient of US$ 7993 [median, US$ 6463], revenue from the public health system of US$ 3450 [3159], and an estimated deficit of -51% of the total cost for the providers.149

A retrospective analysis of medical claims of beneficiaries of health plans has been performed considering hospitalization costs for patients admitted with ACS between 2010 and 2012. The mean cost per patient on medical therapy only was R$ 18 262, for those submitted to PCI, it was R$ 30 611, and for those submitted to CABG, R$ 37 455.150

 Future Research

Additional data are needed for further understanding of the epidemiological distribution of CHD in Brazil, in particular:

— Development of nationwide databases aiming to gather accurate and real time information on the epidemiology of the distinct clinical presentations of CHD, including delivery of care, and performance and outcome measurements.

— Systematic reviews of the prevalence and mortality rates of ACS, stable patients, and post-PCI and CABG, including representative samples of all geographical areas of the country.

— Assessment of the effectiveness of structured nationwide programs for quality and performance measurement of different providers (public, non-for-profit, and for-profit) to understand the current situation, as well as for designing strategies aimed at reducing CVD morbidity and mortality.

Additional economic and cost-effectiveness analyses of the impact of CHD and its diagnostic and therapeutic interventions are required, from a macro level and using micro costing methods for both the public and the private healthcare systems.

Development of structured programs to assess the prevalence, the incidence, and the clinical and economic impact of chronic CHD in the outpatient setting is necessary.

 4. CARDIOMYOPATHY AND HEART FAILURE ICD-10 I42; I50; B57.2.

See Tables 4-1 through 4-14 and Charts 4-1 through 4-10

Abbreviations Used in Chapter 4
BREATHE I Brazilian Registry of Heart Failure
ChCM Chagas Cardiomyopathy
ChD Chagas Disease
CI Confidence Interval
DALY Disability-Adjusted Life Year
FU Federative Unit
GBD Global Burden of Disease
HCM Hypertrophic Cardiomyopathy
HF Heart Failure
HF-PEF Preserved Ejection Fraction Heart Failure
HF-REF Reduced Ejection Fraction Heart Failure
HR Hazard Ratio
ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision
IQR Interquartile Range
LVEF Left Ventricular Ejection Fraction
NChC Non-Chagas Cardiomyopathies
OR Odds Ratio
PAR Population Attributable Risk
REMADHE Repetitive Education and Monitoring for ADherence in Heart Failure
SDI Sociodemographic Index
SEADE Data Analysis State System Foundation (in Portuguese, Fundação Sistema Estadual de Análise de Dados)
SIM Brazilian Mortality Information System (in Portuguese, Sistema de Informações sobre Mortalidade)
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde)
UI Uncertainty Interval
US United States
YLD Year Lived with Disability

Cardiomyopathy and Myocarditis Prevalence and Incidence

According to the GBD Study 2017 estimates, the age-standardized prevalence of cardiomyopathy and myocarditis increased in Brazil by 9.4% (95 UI, 15.3-4.1) from 1990 to 2017, passing from 102.8 (95% UI, 82.5-125.7) to 112.4 (95% UI, 92.2-134.2), respectively (Chart 4-1.A and Table 4-1). In absolute number, the prevalence estimates of cardiomyopathy and myocarditis in Brazil rose from less than 100 000 in 1990 to over 200 000 in 2017, mainly due to population growth and aging (Chart 4-1.B). The cardiomyopathy and myocarditis prevalence was greater in women (115; 95% UI, 95-137) than in men (109; 95% UI, 88-132) in 2017, but the prevalence increase was higher for men in that period, the increase percentage being 6.9 (95% UI, 0.2-14.2) for women and 12.3 (95% UI, 5.4-20) for men.

According to the GBD Study 2017 estimates, the prevalence of cardiomyopathy and myocarditis is highly variable amongst the Brazilian FUs, and the percent change varied unevenly between 1990 and 2017 (Table 4-1). In 2017, the highest rates were observed in the states of São Paulo and Roraima, and the Distrito Federal. From 1990 to 2017, decreased age-standardized prevalence rates were observed in the states of Rio de Janeiro, Rio Grande do Sul, Santa Catarina, and Espírito Santo, while the age-standardized prevalence increased in all other FUs.

Regarding age-standardized incidence rates per 100 000 per-year, the GBD Study 2017 estimates were 46.3 (95% UI, 41.5-52.1), in 1990, and 46.7 (95% UI, 41.8-52.6), in 2017, with a small change of 0.8% (95% UI, -0.3 to 1.8) during that period (Table 4-2). Absolute numbers of incident cases were 54 520 (95% UI, 48 574-61 321), in 1990, and 103 879 (95% UI, 92 496-117 294), in 2017; that increase is related to population growth and aging. Table 4-3 depicts the incidence rates of cardiomyopathy and myocarditis, per 100 000 inhabitants, by age, for both sexes, in 1990 and 2017, and the percent change of the rates. There is an almost 3-fold stepwise increase in the incidence rates from the 15-49 year group to the 50-69 year group, as well as from the latter to the 70+ year group, and these increases are similar for women and men. From 1990 to 2017, the incidence increased in all age groups for women, while tended to decrease in most age groups for men.

 Mortality

According to the GBD Study 2017 estimates, the mortality rates due to cardiomyopathy and myocarditis seemed to increase in the 1990s but decreased in the following 2 decades (Chart 4-2). As shown in Table 4-4, the mortality rates were 10.9 (95% UI, 9.57-11.38), in 1990, and 8.59 (95% UI, 8.16-9.93), in 2017, per 100 000 inhabitants, a decrease of 21.2% (95% UI, -26.8 to -2.6). Despite this decrease in the mortality rates, the number of deaths due to cardiomyopathy and myocarditis increased in that period due to population growth and aging. Cardiomyopathy and myocarditis were responsible for 9734 (95% UI, 8417-10 163) deaths in 1990, rising to 18 812 (95% UI, 17 885-21 745) deaths in 2017. The GBD Study 2017 estimates of mortality rates due to cardiomyopathy refer to cases with cardiomyopathy listed as an underlying cause of death. Deaths due to HF resulting from other specific causes are attributed to the underlying disease, i.e., deaths related to ischemic cardiomyopathy are coded as due to ischemic heart disease. Moreover, for the GBD project, HF is not considered a primary cause of death, and all deaths coded as related to HF are recoded to the baseline condition (see below).

Table 4-4 also depicts the total number of deaths and age-standardized mortality rate (per 100 000 inhabitants) due to cardiomyopathy and myocarditis, as well as the percent change (%), by FU, in Brazil, in 1990 and 2017. Most FUs had decreased mortality rates, with the highest percentages of reductions observed between 1990 and 2017 in the states of Paraná and Goiás. On the other hand, increased mortality rates from 1990 to 2017 were observed only in 3 FUs, with the highest increase, of 46.2% (95% UI, 12.6-63.3), observed in the state of Rio de Janeiro. In 2017, the FUs with the lowest mortality rates (below 5.0) were the states of Acre, Amazonas, Maranhão, Pará, Rio Grande do Norte, and Rio Grande do Sul.

Table 4-5 shows mortality rates due to cardiomyopathy and myocarditis according to sex and by age groups, from the GBD Study 2017 estimates. Women had lower age-standardized mortality rates, as well as a more pronounced reduction from 1990 to 2017. The mortality rates due to cardiomyopathy and myocarditis in women were 9.20 (95% UI, 8.81-9.93) per 100 000 inhabitants, in 1990, and 6.3 (95% UI, 6-6.6) per 100 000 inhabitants, in 2017, a reduction of 31.3% (95% UI, -35.5 to -26.2). Rates in men were 12.83 (95% UI, 9.96-13.67) per 100 000 inhabitants, in 1990, and 11.27 (95% UI, 10.46-14.39) per 100 000 inhabitants, in 2017, a variation of 12.1% (95% UI, -20.9 to 28.2). As expected, the highest mortality rate was observed in the 70+ year group, with rates of 84.2 (95% UI, 74.2-89.1) per 100 000 inhabitants, in 1990, and of 76.6 (95% UI, 72.0-89.9) per 100 000 inhabitants, in 2017. For the 50-69 year group, rates were 21.2 (95% UI, 17.7-22.5) per 100 000 inhabitants, in 1990, and 16.5 (95% UI, 15.3-19.3) per 100 000 inhabitants, in 2017. Overall, mortality rates decreased from 1990 to 2017 in most age groups, remaining stable in the 15-49 year group.

The GBD Study 2017 uses the SDI as an estimate of the socioeconomic level of a location. Chart 4-3 depicts the correlation between the SDI and the age-standardized mortality rate due to cardiomyopathy and myocarditis, per 100 000 inhabitants, both in 1990 and 2017. The correlations observed in 1990 and 2017 were similar and nonsignificant.

In a study reporting data from the SEADE, state of São Paulo, cardiomyopathies were responsible for a total of 3571 deaths, representing 23.3% of the HF-related deaths in 2006: dilated cardiomyopathy accounted for 17.2% of the deaths; alcoholic cardiomyopathy, for 0.45%; and restrictive cardiomyopathies, for 0.37%. Chagas disease and alcoholic cardiomyopathy were responsible for 7.8% and 0.45% of the HF-related deaths, respectively.153

Data of specific cardiomyopathies are scarce. A cohort study of 214 patients with HCM has reported data from a 7-year follow-up in a tertiary hospital in São Paulo, Brazil. The mean age was 37±16 years, and 52% were women. There were 22 deaths (10%), 15 directly related to HCM (11 sudden deaths). The cumulative survival rates were 94.5% at 5 years, 91% at 10 years, and 87.9% at 15 years, with an annual mortality rate of 1%, which is a low mortality considering that the study was conducted in a referral center.154

 Burden of Disease

According to the GBD 2017 estimates, the trends of age-standardized DALY rates due to cardiomyopathy and myocarditis were similar to those of mortality, with a small increase in the 1990s and a decrease during the following decades. Chart 4-4 depicts DALY rates per 100 000 inhabitants, 1990-2017, in Brazil and its regions. The West-Central region had the highest DALY rates during the first 2 decades, with a reduction after that, mostly after 2004. In 2017, the Southeastern region had the highest DALY rates, while the Northern and Southern regions had the lowest DALY rates. As shown in Table 4-6, age-standardized DALY rates were 286 (95% UI, 247-301), in 1990, and 222 (95% UI, 211-251), in 2017, per 100 000 inhabitants, a decrease of 22.4% (95% UI, -27.6 to -7). These changes are similar to those observed in the mortality rates. Despite that decrease in DALY rates, cardiomyopathy and myocarditis resulted in 328 636 (95% UI, 283 325-346 746) DALYs in Brazil, in 1990, and in 490 572 (95% UI, 465 903-556 886) DALYs in Brazil, in 2017, which represents 0.81% of all DALYs.

Table 4-7 shows the DALY rates due to cardiomyopathy and myocarditis according to sex and by age groups, from the GBD Study 2017 estimates. The age-standardized DALY rates were lower in women, and the reduction from 1990 to 2017 was more pronounced in women. The DALY rates, for women, were 234 (95% UI, 223-247) per 100 000 inhabitants, in 1990, and 153 (95% UI, 145-161) per 100 000 inhabitants, in 2017, evidencing a reduction of 34.3% (95% UI, -38.6 to -30). The DALY rates, for men, were 343 (95% UI, 262-366) per 100 000 inhabitants, in 1990, and 299 (95% UI, 280-363) per 100 000 inhabitants, in 2017, evidencing a reduction of 12.8% (95% UI, -21 to 17.6). As expected, the highest DALY rate was observed in the 70+ year group, followed by that of the 50-69 year group. Overall, DALY rates decreased from 1990 to 2017 in most age groups, increasing only in the 15-49 year group for men.

Similarly to that observed for age-standardized mortality rates, there was no correlation between the SDI and the cardiomyopathy and myocarditis DALY rates.

 Chronic Chagas Disease and Chagas Cardiomyopathy Prevalence and Incidence

The 2010 prevalence of ChD in Brazil was estimated at 1 156 821 by the World Health Organization,155which is the last official available estimate, published in 2015. According to this statement, the estimated number of subjects with ChCM in Brazil is 231 364.3Those numbers reveal a significant decreasing trend of ChD human cases in Brazil in relation to previous estimates, which was attributed to various factors, mainly the almost complete interruption of the vectorial and transfusion-related transmission in Brazil.

According to the GBD Study 2017 estimates, the age-standardized prevalence of ChD markedly reduced in Brazil, by 44% (95% UI, 42-27), from 1990 to 2017: from 1811 (95% UI, 1531-2131) per 100 000 inhabitants, in 1990, to 1011 (95% UI, 843-1198) per 100 000 inhabitants, in 2017. The prevalence of ChD in Brazil in 2017 was higher in men [1029 (95% UI, 863-1205)] than in women [991 (95% UI, 824-1186)].

In a systematic review of population-based studies on ChD prevalence in Brazil, performed from 1980 to September 2012, 42 articles with relevant prevalence data were identified from a total of 4985 references.156The pooled estimate of ChD prevalence across studies for the entire period was 4.2% (95% CI, 3.1-5.7), ranging from 4.4% (95% CI, 2.3-8.3) in the 1980s to 2.4% (95% CI, 1.5-3.8) after 2000. The estimated ChD prevalence for males and females was similar (4.1% [95% CI, 2.6-6.6], 4.2% [95% CI, 2.6-6.8], respectively). The highest pooled prevalence was observed in individuals aged >60 years (17.7%; 95% CI, 11.4-26.5), and in the Northeastern (5.0%; 95% CI, 3.1-8.1) and Southeastern (5.0%; CI, 2.4-9.9) regions and in mixed (urban/rural) areas (6.4%; 95% CI, 4.2-9.4). About 4.6 million (95% CI, 2.9-7.2 million) people are estimated to have been infected with T. cruzi in 2010. These estimates are much higher than those from the World Health Organization for 2010.155The authors have observed a high degree of heterogeneity in most pooled estimates (I(2)>75%; P<0.001).

In the NIH REDS-II Chagas retrospective cohort study, initially healthy blood donors with an index T. cruzi -seropositive donation and age, sex, and period-matched seronegative donors were followed up for 10 years.157The differential incidence of cardiomyopathy was of 1.85 per 100 person-years attributable to T. cruzi infection.

 Mortality

According to the GBD Study 2017, the number of deaths due to ChD in Brazil has decreased over the past decades (Chart 4-5). In the 1990s, ChD was responsible for 7049 (95% UI, 6816-7323) deaths, which reduced to 5493 (95% UI, 5221-6015) in 2017. The age-standardized mortality rate showed a more striking decrease (-67.5% change), from 7.3 (95% UI, 7.0-7.6) deaths per 100 000 inhabitants in 1990 to 2.5 (95% UI, 2.3-2.7) per 100 000 inhabitants in 2017, accounting for 0.4% of all deaths in the country. Men had higher age-standardized mortality rates in 2017 than women (3.1, 95% UI, 2.9-3.4; and 1.9, 95% UI, 1.8-2.1, respectively).

Table 4-8 demonstrates the total number of deaths due to ChD, the age-standardized mortality rates (per 100 000 inhabitants), for both sexes, and the percent change (%), by FU, in Brazil, in 1990 and in 2017. There is striking variability among the FU regarding the number of deaths and death rates for both years. In 1990, higher mortality rates (> 10 per 100 000 inhabitants) were observed in the states of Goiás, Minas Gerais, and Bahia, and in the Distrito Federal, with a peak in the state of Goiás (60 per 100 000 inhabitants, 95% UI, 58-66). All FUs showed a reduction in mortality rates, varying from 43% (95% UI, 52-33) in the state of Bahia to 75% (95% UI, 78-72) in the states of Minas Gerais and Goiás. Tables 4-9 and 4-10 reveal data stratified by sex.

The reduction in mortality rates was more pronounced (80% change, UI 82-77) in the age range of 5-14 years, from 2.6 (UI 2.5-2.7) to 0.5 (UI 0.5-0.6) per 100 000 inhabitants. For the other age ranges, most deaths occurred in individuals aged 70+ years, who presented the lowest percent reduction (47%, UI 51-42) during the 1990-2017 period: from 41 (UI 39-43) to 22 (20-24) per 100 000 inhabitants. The decrease in age-standardized mortality rate per 100 000 inhabitants correlates with the SDI of the Brazilian FUs (R2 = 0.40, p=0.01), and the FU with the highest SDI in 1990 presented the highest percent decrease in age-standardized mortality rate from 1990 to 2017 (Chart 4-6).

Several population-based studies have shown a reduction in mortality due to ChD in Brazil in the last decades. Martins-Melo et al.158have reported that nationwide standardized mortality rates reduced gradually, from 3.78 (1999) to 2.78 (2007) deaths/year per 100 000 inhabitants (-26.4%). Nóbrega et al.159have shown that the nationwide standardized mortality rate decreased by 32.4%, from 3.4% in 2000 to 2.3% in 2010. The mortality rate due to cardiac involvement decreased in all regions of Brazil, except for the Northern region, where it increased by 1.6%. The Northeastern region had the smallest, and the West-Central region had the largest decrease. Simões et al.160have studied the evolution of ChD mortality in Brazil from 1980 to 2014 and have forecasted the mortality from years 2015 to 2034. Those authors have estimated a progressive decline in ChD mortality, which would be highest among the young. The expected average reduction was 76.1% as compared to the last period observed (2010-2014) and the last period predicted (2030-2034). The West-Central, Southeastern and Southern regions had a reduction in the rate of ChD deaths between 2000 and 2014. The mortality rate in the Northeastern region did not statistically differ in any period analyzed, while, in the Northern region, it showed an increasing trend.

In a study analyzing all death certificates of individuals who died between 1999 and 2007 in Brazil,158based on the nationwide SIM, ChD was mentioned in 53 930 (0.6%) death certificates, as an underlying cause in 44 537 (82.6%) death certificates, and as an associated cause of death in 9387 (17.4%) death certificates. Acute ChD was responsible for 2.8% of the deaths. The mean standardized mortality rate was 3.36 per 100 000 inhabitants/year. This is 21% higher than the mortality rate considering merely the underlying cause of death (2.78 deaths per 100 000 inhabitants/year). The proportional mortality considering multiple causes of death was 0.6%. Individuals who died from ChD were predominantly males (57%), aged over 60 years (62.8%), and residing in the Southeastern region (53.6%). The West-Central region had the highest proportional mortality of all regions (2.17%).158

In the same database, calculating the mean mortality rate for each municipality of residence and using Empirical Bayesian smoothing, spatial analysis has identified a large cluster at high risk for mortality due to ChD, involving 9 states in the central region of Brazil (Chart 4-7).161

Nóbrega et al., in a descriptive study using data from the SIM of all individuals who died of ChD in Brazil between 2000 and 2010, have observed that, in the 2000-2010 period, most of the deaths (85.9%) due to ChD occurred in males aged > 60 years and were caused by cardiac involvement. During the studied period, the mortality rate decreased in all age ranges, except for that of 80 years and over (Chart 4-8).159

In a retrospective cohort study, probabilistic linkage was used to identify among blood donors from 1996 to 2000 (2842 seropositive and 5684 seronegative for ChD) those who died until 2010.162The authors have identified 159 deaths among the 2842 seropositive blood donors (5.6%) and 103 deaths among the 5684 seronegative blood donors (1.8%). Chagas seropositive donors had a 2.3 times higher risk of death due to all causes (95% CI, 1.8-3.0) than seronegative donors. Among seropositive donors, only 26 had the ICD-10 code indicating ChD as the underlying cause of death (B57.0/B57.5).162The authors have concluded that ChD is an underreported cause of death in the Brazilian mortality database.

Ayub-Ferreira et al. have compared the mechanism of death in HF due to ChCM with that of other etiologies in a prospective clinical trial, the REMADHE trial, which included patients aged 18 years or older, with irreversible chronic HF for at least 6 months and LVEF of less than 50%. Of the 342 patients analyzed, 185 (54.1%) died. Death occurred in 56.4% of ChD patients and in 53.7% of non-ChD patients. Of all ChD group deaths, 48.4% were related to HF worsening, 25.7% to sudden death, and 6.4% to stroke. The cumulative incidence of all-cause mortality and of HF mortality was significantly higher in ChD patients as compared to non-ChD patients.163There was no difference in the cumulative incidence of sudden death mortality between the two groups. In severe Chagas heart disease, progressive HF is the most important mechanism of death.

In the Bambuí Cohort Study, a large population-based cohort study of elderly residents of an endemic area for ChD, 1479 subjects aged 60 years and over (38.1% with T. cruzi positive test) were followed up from 1997 to 2007. During a mean 8.72-year follow-up, 567 participants died. T. cruzi infection was a predictor of mortality among cohort members, and this association remained largely significant after adjustments for age, sex, and conventional cardiovascular risk factors (HR = 1.56; 95% CI, 1.32-1.85). Overall, the PAR for mortality due to T. cruzi infection was 13.2% (95% CI, 9.8-16.4).164

Nadruz et al. have studied the temporal trends in PAR of ChCM for 2-year mortality among patients with HF enrolled in 2002-2004 (era 1) and in 2012-2014 (era 2) in a Brazilian university hospital. They have prospectively studied 362 (15% with ChCM) and 582 (18% with ChCM) HF patients with ejection fraction ≤ 50% in eras 1 and 2, respectively, and have estimated the PAR of ChCM for 2-year mortality. Although the absolute death rates decreased over time in the ChCM and NChC groups, the PAR of ChCM for mortality increased among patients with HF [PAR(era 1)= 11.0 (95% CI, 2.8-18.5%); PAR(era 2)= 21.9 (95% CI, 16.5-26.9); p=0.023 versus era 1], driven by increases in the HR associated with ChD.165

 Burden of Disease

Using findings from the GBD Study 2016, a study has shown that, in 2016, 141 640 DALYs (95% UI, 129 065-155 941) due to ChD were estimated in Brazil, with a relative reduction of 36.7% as compared to 1990 (223 879 DALYs; 95% UI, 209 372-238 591). Age-standardized DALY rates declined at the national level (-69.7%) and in all Brazilian FUs between 1990 and 2016, but with different regional patterns (Chart 4-9). The decrease in the DALY rates was driven primarily by a consistent reduction in the years of life lost rates, the main component of total DALY for ChD. The highest fatal and non-fatal burden due to ChD was observed among males, the elderly, and in those Brazilian FUs encompassing important endemic areas for vectorial transmission in the past, such as the states of Goiás, Tocantins, Minas Gerais, and Bahia, and the Distrito Federal.166

 Heart Failure

Because HF is not considered an underlying cause of death (i.e., garbage code) in the GBD Study, all deaths attributed to HF in death certificates are reclassified and/or redistributed to other causes, according to the GBD method. As such, there is no data from GBD on mortality from HF. Because HF is classified by the GBD as an “impairment”, the only indicators we have for HF from the GBD is prevalence and YLDs, which is the morbidity component of DALYs.

 Prevalence and Incidence

According to the GBD Study 2017 estimates, age-standardized prevalence of HF changed, in Brazil, from 818 (95% UI, 718-923), in 1990, to 772 (95% UI, 680-875), in 2017, with a decrease of 5% (95 UI, -7.1 to -3) in the period (Table 4-10). In absolute numbers, estimates for the prevalence of HF in Brazil rose from 0.67 million in 1990 to almost 1.7 million in 2017, mainly due to population growth and aging. The prevalence of HF is variable amongst Brazilian FUs, and the percent change varied unevenly between 1990 and 2017 (Table 4-11). In 2017, the highest rates were observed in the state of Rio Grande do Norte, and the lowest, in the state of Acre. From 1990 to 2017, decreased age-standardized prevalence rates were observed in most FUs, and increases in rates occurred in 8 FUs, mostly in the Northeastern region.

Table 4-12 depicts HF prevalence according to sex and age groups, from the GBD Study 2017 estimates. The HF prevalence was higher in women (795; 95% UI, 694-901) than in men (751; 95% UI, 656-845) in 2017, and the reduction in prevalence from 1990 to 2017 was more pronounced in men [the percentage of decrease was 7.5 (95% UI, -10.2 to -4.8) for men and 3.2 (95% UI, -6.5 to -0.1) for women]. Regarding age groups, there is a 10-fold increase in the incidence rates from the 15-49 year group to the 50-69 year group, as well as a 6-fold increase from the latter to the 70+ year group, and these increases are similar for women and men. From 1990 to 2017, the prevalence increased only in the 15-49 year group, while decreased in the others, probably associated with increased ischemic events in that age group.

A systematic review has evaluated the burden of HF in Latin America and has included 143 articles published between January 1994 and June 2014, with at least 50 participants aged ≥ 18 years; most studies included (64%) were from Brazil.167The patients’ mean age was 60±9 years, and the mean ejection fraction was 36±9%. The prevalence of HF was 1% (95% CI, 0.1-2.7). Of the studies included, only one assessed incidence, with 1091 individuals identified through multi-stage probability sampling in the city of Porto Alegre, Brazil. The mean age was 42.8±16.9 years, and 55% were women. The incidence of HF in the single population study providing this information was 199 cases per 100 000 person-years.168

In a population-based study in primary care of a medium-sized city in Brazil, 633 individuals aged ≥ 45 years were randomly selected and registered in a primary care program of a medium-sized city in Brazil. The mean age was 59.6±10.4 years, and 62% were females; the prevalence of symptomatic HF (stage C) was 9.3%, and the prevalence of stage B HF (structural abnormalities) was 42.7%. Of the patients with HF, 59% presented with HF-PEF and 41% presented with HF-REF.169

Another population-based study of residents in Zona da Mata, state of Minas Gerais, has involved 7113 frail elderly. The mean age was 72.4 ± 8.0 years, 67.6% were women, and the prevalence of HF was 7.9%.170

In a study that included 166 patients from the rural area of Valença, state of Rio de Janeiro, the mean age was 61 ±14 years, and 51% were men. The main etiologies were hypertensive and ischemic, and 51% of the patients had HF-REF, showing characteristics similar to those of cohorts from non-rural tertiary centers. 171

 Mortality

In a study evaluating data from the SIM, from 2008 to 2012, HF was a frequently used garbage code in Brazil. It was listed as the underlying cause of death in 123 268 (3.7%) of those records and as a multiple cause of death in 233 197 (7%). By using 2 redistribution methods to specific causes of death, only 38.7-44.8% could be reclassified to a defined cause of death with the principal diagnosis, depending on the reclassification method.172Although HF should not be considered the underlying cause of death and rather be in the chain of events that led to death, any analysis of SIM data that uses HF as the underlying cause of death from death certificates must be interpreted with caution, because it may be wrongly estimating the true burden of HF.

Data obtained from the SEADE for mortality in the state of São Paulo in 2006 evaluated 242 832 deaths in estimated 41 654 020 inhabitants.153Heart failure and etiologies associated with HF (except primary valvular disease) were responsible for 6.3% of the total deaths. For these data, there was no distribution or reclassification of the underlying causes of death, and all etiologies associated with HF were included when considering the impact of HF on total mortality.

A study of mortality due to HF in 3 states of Brazil (Rio de Janeiro, São Paulo, and Rio Grande do Sul) has included data from 2 960 857 death certificates from 1999 to 2005. The percentages of death due to HF were 3.0% in the restricted form (HF as the underlying cause of death) and 9.0% in the comprehensive form (HF mentioned in any line of the death certificate) in 1999. The percentages decreased over time and were 2.4% and 8.6%, respectively, in 2005. The mortality rates decreased in most age groups, except in the group aged 80 years or older. The rates increased with age and were clearly higher among men up to 80 years of age.173

A Brazilian cohort study has shown data of 1220 outpatients in a specialized HF clinic followed up for 26±26 months from 1991 to 2000. Patients were in functional classes III and IV, had a mean age of 45.5±11 years, and 78% were men. The main etiologies were dilated cardiomyopathy (37%), ChD (20%), and ischemic cardiomyopathy (17%). During the follow-up period, 415 (34%) patients died, and 71 (6%) patients underwent heart transplantation. Chagas disease was a predictor of poor prognosis.174

More recent data from 700 consecutive patients with HF-REF from the outpatient clinic of a tertiary health center in São Paulo, Brazil, have shown 1-year mortality of 6.8% (47 patients). The composite outcome of death and hospitalization was 17.7% (123 patients), and 7 patients (1%) were submitted to heart transplantation. The patients’ mean age was 55.4±12.2 years, and 67% were men. The main etiologies were hypertensive (26.0%), ischemic (21.9%), and Chagasic (17.0%) forms of cardiomyopathy. High levels of blood urea nitrogen and brain natriuretic peptide, as well as low systolic blood pressure, were independent predictors of 1-year overall mortality in the sample.175

In a study reporting data from a National Database of Multisite Pacemaker, including 3526 patients from 2002 to 2007 cared for at the SUS, the patients’ mean age was 59.8±13.3 years, and 66% were men. The overall survival of patients submitted to cardiac resynchronization therapy in Brazil was 80.1% (95% CI, 79.4–80.8) in 1 year and 55.6% (95% CI, 54.6–56.6) in 5 years, whereas the median overall survival was 30.3 months (IQR, 16.1–50.9). Furthermore, improved survival was observed in the cohort studied, from 2002 throughout 2007 (p=0.055).176

 Hospitalizations

Hospital admissions are main consequences of decompensated HF, resulting in worse prognosis and increasing costs. The BREATHE Study has evaluated a sample of patients admitted due to acute decompensated HF. A total of 1263 patients were included from 51 centers from different Brazilian regions in 2011 and 2012. In-hospital mortality was 12.6%, and care quality indicators based on hospital discharge recommendations were reached in less than 65% of the patients.177

Other studies reporting mortality rates before the BREATHE study178 - 180 have shown similar rates of in-hospital mortality, ranging from 9% to 17%.179

In a comparison of decompensated HF patients in tertiary care teaching hospitals in Brazil and in the US, US patients were older (P<0.01) and had higher prevalence of the ischemic etiology (P<0.01). Length of stay was significantly shorter (5 [IQR, 3-9] vs. 11 [6-19] days; P<0.001) and in-hospital mortality was lower (2.4% vs. 13%; P<0.001) in the US cohort, but fewer clinical events within 3 months after discharge were observed in the Brazilian patients (42% vs. 54%; p = 0.02). This study highlights the importance of improving knowledge about HF in Brazilian patients to improve care and outcomes.181

In the previously cited systematic review that evaluated the burden of HF in Latin America, 64% including studies from Brazil,167the hospital admission rates were 33%, 28%, 31%, and 35% at 3, 6, 12, and 24 to 60 months of follow-up, respectively. The median hospital length of stay was 7.0 [IQR, 5.20-11.00] days. In-hospital mortality was 11.7% (95% CI, 10.4%-13.0%), and the rate was higher in patients with reduced ejection fraction, ischemic heart disease, or ChD. The 1-year mortality rate was 24.5% (95% CI, 19.4-30.0).

Using data from the SUS, the number of hospitalizations and deaths due to HF were described in São Paulo, Brazil, from 1992 to 2010. The in-hospital mortality rate due to HF was 15%. Comparing between the 1992-1993 and the 2008-2009 periods, there was a 32% decrease in the number of hospitalizations due to HF (p = 0.002), a 15% increase in mortality (p = 0.004), and increased hospital length of stay due to HF (from 8.8 to 11.3 days, p = 0.001).182

In 2019, a more recent study with data from DATASUS evaluated HF admissions over a 10-year period (2007 to 2016) in Brazil, as compared to those in the state of Rio Grande do Sul and in the city of Porto Alegre (a city with several referral centers). As depicted in Chart 4-10, that study showed a decline in in-hospital mortality rates from 2007 to 2016 both in Brazil (19% decline) and in the state of Rio Grande do Sul (25% decline), and a more pronounced decline in the city of Porto Alegre (65%).183

 Burden of Disease

According to the GBD 2017 estimates (Table 4-13), the age-standardized YLD rates for HF were 112 (95% UI, 83-141) in 1990 and 109 (95% UI, 81-134) in 2017, per 100 000 inhabitants, corresponding to a 3% decrease (95% UI, -6.7 to 0.3). These changes are similar to those observed in the HF prevalence rates. Despite this decrease in YLD rates, HF resulted in 88 114 (95% UI, 64 078-112 624) DALYs in Brazil, in 1990, and in 234 169 (95% UI, 174 338-291 188) DALYs, in 2017, due to population growth and aging.

The age-standardized YLD rates were similar in women and men in 1990, but the 2017 rates were 105 (95% UI, 82-127) for men and 111 (95% UI, 80-141) for women, due to a 6.8% reduction (95% UI, 10.9 to -2.6) for men as compared to almost no reduction for women (-0.3%, 95% CI, -4.9 to 4.2). As expected, the highest YLD rate was observed in the 70+ year group, followed by the 50-69 year group. Similarly to the changes observed in prevalence, from 1990 to 2017, the greatest YLD increases were observed in the 15-49 year group.

 Health Care Utilization and Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 through 1-16)

According to data from the SUS, there were 2 862 739 hospitalizations due to HF from 2008 to 2018. This number represents one third of total clinical admissions related to cardiovascular conditions in the period studied. Unadjusted costs were R$ 3 597 824 618. In international dollars, adjusted values converted to purchasing power parity for 2018US$ were $ 866 945 691.

During the period observed, there was a reduction in the number of clinical admissions due to HF from 298 474 (157 per 100 000) in 2008 to 222 394 (107 per 100 000) in 2018, with an even reduction over the years. Despite that reduction in the number of admissions, unadjusted healthcare expenditure estimates from the direct payment for care of HF patients increased from 2008 to 2018 by almost 28%, from R$ 272 280 662 (2018 Int$ 65 609 798), in 2008, to R$ 348 832 330 (2018 Int$ 172 008 052), in 2018. The decreasing number of admissions and increased expenditure represent higher costs per admission throughout the observed period (R$ 912 in 2008 to R$ 1568 in 2018). Heart failure accounted for most costs related to clinical admissions due to cardiovascular diseases.

The economic burden of HF in Brazil has been assessed using standard cost of illness framework to assess the costs in 2015. The analysis has assessed the prevalence and associated expenditures on healthcare treatment, productivity losses from reduced employment, costs of providing formal and informal care, and lost wellbeing. The study has found that HF imposes a financial cost of R$ 22.1 billion/US$ 6.8 billion, the second of the four major heart conditions in Brazil: myocardial infarction, HF, hypertension, and atrial fibrillation.184

In the study by Nicolao et al.,183the DATASUS data of HF admissions over a 10-year period (2007 to 2016) have shown a 97% increase in the mean per-patient cost of HF-related hospitalizations from 2007 to 2016. Data from the city of Porto Alegre (a city with several referral hospitals) have shown an even more pronounced increase (135%), but also a more pronounced decrease in mortality as compared to data of Brazil (see above).

 Open Heart Transplantation and Assist Device Placement

The number of heart transplantations performed in Brazil increased from 149 in 2006 to 357 in 2016. Although the number of heart transplantations increased significantly in that period, it represents approximately one-fifth of the estimated population need. The 1-year survival was 73% (data for survival collected from 2010).185

An analysis of cost for heart transplantation in Brazil, of all consecutive heart transplant recipients at a single center from July 2015 to June 2017, has shown an average total cost for the 27 patients included of US$ 74 341, which is lower than those reported for developed countries, but exceeds the reimbursement value per patient by 60%.186

In a descriptive study of a public reference hospital in cardiology, located in the city of Fortaleza, Brazil, 16 patients have been submitted to ventricular assist device implantation from 2008 to 2015. The mean age was 40.1 ± 3.4 years, and 87.5% were men. Chagas heart disease was the main etiology (37.5%). All patients experienced complications during the use of the device, bleeding being the most often [11 (68.8%)]. Regarding the clinical outcome, 10 patients (62.5%) underwent cardiac transplantation and 5 patients (31.3%) died.187

 Future Research

Because HF is considered a garbage code when assigned as the underlying cause of death, studies investigating the better method to reclassify and redistribute this cause are needed to reduce bias and promote better data comparability to enhance health policies.

Brazilian cohort studies for cardiomyopathies are scarce, and some clinical studies in Brazil have reported HF data, but there are few multicenter studies with data from the Brazilian population. It is worth noting the importance of having data for both HF and cardiomyopathy and for both outpatients and hospitalized patients, in addition to fully understand the increasing burden of HF on cardiovascular diseases. More multicenter large-scale studies are needed to better describe the burden, outcomes, and costs of HF in the Brazilian population.

In addition, studies exploring quality of care and costs in HF would help in the development of health policies to improve awareness, access to life-saving interventions, organ donation, and the better use of resources in this complex and demanding disease.

Although mortality rates due to ChD decreased substantially in the last decades, ChD remains an important cause of death in Brazil. Indeed, there is evidence that ChD is an underreported cause of death, and, probably, of hospitalization as well. More data on the hospitalization rates and outcomes in ChCM patients are needed.

 5. VALVULAR HEART DISEASE ICD-9 424; ICD-10 I34 to I38

See Tables 5-1 through 5-4 and Charts 5-1 through 5-10

Abbreviations Used in Chapter 5
AF Atrial Fibrillation
ARF Acute Rheumatic Fever
CABG Coronary Artery Bypass Graft
CAD Coronary Artery Disease
CI Confidence Interval
DALY Disability-Adjusted Life Year
ECG Electrocardiogram
FU Federative Unit
GBD Global Burden of Disease
HIC High-Income Countries
ICD International Statistical Classification of Diseases and Related Health Problems
ICD-9 International Statistical Classification of Diseases and Related Health Problems, 9th Revision
ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision
NRVD Non-Rheumatic Valvular Disease
OR Odds Ratio
RHD Rheumatic Heart Disease
SDI Sociodemographic Index
SIM Brazilian Mortality Information System (in Portuguese, Sistema de Informações sobre Mortalidade )
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde )
TAVI Transcatheter Aortic Valve Implantation
UI Uncertainty Interval
YLL Year of Life Lost

Prevalence Rheumatic Heart Disease

According to the Global Atlas on Cardiovascular Disease Prevention and Control, RHD is estimated to currently affect about 33 million people worldwide, accounting for 1% to 1.5% (319 400 deaths) of all cardiovascular deaths.189Until the middle of the 20thcentury, RHD was the leading cause of heart valve disease in the world. Improved health conditions, early identification of Streptococcus pyogenes infections, and antibiotic use have decreased significantly RHD prevalence in HIC. Published data from 2016 have estimated that RHD is the primary cause of 2.5% of valvular heart disease in the United States of America and Canada, reaching up to 22% in Europe.190Even higher rates have been reported in Brazil, accounting for around 50% of the heart valve surgeries in the SUS.191 - 193

In low- to middle-income countries, on the other hand, the prevalence of RHD is estimated at 444 per 100 000 inhabitants.194In Brazil, RHD persists as the main etiology of heart valve diseases, especially in patients from the SUS. Previous evaluations have shown a prevalence of 3.6 per 1000 inhabitants in Brazil.195Other evaluations have found a prevalence ranging from 1 to 7 per 1000 schoolchildren.196

In Brazil, of 174 patients presenting with acute valvular heart disease to the emergency room of the São Paulo Heart Institute, rheumatic involvement was observed in 60%, followed by degenerative aortic valve disease (15%), and mitral valve prolapse (13%). In total, 27.5% of the patients had isolated mitral regurgitation and 11% had mitral stenosis, with aortic valve disease present in the remaining patients.197

A recent study in Brazil has shown that the regression rates of heart valve disease, especially in patients with moderate/severe ARF, may be lower than previously described. Only 22/69 patients had total regression of mitral regurgitation after rheumatic carditis (31.9%). Aortic regurgitation also has a lower total regression rate than that observed in studies prior to the echocardiographic era (18%). However, most cases have persisted with mild mitral or residual aortic regurgitation.198In another study involving 258 children and adolescents with ARF followed up from 2 to 15 years, valve lesions healed in 25% of the patients with mild carditis, in 2.5% of those with moderate carditis, while no healing was observed in those with severe carditis.199

According to the GBD 2017, from 1990 to 2017, the age-standardized prevalence of RHD had a slight 3.0% (95% UI, 1.6 - 4.3) increase, from 721.4 (95% UI, 688.7 - 754.5) to 743.2 (95% UI, 709 - 778.6) per 100 000 inhabitants, remaining higher in women than in men throughout the whole period (Table 5-1 and Chart 5-1.A). Although small for both sexes, the percent increase was numerically more pronounced in women (4.4%) than in men. The percent increases were higher in the states of Piauí (Northeastern region), Tocantins and Roraima (Northern region). Although the central estimates were higher in these states, the 95% UIs were wide and overlapped with those of other FUs (Table 5-1).200However, it may be hypothesized that the small increase in the RHD prevalence observed in the period may reflect the progress of epidemiological data collection and health statistics.201

The crude prevalence of RHD, however, increased 16.0% (95% UI, 14.4 – 17.5%) from 1990 to 2017, from 690.2 (657.9 – 723.6) to 800.3 (764.1 – 838.2) per 100 000 inhabitants, also remaining higher in women in the period (Chart 5-1.B). Similarly to the trend of age-standardized prevalence rates, the increase in crude prevalence was more pronounced for women than for men.200

The proportional prevalence of RHD in the Brazilian population, thus, showed the same pattern observed for age-standardized and crude prevalence, with a slight increase for both sexes from 1990 to 2017 (Chart 5-1.C).200

Even with the relatively stable trends depicted by the GBD 2017 modeling, RHD is the most prevalent cause of mitral valve disease in Brazil according to published data, when both mitral stenosis (over 90%) and mitral regurgitation (around 55-60%) are considered.197

Mitral stenosis occurs most often in women than in men, in a ratio of 3 to 2. It is a frequent sequela of ARF, affecting more than 85% of the cases even in HIC, such as those in Europe,202with a similar pattern still observed in Brazil.193 , 197 More rarely, mitral stenosis is associated with other diseases, such as mitral annulus calcification, mucopolysaccharidosis, rheumatoid arthritis, and congenital carcinoid syndrome.190 , 197

More recent large-scale screening studies, looking at subclinical RHD, have shown a prevalence of 42 per 1000 in schoolchildren with an average age of 11 years in the Southeastern state of Minas Gerais, being 37 per 1000 for borderline RHD and 5 per 1000 for definite RHD (0.5%). In that study, a higher prevalence was observed in girls (48 per 1000 vs. 35 per 1000) and in children older than 12 years.191The same project has concluded that primary care centers are the ideal scenario for RHD screening, considering the higher population participation and involvement rates.203

 Non-Rheumatic Valvular Heart Disease

According to the GBD 2017, the age-standardized prevalence of NRVD remained relatively stable in Brazil from 1990 to 2017, with a borderline 8.2% increase from 216.2 (95% UI, 207.9 - 224.6) per 100 000 in 1990 to 233.9 (224.6 - 243.2) per 100 000 in 2017. The percent change was similar for men and women (8.9% vs. 7.8%) (Chart 5-2.A). Calcific aortic valve disease, conversely, showed an increasing trend (20.4%), from 53.5 (95% UI, 48.1 - 59.9) per 100 000 in 1990 to 64.4 (95% UI, 57.2 - 72.5) per 100 000 in 2017, for both men (18.5%) and women (24.2%). For mitral degenerative valve disease and other NRVDs, the age-standardized prevalence was also stable, with slight 4.0% and 3.8% increases, respectively (Table 5-1).200

In contrast with age-standardized rates, the crude prevalence showed a compelling 89.4% (95% UI, 85.3 – 93.8) increase from 1990 [131.9 (95% UI, 126.7 – 137.5)] to 2017 [249.9 (95% UI, 239.8 – 260.1)] per 100 000 (Table 5-1 and Chart 5-2.B). The increase was homogeneous for men and women, and suggests that prevalence is increasing disproportionally in older ages (Chart 5-2.B).200

Unlike mitral valve disease, aortic valve disease is predominantly degenerative or calcific. Observational studies have shown that aortic stenosis is seen in 4.5% of the population aged over 75 years in HIC, such as the United States of America.204According to observational studies197 , 205 and the GBD 2017 data,200in Brazil, as well as in the rest of the world, an increasing trend towards degenerative aortic valve disease has been observed, as compared to other etiologies, such as RHD.

Thus, the increase in all-age prevalence of NRVD has been mostly driven by calcific aortic valve disease [114.2% (95% UI, 105.5 – 124.3)], especially for older age groups (Table 5-2), but the rates have been also significant for mitral degenerative valve disease, 79.8% (95% UI, 78.3 – 81.1), and other NRVDs, despite the limited data quality for the latter (Table 5-1). The proportional prevalence of NRVD also increased significantly for both sexes, from 1990 to 2017 (Chart 5-2.C).200

Contrary to that observed for the rheumatic etiology, there has been an increase in mitral valve prolapse as the etiology of primary mitral regurgitation in Brazil: although in the overall population it reaches rates around 1% to 2.5%, with good prognosis in most cases, among patients admitted with heart valve disease in a Brazilian emergency department in 2009 (56 ± 17 years, 54% females), 13% had that etiology.196Conversely, in a hospital registry of heart surgeries in one of the largest capitals of the country (city of Salvador), from 2002 to 2005, only a small proportion of cases was associated with mitral prolapse,193similarly to the results of a study with 78 808 patients using 2 large national databases (the Brazilian Hospital Information System and the SIM) from 2001 to 2007, in which only 0.24% (187) of the cases had reported that underlying cause.206However, data may be biased by the absence of coding for etiologies of heart valve disease in the public health system and most of the private health system.

 Incidence

According to a study based on hospital medical charts in Northeastern Brazil, from 2002 to 2005 (1320 surgeries), the mean annual incidence of cardiac valve surgeries was 4.75 per 100 000 residents and was positively associated with age. The mean annual incidences of RHD and degenerative valvular disease were 2.86 and 0.73 per 100 000 population, respectively.193

 Rheumatic Heart Disease

For RHD, the age-specific incidence followed a bimodal distribution according to the source of surgery reimbursement, increasing almost linearly by 1 case per 100 000 population for each decade of life until the age of 40–49 years, peaking at 4.85 cases per 100 000 population. Following a decline, a second peak occurred at 60–69 years of age (6.54 cases per 100 000 population).193The incidence of RHD had a small 1.9% (95% UI, 0.8 – 3.1) increase in Brazil from 21.4 (95% UI, 20.4 – 22.4) per 100 0000 in 1990 to 21.8 (95% UI, 20.8 – 22.8) per 100 000 in 2017, according to GBD 2017 data. This small increase was relatively homogeneous across the country, with overlapping 95% UIs even in the poorer states of the Northern and Northeastern states.200

In general, the increase in incidence was driven by the age groups ‘under 5 years’, 4.3% (95% UI, 2.5 – 6.2), and ‘5-14 years’, 2.9% (95% UI, 1.5 – 4.3), while, in individuals aged 15-49 years, a marked 12.1% (95% UI, -13.7 to -10.5) decrease was observed. Although this pattern is unexpected, because, in general, the incidence in younger ages declines first, followed by young adults, it may be hypothetically associated with the improvement in early diagnosis and incorporation of data on subclinical disease in the GBD modeling.200

 Non-Rheumatic Valvular Heart Disease

In a different pattern as compared to that of RHD, the NRVD incidence had a significant 7.9% (95% UI, 6.7 – 9.3) increase from 224.5 (95% UI, 217.5 – 231.6) per 100 000 in 1990 to 242.4 (95% UI, 233.8 – 250.8) per 100 000 in 2017, according to the GBD 2017 estimates. This increase was mostly driven by the 20.4% (95% UI, 16.0 – 25.4) increase in calcific aortic valve disease, markedly in individuals aged >70 years, 37.2% (95% UI, 30.6 – 44.2).200

However, the increasing incidence of calcific aortic valve disease also in individuals aged 15-49 years, 23.4% (95% UI, 18.1 – 28.7), is atypical considering disease epidemiology, and may be cautiously interpreted as a possible limitation of the GBD modeling,200because primary data for this cause are scarce in Brazil.

 Mortality

Valvular heart disease is one of the leading causes of cardiovascular death in Brazil, particularly in economically underserved regions, and RHD – the most socially driven etiology – ranked as the 8th/9thcause in past decades.19In the most underserved setting, RHD has been playing an important role for decades, with decreasing trends – not always adequately captured by statistical modeling – following socioeconomic improvement.189 , 194 , 206

Rheumatic Heart Disease

Contrasting with the increasing trend of prevalence, the age-standardized mortality rates attributable to RHD significantly decreased by 50.3% in Brazil, from 2.4 (95% UI, 2.3 – 2.5) to 1.2 (95% UI, 1.1 – 1.2) per 100 000, according to the GBD 2017 study. The percent decrease was similar for men and women (Table 5-3 and Chart 5-3.A). A similar trend was observed for the crude mortality rates (Chart 5-3.B). During the period, the total number of deaths remained stable [2648 (95% UI, 2550 - 2728) and 2682 (95% UI, 2585 – 2797) in 1990 and 2017, respectively], despite population growth (Table 5-3). These trends may reflect improvement in health conditions, and better and earlier access to healthcare.207 , 208

The proportional mortality attributable to RHD in Brazil also showed a decreasing pattern in the same period, with a less steep trend (Chart 5-3.C).207 , 208

In 1990, RHD ranked the 9thamong the causes of death in Brazil (8thto 9thin different states), and moved to the 12thin 2017 (10thto 12thin most states, remaining as the 9thonly in the state of Paraíba).207 , 208

The more compelling decrease in mortality rates was observed in lower ages, especially the ‘under-5’ and ‘5-14 year’ age groups, -82.5% (95% UI, -87.9 to -74.4) and -69.8% (95% UI, -72.4 to -65.6) per 100 000, respectively (Table 5-2).207 , 208 This may be associated with the better treatment of early and acute presentations, while chronic sequelae still persist as a challenge.

According to the GBD 2017 data, there was no correlation between age-standardized mortality rates and SDI in 1990 (r2=0.275, p=0.59) and in 2017 (r2=0.233, p=0.83). However, there was a significant correlation between the percent change in age-standardized mortality rates and SDI in 1990 (Chart 5-4) (r2=0.073, P<0.001), which did not reach statistical significance in 2017 (r2=0.064, p=0.06). Considering RHD as the most socially-driven etiology of heart valve disease, this mismatch was probably associated with: a) differences in the SDI within the FUs, with discrepant socioeconomic patterns in subregions of the states, which could bias the model; b) the percent change over the decades may represent a more precise measure of the model’s improvement, and the reduction in socioeconomic gap between the Brazilian FUs from 1990 to 2017 may have contributed to reduce the magnitude of the statistical correlation.

 Non-Rheumatic Valvular Heart Disease

According to the GBD 2017 study, age-standardized mortality rates attributable to NRVD remained relatively stable from 1990 to 2017, with a small 7.1% (95% UI, -9.1 – 13.0) increase (Table 5-3 and Chart 5-5.A). However, for crude mortality rates, the increase was significant, 87.5% (95% UI, 63.5 – 96.9), with a considerable contribution of older ages, markedly over 70 years of age, 45.6% (95% UI, 10.0 – 57.1) (Table 5-3 and Chart 5-5.B). The patterns were similar for men and women. Similar trends were observed for calcific aortic valve disease mortality rates, with a marked 108% increase in the elderly (≥70 years), reflecting the association with population aging (Table 5-2). For mitral degenerative valve disease, the age-standardized mortality rates decreased by 10.8% (95% UI, -47.6 to 2.4), as opposed to a 50.1% increase in the crude prevalence (Tables 5-1 and 5-3), as a result of the increasing rates, 17.7% (95% UI, -42.1 to 39.2), in septuagenarians and older (Table 5-2).207 , 20 8

The increasing mortality rates in older ages due to NRVD noticeably contrasts with the trends observed for RHD, possibly reflecting a higher prevalence and, consequently, mortality in the age groups >70 years, for both aortic and mitral NRVD (Table 5-2). From 1990 to 2017, an increasing burden of calcific aortic valve disease, in both males and females, associated with an increase in mortality in that age group. The 95% UIs are overall wide for NRVD mortality estimates, especially for each specific disease in separate.207 , 208

The proportional mortality attributable to NRVD in Brazil showed a marked increasing pattern in the same period, possibly driven by the steeper trends of calcific aortic valve disease (Chart 5-5.C).208

In 1990, NRVD ranked as the 10thcause of death in Brazil (8thto 11thin different states), and moved to the 9thin 2017 (8thto 10thin most states, remaining as the 11thonly in the state of Sergipe) (Chart 5-4).208

The GBD 2017 data demonstrated significant and strong correlations between the SDI and the age-standardized mortality rates of NRVD in general in 1990 (r2=0.62, p=0.002) and 2017 (r2=0.618, p=0.001), and a similar pattern for calcific aortic valve disease (1990: r2=0.65, p=0.002; and 2017: r2=0.65, P<0.001) (Chart 5-6). As the socioeconomic development correlates with epidemiological transition and life expectancy, a higher SDI is associated with more elderly individuals at risk of degenerative valvular conditions and less prone to infectious etiologies, such as RHD.

Additionally, the percent changes in age-standardized mortality rates from 1990 to 2017 also correlated with SDI in 1990 and 2017 for calcific aortic valve disease (1990: r2=0.17, p=0.005; and 2017: r2= 0.23, p = 0.003), but not for NRVD in general.

For degenerative mitral valve disease and other NRVDs, no significant correlations were observed between the SDI and the age-standardized mortality rates – or their percent changes over time.

 Burden of Disease Rheumatic Heart Disease

According to the GBD 2017 data, the age-standardized DALY rate attributable to RHD significantly decreased 40% in Brazil, from 118.9 (95% UI, 106.1 – 134.7) per 100 000 in 1990 to 76.5 (95% UI, 63.3 – 93.7) per 100 000 in 2017 (Chart 5-7.A). The decrease rates observed in the period were similar for men and women, 44.4% (95% UI, 31.2 – 42.3) and 37.9% (95% UI, 31.8 – 44.0), respectively (Table 5-4).209

Age-standardized DALY rates decreased in all Brazilian states, with a steeper trend in the regions with the highest rates in 1990: West-Central and Southeast (Table 5-2). The DALY proportion showed a more stable trend for Brazil, with a slight decrease, although an increase in the Northern and Northeastern regions persisted (Chart 5-7.B). The Southeastern and West-Central regions had the highest age-standardized DALY rates and proportional DALY during the whole period analyzed.209

A similar downward pattern was observed for the RHD age-standardized YLL rates, which ranged from 84.9 (95% UI, 81.1 – 87.8) per 100 000 in 1990 to 36.1 (95% UI, 34.8 – 37.8) per 100 000 in 2017, with a 57.4% (95% UI, 54.8 – 59.4) decrease.200 , 209

The GBD 2017 estimates showed a significant correlation between age-standardized DALY rates and SDI in 1990 (r2=0.056, p=0.001) and in 2017 (r2=0.068, p=0.001). In addition, there was a significant correlation between the percent change in age-standardized DALY rates and SDI in 1990 (r2=0.03, P<0.008), although this was not observed in 2017 (r2=0.019, p=0.146) (Chart 5-8), suggesting that the less socially developed areas in 1990 – bearing a higher disease burden – had greater room for improvement following social development over the decades.

 Non-Rheumatic Valvular Heart Disease

According to the GBD 2017, the age-standardized DALY rate attributable to NRVD decreased slightly (8.0%) in Brazil, from 42.8 (95% UI, 36.6 – 45.8) per 100 000 in 1990 to 39.4 (95% UI, 39.4 – 42.2) per 100 000 in 2017 (Table 5-4 and Chart 5-9.A). The discrete decrease in rates observed in the period was similar for men and women. Regarding specific diseases, rates decreased more significantly for mitral degenerative valve disease, -18.7% (95% UI, -9.3 to -43.4), as compared to calcific aortic valve disease and other valve diseases, although the UIs were wide in this case. The trends observed for YLLs were similar.200 , 209

The relatively stable trend was similar in all Brazilian states, and the age-standardized DALY rates remained higher for the Southern and Southeastern regions during the whole period, followed by the West-Central, Northern and Northeastern regions (Chart 5-9.A).

Similarly to that observed for mortality, the stable age-standardized DALY rates contrast with the increase of crude rates [38.7% (95% UI, 27.5 – 47.2)] in the period, again suggesting that morbidity associated with NRVD is shifting to the elderly, presumably following changes in the population age composition.209 , 210

The proportional DALY rates in Brazil increased, and, from 1990 to 2017, the Southern and Southeastern regions accounted for the highest DALY proportions in the period, according to the GBD estimates (Chart 5-9.B).209 , 210

Still according to the GBD 2017 data, there were significant correlations between the age-standardized DALY rates of NRVD in general and SDI in 1990 (r2=0.65, p=0.043), but not in 2017 (r2=0.49, p=0.067). Percent changes in age-standardized DALY rates (1990 – 2017) correlated with SDI in 1990 (r2=0.32, p=0.003) and 2017 (r2=0.33, p=0.002). For calcific aortic valve disease, significant correlations were observed between DALY and SDI in 1990 (r2=0.67, p=0.002) and 2017 (r2=0.57, p=0.004) (Chart 5-10), as well as between percent changes in DALY rates and SDI in both years, suggesting the effect of socioeconomic development also as a determinant of some types of NRVD.

For degenerative mitral valve disease and other NRVDs, however, no correlations were observed between age-standardized DALY rates – and their percent changes over time – and SDI, except for the weak association between DALY rates and SDI in 2017 (r2=0.08, p=0.02), based on the GBD estimates.

 Complications and Associated Diseases Arrhythmias associated with Valve Disease

Atrial fibrillation is also a complicating factor for patients with valvular heart disease, usually occurring in those with more advanced natural history. It is more commonly associated with mitral valve disease, especially mitral stenosis. Atrial fibrillation was observed in 34% of a cohort of 427 patients (mean age 50±16 years, 84% females) with severe mitral stenosis, being more frequent in patients who died during follow-up (27/41, 66%) as compared to survivors (114/378, 30%), reinforcing its role as a prognosis marker in heart valve disease.211

Atrial fibrillation can also develop in severe aortic valve disease, especially in older and postoperative patients. In a retrospective cohort of 348 patients, with a mean age of 76.8±4.6 years, postoperative AF was observed in 32.8% (n = 114), but rates were higher in patients aged 80 years and older (42.9% vs. 28.8% in patients aged 70-79 years, p=0.017).212

In another retrospective assessment conducted in the state of Pernambuco (Northeastern Brazil), involving 491 consecutive patients after surgery for valvular heart disease, the incidence of AF was 31.2% and associated with age >70 years (OR=6.82; 95% CI, 3.34 - 14.10, p<0.001), mitral valve disease (OR=3.18; 95% CI, 1.83 - 5.20, P<0.001), and no perioperative use of beta-blockers, among other factors.213

Valvular heart disease (17.5%) and arrhythmias (AF and atrial flutter - 50.7%) were the main cardioembolic source of stroke in a study involving 256 patients (60.2 ± 6.9 years, 132 males) in the Southern region of Brazil.214

 Association between Valvular Heart Disease and Coronary Artery Disease

Due to the increased surgical risk of combined valve procedures and coronary revascularization, it is essential to recognize the prevalence of obstructive CAD in association with valvular heart disease. Studies have shown a lower prevalence of CAD in patients with RHD as compared to those with NRVD, possibly as a reflection of the lower median age of RHD patients and the higher prevalence of coronary risk factors in individuals with NRVD.215

In a study in Rio de Janeiro (Southeastern Brazil) including 1412 candidates for cardiac surgery of any indication, 294 cases with primary valvular heart disease of rheumatic and non-rheumatic etiologies were selected. All patients were aged ≥40 years and had coronary angiography performed. The prevalence of CAD in RHD and NRVD patients was 4% and 33.6% (p <0.0001), respectively. Characteristics and risk factors, such as age, typical chest pain, hypertension, diabetes mellitus, and dyslipidemia, were significantly associated with obstructive CAD.216

In another study in Brazil evaluating 712 patients with valvular heart disease, mean age of 58±13 years, the incidence of obstructive CAD was 20%. However, in younger patients (<50 years), the prevalence was much lower (3.3%).217These data are similar to those observed in another study that included 3736 patients (mean age of 43.7 years), in which the prevalence of obstructive CAD combined with valvular heart disease was 3.42%.215

 Healthcare Utilization and Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 through 1-16)

According to the SUS administrative database, the total crude expenses (reimbursement) with hospital admissions for the clinical treatment of valvular heart disease in Brazil showed a significant 94% increase, from R$ 1 051 959 34, in 2008, to R$ 2 043 358, in 2018, in an almost-linear pattern. Adjusting and converting these values to international dollars in 2018, the total costs for the public health system were $ 1 014 294, in 2008, and $ 1 007 587, in 2018, for hospitalization due to valvar conditions.

Similarly, unadjusted costs associated with valvular surgical/interventional procedures (codes related to valve surgery, percutaneous mitral commissurotomy, other types of valvuloplasty) also increased from 2008 to 2018 (with a decrease after correction for international dollar), from R$ 130 588 598 (2018 Int$ 125 912 942) to R$ 180 735 108 (2018 Int$ 89 119 874), although with less magnitude as compared to clinical admissions (94% vs. 38%).201

The number of surgical/interventional admissions related to valve diseases did not grow much in Brazil from 2008 to 2018, ranging from 13 129 in 2008 to 14 294 in 2018. This is presumably associated with the growing complexity and costs of interventions (markedly, devices and prostheses) and denotes the economic burden posed by the incorporation of new procedures and technologies, but is also a marked effect of inflation on healthcare costs, considering values adjusted to Int$. In this scenario, the future incorporation of well-established therapies not yet reimbursed by the SUS, such as TAVI, will contribute to increase the economic burden, although expenses with judicial demands may overcome ordinary costs.218

The total number of admissions in this period was 172 126, and most of them occurred in the Southeastern region (41.2%), followed by the Northeastern (25.7%), Southern (20.2%), West-Central (7.5%), and Northern (5.4%) regions.201

A dramatic drop was observed for some types of procedures, despite their growing indications, such as the percutaneous mitral commissurotomy. For this specific procedure, the downward numbers may be associated with the lagged reimbursement tables of SUS, limiting the number of hospitals that perform this intervention. The absolute number of open valve surgeries remained stable in the period, from 12 201 (2008) to 12 088 (2018), despite the growing number of cases of valvular heart disease – especially NRVD – and the growing burden in the elderly.200 , 201

In none of the periods, the increase in the number of admissions paralleled the increasing expenses, suggesting a progressive complexity – and, consequently, cost – of the procedures to treat heart valve disease.201

From the SUS administrative database, valve procedures associated with RHD sequelae cannot be differentiated from those associated with other etiologies, since no specific coding is available, and the reporting of ICD coding is imprecise.201

Interestingly, observational studies have reinforced that RHD remain as the main etiology associated with cardiac surgery in young people in Brazil, reaching up to 60% in a study performed in the city of Salvador, Bahia (Northeastern Brazil).193Moreover, at the São Paulo Heart Institute (Southeastern region), the number of heart valve surgeries associated with RHD has increased substantially over the past 10 years, from around 400 surgeries/year in 1990 to almost 600 after 2000.219Between 2008 and 2015, there were 26 054 hospital admissions due to ARF sequelae, 45% of which due to heart disease, leading to a possibly underestimated total cost of US$ 3.5 million annually.192 , 201

Overall, valve diseases of rheumatic origin account for about 90% of the cardiac surgeries in children and over 30% of the cardiac surgeries in adults, most of them in young ages,220also according to observational studies and hospital-based registries. However, few epidemiological studies have estimated the cause-specific burden of valve diseases in Brazil.

 Mitral Valve Disease

Based on SUS administrative data from 2001 to 2007 and regarding mitral valve surgery, in a retrospective series of 78 808 consecutive surgical patients, the mean age was 50.0 years (35.9 - 62.5) and 40 106 were females (50.9%). Again, RHD was the main etiology, accounting for 53.7% of the total patients undergoing surgery, and over 94% of the patients undergoing procedures due to mitral stenosis. Mitral stenosis was the largest single surgical indication, accounting for 38.9% of the total. Overall, valve replacement was done in 69.1% of the surgeries. In-hospital mortality was 7.6%.206

Surgical mortality was slightly higher in women than in men (7.8% vs. 7.3%; p<0.001), and considerably higher in people aged ≥80 years. On the other hand, the lowest mortality was observed for those between 20 and 39.9 years (p<0.001). Patients with combined aortic and mitral surgeries (reflecting rheumatic etiology) were the youngest (median, 43.3 years). Surgery for aortic stenosis was more common in older individuals (median, 58.0 years) (p<0.001). Valve repair had lower mortality (3.5%) as compared to valve replacement (6.9%), multiple valve repair and/or replacement (8.2%), and concomitant CABG (14.6%) (P<0.001). Associated CABG occurred in 7147 patients (9.1% of the sample).206

Regarding percutaneous commissurotomy, studies in Brazil have shown a much higher proportion of females (85%) – coincident with the epidemiology of RHD and noticeably mitral stenosis – and of young people (<40 years).221 , 222

Aortic Valve Disease

A cohort of 724 consecutive patients, who underwent cardiac surgery at the São Paulo Heart Institute, has evidenced, similarly to other studies, a higher rate of women (55%) and predominance of RHD (60%). However, in that series, there was a great proportion of aortic valve disease (396 cases) as compared to mitral valve disease (306 cases) and other series. Of the patients with mitral valve disease, 39.9% had stenosis, 38.4% regurgitation, and 21.7% mitral prosthesis dysfunction. In patients undergoing aortic valve interventions, stenosis was observed in 51.6%, regurgitation in 29.3%, and prosthesis dysfunction in 19.1%. The study suggests an increase in aortic valve disease as compared to mitral valve disease in a tertiary hospital in the Southeastern region of Brazil.223

Another retrospective cohort study has been conducted in the city of Porto Alegre (Southern Brazil), with 1065 patients (mean age, 61.4 ± 11.8 years; 38% women). Aortic valve replacement was done in 18.8% and mitral valve replacement in 13.4%. Concomitant coronary revascularization was performed in 60.3% of the sample, and valve surgeries in 32.7%. Overall in-hospital mortality was 7.8%, being lower for isolated CABG (5.9%), intermediate for valve surgery (aortic and/or mitral and/or tricuspid = 8.6%), and higher for combined valvular and CABG procedures (20.0%).224

 Transcatheter Aortic Valve Implantation in Brazil

As in other countries, TAVI gained importance in Brazil in the past 20 years. It is estimated that over 100 000 percutaneous aortic valve implantations have been performed worldwide to date.205 ,2018The first TAVI implantation in Brazil occurred in 2008. The Brazilian TAVI registry has reported 418 TAVI performed in 18 centers until 2014, and this number has grown exponentially since then. Femoral access was the choice in 96.2% of the procedures, and the prostheses used were CoreValve®(86.1%) and Sapien XT®(13.9%). All-cause mortality of this initial experience at 30 days and 1 year was 9.1% and 21.5%, respectively.225

Data from the TAVI registry updated in 2017 revealed a total of 819 patients under clinical follow-up, demonstrating that the procedure has a low incidence of complications – especially early hard clinical outcomes – and highlighting rates of postprocedural renal failure around 18%.226 , 227

In another assessment performed in the city of Rio de Janeiro, of 136 patients undergoing TAVI [median age, 83 (80-87) years; 51% males], perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and 1-year mortality, 15.5%.228

Of 819 percutaneous aortic valves implanted until 2017, 135 patients (20.1%) required permanent pacemaker implantation. These patients were older (82.5 vs. 81.1 years; p=0.047), predominantly men (59.3% vs 45%; p=0.003), and had previous right bundle-branch block (OR=6.19; 95% CI, 3.56 - 10.75, p≤0.001). The use of CoreValve®prosthesis (OR=3.16; 95% CI, 1.74 - 5.72, p≤0.001) and baseline transaortic gradient >50 mm Hg (OR=1.86; 95% CI, 1.08 - 3.20, p=0.025) were independent predictors of permanent pacemaker implantation.227

 Future Research

Despite the noticeable improvement in past decades, there is still paucity of primary data about the epidemiology of valvular heart disease in Brazil, and plenty of room for future research. There are some administrative challenges for data collection and the development of nationwide registries associated with coding of hospital admissions and procedures. Especially in the SUS, the current codes do not allow discrimination of crucial variables, such as the valve involved, type of valvular dysfunction, type of prosthesis, and, especially, etiology and association with systemic diseases. Thus, refining the coding system or implementing mandatory clinical and surgical reports – as previously done for percutaneous coronary interventions – may be an initial step to improve accuracy in data acquisition.

As the country has some significant cohorts of patients with valvular heart disease, mid- and long-term follow-up of these samples should be warranted. Of note, there are research initiatives that require incentives and funding for their continuation, such as ongoing studies on long-term prognosis of subclinical RHD in children and adolescents,191 , 203 genetic and immune determinants of response to streptococcal infections leading to RHD,229clinical and procedural predictors of short- and long-term events after percutaneous mitral commissurotomy,211 , 230 and a national TAVI registry.225

Regarding echo screening for RHD, primary data suggest that the strategy seems to be cost-effective in Brazil,231but its application outside research and integration into health systems need continuing investigative efforts – as for other countries. An echocardiographic risk score to predict RHD progression has been derived from a Brazilian cohort,232but its broader validation in other settings is still pending. In addition, continuing efforts have been directed to the development of vaccines for streptococcal infections,229and collaborative studies on their efficacy and clinical application to reduce RHD burden should be warranted. In the opposite spectrum of valvular heart disease, the incorporation of TAVI in the Brazilian SUS seems to be close,232and the evaluation of its actual clinical, budgetary and social impact on public healthcare outcomes will require extensive research.

Finally, other promising strategies to provide early diagnosis and prioritization of referrals in low-resourced areas should be further investigated in Brazil. As an example, the availability of imaging modalities for the management of valvular heart disease – markedly echocardiography – is limited and unequally distributed in the country. In this scenario, the implementation of tele-echocardiography, with task-shifting of imaging acquisition to non-physicians (still not allowed by Brazilian healthcare regulations outside research) and remote reading, has been evaluated.233Despite its good overall diagnostic performance and discrimination of patients at higher cardiovascular risk,234the impact on clinical outcomes and the feasibility and cost-effectiveness of the strategy are yet to be explored. Similarly to that observed for other novel modalities such as tele-ECG, AF screening,235and remote consultations, the incorporation of imaging innovations to improve access to cardiovascular care in Brazil may require extensive discussions, based on robust scientific evidence.

 6. ATRIAL FIBRILLATION AND ATRIAL FLUTTER ICD-10 I48

See Tables 6-1 through 6-7 and Charts 6-1 through 6-3

Abbreviations Used in Chapter 6
AF Atrial Fibrillation
BNP B-type Natriuretic Peptide
CABG Coronary Artery Bypass Grafting
ChD Chagas Disease
CI Confidence Interval
DALY Disability-Adjusted Life Year
ECG Electrocardiogram
ELSA-Brasil The Brazilian Longitudinal Study of Adult Health
FU Federative Unit
GARFIELD-AF The Global Anticoagulant Registry in the FIELD-AF
GBD Global Burden of Disease
HF Heart Failure
HR Hazard Ratio
ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision
ICU Intensive Care Unit
IMPACT-AF A Multifaceted Intervention to Improve Treatment with Oral Anticoagulants in Atrial Fibrillation
INR International Normalized Ratio
NOAC New Oral Anticoagulant
OR Odds Ratio
PPP Purchasing Power Parity
SD Standard Deviation
SDI Sociodemographic Index
SUS Brazilian Unified Health System (in Portuguese, Sistema Único de Saúde)
TIA Transient Ischemic Attack
TTR Time in Therapeutic Range
UI Uncertainty Interval
VKA Vitamin K Antagonist

Prevalence and Incidence

According to the GBD Study 2017 estimates, the age-standardized prevalence rate of AF and flutter had a small increase in Brazil: from 619 (95% UI, 516-728) in 1990 to 641 (95% UI, 537-751) in 2017 per 100 000 inhabitants, for both sexes, with a 3.5% (95% UI, 1.7-5.3) change in that period. The prevalence of AF and flutter was higher in men [in 1990: 759 (95% UI, 630-893); in 2017: 787 (95% UI, 657-925)] than in women [in 1990: 499 (95% UI, 418-587); in 2017: 522 (95% UI, 440-610)], although the percent change was greater for women (4.6%; 95% UI, 2.3-7) than for men (3.7%; 95% UI, 1.4-5.9) in the period. In absolute numbers, estimates for the prevalence of AF and flutter in Brazil rose from 0.5 million in 1990 to 1.4 million in 2017, mainly due to population growth and aging (Table 6-1 and Chart 6-1). In 2017, the proportion of patients with prevalent AF was 0.67% (95% UI, 0.56-0.78).

According to the GBD Study 2017, the prevalence rate of AF and flutter is different among the Brazilian FUs, being highest in the FUs of the Southeastern region in 1990 and 2017 (states of São Paulo, Rio de Janeiro and Minas Gerais), and lowest in the FUs of the Northeastern or Northern regions (states of Maranhão, Pernambuco and Alagoas in 1990, and Maranhão, Pernambuco and Pará in 2017). That might be due to a delayed epidemiologic transition and a lower rate of diagnosis in the lowest-income FUs. Men have consistently higher prevalence rates in both time periods across the FUs (Chart 6-1).

According to the GBD Study 2017 estimates, the age-standardized incidence rates per 100 000 per-year were 44 (95% UI, 36-54) in 1990 and 46 (95% UI, 38-55) in 2017. Those rates were also higher for men in both time periods [women, 1990: 38 (95% UI, 31-45), 2017: 39 (95% UI, 32-47); men, 1990: 53 (95% UI, 43-64), 2017: 54 (95% UI, 44-65)].

Data from the ELSA-Brasil, a six-center cohort study of civil servants in Brazil that included 14 424 adults with valid ECG (45.8% men, age range 35 to 74 years), have shown a prevalence of 0.3% (48 cases) of AF and atrial flutter (men, 0.5%; women, 0.2%) in the baseline ECG. The odds of presenting AF or atrial flutter increased with age, for both sexes, with the highest prevalence in the oldest age strata, between 65 and 74 years (women: OR: 17; 95% CI, 2.1-135.9; men: OR: 52.3; 95% CI, 3.1-881.8). There was no difference in prevalence according to self-reported race, for both sexes (men: Black 0.3%, Mixed 0.4%, White 0.6%; p=0.42; and women: Black 0.3%, Mixed 0.2%, White 0.2%; p=0.84).237

The GARFIELD-AF Registry is a worldwide study that included patients (≥18 years) with AF diagnosed within the previous 6 weeks and had at least 1 additional risk factor for stroke as evaluated by the study investigator. In Brazil, 41 sites (82.3% cardiologists) included 1065 patients with non-valvular AF between 2010 and 2014 (mean age [SD]: 68 [13] years, 55% males). The prevalence of the AF types was described as follows: new-onset AF in 52% of the patients; paroxysmal AF in 25%; persistent AF in 14%; and permanent AF in 8%.238The high prevalence of new-onset AF might be attributed to the inclusion criterion: AF diagnosed within the previous 6 weeks.

Another cross-sectional population-based study in a deprived neighborhood of São Paulo, including 1524 individuals aged 65 years or older, has found AF in 2.4% of the participants (men, 3.9%; women, 2.0%).239

Telehealth systems in Brazil have provided vast epidemiological data on arrhythmias, including patients seen in primary care facilities and emergency departments. Among 262 685 patients in primary care centers, who underwent ECGs using telehealth in the state of Minas Gerais in 2011, the prevalence of AF was 1.8%, increased sharply with age (OR: 1.08; 95% CI, 1.07-1.08), and was higher in men (2.4%) in all age groups, ranging from 0.2% (20-29 years of age) to 14.6% in nonagenarians as compared to women (1.3%), ranging from 0.1% (20-29 years of age) to 8.7% in nonagenarians (OR: 1.77; 95% CI, 1.68-1.89).240 , 241

A total of 676 621 ECGs from patients (mean age 51±19 years, 57.5% women) routinely visiting 125 primary care centers from January 2009 through April 2016 were analyzed by the telemedicine service of the Federal University of São Paulo. The 7-year prevalence of AF was 2.2% (n = 14 968). The 2025 prevalence of AF in Brazil projected by that study is 1.7%.246

Of 260 879 ECGs performed between March and September 2015 at primary care centers using a telehealth system in the state of Minas Gerais, 304 (0.1%) were stratified as a cardiovascular emergency. Atrial fibrillation and flutter with low- or high-ventricular response were the cause of 22% of those emergencies.243

The prevalence of AF in 1518 individuals (mean age 58±16 years, 66% female), who were in a waiting list for echocardiogram in primary care and were screened for AF with a portable device, was 6.4%. Older age was a risk factor (9.3% vs. 4.8% in those aged over and under 65 years, respectively, P=0.001), and AF was associated with heart disease on echocardiogram (OR: 3.9; 95% CI, 2.1 - 7.2, p<0.001). The authors suggest that AF screening could be a useful primary care tool to stratify risk and prioritize echocardiogram.244

 Mortality

According to the GBD Study 2017, the number of AF deaths in Brazil have increased over the past few years, due to population growth and aging. In the 1990s, AF was responsible for 2649 (95% UI, 2428-2836) deaths, which rose to 10 059 (95% UI, 9390-10 698) in 2017. However, the age-standardized mortality rate due to AF remained stable, with a rate of 4.7 (95% UI, 4.4-5.1) deaths per 100 000 inhabitants in 1990, and of 4.8 (95% UI, 4.5-5.2) per 100 000 inhabitants, in 2017, accounting for 0.7% of all deaths in the country. Although age-standardized prevalence rates were consistently higher in men, women had higher age-standardized mortality rates in 2017 (women: 4.9, 95% UI, 4.8-5.3; men: 4.6, 95% UI, 3.9-5.2), consistent with data from other countries.245 , 246 When considering individuals aged > 70 years, the mortality rate increases from 1990 (52, 95% UI, 48-55) to 2017 (74, 95% UI, 69-79). Of note, because mortality based on vital registration data alone provides an implausibly steep increase over time, possibly due to changes in ascertainment rather than the epidemiology of AF, the GBD Study 2017 assumes, a priori , that age and sex-specific mortality rates are not increasing or decreasing over time.247As such, the small changes over time herein reported are intentionally lower than the real changes in raw data.

Table 6-2 demonstrates the total number of deaths, the age-standardized mortality rate due to AF (per 100 000 inhabitants, both sexes), and percent change, by FU, in Brazil, in 1990-2017. The FUs with the highest percentages of reduction observed between 1990 and 2017 were the states of Espírito Santo, Roraima, Goiás, and Minas Gerais, in that order. On the other hand, the FUs with the highest percentages of increase observed between 1990 to 2017 were the Distrito Federal, and the states of Alagoas and Sergipe. However, these data should be interpreted with caution because they can be inconsistent due to reporting issues. Tables 6-3 and 6-4 reveal data stratified by sex.

Regarding AF mortality rates according to age groups, the most significant increase was observed in the eldest: 70+ year group (51.6, 95% UI, 47.7-55.3 per 100 000 in 1990; and 74, 95% UI, 69.3-78.7 per 100 000 in 2017) with a percent change of 43.4 (95% UI, 35.9-50.6), followed by the 50-69 year group (2.6, 95% UI, 2.3-2.8 per 100 000 in 1990; and 2.8, 95% UI, 2.5-3.0 per 100 000 in 2017) with a percent change of 6.0 (95% UI, 0.3 - 10.9).

The GBD Study 2017 uses the SDI as an estimate of the socioeconomic level of a location. As demonstrated in Chart 6-2, there is no statistically significant correlation between the age-standardized mortality rate due to AF and flutter per 100 000 inhabitants and the SDI of the Brazilian FUs (p=0.37), possibly because the prevalence is lower in the lowest income FUs, as mentioned above.

In a prospective analysis of the Bambuí Cohort Study, – which included all dwellers aged ≥ 60 years on January 1, 1997, in Bambuí, Brazil, located in an endemic area for ChD – a total of 1462 participants with (38%) and without ChD, mean age of 69 (63-74) years, 61% women, were followed up for 10 years. Death occurred in 556 participants. The presence of AF or flutter at baseline was independently associated with an increase in all-cause mortality (HR: 2.35; 95% CI, 1.53-3.62) among patients with ChD and among those without ChD (HR: 1.92; 95% CI, 1.05-3.51).248

A study assessing 302 patients [mean age (SD), 58 (15) years; 53% women] with both valvular (32%) and non-valvular AF, followed up for 1 year, has shown a mortality rate of 10% and no difference between valvular and non-valvular AF. The causes of death were HF in 25 patients (83%), sudden cardiac death in 3 (10%), and thrombosis in a mechanical valve prosthesis in 2 (7%).249

 Burden of Disease

According to the GBD 2017 estimates, AF resulted in 226 810 (95% UI, 187 976-272 166) DALYs in Brazil in 2017, which represent 0.37% of all DALYs. The age-standardized DALY rate was 104 (95% UI, 86-124) per 100 000 in 2017, greater for men (115; 95% UI, 92-141) than for women (93; 95% UI, 79-109), although the proportion of DALYs is higher for women (0.43%; 95% UI, 0.39-0.48) as compared to that for men (0.33%; 95% UI, 0.28-0.39). Comparing to 1990, there was a small increase in DALY rates in the country by 4.6% (UI 95%, 1.7-7.2). The number of DALYs and DALY rates due to AF and flutter in 1990 and 2017, according to the Brazilian FUs, for both sexes, are reported in Tables 6-5 to 6-7.

No association between age-standardized DALY rates due to AF and SDI was found in Brazil, similarly to that reported for the age-standardized mortality rates (Chart 6-3).

 Health Care Utilization and Cost (Refer to Tables 1-6 through 1-9 and Charts 1-15 through 1-16)

From 2008 to 2018, there were 321 866 hospitalizations for AF, and 1250 ablation procedures for AF and flutter were performed by the SUS, with unadjusted costs of R$ 231 850 160 and 6 950 612, respectively. After adjusting for Brazilian inflation, the costs were R$ 418 504 911 and R$ 12 546 315, respectively. In international dollars converted to PPP-adjusted to US$ 2018, $ 403 520 568 and $ 6 701 749, respectively.

An analysis of the economic burden of heart conditions in Brazil estimated an AF prevalence of 0.8% (1 202 151 cases) in 2015. The authors estimated a total cost for AF of R$ 3921 million (US$ 1.2 billion).250

 Complications Stroke

A stroke registry in the city of Joinville has described all 429 cases of stroke that occurred in 2015. Of those, 87.2% (374/429) were ischemic strokes. Atrial fibrillation was detected in 11.4% (49/429) of the patients and in 58% (49/84) of all cardioembolic strokes.251Similarly, AF has been detected in 58% of 359 patients with cardioembolic stroke in a one-center, consecutive sample in the city of Curitiba, Brazil.252

In a retrospective analysis of 215 patients hospitalized for stroke, AF occurred in 16.3%, and there was an association of AF with increasing age: while in patients aged <65 years, the AF prevalence was 5%, in those aged > 80 years, it increased to 26% (p=0.01).253

Among patients hospitalized for acute ischemic stroke or TIA, a score system for AF diagnosis, based on clinical and echocardiographic variables, has been developed and validated in a Brazilian cohort. Age (OR: 1.04; 95% CI, 1.02-1.08), National Institutes of Health Stroke Scores at admission (OR: 1.10; 95% CI, 1.05-1.16), and the presence of left atrial enlargement (OR: 2.5; 95% CI, 1.01-6.29) were predictors of AF and TIA (C-statistic = 0.76; 95% CI, 0.69-0.83).254

 Heart Failure

In a retrospective study of 659 patients with consecutive hospitalizations due to decompensated HF in 2011, the prevalence of AF was 40% (73% permanent AF). Atrial fibrillation was associated with increasing age (P<0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (p = 0.02), higher ejection fraction (P<0.0001), and enlarged left atrium (P<0.0001). Patients with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 days versus 16.3 ± 12, p = 0.001).255

 Falls

Data from a retrospective study including 107 patients with AF and mean age of 78 years have revealed that 51% had reported at least one fall in the previous year. The risk was higher among patients with diabetes and using amiodarone.256

 Dementia

In a cross-sectional study with 1524 participants aged > 65 years, dementia was diagnosed in 11% of those with AF versus 4% of those without AF (p=0.07). The authors have found an OR of dementia of 2.8 (95% CI, 1.0-8.1; p = 0.06) among subjects with AF.257

 Atrial fibrillation type and complications

In a retrospective study, data from 407 patients treated for AF in a cardiology emergency department during the first trimester of 2012 have revealed that the prevalence of HF and stroke was higher in patients with persistent AF (n=188) and flutter (n=51) as compared to patients with paroxysmal AF (n=168) (HF: 51.2% vs. 45.1% vs. 19.7%; P<0.01; and stroke: 10.7% vs. 9.8% vs. 1.6%; P<0.01).258

 Influence of the Risk Factors on Atrial Fibrillation and Flutter

The GARFIELD-AF Registry, a non-interventional, observational, worldwide study, has included 1065 patients (≥ 18 years) with non-valvular AF diagnosed within the previous 6 weeks at 41 sites in Brazil (82.3% cardiologists). The mean (SD) age was 68 (13) years, and 55% were males. Current/previous smoking was found in 32%, hypercholesterolemia in 42%, obesity in 29%, diabetes in 25%, and hypertension in 81% of the patients.238

Among 262 685 patients in primary care centers who underwent ECGs using telehealth in the state of Minas Gerais in 2011, the self-reported prevalence of risk factors among AF patients was: hypertension, 51.8%; diabetes, 7.3%; smoking, 6.7%; dyslipidemia, 3.5%. Only hypertension had a significant association with AF in comparison with non-AF subjects (51.8% vs 31.7%; OR adjusted for age and sex: 1.32; 95% CI, 1.24–1.40).

A cross-sectional study comparing AF subjects with healthy controls has found a higher frequency of sleep apnea in the AF group as compared to the control group (81.6% versus 60%, p = 0.03).259

 Associated Diseases and Comorbidities

The incidence of AF among 300 elderly patients (mean age, 75±8 years; 56% women) monitored with pacemakers, free of AF at baseline, was 22% in a 435-day follow-up,260and reached 85% in patients with pacemakers and chronic kidney disease in a 1-year follow-up.261

In patients with cardiovascular disease who visit the emergency department, the prevalence of AF is 40% in those with decompensated HF255and 44% in those with valvular heart disease.262

A study including patients from an ICU has found an AF incidence of 11% during the ICU length of stay.263

 Perioperative atrial fibrillation and cardiovascular surgery

In the postoperative period of cardiac surgery, AF has occurred in 12% to 33% of the patients.264 -266Valve replacement surgeries were associated with a higher occurrence of AF (31%-33%) during hospitalization as compared to CABG (12%-16%).

Advanced age, mitral valve disease, and no beta-blocker use were associated with postoperative AF in valvular surgery.267Among those who underwent CABG, the postoperative AF incidence was associated with a left atrium > 40.5 mm and age > 64.5 years.268

 Atrial fibrillation and Chagas disease

Case reports have described AF in patients with orally acquired acute ChD,269probably related to acute Chagas myocarditis.

In the Bambuí Cohort Study, 1462 participants aged 60 years and over (mean age, 69 years; ChD n=557, 38.1%) with baseline ECG were followed up for 10 years; the endpoint was mortality. Atrial fibrillation was more frequently observed in ChD subjects: 6.1% vs 3.4% (OR: 3.43; 95% CI, 1.87-6.32, adjusted for age, sex, and clinical variables), and was an independent risk factor for death (HR: 2.35; 95% CI, 1.53-3.62, adjusted for age, sex, clinical variables, and BNP levels) in ChD subjects.248

In a large sample of 264 324 patients who underwent tele-ECG in a primary healthcare unit in 2011, ChD was self-reported by 7590 (2.9%). The mean age of ChD subjects was 57.0 (SD: 13.7) years, and that of non-ChD subjects was 50.4 (SD: 19.1) years, with 5% of octogenarians in both groups. Atrial fibrillation was observed in 5.35% of the ChD subjects and in 1.65% of non-ChD ones (OR: 3.15; 95% CI, 2.83-3.51, adjusted for age, sex, and self-reported co-morbidities). In octogenarians, the prevalence of AF reached 16.26% of the patients: 15.47% of women and 17.95% of men.270

In the baseline of the NIH-SaMi-Trop Cohort Study, which recruited ChD patients (n=1959, 67.5% females, median age 59, Q1-Q3: 49-69 years) with suspected cardiac disease in 21 municipalities of the Northern Minas Gerais, the prevalence of AF was 4.5%, being higher in men than in women (5.6 vs 2.6%, P<0.001) and in those with high versus normal NT-ProBNP levels (14.6% vs 2.1%, P<0.001).271

In a systematic review and meta-analysis, Rojas et al. have evaluated the frequency of electrocardiographic abnormalities in ChD in the general population. Forty-nine studies were selected, including 34 023 (12 276 ChD and 21 747 non-ChD) patients. The AF prevalence was significantly higher in ChD patients (OR: 2.11; 95% CI, 1.40-3.19).272

In a sample of 424 ChD patients under the age of 70 years (41.7% females; mean age, 47 [SD:11]), followed up for 7.9 (SD: 3.2) years, Rassi et al. have found an AF prevalence of 13.3 (SD 3.1%), with strong association with the risk of death (HR: 5.43 [2.91–10.13]) in univariate analysis.273

In 330 patients with ChD (mean age 49 ± 12 years; 58% men), 26 of whom had AF, an analysis exploring the risk factors for ischemic cerebrovascular events has found no increase in the risk of stroke among ChD patients with AF as compared to ChD patients in sinus rhythm.274

 Awareness, Treatment and Control Anticoagulation

There was a high variation in the use of anticoagulation in patients with AF, from 1.5% to 91%. Studies with samples from primary care were more likely to have low use of anticoagulation as compared to samples recruited from tertiary centers or cardiologists, as detailed below.

Among 4638 subjects with AF in primary care centers of 658 municipalities in the state of Minas Gerais, Brazil [mean (SD) age, 70 (14) years; 54% men], who underwent ECG using telehealth in 2011, the use of VKAs was reported by 1.5%, and that of aspirin, by 3.1%.241

In a study of patients from 125 primary care centers in 9 states of four Brazilian geographic regions, from January 2009 through April 2016, a subset of patients with AF (n=301) was identified, 189 (63%) of whom were at high risk for stroke; only 28 (15%) were regular oral anticoagulant users, and 102 (54%) were using aspirin.242

The GARFIELD-AF Registry is a worldwide study that included patients (≥18 years) with AF diagnosed within the previous 6 weeks and at least 1 additional risk factor for stroke as judged by the study investigator. In Brazil, among 1041 patients included (82.3% by cardiologists) between 2010 and 2014, the mean (SD) age was 68 (13) years, 55% were males, 86% had CHA2DS2-VASc score ≥ 2, 19% were not using anticoagulation therapy at baseline, 26% were only receiving antiplatelet therapy, 29% were using VKAs, and 26% were receiving NOACs.238

The IMPACT-AF,275a clustered randomized trial to improve treatment with anticoagulants in patients with AF conducted in Argentina, Brazil, China, India and Romania, has shown that two-thirds of the patients were on oral anticoagulation at baseline: 83% were on a VKA and 15% were on a NOAC. Patients from Brazil (n=360) were most often on oral anticoagulation at baseline (91%), and 27% were on NOACs. Of all patients taking VKAs in Brazil, 40.3% had INR values between 2 and 3 prior to the baseline visit.

A cross-sectional study including 162 patients from a university hospital in the city of Porto Alegre, Brazil [mean age (SD), 69 (12) years; 57% males; 96% with CHA2DS2-VASc ≥ 2], has found that 55 (34%) patients were using anticoagulants and 80 (50%) patients were on aspirin.276

A cross-sectional study from a university hospital in the city of Rio de Janeiro, Brazil, has included 659 consecutive hospitalizations due to decompensated HF, from January 2006 to December 2011. Patients with AF (n=264; 40%) had a median CHA2DS2-VASc score of 4, which was ≥ 2 in 90% of the patients. The anticoagulation rate was 53% on admission and 67% on discharge.255

A stroke registry in the city of Joinville has described all 429 cases of stroke that occurred in 2015, of which, 87.2% (374/429) were ischemic strokes. Atrial fibrillation was detected in 11.4% (49/429) of the patients and in 58% (49/84) of all cardioembolic strokes. Of the 26 patients with known prior AF, 19 (73%) were not anticoagulated, 20 (77%) had a CHA2DS2-VASc score ≥ 3, and 21 (81%) had a HAS-BLED score < 3.251

The quality of warfarin therapy has been evaluated using the parameter TTR in different samples in Brazil. In general, samples are not composed by only AF patients. Patients with AF using anticoagulants have worse TTR as compared to other indications, such as prosthetic valves. The TTR varied between 46% and 67% in the studies.249 , 277 - 279 Age > 65 years, but not health literacy, was associated with a higher TTR.278

 Rhythm or rate control (medication, cardioversion, catheter ablation)

A cross-sectional study with 167 AF patients has found that rate control was more common than rhythm control as treatment strategy (79% vs. 21%; P<0.001). In the subgroup with paroxysmal AF, both strategies were equally used (rate control, 53%; rhythm control, 47%; p = 0.69). Patients with persistent AF were more likely to be receiving rate control treatment (96% vs. 4%; P<0.001). Among those in rhythm control, amiodarone (43%), sotalol (16%), and propafenone (14%) were the drugs mostly prescribed. Beta-blockers were prescribed for 81% of the patients in rate control.280Amiodarone was mentioned by 83% of the doctors as the choice for rhythm control strategy.281

Data from 125 primary care centers have found that, among the patients with AF (n=301), 91 (30.2%) were not receiving any type of treatment for rate or rhythm control. Of the remaining 210 patients on treatment, 147 (70%) used rate control agents (beta-blockers, digoxin, diltiazem, or verapamil) and 25 (12%) used at least one antiarrhythmic drug (amiodarone or propafenone). The simultaneous use of antiarrhythmic drugs and beta-blockers was reported by 36 (17%) respondents.242

Atrial fibrillation ablation has been reported in the first Latin American Transcatheter Ablation Registry that included 742 patients for AF ablation, either first-time or re-do procedures, performed between January 1stand December 31st, 2012, in 18 centers in Brazil.282

In a one-center case series, a total of 225 patients with paroxysmal AF [64 women (29%) and 161 men (61%)] underwent catheter ablation with a recurrence of 21% among women and of 20% among men (p = 0.89) in a 1-year follow-up.283

 Future Research

The First Brazilian Cardiovascular Registry of Atrial Fibrillation: the RECALL study is a registry in AF that finished inclusion of patients in 2019 with 4584 subjects and will probably be published in 2020. It will be the largest Brazilian registry with data from all country regions regarding the characteristics and treatment of AF patients from 73 centers in Brazil.284

Ongoing cohort studies, such as the ELSA-Brasil, have the potential to fill the information gaps on incidence, risk factors, risk prediction – including genetics – and prevention of AF in Brazil. To our knowledge, there is neither an original published study with information on the incidence of AF in Brazil nor longitudinal data on risk factors.

Studies designed to screen AF in a population base or selected populations by use of ECG or screening devices are ongoing and should bring information on the relevance of including this strategy in primary care or specialized centers.

Implementation strategies to enhance anticoagulation use among AF patients should be encouraged, particularly in primary care settings.

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Source: Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade – SIM) with redistribution of ill-defined causes and correction for underreporting (according to GBD 2017 coefficients) and IBGE population.56

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from DATASUS.56 Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from Global Burden of Disease Study 2017 (GBD 2017).66

Data derived from DATASUS.56 Data derived from DATASUS.56 Data derived from the Global Burden of Disease Study 2017 (GBD 2017).109 Data derived from the Global Burden of Disease Study 2017 (GBD 2017).109 Data derived from the Global Burden of Disease Study 2017 (GBD 2017).109

– Number of deaths and age-standardized mortality rates (per 100 000) for stroke and ischemic stroke in Brazil and Brazilian Federative Units, 1990 and 2017, and percent change
Cause of death and location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.3 - Stroke
Acre 146 (140;152) 101 (96,3;104,9) 318 (297;337) 59,3 (55,4;63,1) -41,3 (-45,4;-36,8)
Alagoas 1767 (1697;1843) 138,2 (133;143,6) 2341 (2227;2457) 79,4 (75,4;83,5) -42,6 (-45,8;-39,3)
Amapá 74 (70;77) 90,1 (85;93,9) 242 (226;256) 57,7 (54;61,3) -35,9 (-40;-31,5)
Amazonas 679 (636;714) 99 (92,7;103,9) 1407 (1332;1476) 58,7 (55,7;61,7) -40,7 (-44,4;-36,6)
Bahia 6405 (6059;6787) 96 (90,8;101,7) 9239 (8841;9681) 58,3 (55,7;61,4) -39,3 (-43,1;-35)
Brazil 97101 (95272;98780) 122,9 (120,6;125) 122783 (119899;125348) 56,6 (55,2;57,8) -54 (-55,1;-53)
Ceará 3266 (3038;3496) 80,7 (74,7;86,7) 5444 (5193;5691) 54,8 (52,2;57,2) -32,2 (-37,5;-26,3)
Distrito Federal 536 (516;556) 117,2 (113;121,2) 961 (902;1028) 53,5 (49,9;57,1) -54,4 (-57,5;-51)
Espírito Santo 1972 (1914;2030) 172,1 (166,9;177,1) 2188 (2079;2303) 54,6 (51,9;57,4) -68,3 (-69,9;-66,5)
Goiás 1920 (1845;2004) 121,4 (116,7;126,6) 2925 (2779;3091) 48,2 (45,8;50,9) -60,3 (-62,4;-58)
Maranhão 2563 (2374;2779) 101 (93,1;110,6) 4261 (4020;4592) 68,9 (65;74,3) -31,7 (-36,6;-26,6)
Mato Grosso 637 (596;683) 93,3 (87,3;99,6) 1407 (1328;1491) 51,9 (48,9;55) -44,4 (-48,8;-38,9)
Mato Grosso do Sul 937 (904;973) 121,6 (117,6;126,2) 1554 (1477;1642) 60,4 (57,4;63,8) -50,3 (-53,4;-47,3)
Minas Gerais 10859 (10542;11270) 127 (123,3;131,2) 12638 (12067;13238) 50,5 (48,2;53) -60,2 (-62,2;-58,1)
Pará 2210 (2066;2326) 117,3 (109,8;123,5) 3993 (3776;4201) 66 (62,3;69,5) -43,8 (-47,6;-39,4)
Paraíba 2070 (1958;2194) 92,5 (87,4;98,1) 2856 (2642;3073) 60,8 (56,2;65,4) -34,3 (-40,6;-27,8)
Paraná 6603 (6394;6801) 174,4 (169;179,4) 7455 (7111;7818) 63,8 (60,9;66,8) -63,4 (-65,2;-61,5)
Pernambuco 5744 (5538;5948) 145,5 (140,2;150,6) 6553 (6236;6877) 68,7 (65,3;72,2) -52,8 (-55,1;-50)
Piaui 1422 (1322;1536) 106,4 (98,8;115,1) 2294 (2169;2512) 63,7 (60,2;69,6) -40,1 (-44,6;-35,2)
Rio de Janeiro 13533 (13076;13920) 160,9 (155,4;165,5) 12650 (12074;13184) 60 (57,3;62,5) -62,7 (-64,6;-60,8)
Rio Grande do Norte 1180 (1106;1257) 74,2 (69,7;79,2) 1704 (1604;1806) 45 (42,3;47,7) -39,4 (-44,7;-33,7)
Rio Grande do Sul 7282 (6967;7528) 135,4 (129,5;139,9) 8818 (8373;9257) 60,3 (57,2;63,3) -55,5 (-57,9;-53)
Rondônia 384 (357;413) 140,1 (131,2;149,5) 764 (691;849) 60,9 (55,2;67,3) -56,5 (-61,2;-51,4)
Roraima 50 (45;54) 126,6 (117,3;136,8) 152 (135;171) 61,3 (54,7;68,5) -51,6 (-58;-44,9)
São Paulo 20625 (19917;21335) 121,8 (117,5;126,1) 24963 (23878;26094) 51 (48,7;53,3) -58,1 (-60,4;-55,8)
Santa Catarina 2947 (2832;3048) 148,9 (142,8;153,8) 3539 (3358;3729) 51,9 (49,3;54,6) -65,1 (-66,9;-63)
Sergipe 919 (877;957) 110,6 (105,7;115,2) 1328 (1269;1392) 65,5 (62,5;68,7) -40,8 (-44,4;-37,2)
Tocantins 373 (330;409) 121,4 (110,6;132,1) 790 (741;853) 60,1 (56,3;64,9) -50,5 (-55,4;-44,6)
B.2.3.1 - Ischemic stroke
Acre 51 (48;54) 43,7 (41,2;45,9) 110 (102;120) 22,5 (20,6;24,4) -48,5 (-53,1;-43,4)
Alagoas 708 (669;750) 61,4 (58,2;64,9) 906 (851;964) 31,9 (29,9;34,1) -48 (-52,3;-43,7)
Amapá 29 (27;31) 43,2 (40,2;45,5) 83 (76;89) 22,9 (21;24,6) -46,9 (-51,3;-42,1)
Amazonas 247 (228;263) 43,4 (40;46,1) 492 (461;525) 22,6 (21,1;24,2) -47,8 (-52;-42,6)
Bahia 2466 (2310;2638) 40,2 (37,7;42,9) 3488 (3281;3697) 21,9 (20,6;23,3) -45,4 (-50;-40,4)
Brazil 37045 (36222;37909) 54,8 (53,6;55,9) 47453 (45939;48713) 22,6 (21,9;23,2) -58,7 (-60;-57,4)
Ceará 1279 (1165;1399) 33,5 (30,5;36,6) 2266 (2119;2411) 22,5 (21,1;24) -32,7 (-39,9;-24,2)
Distrito Federal 153 (144;162) 50,9 (48,2;53,5) 325 (299;353) 22,4 (20,6;24,3) -56,1 (-60,1;-51,7)
Espírito Santo 746 (712;782) 80,9 (77,5;84,4) 810 (759;869) 21,1 (19,7;22,6) -74 (-75,8;-71,9)
Goiás 623 (589;658) 52,2 (49,4;55,1) 1005 (940;1081) 18,1 (16,9;19,5) -65,3 (-67,9;-62,5)
Maranhão 812 (712;937) 37,2 (32,6;43) 1582 (1457;1733) 26,3 (24,3;28,9) -29,2 (-36,4;-21,1)
Mato Grosso 226 (209;245) 42 (39;45,2) 492 (459;529) 20,5 (19,1;22) -51,2 (-55,9;-46)
Mato Grosso do Sul 317 (300;334) 51,3 (48,8;54) 543 (508;584) 22,7 (21,2;24,4) -55,8 (-59,7;-51,7)
Minas Gerais 3976 (3792;4182) 56,4 (53,8;59) 4748 (4435;5040) 19,2 (17,9;20,4) -65,9 (-68,5;-63,4)
Pará 959 (890;1015) 58 (53,8;61,2) 1551 (1442;1657) 27,5 (25,5;29,3) -52,6 (-56,7;-48,4)
Paraíba 853 (787;928) 40 (37;43,3) 1163 (1065;1266) 24,2 (22,1;26,5) -39,4 (-46,7;-31,4)
Paraná 2537 (2416;2649) 82,5 (78,8;86,1) 3107 (2930;3296) 28,1 (26,5;29,8) -65,9 (-68,2;-63,6)
Pernambuco 2296 (2183;2413) 65,8 (62,7;69) 2429 (2266;2589) 26,3 (24,4;28,1) -60,1 (-63,1;-56,7)
Piaui 523 (472;587) 43,8 (39,6;49,1) 922 (859;1023) 25,6 (23,8;28,4) -41,7 (-47,5;-35,4)
Rio de Janeiro 4769 (4552;4985) 68,3 (65,2;71,3) 4520 (4224;4807) 22 (20,6;23,4) -67,8 (-70,1;-65,2)
Rio Grande do Norte 565 (523;611) 36,9 (34,2;39,8) 699 (648;751) 18,2 (16,8;19,6) -50,7 (-56,3;-44,9)
Rio Grande do Sul 3219 (3048;3377) 70,1 (66,5;73,2) 3691 (3446;3933) 25,6 (23,9;27,4) -63,4 (-66,1;-60,6)
Rondônia 110 (101;120) 61,3 (57;65,7) 282 (253;314) 25,1 (22,7;28) -59 (-63,6;-53,7)
Roraima 15 (13;16) 59,1 (54,5;64,2) 52 (46;58) 26,2 (23,2;29,3) -55,7 (-62,1;-48,8)
São Paulo 7894 (7483;8299) 56,8 (53,9;59,6) 9945 (9357;10577) 21,3 (20;22,7) -62,5 (-65,3;-59,5)
Santa Catarina 1164 (1104;1224) 71,1 (67,5;74,5) 1419 (1328;1513) 22,4 (20,9;23,8) -68,6 (-70,8;-66,1)
Sergipe 389 (367;411) 49,1 (46,2;51,8) 526 (494;559) 26,9 (25,2;28,6) -45,3 (-49,7;-40,5)
Tocantins 119 (107;132) 53,8 (48,5;59,7) 297 (275;320) 23,6 (21,9;25,5) -56 (-60,9;-49,9)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109

– Age-standardized DALY rates (per 100 000) for stroke and stroke subtypes in Brazil, 1990 and 2017, and percent change
Cause of death and age group 1990 2017 Percent change (95% UI)
B.2.3- Stroke
15-49 years 900.8 (875.2;928) 427.2 (412;442.6) -52.6 (-54.4;-50.8)
50-69 years 6472.1 (6299.3;6661.2) 2930.7 (2823.1;3041.8) -54.7 (-56.2;-53.1)
5-14 years 76.6 (65.6;82.7) 34.2 (31;37.5) -55.3 (-59.6;-49.8)
70+ years 15340.3 (14965.2;15714.6) 8044.9 (7764.8;8361) -47.6 (-49;-46.2)
Age-standardized 2511.9 (2457.3;2567.6) 1145.3 (1107.8;1185.3) -54.4 (-55.5;-53.2)
All Ages 1638.6 (1601.9;1675.6) 1225 (1185.3;1267.6) -25.2 (-27.2;-23.1)
Under 5 374.3 (302.2;473.7) 60.2 (51.7;70.9) -83.9 (-88.5;-77.8)
B.2.3.1- Ischemic stroke
15-49 years 125.4 (118.1;134) 60.6 (54.5;67.2) -51.6 (-56.6;-48.1)
50-69 years 1815 (1728.7;1901.4) 750.4 (693.5;808.9) -58.7 (-60.9;-56.4)
5-14 years 9.2 (7.6;11.3) 4.2 (3.3;5.5) -53.9 (-59.4;-48.5)
70+ years 8120.6 (7833.9;8406.8) 4071.1 (3858.5;4306.3) -49.9 (-51.8;-47.8)
Age-standardized 871.4 (841.1;902.4) 387.3 (363.8;411.5) -55.6 (-57.3;-53.8)
All Ages 489.8 (471.5;508.9) 399.7 (375.2;425.1) -18.4 (-21.8;-15.1)
Under 5 21.6 (15.5;30.9) 2.7 (2.2;3.4) -87.4 (-92.3;-79.9)
B.2.3.2- Intracerebral hemorrhage
15-49 years 551.1 (532.8;582.6) 231.9 (219.7;241.4) -57.9 (-61.3;-55.8)
50-69 years 3889.2 (3785.6;4001.8) 1681.4 (1626.7;1736.2) -56.8 (-58.4;-55.1)
5-14 years 22.7 (19;25.3) 9.7 (8.4;11) -57.2 (-64.5;-49.3)
70+ years 6557.5 (6353.6;6729.9) 3451.2 (3343.6;3564.8) -47.4 (-49.2;-45.5)
Age-standardized 1322.1 (1291.8;1358.2) 576.9 (560.7;594.9) -56.4 (-57.8;-55.1)
All Ages 893 (872.1;919.4) 626.5 (608.5;645.9) -29.9 (-32.3;-27.7)
Under 5 89.5 (56.4;137.1) 10 (7.9;12.6) -88.8 (-93.9;-79.4)
B.2.3.3- Subarachnoid hemorrhage
15-49 years 224.3 (198.4;234.1) 134.6 (127.8;146.1) -40 (-43.9;-30.9)
50-69 years 767.9 (694.1;806.4) 499 (472.4;530.5) -35 (-39.1;-28.4)
5-14 years 44.7 (38;48.3) 20.3 (18.3;22.3) -54.7 (-58.9;-47.7)
70+ years 662.2 (627.5;712.9) 522.6 (484.9;553) -21.1 (-27.7;-15.6)
Age-standardized 318.4 (287;332.2) 181 (173.1;191) -43.1 (-46.3;-37.2)
All Ages 255.7 (228.7;267.6) 198.8 (189.9;210.2) -22.2 (-26.8;-13.2)
Under 5 263.3 (204;315.7) 47.5 (40.8;56.2) -82 (-86.4;-74)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109

– Number of DALYs and age-standardized DALY rates (per 100 000) for stroke and stroke subtypes for men, in Brazil and its Federative Units, 1990 and 2017, and percent change
Cause of death and location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.3- Stroke
Acre 2185.8 (2055.7;2310) 2076.4 (1959.4;2190.7) 4056.6 (3718;4393) 1351.9 (1238.4;1462.5) -34.9 (-40.6;-28.6)
Alagoas 23037.9 (21383.3;24816.4) 3180.3 (2982.5;3389.5) 25242.2 (23619.6;26883.8) 1808.9 (1691.8;1922.6) -43.1 (-47.4;-38.5)
Amapá 1034.6 (965.2;1094.9) 1809.2 (1692.8;1912.7) 3381.8 (3134.1;3607) 1374.3 (1282.1;1461.9) -24 (-29.8;-17.9)
Amazonas 9553.6 (8816.9;10213.4) 2093.4 (1938.6;2239.5) 17349.2 (15990.9;18542.4) 1276.7 (1184.2;1362.4) -39 (-44;-33.1)
Bahia 79746.6 (73741.8;86039.8) 2199.7 (2029.8;2372.4) 105759.2 (99250.7;112353.9) 1484.6 (1393.9;1577.1) -32.5 (-38.3;-26.2)
Brazil 1340726.1 (1301608;1381197.7) 2901.8 (2824.3;2983.3) 1365881.1 (1320048.1;1415334.4) 1334.5 (1289.5;1381.5) -54 (-55.4;-52.5)
Ceará 40155.1 (36356.6;44353) 1867.9 (1704.3;2040.7) 52142.8 (49017.4;55405.8) 1187.3 (1115.9;1260.7) -36.4 (-42.4;-29.7)
Distrito Federal 8537.6 (8039.6;9059.3) 2500.7 (2380;2633.5) 11737.5 (10824.2;12680.1) 1133 (1049;1220.2) -54.7 (-58.4;-50.9)
Espírito Santo 27222.3 (26107.5;28325.5) 3603.3 (3461.5;3739.1) 24872.8 (23306.7;26481.7) 1282 (1202.4;1361.2) -64.4 (-66.8;-61.8)
Goiás 29376.9 (27812.5;31309.7) 2478.4 (2351.1;2632) 36251.9 (33907.6;38650.9) 1128.3 (1056.4;1200.3) -54.5 (-57.7;-50.9)
Maranhão 48618.1 (43268.6;54586.2) 3233.4 (2920.4;3559.2) 52331.8 (48765.6;56040.7) 1736.2 (1619.1;1857) -46.3 (-52.5;-39.3)
Mato Grosso 10626.9 (9676.9;11652.5) 2101.4 (1919.4;2294.5) 18983.8 (17675.4;20267.4) 1183.4 (1106.4;1259.7) -43.7 (-49;-37.5)
Mato Grosso do Sul 14122.2 (13298.1;14951) 2705.6 (2569.5;2851.5) 18664 (17425.5;19960.7) 1387.8 (1299.8;1482.5) -48.7 (-52.3;-44.6)
Minas Gerais 161794.5 (154754.4;170766.6) 3124.2 (2993.3;3285.8) 143536.1 (135085.5;153049.9) 1231.9 (1157.6;1313.9) -60.6 (-63.5;-57.7)
Pará 28382.9 (26206.8;30473.3) 2437.9 (2254.7;2606.9) 51273.2 (47548.3;54706.6) 1571.3 (1462.4;1670.3) -35.5 (-41.2;-29.3)
Paraíba 22193 (20368;24263.9) 1936.3 (1764.3;2121.9) 27109.7 (24423.5;30026.9) 1350.3 (1216.8;1495.6) -30.3 (-38.8;-20.4)
Paraná 92749.7 (88831.5;96784.9) 3678.5 (3538.6;3825.8) 80945 (75854.2;86058.7) 1400.7 (1313.7;1487) -61.9 (-64.5;-59.2)
Pernambuco 65395.8 (62156.5;68861.5) 2991 (2847;3142.5) 69666.6 (65443.1;74126) 1614.1 (1513.1;1713.9) -46 (-49.6;-42.1)
Piauí 19669.4 (17738.3;21781.8) 2619.3 (2388.7;2872.8) 23916.7 (22435.2;25778.9) 1448.6 (1356.9;1561.6) -44.7 (-50;-38.8)
Rio de Janeiro 184276.5 (175451.6;192077) 3962.5 (3782.2;4120.9) 137791.2 (129209;147280.8) 1484.8 (1394;1583.2) -62.5 (-65.1;-59.8)
Rio Grande do Norte 13443.1 (12350.1;14560.8) 1633.8 (1495.3;1773.6) 18039.1 (16816.2;19404) 1085.1 (1009.3;1170.2) -33.6 (-40.6;-26.1)
Rio Grande do Sul 90124.8 (85087.9;94419.2) 2897.9 (2730.7;3029.6) 85557 (78513.9;91514.3) 1310.6 (1204.4;1399.5) -54.8 (-58.2;-51.3)
Rondônia 7265.8 (6579.4;8016.9) 3011.3 (2742.2;3291.6) 9560.1 (8267.2;11057.2) 1294.1 (1124.2;1488.5) -57 (-63.3;-49.7)
Roraima 949.2 (833.8;1085.1) 2284.8 (2043.1;2564.1) 2144.1 (1803.1;2514.8) 1185.9 (1008.1;1374.6) -48.1 (-57.3;-38.1)
Santa Catarina 37772.9 (35903.6;39627.8) 3023.9 (2877.4;3170.4) 37174.2 (34286.7;39901.5) 1075 (995.5;1150.9) -64.4 (-67;-61.7)
São Paulo 306031.7 (291022;320718.4) 2950.4 (2815.7;3084) 284773.8 (266487.2;302539.1) 1234.2 (1156.7;1308.1) -58.2 (-61;-55)
Sergipe 10495.6 (9904.8;11088.7) 2433.8 (2298.2;2564.6) 14207 (13364.2;15173.1) 1497.7 (1410.4;1596.9) -38.5 (-43.4;-33.2)
Tocantins 5963.4 (4989.1;6786.8) 2363.3 (2064.7;2648.7) 9413.7 (8582.8;10360.7) 1316 (1200;1448.6) -44.3 (-51.5;-34.9)
B.2.3.1- Ischemic stroke
Acre 618.6 (570.6;666.7) 717.8 (663.9;771.4) 1173.2 (1053.7;1293.6) 441.9 (397;487.4) -38.4 (-45.2;-31.1)
Alagoas 7174.6 (6632.2;7849.1) 1129.9 (1044.1;1234.1) 8207.6 (7511.2;8930.5) 631.6 (579.3;686.7) -44.1 (-50.1;-37.8)
Amapá 321.8 (294.1;347.8) 700 (641.2;755.6) 983.4 (886.2;1080.5) 479 (432.3;523.2) -31.6 (-38.3;-24.5)
Amazonas 2794 (2546.9;3043.9) 750.3 (685.8;817.2) 4980.4 (4506.6;5491.5) 422.3 (382.8;464.2) -43.7 (-49.3;-37.3)
Bahia 23360.8 (21326.4;25677.3) 723.9 (659.9;793.4) 32950.3 (30333.4;35703.4) 486 (447.3;526.4) -32.9 (-40;-25.2)
Brazil 399936.6 (384258.7;417610.5) 1011 (973.7;1050.4) 444686.8 (419137.4;471530) 463.4 (436.9;490.2) -54.2 (-56.5;-52.2)
Ceará 11960.3 (10725.4;13374.7) 616.7 (550.4;690.6) 17787 (16310.4;19333.8) 418.8 (383.3;456.6) -32.1 (-41;-23.5)
Distrito Federal 2081.9 (1927.3;2271.5) 863.5 (801.5;934.9) 3486.6 (3111.4;3853.3) 415.1 (374.3;456) -51.9 (-56.9;-46.2)
Espírito Santo 8136.6 (7612.8;8726.9) 1280.8 (1203.2;1368.2) 7872 (7206.4;8608.3) 435.9 (399.3;475.3) -66 (-69.1;-62.6)
Goiás 7772.7 (7148.3;8470.7) 799.3 (741.5;864.3) 10856.7 (9840;11962.2) 369.8 (336.1;405.8) -53.7 (-58.1;-48.6)
Maranhão 11361.5 (10150.7;12898.4) 901.9 (799.8;1020.4) 16393.4 (14900.7;17870.1) 578.9 (527.5;630.6) -35.8 (-43.4;-26.8)
Mato Grosso 3275.8 (2935.7;3611.7) 809.8 (728.8;890) 5907.8 (5344;6475.2) 410.9 (371.6;449.3) -49.3 (-54.9;-43.2)
Mato Grosso do Sul 4003.7 (3719.2;4320.3) 920.9 (857.5;990.1) 5616.4 (5139.2;6154.2) 451.4 (413.3;493.6) -51 (-55.7;-45.4)
Minas Gerais 45397.8 (42188;49142.4) 1032 (966.8;1106.1) 45377.1 (41325.5;49776.8) 404.9 (369;443.4) -60.8 (-64.6;-56.6)
Pará 9746.8 (8897.6;10553.4) 988.9 (905.2;1067) 16640.4 (15023.9;18274.6) 567 (512.9;618.9) -42.7 (-48.5;-35.9)
Paraíba 7338.7 (6537.4;8331.7) 662.5 (589.7;752.4) 8861 (7875.9;9862.6) 451.6 (402;502.2) -31.8 (-42.2;-19.6)
Paraná 29844.1 (27803.5;31821.9) 1395.8 (1309.4;1479.1) 29745 (27186.2;32365.5) 545.8 (499;592.4) -60.9 (-64.7;-56.8)
Pernambuco 20621.5 (19138.5;22088.7) 1056.1 (986.5;1126.5) 20528.9 (18761.4;22301) 512.2 (469;555.5) -51.5 (-56.3;-46.5)
Piauí 5761.5 (5099.4;6525) 885.1 (784;1003.8) 7811.8 (7126.5;8529.2) 487.7 (445.2;532.9) -44.9 (-51.4;-37.5)
Rio de Janeiro 49857.6 (46267.7;53745.2) 1274.3 (1191;1361.4) 41594.5 (37885.7;45512.7) 476.1 (433.5;520.1) -62.6 (-66.3;-58.8)
Rio Grande do Norte 5114.5 (4628.4;5664.3) 660.2 (597.4;731) 6177.2 (5613.2;6753.1) 387.4 (351.2;423.7) -41.3 (-48.9;-33.4)
Rio Grande do Sul 31368.4 (29142.6;33607.5) 1192.5 (1112.2;1269.8) 29881.3 (26896.7;32904.7) 479.7 (434.4;526.7) -59.8 (-63.4;-55.4)
Rondônia 1976.1 (1763.6;2194.1) 1102.7 (997.2;1205.7) 3130.3 (2728.8;3606.5) 471.6 (411.8;543.1) -57.2 (-63.5;-49.8)
Roraima 232.6 (203.3;266.8) 829.1 (738.7;936) 622.5 (532.3;717.9) 422.1 (361.6;485.3) -49.1 (-57.1;-39.7)
Santa Catarina 12066 (11272.6;12969.4) 1161.9 (1090.7;1245.2) 12855.1 (11617.8;14085.1) 406.9 (370.4;444.8) -65 (-68.3;-61.2)
São Paulo 92643.3 (86120.5;99963.6) 1076.5 (1003.8;1149) 97487.5 (88497;106189.9) 452.3 (411.4;491.7) -58 (-62;-53.9)
Sergipe 3514.4 (3243.3;3784.8) 896.1 (827.4;963) 4688.6 (4301.9;5103) 537 (492.6;584.8) -40.1 (-46.2;-32.9)
Tocantins 1590.9 (1380.1;1806.6) 799.2 (704.9;903.2) 3070.7 (2762.7;3412.2) 454.9 (409.6;504.6) -43.1 (-50.8;-33.4)
B.2.3.2- Intracerebral hemorrhage
Acre 1167.7 (1091.3;1249.8) 1103.5 (1027.3;1177) 2307.8 (2068.3;2536.5) 749.5 (674.7;823.3) -32.1 (-39.6;-23.9)
Alagoas 12772.1 (11548.1;13954.3) 1755.3 (1608.7;1896.2) 14334.6 (13275.7;15483.4) 1004.8 (929.5;1085.5) -42.8 (-48.1;-36.7)
Amapá 560.5 (514.3;598.7) 932.7 (858.7;997.3) 1937.6 (1732.9;2099.3) 748.9 (677.5;810.1) -19.7 (-27.5;-11)
Amazonas 5416 (4917.7;5858.5) 1146.7 (1043.6;1240.1) 10027.2 (8951.6;10869.8) 713.8 (645.2;772.7) -37.8 (-44;-30.6)
Bahia 44882.2 (40975.9;49072.8) 1234.7 (1126.8;1348.4) 59717.2 (55175.3;64266.8) 825.2 (762.5;886.5) -33.2 (-40.1;-25.3)
Brazil 770369.3 (745080;807453.6) 1601 (1552.2;1665.3) 746738 (720304;771926) 709.9 (684.6;733.7) -55.7 (-57.5;-53.9)
Ceará 21836.7 (19497.2;24283.5) 1026.3 (913.7;1136) 27995 (25907.6;30104.9) 631 (584.4;678.5) -38.5 (-44.8;-30)
Distrito Federal 5129.2 (4782;5672.3) 1378.5 (1293.1;1493.8) 6413 (5860.8;7055.5) 577.3 (530.7;632.9) -58.1 (-62.2;-53.6)
Espírito Santo 15950.1 (15082.9;17014.5) 2001.8 (1896;2121.2) 13712.2 (12714;14769.9) 687.1 (637.9;738.7) -65.7 (-68.6;-62.6)
Goiás 17762.5 (16634;19235.8) 1430.3 (1342.8;1543.6) 20310.6 (18792.9;21876.5) 613.1 (566.7;659.2) -57.1 (-61.3;-52.8)
Maranhão 28903.2 (24480.3;33872.2) 1930 (1685.5;2188.7) 28870.1 (26565.9;31653.8) 946.4 (871.3;1037.4) -51 (-58.3;-42.1)
Mato Grosso 5628.1 (5070.6;6250.4) 1062.2 (956.7;1176.1) 10360.1 (9507.4;11268.1) 622.6 (573.7;675.4) -41.4 (-48.1;-33.7)
Mato Grosso do Sul 8383 (7809.6;8980.7) 1528.5 (1437.3;1632.1) 10743.1 (9937.4;11597) 776.6 (718.3;836.1) -49.2 (-53.7;-44.1)
Minas Gerais 96380.6 (91111.2;106323.6) 1776.3 (1681.8;1936) 78424.5 (72806.4;84694.7) 659.8 (613.3;712.3) -62.9 (-66.6;-59.4)
Pará 15142.2 (13771.6;16408.1) 1245 (1128.4;1348.2) 28065.2 (25497.2;30355.1) 832.9 (758.6;901.5) -33.1 (-40.6;-24.6)
Paraíba 11940.1 (10701.6;13143.1) 1052.4 (943.8;1157.3) 15086.6 (13425.1;17023.7) 746.3 (664.9;841.2) -29.1 (-39;-17.3)
Paraná 52954.5 (49873.2;56180.2) 1974.1 (1867.5;2087) 41469.1 (38186.9;44696.4) 694.9 (641.3;748.6) -64.8 (-68.2;-61.6)
Pernambuco 38213.7 (35818.5;40711.7) 1697.4 (1591.6;1806.2) 40983.9 (38031;44233.3) 927.6 (861.4;998.2) -45.4 (-49.9;-40.2)
Piauí 11080.4 (9834.8;12452) 1461.3 (1308.5;1628.8) 13195.7 (12198.6;14309.5) 791.9 (731.9;859.9) -45.8 (-51.9;-38.3)
Rio de Janeiro 112722 (106431.2;121878.2) 2297.5 (2175.7;2458.4) 79599.8 (73519.4;85665.3) 832.6 (772;895.4) -63.8 (-66.8;-60.5)
Rio Grande do Norte 6460 (5806.7;7074.2) 795 (712.9;873.8) 9624.8 (8747.5;10531.3) 571.4 (519.9;624.3) -28.1 (-37.1;-17.4)
Rio Grande do Sul 49620.5 (46236.1;52719.3) 1469.8 (1370.4;1556.4) 46196.2 (41693.4;49971.8) 687 (620.3;740.7) -53.3 (-57.8;-48.8)
Rondônia 4291.7 (3827.1;4779.5) 1649.2 (1485.9;1829.5) 5219.4 (4433.5;6116.6) 681.4 (579.1;794.2) -58.7 (-65.9;-50.3)
Roraima 540.1 (467.9;624.4) 1208.3 (1063.9;1371.2) 1177.9 (971;1399.6) 616 (514.5;726.2) -49 (-59.4;-37.6)
Santa Catarina 21310.9 (20042.4;22571.8) 1599.1 (1505.4;1692.3) 19391.8 (17418.6;21070.9) 538.4 (485.1;583.1) -66.3 (-69.7;-63)
São Paulo 172309 (162089.8;184997.1) 1566.5 (1474;1673.6) 148579.1 (137505.7;159473) 622.3 (576.6;667) -60.3 (-63.5;-56.5)
Sergipe 5586 (5171.6;5990.8) 1301.8 (1199.4;1396) 7869.5 (7245.8;8471.6) 807.4 (743.9;870.3) -38 (-44.4;-30.7)
Tocantins 3426.4 (2825.3;3946.7) 1306.7 (1114.8;1488.8) 5125.9 (4593.1;5697.7) 703.9 (629.4;782.3) -46.1 (-53.8;-35.7)
B.2.3.3- Subarachnoid hemorrhage
Acre 399.5 (338.4;452.9) 255 (224.7;282.1) 575.6 (512.3;647.3) 160.5 (142.9;180.2) -37.1 (-46.3;-25.3)
Alagoas 3091.2 (2560.5;3728.8) 295.1 (256.9;338.7) 2700.1 (2424.9;3128.4) 172.5 (155.2;198.2) -41.5 (-51.6;-28)
Amapá 152.3 (137.1;172.9) 176.6 (159.2;208.9) 460.9 (405.1;563.3) 146.5 (129;179.3) -17.1 (-28.4;-3.6)
Amazonas 1343.6 (1203.1;1505.9) 196.3 (176.8;224.8) 2341.6 (2099;2674.1) 140.6 (126.5;160.4) -28.4 (-37.6;-17.3)
Bahia 11503.7 (10112.3;12962.3) 241.1 (213.5;272.3) 13091.8 (11817.2;15500) 173.4 (156.8;204.8) -28.1 (-37.4;-15.5)
Brazil 170420.1 (137803.5;181911.2) 289.9 (237.9;307.2) 174456.3 (165617.4;190897.1) 161.2 (152.9;175.4) -44.4 (-48.2;-31.2)
Ceará 6358.1 (4960.5;8487.7) 224.9 (181.7;281.6) 6360.8 (5714;7533.9) 137.4 (123.6;162) -38.9 (-51.8;-23.8)
Distrito Federal 1326.5 (1012.9;1471.9) 258.7 (192.2;284.4) 1837.9 (1527.4;2085.5) 140.6 (113.6;158.6) -45.7 (-52.6;-36.5)
Espírito Santo 3135.6 (2225.9;3470.1) 320.7 (225.1;353.4) 3288.6 (2923.6;3700.8) 159 (141.6;178.1) -50.4 (-57.2;-31.6)
Goiás 3841.6 (3321.9;4212.2) 248.8 (213.8;272.9) 5084.6 (4525.1;5969.8) 145.5 (130.1;169.2) -41.5 (-48.9;-27.5)
Maranhão 8353.4 (6626.3;10082.5) 401.5 (324.6;464) 7068.2 (6109.5;7958.4) 210.9 (181.9;237.7) -47.5 (-55.7;-34.1)
Mato Grosso 1723 (1532.7;1937.7) 229.3 (203.9;259.4) 2715.9 (2409.9;3105) 149.9 (133.5;169.8) -34.6 (-43.9;-24.4)
Mato Grosso do Sul 1735.6 (1459.8;1929.6) 256.1 (216.3;282.8) 2304.4 (2053.5;2587.7) 159.7 (142.7;178.4) -37.7 (-46.5;-26.4)
Minas Gerais 20016 (14378.2;22114) 315.9 (228;348.2) 19734.6 (17598.5;21729.3) 167.2 (149.8;183.9) -47.1 (-53.4;-30.5)
Pará 3493.9 (3052.8;3985.1) 204 (180.5;243) 6567.6 (5796.3;7642.6) 171.5 (151.3;200.7) -15.9 (-26.5;-2.6)
Paraíba 2914.1 (2445;3552.5) 221.5 (186.3;261.9) 3162 (2739.4;3774.1) 152.3 (132;181.2) -31.2 (-44.8;-12.3)
Paraná 9951.1 (7039.7;10916.8) 308.7 (213.4;339.7) 9730.8 (8612.3;10810.2) 160 (141.5;176.9) -48.2 (-54.6;-32.2)
Pernambuco 6560.6 (5947.2;7353.4) 237.5 (216.1;264.8) 8153.8 (7346.1;9731.2) 174.3 (157.3;207.5) -26.6 (-35.5;-15.6)
Piauí 2827.6 (2252.6;3497.2) 273 (224.6;324.2) 2909.2 (2626.4;3236.3) 168.9 (152.7;187.7) -38.1 (-49;-24.2)
Rio de Janeiro 21696.8 (12606.3;24282.3) 390.7 (228.4;436.3) 16596.8 (14887;18587.5) 176.1 (157.6;196.4) -54.9 (-61.3;-27.9)
Rio Grande do Norte 1868.7 (1569.2;2321.5) 178.6 (151.8;242.9) 2237 (1953.7;3000.2) 126.3 (110.4;169.3) -29.3 (-41.4;-13.1)
Rio Grande do Sul 9135.9 (8004;9984.6) 235.6 (207.7;257.1) 9479.5 (8496.8;10627.1) 143.9 (129.5;161.1) -38.9 (-46;-29.1)
Rondônia 998 (861.6;1120.5) 259.4 (226.5;292.9) 1210.5 (998.6;1457.5) 141.1 (116.3;169) -45.6 (-56.4;-32.5)
Roraima 176.6 (151.6;207.6) 247.4 (214.1;288.5) 343.6 (283.1;418.6) 147.7 (122.5;178.1) -40.3 (-52.6;-26)
Santa Catarina 4396 (3777.2;4803.4) 262.9 (223.5;286.9) 4927.3 (4405.4;5845.1) 129.8 (117;151.9) -50.6 (-57.1;-36.4)
São Paulo 41079.4 (30860;45135.8) 307.4 (238.8;335.9) 38707.2 (35088.4;43735.2) 159.6 (144.9;178.4) -48.1 (-54.5;-31.5)
Sergipe 1395.2 (1215.1;1623.4) 235.9 (209.6;267.2) 1648.9 (1489.4;1907.3) 153.3 (138.8;176.8) -35 (-44.4;-23.1)
Tocantins 946.1 (683.9;1191.2) 257.4 (195.8;315.3) 1217 (1071.4;1397.6) 157.3 (138.6;181.4) -38.9 (-51.6;-20.1)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109

– Number of DALYs and age-standardized DALY rates (per 100 000) for stroke and stroke subtypes for women, in Brazil and its Federative Units, 1990 and 2017, and percent change
Cause of death and location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.3- Stroke
Acre 1767.8 (1667.5;1870.6) 1862.6 (1754.2;1968.1) 3210.2 (2987;3441.9) 1026.8 (954.3;1102.8) -44.9 (-49.1;-40.5)
Alagoas 20195.9 (18814.5;21710) 2493.7 (2346.1;2633.1) 24797.1 (23207.9;26570.3) 1438.5 (1347.2;1540) -42.3 (-46.8;-36.9)
Amapá 885.9 (829.3;941.5) 1535.4 (1426.6;1629.7) 2656 (2406.8;2886.7) 998.8 (904.3;1088) -34.9 (-40.6;-29)
Amazonas 8123.3 (7479.5;8682.2) 1784.6 (1640.3;1906.5) 14351.6 (13285.1;15406.9) 1007.4 (932.8;1079.1) -43.5 (-48.1;-38.3)
Bahia 77106.2 (71098.5;83950.6) 1933.3 (1780.5;2103.5) 89411.6 (83626.9;95362.2) 1033.8 (966.7;1102) -46.5 (-51.4;-41.3)
Brazil 1107653.4 (1072336.2;1140018.5) 2162.9 (2095.1;2225.5) 1228780.5 (1175631.6;1283687.7) 990.7 (947.7;1034.7) -54.2 (-55.9;-52.7)
Ceará 37337.5 (33441.1;40681.5) 1555.4 (1404.6;1695.6) 51423.9 (47690.4;54659.7) 951.5 (881.9;1012.3) -38.8 (-44.5;-32.1)
Distrito Federal 8067.4 (7639.3;8468) 2039.3 (1936;2134.4) 10665.5 (9807.7;11556.2) 770.8 (709.6;836.4) -62.2 (-65.4;-58.8)
Espírito Santo 21284.7 (20412.8;22164.8) 2644.9 (2544.4;2750.1) 21595.1 (20097.5;23121.8) 941.9 (877;1008) -64.4 (-67;-61.7)
Goiás 23755.9 (22547.1;25022.6) 2280.3 (2172.2;2397.1) 30858.1 (28577.4;33385.6) 870.2 (806.8;940.7) -61.8 (-64.7;-58.9)
Maranhão 26645.2 (23289;30127.1) 1598.1 (1391.9;1827.3) 38732.2 (35890.3;42214.2) 1118.5 (1036;1221.3) -30 (-37.8;-20.8)
Mato Grosso 7767.3 (7044.7;8529.5) 1700 (1544;1865.8) 14325.6 (13207.9;15664.7) 918.2 (846.6;1003.1) -46 (-52.2;-38.9)
Mato Grosso do Sul 10877.7 (10222.6;11460.6) 2195.2 (2083.8;2306.8) 15366.3 (14302.6;16510.3) 1046.1 (973.5;1122.9) -52.3 (-56.3;-48.4)
Minas Gerais 123754.1 (117958.9;129630.2) 2196.3 (2102.1;2298.1) 127819.1 (119352.2;136487.9) 939 (876.7;1002.2) -57.2 (-60.1;-54.4)
Pará 25165.5 (23222.5;26905.8) 2068.3 (1909.5;2211.6) 37338 (34648.9;39990.2) 1071.3 (992.2;1149.1) -48.2 (-52.7;-43.4)
Paraíba 22951.4 (21103.1;24889.3) 1790 (1649;1937.3) 27800.7 (25165.5;30858.9) 1093.1 (988.4;1214.1) -38.9 (-45.7;-30.9)
Paraná 68876 (65849.9;71792.3) 2694.2 (2581.2;2801.1) 70346.7 (65904.8;75129.8) 1027.9 (964.2;1097.5) -61.8 (-64.3;-59.1)
Pernambuco 65476.7 (62212.1;68590.4) 2548.1 (2424;2666.7) 66471.3 (61893.2;70853.2) 1189.6 (1108.5;1266.9) -53.3 (-56.3;-50)
Piauí 14762.7 (13259.2;16152.3) 1745.7 (1576.7;1913.4) 21016.8 (19347.1;23129.4) 1080.9 (996;1188.6) -38.1 (-44;-30.8)
Rio de Janeiro 163177.5 (155826.3;170272.8) 2857.2 (2732.3;2972.6) 135969.3 (127343.8;144657.3) 1113.5 (1043.6;1182.9) -61 (-63.6;-58.3)
Rio Grande do Norte 12237.7 (11243.8;13264.5) 1354.1 (1243.1;1464.4) 16462.8 (15243.4;17811.1) 800.9 (741;867.3) -40.9 (-46.3;-34.5)
Rio Grande do Sul 82214.5 (78371.8;85849.8) 2219.2 (2112.8;2314.9) 84773.5 (78795.6;90367.8) 1020.9 (950.7;1088.9) -54 (-57.2;-50.6)
Rondônia 4807.8 (4391.3;5259.5) 2385 (2193.9;2590.8) 7762.8 (6762.2;8807.3) 1058.4 (926.2;1198.1) -55.6 (-62.1;-48.7)
Roraima 619.9 (547.3;696.3) 2014.6 (1792.5;2238) 1500.1 (1285.1;1737.4) 914.8 (787.5;1048.3) -54.6 (-62;-45.2)
Santa Catarina 32138 (30574;33582.2) 2345.2 (2228.7;2447.9) 34801.4 (32383.6;37454.8) 846.2 (788.9;910.2) -63.9 (-66.6;-61.2)
São Paulo 233492.6 (222621.3;243756.9) 2013.9 (1920.5;2105.9) 257929.8 (239779.5;274998.1) 894 (832.2;952.5) -55.6 (-58.7;-52.6)
Sergipe 9537.5 (8911.3;10080.5) 1935.3 (1815.6;2042.8) 13345 (12402.1;14314.6) 1112.9 (1034.8;1191.9) -42.5 (-47.1;-37.1)
Tocantins 4626.6 (3885.4;5271.5) 2097.4 (1835.7;2348.9) 8049.8 (7349.6;8763.6) 1151.2 (1051.9;1253.8) -45.1 (-52.1;-36.8)
B.2.3.1- Ischemic stroke
Acre 444.9 (409.5;479.3) 608.7 (561.8;654.7) 902.7 (811.5;996.9) 326.8 (294.5;360.3) -46.3 (-51.5;-40.3)
Alagoas 6023.2 (5547.1;6516) 856.7 (788.5;926.5) 7766.5 (7055.1;8495.2) 470.6 (428;514.9) -45.1 (-50.8;-38.9)
Amapá 265.9 (242.6;289.3) 581.6 (530;629.3) 765.2 (674.4;854.7) 336.3 (297;375.7) -42.2 (-48.1;-35.8)
Amazonas 2290.6 (2070;2488.4) 624 (566.8;677.8) 4150 (3727.4;4582.2) 329.5 (295.8;363.5) -47.2 (-52.5;-41.2)
Bahia 22713.7 (20772.4;24878.4) 623.8 (569.8;683.6) 27251.9 (24803.3;29866.6) 310.7 (282.1;341) -50.2 (-55.4;-44.5)
Brazil 331981.3 (316368.4;347711) 747.7 (713.7;780.1) 401935.6 (371989.2;433351) 326.3 (302.2;351.8) -56.4 (-58.8;-54.1)
Ceará 10460.7 (9309.4;11614.4) 483.2 (430.3;536) 17418.5 (15794.8;18990.5) 315.7 (285.6;344.3) -34.7 (-42.2;-25.5)
Distrito Federal 1824.5 (1676.1;1966.4) 685.8 (636.7;737.7) 3106.5 (2760.9;3501.9) 266.2 (237.8;298.3) -61.2 (-65.4;-56.8)
Espírito Santo 6145.4 (5729.6;6600.7) 927.7 (871.2;989.9) 6859.1 (6208.3;7536.9) 304 (275.3;334.3) -67.2 (-70.2;-63.9)
Goiás 6143.4 (5644.8;6602.7) 804.8 (746.4;862.9) 9041.8 (8039.9;10070.3) 277 (247.5;307) -65.6 (-69;-61.8)
Maranhão 6015.4 (5053;7099.9) 444.2 (367.5;530.1) 10822.4 (9615.6;12156.4) 324.4 (288.3;364.7) -27 (-37.1;-14.1)
Mato Grosso 1936.9 (1730.7;2144.1) 579.9 (519.9;639.6) 4094.2 (3653.7;4555.7) 300.5 (269;333.6) -48.2 (-54.3;-40.9)
Mato Grosso do Sul 2719.9 (2519.2;2923.8) 696.2 (644.8;746.8) 4484.7 (4031.8;4957.1) 324.5 (292.4;358.5) -53.4 (-58.3;-48.2)
Minas Gerais 35992.5 (33442.6;38488.3) 745.3 (697.4;793.9) 41120.2 (37036.1;45138.4) 296.9 (267;326.4) -60.2 (-63.8;-56.4)
Pará 8549.8 (7800.8;9221) 821.7 (750.3;883.5) 11848 (10668.4;13072.2) 370.9 (334.4;408.8) -54.9 (-60;-49.8)
Paraíba 6790.1 (6100.7;7542.4) 562.3 (505.8;621.7) 9145.2 (8214.6;10210.5) 345.4 (310;386.5) -38.6 (-46.9;-30)
Paraná 21328.3 (19837.5;22825.2) 1018.3 (954.7;1085.5) 25351.3 (22978.4;27818.6) 381.4 (346;418.7) -62.5 (-65.9;-58.8)
Pernambuco 20813.8 (19337.3;22311.5) 897.4 (835.9;959.7) 20486 (18571.5;22484.9) 371.3 (336.9;407.6) -58.6 (-62.6;-54.3)
Piauí 3806.7 (3359.2;4298.2) 518 (458.2;583.8) 6861.3 (6175.8;7614.2) 348.2 (313.2;386.4) -32.8 (-40.7;-24)
Rio de Janeiro 45951.2 (42906.6;49127.3) 911.1 (852.2;970.1) 42263.4 (38418.9;46502.1) 336.1 (305.4;369.6) -63.1 (-66.4;-59.5)
Rio Grande do Norte 4389.4 (3954;4826.9) 516.8 (465.8;567.9) 5556.1 (4975.4;6161.1) 265.8 (237.2;294.6) -48.6 (-54.5;-41.7)
Rio Grande do Sul 29458.4 (27295.1;31550.4) 895.7 (833.5;953.9) 31776.4 (28691.4;34814.6) 367.6 (331.6;403.4) -59 (-62.7;-55.1)
Rondônia 1058.6 (955.1;1174.3) 804 (731.9;882.3) 2282.1 (1981;2588.8) 357.4 (311.9;404) -55.5 (-62.1;-48.7)
Roraima 140 (122.6;157.4) 739.9 (656.3;827) 433 (371.9;499.1) 331.8 (287.4;379.6) -55.2 (-62.2;-46.2)
Santa Catarina 10349.1 (9571.8;11121) 910.1 (847;972.5) 12306.8 (11098;13645.2) 310.4 (281;342.7) -65.9 (-69.2;-62.4)
São Paulo 72124.2 (66732.6;77418.9) 733.7 (681.9;784.3) 89212.1 (80399.2;97949) 310.1 (280.1;340.3) -57.7 (-61.6;-53.7)
Sergipe 3143.7 (2870.4;3420.7) 683.8 (624.9;743.8) 4299.2 (3883.7;4707.7) 372 (335.7;406.8) -45.6 (-51.6;-39.2)
Tocantins 1101.1 (958.3;1252.5) 685.3 (606.7;768.8) 2331.2 (2078.4;2585.9) 360.1 (321.8;399.9) -47.5 (-54.6;-39.4)
B.2.3.2- Intracerebral hemorrhage
Acre 874.7 (812.9;936.3) 923.1 (856.1;989.3) 1599.2 (1461.9;1744.8) 505.7 (461;552.2) -45.2 (-51.2;-39.3)
Alagoas 9872.6 (9062.5;10730.1) 1226.4 (1127.7;1322.2) 12763.3 (11791.5;13850.8) 733.8 (676.7;796.4) -40.2 (-46.2;-33.1)
Amapá 439.7 (406.5;470) 729.9 (668.2;779.6) 1319.2 (1165.7;1460.5) 485.9 (429.7;538.1) -33.4 (-40.7;-24.9)
Amazonas 4241.5 (3841.4;4559.2) 918 (830.8;989.4) 7271.3 (6627.5;7883.3) 503.5 (459.3;545.9) -45.1 (-50.5;-38.7)
Bahia 39495.1 (36010.5;43294.5) 993.4 (903.6;1090.2) 44388.6 (40962.7;47759) 515.9 (475.7;555.3) -48.1 (-53.8;-42.1)
Brazil 563999.7 (545387.7;584682.8) 1070.2 (1035.3;1106.6) 580172.8 (555092.6;606176.7) 465.2 (445;485.9) -56.5 (-58.7;-54.5)
Ceará 18233.6 (16299.5;20228.9) 772.8 (688.7;861.4) 24338.9 (22304.9;26159.7) 453.1 (415.4;487.5) -41.4 (-48.8;-33.2)
Distrito Federal 4240.9 (3979.9;4508.9) 1005.6 (949;1069.6) 4945.6 (4453.2;5505.7) 345.3 (314.1;384.1) -65.7 (-69.4;-61.7)
Espírito Santo 11142.1 (10603;11788.2) 1321.2 (1257.8;1394.8) 10272.9 (9453.4;11232.8) 445.3 (409.9;487.5) -66.3 (-69.3;-63.3)
Goiás 12855.7 (12049.1;13698) 1147.9 (1079.5;1224.7) 15021.7 (13681.7;16488.2) 415.3 (379.8;455) -63.8 (-67.3;-60.4)
Maranhão 12042.9 (9978.3;14209.6) 765.5 (599.9;923.2) 19249 (17310;21828.7) 557.1 (499.7;633.4) -27.2 (-37.8;-11.3)
Mato Grosso 3853.5 (3437.3;4288.6) 817 (728.9;905.6) 6957.4 (6329.9;7833.2) 433.6 (394.8;486.6) -46.9 (-54.1;-38.6)
Mato Grosso do Sul 5943.8 (5561.7;6313.3) 1148.3 (1080.5;1215) 7653.1 (7025.6;8338.4) 513.4 (471.2;560.2) -55.3 (-59.8;-50.7)
Minas Gerais 64366 (60674.3;68220.4) 1099.1 (1037.2;1163.7) 60695 (56080.7;65783.6) 445.7 (411.9;483) -59.4 (-63;-55.4)
Pará 12175.4 (11139.9;13184) 978.4 (892.1;1059.1) 18001 (16375.4;19576.3) 509.9 (464;555.1) -47.9 (-54;-41.2)
Paraíba 11111.2 (10082.5;12219.4) 868.2 (787.5;953.5) 13504.5 (12040;15189.3) 535.8 (476.9;602.6) -38.3 (-46.7;-28.4)
Paraná 35261.9 (33355.6;37203.2) 1301.5 (1228.2;1375.8) 31095.5 (28671.9;33664.6) 447.4 (412.9;484.6) -65.6 (-68.7;-62.4)
Pernambuco 35167.1 (32910.5;37242.7) 1332.3 (1249;1406.7) 33631.6 (31062.3;36327.8) 599.2 (553.1;646.5) -55 (-59;-50.7)
Piauí 7420.7 (6473.6;8346.5) 888.3 (775.7;998.5) 10247.3 (9366.6;11531.5) 529 (483;595.7) -40.4 (-47.8;-31.4)
Rio de Janeiro 88936.8 (84337.9;93896) 1501.8 (1423.9;1582.9) 68013.5 (62977;73431) 555.9 (515.3;599.1) -63 (-66.3;-59.6)
Rio Grande do Norte 5639.4 (5056.1;6175) 626.4 (561.9;686.3) 7840.9 (7108.5;8599.3) 383.7 (347.4;421.2) -38.7 (-46.2;-29.8)
Rio Grande do Sul 40495.5 (37779.2;42885.8) 1036.9 (967.6;1098.7) 39133.7 (35903.4;42395.5) 472.7 (432.7;511.1) -54.4 (-58.6;-49.5)
Rondônia 2628.7 (2371.6;2911.8) 1227.9 (1117.7;1354.8) 3779.6 (3245.4;4369.3) 501 (433.1;579.1) -59.2 (-65.6;-51.6)
Roraima 328.6 (286.2;373.3) 992.7 (870.9;1116.1) 736.9 (617.6;867) 430 (361.4;504.1) -56.7 (-64.8;-46.4)
Santa Catarina 16220.7 (15245.9;17192.1) 1118.6 (1052.1;1188.3) 15768.8 (14405.3;17123) 377.2 (345.2;409.4) -66.3 (-69.7;-62.9)
São Paulo 113907.8 (107421.3;120928.2) 942.3 (886.5;1000.5) 111325 (103027.9;120702.2) 383.3 (354.6;414.6) -59.3 (-63;-55.4)
Sergipe 4704.6 (4381.8;5022.3) 963.7 (897.4;1029.7) 6663.5 (6108.6;7225.7) 552.1 (505.7;600.2) -42.7 (-48.5;-35.7)
Tocantins 2399.1 (1989.3;2787) 1052.1 (902.5;1202.8) 3955.6 (3568.2;4425.3) 560.4 (506.6;627.1) -46.7 (-54.7;-36.9)
B.2.3.3- Subarachnoid hemorrhage
Acre 448.2 (407.7;497.6) 330.8 (302.6;363.3) 708.2 (638.6;792.2) 194.2 (174.9;216.9) -41.3 (-48.2;-34)
Alagoas 4300.1 (3589.8;5036.8) 410.6 (351;468.2) 4267.3 (3820.8;4772.1) 234.1 (208.7;261.8) -43 (-52.3;-29.4)
Amapá 180.3 (163.7;201.9) 223.8 (202.9;252.3) 571.6 (511;643.2) 176.7 (158;198.7) -21.1 (-31.2;-9.9)
Amazonas 1591.2 (1418;1789.1) 242.6 (217.8;270.9) 2930.3 (2642.6;3273.2) 174.4 (156.1;192.6) -28.1 (-37.5;-18.8)
Bahia 14897.5 (13287.5;16507.2) 316.1 (283.5;351.9) 17771.1 (16139.9;19611.7) 207.1 (188.6;228.5) -34.5 (-42.6;-24.3)
Brazil 211672.4 (199208.9;221899.8) 345.1 (324.7;363.2) 246672.1 (231937.6;260803.4) 199.2 (187.4;210.1) -42.3 (-46.1;-39)
Ceará 8643.3 (6852.4;10486.6) 299.4 (244.9;357.4) 9666.5 (8677.7;10600.5) 182.6 (164.3;200.1) -39 (-50.4;-26.6)
Distrito Federal 2002 (1803;2168.1) 347.8 (316.2;375.5) 2613.4 (2319;2911.4) 159.4 (141;177.5) -54.2 (-59.3;-47.8)
Espírito Santo 3997.2 (3523.8;4296.8) 396 (345.6;425) 4463.2 (4009.2;4908.2) 192.6 (173.2;211.2) -51.4 (-56.9;-43.7)
Goiás 4756.8 (4346.9;5221.2) 327.6 (300.5;359.9) 6794.6 (6134.7;7577.9) 177.8 (160.7;197.9) -45.7 (-51.6;-38.3)
Maranhão 8586.9 (6391.4;11138.3) 388.5 (299.2;491.9) 8660.9 (7731.3;9594.6) 237 (211.2;263.3) -39 (-51.4;-23.6)
Mato Grosso 1976.9 (1748.4;2227.8) 303.1 (269.1;341.7) 3274 (2926.5;3658.6) 184.1 (165.4;204.9) -39.2 (-47.7;-29.8)
Mato Grosso do Sul 2214 (1954.7;2430) 350.7 (315.4;383.4) 3228.6 (2883.8;3619.9) 208.3 (186.4;233) -40.6 (-48.1;-31.7)
Minas Gerais 23395.6 (21454;25318.2) 351.9 (322.6;381.9) 26003.9 (23613.8;28559.9) 196.4 (178.8;214.9) -44.2 (-50;-37.7)
Pará 4440.4 (3942.4;4957.1) 268.2 (240.2;299.8) 7488.9 (6775.2;8285.9) 190.5 (171.6;211.1) -29 (-37.1;-19.3)
Paraíba 5050.1 (4155.5;5968.1) 359.5 (295.4;422.2) 5151 (4436.2;5838.5) 211.9 (182.7;240.2) -41.1 (-53;-27.7)
Paraná 12285.8 (11347.4;13264.7) 374.4 (343.4;405.7) 13900 (12510.5;15373.5) 199.1 (179.6;219.1) -46.8 (-53;-40.1)
Pernambuco 9495.7 (8636;10672.6) 318.4 (290.2;361.1) 12353.7 (11186.9;13775.6) 219.1 (198.7;243.7) -31.2 (-39.6;-22.6)
Piauí 3535.2 (2860;4197.6) 339.4 (278.5;403.6) 3908.2 (3521;4310.2) 203.7 (183.8;224.5) -40 (-49.9;-27.8)
Rio de Janeiro 28289.5 (25607.4;30525.9) 444.3 (403.8;479.4) 25692.3 (23122.1;28299.6) 221.6 (200.2;244.4) -50.1 (-55.6;-43.3)
Rio Grande do Norte 2208.9 (1905.2;2660.8) 210.9 (182.9;259.7) 3065.8 (2734.3;3771.2) 151.5 (135.3;186) -28.2 (-39.4;-16.6)
Rio Grande do Sul 12260.7 (11247.3;14498.1) 286.6 (262.9;339.3) 13863.3 (12280.1;15559.9) 180.6 (160.3;202.5) -37 (-44.8;-29)
Rondônia 1120.6 (1002.6;1250.6) 353.1 (315.9;395.2) 1701.2 (1439.6;1988.5) 200 (169.9;234.3) -43.4 (-53.1;-32.1)
Roraima 151.2 (130.8;181.3) 282 (242.8;345.6) 330.2 (273;406.4) 153 (127.5;188.8) -45.8 (-56.1;-32.4)
Santa Catarina 5568.2 (5137.7;6024.6) 316.5 (290.8;342.4) 6725.8 (6071.4;7486.2) 158.6 (143.3;176.2) -49.9 (-55.5;-43.4)
São Paulo 47460.6 (43883.2;51172.3) 337.9 (312.7;365.3) 57392.7 (51539.2;62558) 200.5 (180.5;218) -40.7 (-47.3;-33.9)
Sergipe 1689.1 (1486.9;1900.9) 287.8 (256.9;325.8) 2382.3 (2149.2;2638.5) 188.8 (170.3;210.1) -34.4 (-43.9;-25.1)
Tocantins 1126.4 (839.2;1386.1) 360 (280.2;438.7) 1763.1 (1534.2;1962.8) 230.6 (201.3;256.2) -35.9 (-48.5;-18.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109

– Age-standardized DALY rates (per 100 000) for stroke and stroke subtypes, for men, in Brazil, 1990 and 2017, and percent change
Cause of death and age group 1990 2017 Percent change (95% UI)
B.2.3- Stroke
15-49 years 986.5 (948.5;1024.5) 432.8 (415.2;452.5) -56.1 (-58.4;-53.6)
50-69 years 7867.2 (7612.7;8119.2) 3538 (3397.9;3689.8) -55 (-56.9;-53.1)
5-14 years 83.1 (69.7;91.1) 35.7 (31.8;39.7) -57.1 (-62.4;-50.4)
70+ years 17208.4 (16711.1;17728.9) 9407.6 (9006.8;9773.9) -45.3 (-47.4;-43.3)
Age-standardized 2901.8 (2824.3;2983.3) 1334.5 (1289.5;1381.5) -54 (-55.4;-52.5)
All Ages 1814.8 (1761.9;1869.6) 1319.5 (1275.2;1367.3) -27.3 (-29.6;-24.7)
Under 5 410.2 (325.6;536.1) 70.8 (58.7;84.7) -82.8 (-87.9;-75.9)
B.2.3.1- Ischemic stroke
15-49 years 146.5 (137.3;158.8) 66.3 (60;73.2) -54.7 (-59.7;-50.7)
50-69 years 2283.9 (2165.8;2401.8) 952.4 (887.3;1020) -58.3 (-61.1;-55.6)
5-14 years 10.9 (8.9;13.6) 4.2 (3.3;5.5) -61.2 (-66.6;-55.8)
70+ years 8926.8 (8590.6;9283.7) 4660.5 (4394.5;4925) -47.8 (-50.4;-45.3)
Age-standardized 1011 (973.7;1050.4) 463.4 (436.9;490.2) -54.2 (-56.5;-52.2)
All Ages 541.4 (520.1;565.3) 429.6 (404.9;455.5) -20.6 (-25;-17)
Under 5 24.6 (16.8;34.3) 3 (2.2;3.9) -87.6 (-93.3;-78.5)
B.2.3.2- Intracerebral hemorrhage
15-49 years 644.8 (614.9;701.4) 257.6 (241.6;271.2) -60.1 (-64.4;-57.1)
50-69 years 4886.7 (4702.7;5077.9) 2143 (2055.1;2228.8) -56.1 (-58.2;-54)
5-14 years 25 (20.4;28.9) 10 (8.2;11.8) -60.1 (-69.4;-49.4)
70+ years 7674.2 (7361.5;7956.2) 4238.2 (4048.2;4415.7) -44.8 (-47.4;-41.9)
Age-standardized 1601 (1552.2;1665.3) 709.9 (684.6;733.7) -55.7 (-57.5;-53.9)
All Ages 1042.8 (1008.5;1093) 721.4 (695.9;745.7) -30.8 (-34.2;-27.8)
Under 5 108.9 (61.6;169) 12.1 (8.8;16) -88.9 (-94.1;-76.9)
B.2.3.3- Subarachnoid hemorrhage
15-49 years 195.1 (150.6;208.4) 108.9 (102;128.8) -44.2 (-49.5;-22.9)
50-69 years 696.6 (566.1;745.5) 442.6 (414.3;479.7) -36.5 (-41.7;-23.2)
5-14 years 47.2 (39.3;52.5) 21.4 (18.9;24.2) -54.6 (-60.4;-44.4)
70+ years 607.4 (558;657.4) 508.9 (436.7;551.9) -16.2 (-24.4;-7.6)
Age-standardized 289.9 (237.9;307.2) 161.2 (152.9;175.4) -44.4 (-48.2;-31.2)
All Ages 230.7 (186.5;246.2) 168.5 (160;184.4) -26.9 (-32.5;-7.7)
Under 5 276.7 (203.1;344.3) 55.7 (46.8;65.9) -79.9 (-85.1;-70.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.109

Data derived from the Global Burden of Disease Study 2017 (GBD 2017).109

Data derived from Global Burden of Disease Study 2017 (GBD 2017).151 Data derived from Global Burden of Disease Study 2017 (GBD 2017).151 Data derived from Global Burden of Disease Study 2017 (GBD 2017).151 Data derived from Global Burden of Disease Study 2017 (GBD 2017).151

Data derived from DATASUS.152

Data derived from Global Burden of Disease Study 2017 (GBD 2017).151 Data derived from Global Burden of Disease Study 2017 (GBD 2017).188 Data derived from Global Burden of Disease Study 2017 (GBD 2017).188

– Number of incident cases and age-standardized incidence rate (per 100 000) of cardiomyopathy and myocarditis, and percent change of rates, in Brazil and its Federative Units, 1990 and 2017
1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
Brazil 54520.4 (48574.3;61320.7) 46.3 (41.5;52.1) 103879.4 (92495.6;117294.5) 46.7 (41.8;52.6) 0.8 (-0.3;1.8)
Acre 125.8 (111;143) 44.8 (40;50.7) 340.7 (303.3;383.1) 46 (41.1;52) 2.8 (-0.5;6.4)
Alagoas 826.5 (732.4;929.4) 43.6 (38.8;49.3) 1551.4 (1378.8;1749) 46.5 (41.5;52.4) 6.8 (3.5;10.2)
Amapá 85.4 (75.2;97.2) 47.5 (42.5;53.4) 311.1 (274.3;352.6) 47.6 (42.5;53.6) 0.3 (-2.8;3.9)
Amazonas 645.3 (565.6;732.6) 46.4 (41.5;52.6) 1586.5 (1410.7;1793.3) 46.6 (41.6;52.8) 0.5 (-2.9;4.3)
Bahia 4183 (3713.7;4708.9) 45.3 (40.3;50.9) 7177 (6366.6;8059.8) 45.1 (40;50.7) -0.3 (-3.4;2.7)
Ceará 2232.8 (1990.7;2511.3) 43.2 (38.7;48.7) 4589.2 (4084.6;5197.2) 46.4 (41.4;52.7) 7.5 (3.4;11)
Distrito Federal 502.7 (439.4;574.4) 45.2 (40.3;51.3) 1258.3 (1107.5;1428.3) 45.3 (40.4;51) 0.2 (-3.3;3.7)
Espírito Santo 976.1 (856.5;1104.3) 48.1 (42.8;54.4) 1992.5 (1757;2263.2) 48.2 (42.9;54.4) 0.2 (-3.2;3.8)
Goiás 1391.1 (1220.9;1574.2) 46.3 (41.4;52.2) 3233.1 (2869.8;3671.6) 47.3 (42.2;53.5) 2.3 (-0.8;5.4)
Maranhão 1568.5 (1390.4;1771.6) 43.3 (38.6;48.9) 3314.6 (2958.6;3716.8) 46.7 (41.7;52.6) 8 (4.5;12)
Mato Grosso 628.1 (549.8;715.5) 45.6 (40.7;51.7) 1567.2 (1394.8;1780.2) 46.8 (41.9;52.9) 2.7 (-1;6.3)
Mato Grosso do Sul 648.6 (572.4;728) 48.6 (43.4;54.8) 1426.5 (1264.1;1616.6) 50.6 (45.2;57) 4.1 (0.8;7.7)
Minas Gerais 5880.7 (5207.1;6646.3) 46 (41;52) 11181 (10003.5;12646.6) 47 (42.2;53.2) 2.2 (-1;5.5)
Pará 1548.2 (1365.8;1749.4) 45.4 (40.6;51.3) 3561 (3155.4;4003.7) 45.5 (40.5;51.4) 0.2 (-3.2;3.9)
Paraíba 1181.3 (1051.4;1331.4) 43.2 (38.6;48.9) 2068.4 (1841.2;2347.2) 46.3 (41.2;52.5) 7.1 (3.6;10.5)
Paraná 3140.9 (2777.5;3572.6) 47.1 (41.9;53.3) 5728 (5060.1;6535.4) 47 (41.9;53.2) -0.2 (-3.8;3)
Pernambuco 2639 (2333.6;2961.8) 45.6 (40.5;51.3) 4609.7 (4098.5;5160.5) 46.1 (41.1;51.6) 1.1 (-2.4;4.5)
Piauí 865.4 (765.7;974.5) 43.8 (39;49.4) 1652.7 (1471;1863.8) 45.8 (40.7;51.6) 4.5 (0.8;8.3)
Rio de Janeiro 5321.9 (4706.8;6019.7) 46.7 (41.6;52.5) 9236.1 (8183.4;10524.9) 46.4 (41.3;52.5) -0.5 (-4.1;3.1)
Rio Grande do Norte 886.2 (790.4;995.2) 44.3 (39.7;49.8) 1723.7 (1535.1;1947.9) 46.2 (41.2;52.1) 4.2 (1;7.7)
Rio Grande do Sul 3927.6 (3482.4;4424.5) 49.5 (44.1;55.8) 6475.7 (5749;7325.7) 48.5 (43.2;54.5) -2.1 (-5.5;1.4)
Rondônia 330.5 (289.3;379.1) 45.6 (40.6;51.4) 746.3 (660.9;847.2) 46 (41.2;52.2) 0.9 (-2.6;4.4)
Roraima 61.2 (53.3;70.9) 46.1 (41.2;52) 212.3 (187.3;240.4) 46.4 (41.3;52.4) 0.9 (-2.4;4.2)
Santa Catarina 1694 (1503.4;1912.2) 47.8 (42.9;54.2) 3554.7 (3148.4;4033.5) 47.5 (42.4;53.4) -0.7 (-4.2;3.5)
São Paulo 12421.8 (10980.5;13984.7) 47.6 (42.4;53.5) 22999.9 (20352.4;26154.9) 46.6 (41.6;52.7) -1.9 (-5.5;1.4)
Sergipe 520.8 (463.6;584.1) 45.3 (40.5;51.4) 1075.4 (957.1;1218.6) 47.3 (42.1;53.4) 4.5 (1;7.8)
Tocantins 287 (253.9;325.8) 44.8 (40;50.5) 706.6 (629;798) 47.1 (42.1;53.1) 5.1 (1.6;8.9)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188

– Number of deaths and age-standardized mortality rate per 100 000 inhabitants due to Chagas disease, in 1990 and 2017, and percent change of rates, in Brazil and its Federative Units
Location 1990 2017 Percent change (95% UI)
Number of deaths (95% UI) Mortality Rate (95% UI) Number of deaths (95% UI) Mortality Rate (95% UI)
Acre 1.8 (1.6;1.9) 0.9 (0.9;1) 2.1 (1.8;2.4) 0.3 (0.3;0.4) -63.9 (-69.7;-56.2)
Alagoas 68.4 (54.3;78.8) 4.8 (3.8;5.5) 79.9 (72;90.2) 2.5 (2.3;2.9) -46.6 (-56.5;-28.3)
Amapá 0.5 (0.5;0.5) 0.5 (0.4;0.5) 1 (0.9;1.1) 0.2 (0.2;0.2) -58.2 (-63.9;-52)
Amazonas 3.8 (3.5;4.1) 0.4 (0.4;0.5) 4.6 (4.1;5.5) 0.2 (0.1;0.2) -61.3 (-66.6;-53.6)
Bahia 682.2 (629.5;736.3) 9.2 (8.5;9.9) 788.1 (728;871.6) 5 (4.6;5.5) -45.7 (-51.7;-39.2)
Brazil 7049.3 (6816.6;7323.9) 7.3 (7;7.6) 5493.6 (5221.2;6014.7) 2.5 (2.3;2.7) -66.3 (-68.3;-63.5)
Ceará 44.2 (36.7;55.8) 1 (0.9;1.3) 53.8 (48.3;61.5) 0.5 (0.5;0.6) -47.6 (-59.4;-34.1)
Distrito Federal 235.6 (223.8;249.1) 34.9 (33.1;36.8) 211 (191.3;248.7) 9.7 (8.8;11.5) -72.2 (-74.9;-67.6)
Espírito Santo 10.7 (9.9;11.6) 0.7 (0.7;0.8) 9.2 (8.2;10.9) 0.2 (0.2;0.3) -69.8 (-73.4;-64.5)
Goiás 1131.6 (1067;1212.8) 55.2 (51.9;59.4) 815.2 (753.8;917.7) 13 (12;14.6) -76.4 (-78.2;-74.2)
Maranhão 15.7 (12.4;19.5) 0.6 (0.5;0.7) 17.5 (15.5;20.8) 0.3 (0.2;0.3) -52.4 (-61.3;-32.7)
Mato Grosso 39.6 (35.8;44.1) 4.4 (4;4.9) 57 (51.1;68.5) 1.8 (1.7;2.2) -58.3 (-63.6;-50.8)
Mato Grosso do Sul 55 (50.5;59.3) 5.7 (5.3;6.1) 53 (47.6;60.1) 1.9 (1.7;2.2) -66.4 (-70.5;-61.6)
Minas Gerais 2195.4 (2095;2316.9) 21 (20;22.1) 1390.3 (1294.6;1519.6) 5.5 (5.1;6) -73.6 (-75.7;-71.4)
Pará 24.1 (21.9;26.3) 1 (1;1.1) 29.1 (25.4;35.6) 0.4 (0.4;0.5) -58.3 (-64.6;-48.2)
Paraíba 35.3 (27.2;42.3) 1.5 (1.2;1.8) 38.3 (34.3;42.9) 0.8 (0.7;0.9) -45.1 (-57.6;-24.7)
Paraná 384.7 (365.1;406.4) 7.4 (7;7.8) 251.4 (232.2;277.9) 2 (1.9;2.2) -72.7 (-75.1;-69.5)
Pernambuco 163.5 (149.3;175.1) 3.5 (3.2;3.8) 143.4 (130.4;157.7) 1.5 (1.3;1.6) -58.7 (-63.5;-51.8)
Piauí 59.5 (49.7;71.3) 4.1 (3.4;4.9) 71 (64;81.2) 2 (1.8;2.3) -51.4 (-60.2;-38.5)
Rio de Janeiro 77 (71.5;82.6) 0.8 (0.7;0.8) 58.6 (53.1;65.7) 0.3 (0.2;0.3) -64.8 (-68.7;-60)
Rio Grande do Norte 14.7 (12.8;17.1) 0.9 (0.8;1) 16.2 (14.3;18.3) 0.4 (0.4;0.5) -51.4 (-62.5;-39.8)
Rio Grande do Sul 61.3 (56.8;65.7) 0.9 (0.9;1) 48.7 (44.4;55.6) 0.3 (0.3;0.4) -64.8 (-68.6;-58.9)
Rondônia 25 (22.3;27.9) 5.8 (5.2;6.4) 24.1 (20.7;28.4) 1.7 (1.4;1.9) -71.3 (-75.8;-65.3)
Roraima 0.5 (0.5;0.6) 0.7 (0.6;0.8) 0.8 (0.6;1) 0.2 (0.2;0.3) -69.2 (-75.4;-60.8)
Santa Catarina 13.1 (12.1;14.1) 0.5 (0.5;0.5) 12.4 (11.1;14.3) 0.2 (0.1;0.2) -68.2 (-72.2;-62.2)
São Paulo 1653.4 (1583.9;1727.4) 7.4 (7.1;7.8) 1248.9 (1168.1;1356.1) 2.4 (2.3;2.7) -67 (-69.2;-64)
Sergipe 10.6 (9.4;12.1) 1.2 (1.1;1.4) 11.8 (10.7;13.3) 0.5 (0.5;0.6) -55.3 (-62.9;-44.5)
Tocantins 42.3 (34.1;52.3) 10.1 (8.4;12.3) 56.3 (50.2;64.6) 4.1 (3.6;4.7) -59.6 (-68.4;-48.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188

– Number of deaths and age-standardized mortality rate for males due to Chagas disease, per 100 000 inhabitants, in 1990 and 2017, and percent change of rates, in Brazil and its Federative Units
Location 1990 2017 Percent change (95% UI)
Number of deaths (95% UI) Mortality Rate (95% UI) Number of deaths (95% UI) Mortality Rate (95% UI)
Acre 1.3 (1.2;1.5) 1.3 (1.2;1.5) 1.4 (1.2;1.7) 0.5 (0.4;0.6) -64.1 (-71.8;-55.1)
Alagoas 42.6 (32.8;50.5) 6.2 (4.8;7.4) 46.5 (40.2;54.3) 3.3 (2.8;3.8) -47.3 (-58.1;-26.3)
Amapá 0.3 (0.3;0.4) 0.6 (0.6;0.7) 0.7 (0.6;0.8) 0.3 (0.2;0.3) -57.3 (-64.9;-48)
Amazonas 2.9 (2.5;3.2) 0.6 (0.6;0.7) 3.3 (2.8;4.1) 0.2 (0.2;0.3) -62.6 (-69.1;-53.3)
Bahia 449.9 (402.3;501.3) 12.7 (11.3;14.2) 511.7 (459;580.7) 7.2 (6.4;8.1) -43.3 (-51.7;-33)
Brazil 4411.2 (4207.8;4651.3) 9.5 (9;10) 3094.4 (2868.4;3448.7) 3.1 (2.9;3.4) -67.5 (-70.1;-63.8)
Ceará 30.1 (24;40.2) 1.5 (1.2;2) 34.5 (29.7;40.3) 0.8 (0.7;0.9) -48.3 (-62;-32.1)
Distrito Federal 136.9 (127;147.8) 41.3 (38.2;44.7) 108 (93.7;132.2) 11.2 (9.7;13.7) -72.9 (-76.6;-67.7)
Espírito Santo 7.5 (6.8;8.4) 1 (0.9;1.1) 5.9 (5.1;7.3) 0.3 (0.3;0.4) -70.4 (-75;-63.1)
Goiás 684.1 (634.4;744.1) 60.3 (55.7;66) 453.1 (406.4;522.9) 15.1 (13.6;17.4) -75 (-77.7;-71.7)
Maranhão 11.4 (8.5;13.6) 0.9 (0.7;1.1) 11.9 (10.3;14.3) 0.4 (0.3;0.5) -54.2 (-63.5;-31.4)
Mato Grosso 27 (23.5;30.8) 5.5 (4.8;6.2) 36 (31.3;43.8) 2.2 (2;2.7) -58.8 (-65.7;-49.3)
Mato Grosso do Sul 38.9 (34.9;42.8) 7.6 (6.9;8.4) 33.5 (29.3;39.5) 2.5 (2.2;3) -66.8 (-71.9;-60.5)
Minas Gerais 1342.2 (1256.4;1447) 26.6 (24.9;28.7) 744.3 (672;833.9) 6.5 (5.9;7.3) -75.5 (-78.1;-72.3)
Pará 17.3 (15.4;19.4) 1.5 (1.3;1.7) 20.8 (17.5;26) 0.6 (0.5;0.8) -58 (-66.1;-47)
Paraíba 22.1 (16.8;27.9) 2 (1.5;2.5) 23 (19.9;26.6) 1.1 (1;1.3) -43.6 (-58.9;-17.5)
Paraná 253.3 (234.6;273.2) 9.6 (8.9;10.3) 139.8 (125;159.6) 2.5 (2.2;2.8) -74.2 (-77.5;-70.2)
Pernambuco 103.2 (92.7;113) 4.8 (4.3;5.3) 83.8 (73.8;95) 2 (1.7;2.2) -59.4 (-65.6;-51.2)
Piauí 40.4 (33.2;49.7) 5.8 (4.8;7.2) 44.6 (39.4;52.1) 2.7 (2.4;3.1) -53.9 (-63.5;-40.1)
Rio de Janeiro 47.4 (42.8;52.3) 1.1 (1;1.2) 31.7 (27.2;36.8) 0.3 (0.3;0.4) -67.4 (-72.5;-61.1)
Rio Grande do Norte 10.6 (9;12.8) 1.4 (1.1;1.6) 11.3 (9.6;13.1) 0.7 (0.6;0.8) -50.4 (-63.4;-35.3)
Rio Grande do Sul 40.4 (36.3;44.5) 1.3 (1.2;1.5) 28.9 (25.3;34.2) 0.4 (0.4;0.5) -67.3 (-72.2;-60.5)
Rondônia 18.1 (15.5;20.7) 7.2 (6.2;8.2) 14.5 (11.8;18) 1.9 (1.6;2.4) -73.2 (-78.8;-65.6)
Roraima 0.5 (0.4;0.5) 1.1 (0.9;1.3) 0.6 (0.5;0.8) 0.3 (0.3;0.4) -68.4 (-76;-58.3)
Santa Catarina 8.6 (7.7;9.5) 0.7 (0.6;0.8) 7.3 (6.2;8.7) 0.2 (0.2;0.2) -69.9 (-74.9;-62.9)
São Paulo 1039.3 (976.2;1108.4) 9.7 (9.1;10.4) 655 (592.6;739.1) 2.9 (2.7;3.3) -69.8 (-73.2;-65.6)
Sergipe 7 (6;8.3) 1.7 (1.5;2) 7.7 (6.7;8.8) 0.8 (0.7;0.9) -54.3 (-64.5;-42)
Tocantins 27.7 (21.6;34.8) 12 (9.6;15.1) 34.6 (29.6;40.9) 4.9 (4.2;5.7) -59.4 (-69.7;-45.9)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.188

Data derived from Global Burden of Disease Study 2017 (GBD 2017).188

Data derived from Global Burden of Disease Study 2017 (GBD 2017).188

Data derived from Global Burden of Disease Study 2017 (GBD 2017).188

<italic>Data derived from Global Burden of Disease Study 2017 (GBD 2017).<sup>188</sup></italic> Source: Martins-Melo et al.161

Source: Nóbrega et al.159

Source: Martins-Melo et al.166

Source: Nicolao et al.183

– Number of deaths, age-standardized mortality rate (per 100 000), and percent change of rates, by cardiovascular groups of causes of death, in Brazil and its Federative Units, 1990 and 2017
Cause of death and Location 1990 2017 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Number (95% UI) Rate (95% UI)
B.2.1- Rheumatic heart disease
Acre 6.8 (6.3;7.3) 2.6 (2.5;2.8) 9.6 (8.8;10.4) 1.4 (1.3;1.5) -46.2 (-51.8;-40.2)
Alagoas 43.8 (37.3;51.6) 2.2 (1.9;2.5) 37.5 (34.9;40.2) 1.1 (1.1;1.2) -47.3 (-54.4;-36.5)
Amapá 2.7 (2.5;2.9) 1.8 (1.7;2) 6.6 (6;7.3) 1.1 (1;1.3) -37.3 (-44.6;-29.1)
Amazonas 18.3 (16.9;19.7) 1.5 (1.4;1.6) 26 (23.7;28.2) 0.8 (0.8;0.9) -44.7 (-49.7;-39)
Bahia 171.9 (155.9;186.2) 1.8 (1.6;1.9) 172 (159.2;185.3) 1.1 (1;1.2) -40.3 (-46;-33.1)
Brazil 2647.8 (2549.9;2727.7) 2.4 (2.3;2.5) 2682.3 (2584.5;2796.7) 1.2 (1.1;1.2) -50.3 (-52.4;-47.5)
Ceará 62.6 (51.4;72) 1.2 (1;1.3) 64.6 (60.2;69.2) 0.7 (0.6;0.7) -44.3 (-51.3;-33.7)
Distrito Federal 33.4 (31.2;35.8) 3.7 (3.5;4) 38.9 (35.8;42.7) 1.6 (1.5;1.8) -56.8 (-61;-52.4)
Espírito Santo 40.3 (38.1;42.6) 2.2 (2.1;2.4) 46.8 (43.4;50.8) 1.1 (1;1.2) -50.6 (-54.7;-45.8)
Goiás 74.6 (69.8;79.9) 2.8 (2.6;3) 100.8 (93.9;108.4) 1.5 (1.4;1.6) -46.8 (-51.2;-42)
Maranhão 100.4 (80.9;123.3) 2.3 (2;2.8) 59.8 (55.6;64.6) 0.9 (0.8;0.9) -62.6 (-68.9;-55.4)
Mato Grosso 23.9 (22.1;26) 1.9 (1.8;2.1) 32.3 (30;34.9) 1 (0.9;1.1) -47.7 (-52.6;-42)
Mato Grosso do Sul 25 (22;27.3) 2.1 (2;2.3) 33.3 (30.8;36.2) 1.2 (1.1;1.3) -44.7 (-50;-38.8)
Minas Gerais 331.2 (311.9;350.1) 2.8 (2.6;2.9) 343 (321;367.1) 1.4 (1.3;1.5) -50.6 (-54.5;-46.2)
Pará 52.4 (47;57.1) 1.7 (1.6;1.8) 70.3 (65.5;75.3) 1 (0.9;1) -43.5 (-48.8;-37.2)
Paraíba 61.5 (53.4;70.2) 2.2 (2;2.5) 49.1 (44.5;53.8) 1.1 (1;1.2) -51.8 (-58.3;-43.7)
Paraná 186.5 (177.8;196) 3.3 (3.1;3.4) 206.6 (193;221.9) 1.6 (1.5;1.8) -49.5 (-53.4;-45.3)
Pernambuco 113.9 (105.4;122.5) 2 (1.8;2.1) 132.3 (122.1;143.1) 1.3 (1.2;1.4) -33.3 (-38.9;-26.3)
Piauí 26.2 (19.9;31.3) 1.3 (1.1;1.5) 25.1 (23.3;27.1) 0.7 (0.6;0.7) -47.5 (-55.3;-34.8)
Rio de Janeiro 242.4 (230.8;253.8) 2.2 (2.1;2.3) 230.3 (215.4;247) 1.1 (1;1.2) -49.2 (-53;-44.7)
Rio Grande do Norte 31.9 (28.4;35.1) 1.6 (1.5;1.8) 44.1 (40.4;48.1) 1.2 (1.1;1.3) -28.4 (-37.4;-16.5)
Rio Grande do Sul 136.7 (129.5;143.6) 1.9 (1.8;2) 128.1 (118.5;137.7) 0.9 (0.8;1) -52.3 (-56.1;-48.1)
Rondônia 14.5 (13.3;15.8) 2.4 (2.2;2.6) 18.6 (16.5;21) 1.2 (1.1;1.4) -49.5 (-56.3;-41.7)
Roraima 1.8 (1.6;2) 1.8 (1.7;2) 3.5 (3;4) 0.9 (0.8;1.1) -49.1 (-56.6;-39.5)
Santa Catarina 72.3 (68.4;76) 2.4 (2.3;2.6) 86.2 (79.9;92.9) 1.2 (1.1;1.2) -52.9 (-56.6;-48.6)
São Paulo 735.7 (704.1;764.8) 3.1 (3;3.2) 671.8 (632;718.7) 1.3 (1.2;1.4) -57.8 (-60.6;-54.7)
Sergipe 24.3 (22.2;26.6) 2.1 (2;2.3) 28.2 (26.2;30.6) 1.3 (1.2;1.4) -41.2 (-46.6;-34.5)
Tocantins 12.6 (8.5;15.5) 2.3 (1.8;2.7) 16.9 (15.3;18.6) 1.1 (1;1.3) -49.7 (-57.7;-37.2)
B.2.5- Non-rheumatic valvular heart disease
Acre 2.4 (2.2;2.8) 1.4 (1.3;1.7) 8.6 (7.3;9.5) 1.5 (1.3;1.7) 6.3 (-18.1;22)
Alagoas 14.4 (12.8;19) 1.1 (0.9;1.4) 42.3 (37.9;50.9) 1.4 (1.2;1.7) 31.4 (8.4;50.9)
Amapá 1.9 (1.3;2.1) 1.9 (1.4;2.1) 9.8 (6.4;10.9) 2.1 (1.4;2.4) 10.7 (-13.2;24.9)
Amazonas 11.9 (10.2;13.6) 1.5 (1.3;1.7) 40.5 (33.5;44.9) 1.5 (1.3;1.7) 5.5 (-12.3;18.3)
Bahia 96.1 (85.1;116.3) 1.4 (1.2;1.7) 197.5 (179.7;255.7) 1.2 (1.1;1.6) -9 (-19.7;14.4)
Brazil 1495.1 (1284.4;1620.4) 1.7 (1.5;1.9) 3974.4 (3116.8;4165.1) 1.8 (1.4;1.9) 7.1 (-9.1;13)
Ceará 33.7 (26;60.7) 0.8 (0.6;1.5) 106.6 (96.7;136.7) 1.1 (1;1.4) 33.1 (-13.6;68.6)
Distrito Federal 13.4 (10.3;14.5) 2.3 (1.8;2.5) 41.6 (36.3;47.7) 2.1 (1.9;2.5) -6.6 (-18.4;16.3)
Espírito Santo 30.9 (20.9;33.9) 2.4 (1.7;2.6) 86.1 (59.1;95.1) 2.1 (1.4;2.4) -10.9 (-19.2;-2.6)
Goiás 31.4 (26.2;34.1) 1.7 (1.4;1.9) 97.3 (83.6;106.9) 1.5 (1.3;1.7) -9.9 (-17;-0.9)
Maranhão 26.1 (19.5;46) 1 (0.7;1.8) 62.2 (52.7;100.7) 1 (0.8;1.6) -1.9 (-16.9;19)
Mato Grosso 12.9 (11.4;14.5) 1.6 (1.4;1.8) 46.2 (39.6;51.2) 1.6 (1.4;1.8) 3.3 (-10.8;15.6)
Mato Grosso do Sul 16.5 (13;18) 1.9 (1.5;2.1) 50.6 (39.1;56) 1.9 (1.5;2.1) -0.4 (-12.2;10.7)
Minas Gerais 153.8 (135.2;169.9) 1.6 (1.5;1.8) 419.1 (332.3;454.1) 1.7 (1.3;1.8) 2.8 (-15.8;13.1)
Pará 27.3 (24.8;34.4) 1.3 (1.1;1.6) 90.3 (81.5;107) 1.4 (1.3;1.7) 11.1 (-5.4;24.9)
Paraíba 17.5 (13.9;31.9) 0.8 (0.6;1.4) 39.3 (32.8;68.9) 0.8 (0.7;1.5) 10.1 (-11.1;33.2)
Paraná 105.3 (71.9;114.2) 2.4 (1.7;2.6) 293.1 (178.1;325.9) 2.5 (1.5;2.7) 4.1 (-14.8;14.3)
Pernambuco 66.5 (59.1;75.4) 1.5 (1.4;1.8) 172.1 (138.3;188.5) 1.8 (1.4;2) 17.2 (-4;31)
Piauí 13.1 (10.2;24.1) 0.9 (0.7;1.7) 34 (29.9;51.7) 0.9 (0.8;1.4) 1.1 (-22.9;23.9)
Rio de Janeiro 150.6 (135.6;201.8) 1.6 (1.5;2.3) 357.5 (305.4;408) 1.7 (1.5;1.9) 3.7 (-15.2;14.2)
Rio Grande do Norte 16.5 (13.9;24.9) 1 (0.8;1.5) 49 (44.2;62.1) 1.3 (1.2;1.6) 28.6 (-9.9;57.7)
Rio Grande do Sul 140.6 (98.8;152.4) 2.3 (1.6;2.5) 389.2 (217.1;436.1) 2.7 (1.5;3) 15.2 (-12.5;27.8)
Rondônia 5.9 (5.2;7.1) 1.6 (1.4;1.9) 19.5 (16.9;24.1) 1.4 (1.2;1.8) -9.1 (-20.9;3.3)
Roraima 0.9 (0.8;1.2) 1.7 (1.4;2.4) 4.3 (3.7;5.6) 1.5 (1.3;1.9) -6.7 (-32.7;15.8)
Santa Catarina 61 (37.5;67.1) 2.7 (1.6;3) 177.4 (104.2;198.4) 2.5 (1.5;2.9) -4.4 (-15.1;4.4)
São Paulo 431.6 (309.8;460.1) 2.2 (1.7;2.3) 1097 (770;1195.5) 2.2 (1.6;2.4) 1.9 (-14.5;10.9)
Sergipe 7.7 (6.6;12.2) 0.9 (0.8;1.4) 23.3 (20.8;33.8) 1.1 (1;1.6) 24.3 (-0.4;44.1)
Tocantins 5.2 (4.1;7.4) 1.5 (1.2;2.3) 19.9 (17.6;22.7) 1.5 (1.3;1.7) -3.3 (-38.6;21.9)
B.2.5.1- Non-rheumatic calcific aortic valve disease
Acre 1.4 (1.1;1.6) 0.9 (0.7;1) 5.6 (4.8;6.8) 1 (0.9;1.2) 14.9 (-4.1;52.3)
Alagoas 7.2 (6.1;9.1) 0.6 (0.5;0.7) 26.8 (23.5;34.2) 0.9 (0.8;1.1) 60.5 (35.4;93.6)
Amapá 1.1 (0.6;1.3) 1.2 (0.7;1.4) 6.3 (4.5;7.4) 1.4 (1;1.7) 17.3 (-0.1;59.6)
Amazonas 7.9 (4.9;8.9) 1 (0.7;1.1) 29.4 (24.2;33) 1.2 (0.9;1.3) 13 (-2.6;56.4)
Bahia 62.9 (40.6;72.3) 0.9 (0.6;1) 134.5 (120.5;178) 0.8 (0.8;1.1) -7.2 (-24.2;59)
Brazil 950.4 (722.7;1016.7) 1.1 (0.9;1.2) 2806 (2349.2;3132) 1.3 (1.1;1.4) 16.3 (9.6;34)
Ceará 17.3 (12.9;29.7) 0.4 (0.3;0.7) 68.6 (59.3;99.2) 0.7 (0.6;1) 62.7 (21;108.7)
Distrito Federal 8.3 (7.1;9.9) 1.5 (1.3;1.8) 29.2 (24.8;40.5) 1.6 (1.3;2.2) 1.4 (-14.4;36.2)
Espírito Santo 17.6 (11.7;19.9) 1.4 (1;1.6) 56.9 (43.8;64.3) 1.4 (1.1;1.6) -1.9 (-14.3;21.5)
Goiás 19.4 (13.8;21.9) 1.1 (0.8;1.3) 67.5 (60;77.2) 1.1 (1;1.2) -3.8 (-16.4;24.2)
Maranhão 13.2 (10.3;18.6) 0.5 (0.4;0.8) 41.1 (34.9;62.2) 0.7 (0.6;1) 25.3 (5.3;61.9)
Mato Grosso 7.7 (6;8.8) 1 (0.8;1.1) 30.9 (27.5;37) 1.1 (1;1.3) 10.3 (-4.6;41.6)
Mato Grosso do Sul 10.6 (7.1;12) 1.3 (0.9;1.5) 36 (28.9;40.3) 1.4 (1.1;1.5) 6.4 (-7.6;38.8)
Minas Gerais 98 (73.1;109) 1.1 (0.8;1.2) 295 (242.1;330.1) 1.2 (1;1.3) 10.4 (0.3;30.5)
Pará 15.1 (12.3;17.6) 0.7 (0.6;0.9) 55.4 (48;72.2) 0.9 (0.8;1.1) 19.9 (3.5;47.8)
Paraíba 8.9 (6.7;17.1) 0.4 (0.3;0.8) 25.8 (20.1;49.3) 0.6 (0.4;1.1) 39.6 (10.9;72.5)
Paraná 66.8 (42.3;75.1) 1.6 (1;1.8) 213.8 (136.2;240.2) 1.8 (1.2;2) 15.2 (3;34.3)
Pernambuco 35.8 (29.4;41.1) 0.8 (0.7;1) 111.3 (95.1;129.6) 1.2 (1;1.3) 36.7 (19.2;56.2)
Piauí 6 (4.6;10.6) 0.4 (0.3;0.8) 20 (16.4;33.7) 0.6 (0.5;0.9) 24 (-0.4;61.9)
Rio de Janeiro 94.3 (81.2;132.4) 1.1 (0.9;1.5) 262.7 (234.5;331) 1.3 (1.1;1.6) 17.9 (1.2;32.7)
Rio Grande do Norte 10.2 (8.3;13.1) 0.6 (0.5;0.8) 34.5 (30.4;44.4) 0.9 (0.8;1.2) 44 (17.3;86.2)
Rio Grande do Sul 93.5 (61.7;103.8) 1.6 (1.1;1.8) 289 (173.5;325.4) 2 (1.2;2.2) 25.1 (4.5;43.9)
Rondônia 3.5 (2.6;4.1) 1 (0.8;1.2) 13.1 (11;17.3) 1 (0.8;1.3) -3 (-21.4;30.3)
Roraima 0.6 (0.4;0.7) 1.2 (0.9;1.4) 3.3 (2.7;4.1) 1.2 (1;1.5) 3.7 (-16.7;46.1)
Santa Catarina 40.2 (21.4;46.1) 1.8 (1;2.1) 132.6 (80.9;149.9) 1.9 (1.1;2.2) 4.8 (-6.6;29.4)
São Paulo 296.7 (198;326.2) 1.5 (1.1;1.7) 790.7 (611;885) 1.6 (1.2;1.8) 5.1 (-4;27.3)
Sergipe 3.8 (3.1;6.3) 0.5 (0.4;0.7) 14 (11.4;23.5) 0.7 (0.5;1.1) 48.6 (25.2;76.3)
Tocantins 2.5 (2;3.5) 0.8 (0.6;1.2) 12 (10.3;15.9) 0.9 (0.8;1.2) 13.4 (-11.5;49.4)
B.2.5.2- Non-rheumatic degenerative mitral valve disease
Acre 0.8 (0.7;1.4) 0.4 (0.4;0.8) 2.3 (1.7;2.8) 0.4 (0.3;0.5) -13.6 (-53.6;12)
Alagoas 6.4 (5.2;9.7) 0.4 (0.4;0.7) 13.8 (10.5;16.7) 0.4 (0.3;0.5) -1 (-35.6;24.3)
Amapá 0.6 (0.5;0.9) 0.6 (0.5;0.9) 2.8 (1.5;3.5) 0.6 (0.3;0.7) -5.4 (-54.4;19)
Amazonas 3.6 (2.9;6.3) 0.4 (0.3;0.7) 9.6 (7.2;12) 0.3 (0.3;0.4) -13.8 (-52.1;11.2)
Bahia 30.9 (24.8;55.3) 0.4 (0.3;0.8) 58.3 (44.5;75.6) 0.4 (0.3;0.5) -12.5 (-45.7;11.9)
Brazil 510.6 (450.7;676.7) 0.5 (0.5;0.7) 1086.1 (621.9;1214.9) 0.5 (0.3;0.5) -10.8 (-47.6;2.4)
Ceará 14.5 (6.7;28.8) 0.3 (0.2;0.7) 34.4 (22.8;39.9) 0.3 (0.2;0.4) 2.3 (-51.5;71.2)
Distrito Federal 4.8 (2.8;5.5) 0.7 (0.4;0.8) 11.4 (4.4;14.4) 0.5 (0.2;0.7) -25.4 (-61.7;-7.7)
Espírito Santo 12.7 (7.9;16.4) 0.9 (0.6;1.2) 27.2 (12.3;32.9) 0.7 (0.3;0.8) -25.7 (-53.2;-11.9)
Goiás 11.2 (9.8;15.1) 0.5 (0.5;0.8) 27.1 (17.8;31.5) 0.4 (0.3;0.5) -23.2 (-50.5;-5.8)
Maranhão 10.8 (4.8;26.3) 0.4 (0.2;1) 17.1 (9.6;37.7) 0.3 (0.1;0.6) -33.4 (-48.1;-10.8)
Mato Grosso 4.8 (4;6.5) 0.5 (0.4;0.7) 14.1 (8.2;16.5) 0.5 (0.3;0.5) -10.3 (-50.3;12.3)
Mato Grosso do Sul 5.6 (4.7;7.5) 0.6 (0.5;0.8) 13.7 (7.5;16.9) 0.5 (0.3;0.6) -14.8 (-51.4;5.8)
Minas Gerais 52.7 (46.2;74.3) 0.5 (0.5;0.8) 116.6 (70;135.7) 0.5 (0.3;0.5) -12.1 (-50.7;7.4)
Pará 11.1 (8.9;16.6) 0.5 (0.4;0.7) 30.4 (20.2;35.2) 0.5 (0.3;0.5) -3.9 (-40.7;18.8)
Paraíba 7.3 (3.7;14.5) 0.3 (0.2;0.6) 11.2 (7.1;19.1) 0.2 (0.2;0.4) -22 (-45;5.2)
Paraná 36.5 (25.4;49.7) 0.7 (0.5;1) 74.2 (32.6;98.5) 0.6 (0.3;0.8) -18.9 (-53.8;-3.3)
Pernambuco 29.2 (24.3;36) 0.6 (0.5;0.8) 57.2 (32.8;66.9) 0.6 (0.3;0.7) -8.1 (-41.3;8.9)
Piauí 6 (2.9;12.6) 0.4 (0.2;0.9) 12 (8.1;17) 0.3 (0.2;0.5) -18.7 (-50.7;20.3)
Rio de Janeiro 54 (41.3;69.8) 0.6 (0.4;0.7) 89.8 (52;104.2) 0.4 (0.2;0.5) -23 (-52;-9)
Rio Grande do Norte 5.5 (3.1;11.5) 0.3 (0.2;0.7) 12.5 (9.9;16.1) 0.3 (0.3;0.4) 1.3 (-46.2;62.2)
Rio Grande do Sul 44.8 (30.8;61.3) 0.7 (0.5;0.9) 94.5 (39;135.6) 0.6 (0.3;0.9) -6.7 (-49.3;10.9)
Rondônia 2.1 (1.7;3.4) 0.5 (0.4;0.8) 5.3 (3.9;6.7) 0.4 (0.3;0.5) -25.1 (-52.5;-2.4)
Roraima 0.2 (0.2;0.6) 0.4 (0.2;1) 0.7 (0.5;1.5) 0.2 (0.2;0.5) -41.8 (-65.4;-12.9)
Santa Catarina 19.9 (13.3;30.3) 0.8 (0.5;1.3) 42.4 (18.9;60.8) 0.6 (0.3;0.9) -25.7 (-54.3;-10.7)
São Paulo 128.9 (98.6;180) 0.6 (0.5;0.9) 292.7 (118.9;351.9) 0.6 (0.2;0.7) -5.7 (-55.2;16.5)
Sergipe 3.4 (2.1;5.8) 0.4 (0.2;0.7) 8 (5.3;9.6) 0.4 (0.2;0.4) -2.4 (-41.6;23.1)
Tocantins 2.3 (1.4;3.7) 0.4 (0.2;0.7) 6.8 (4.2;8) 0.5 (0.3;0.6) -19.2 (-63.8;33.1)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.236

– Number of DALY, age-standardized DALY rates (per 100 000), and percent change of rates by cardiovascular groups of causes of death, in Brazil and its Federative Units, 1990 and 2017
Cause of death and Location 1990 Percent change (95% UI)
Number (95% UI) Rate (95% UI) Rate (95% UI)
B.2.1- Rheumatic heart disease
Acre 460.8 (410.3;524.6) 127.1 (114.1;144.3) 671 (557.8;816.4) 79.5 (67.1;95.5) -37.5 (-43.8;-30.7)
Alagoas 3143.3 (2600.7;3851.6) 125 (105.1;149.3) 2632.8 (2168.9;3233.3) 73.8 (61.1;90.1) -40.9 (-50;-30.9)
Amapá 204.8 (173.1;242.1) 91.4 (78.4;106.6) 551.5 (440.6;687.6) 71.1 (57.7;87.5) -22.2 (-29.7;-14.4)
Amazonas 1528 (1267.3;1848.2) 85.2 (71.4;102.2) 2460.5 (1938.2;3170.4) 62.1 (49.5;78.9) -27.1 (-33.3;-20.8)
Bahia 12095.4 (10485.4;13973.7) 103.7 (90.3;120.3) 11460 (9428.5;14129.4) 70.5 (58.1;86.8) -32.1 (-38.7;-24.8)
Brazil 163388 (144922.3;186177.2) 118.9 (106.1;134.7) 162013.6 (134153.5;198443.9) 71.2 (59;87.2) -40.1 (-45.4;-34.6)
Ceará 5090.4 (4101.6;6158.3) 81.2 (65.9;98.4) 5664.1 (4357.1;7338.2) 56.4 (43.5;72.8) -30.6 (-39.8;-20.8)
Distrito Federal 2073.5 (1853.8;2341.2) 151.6 (137.6;168.9) 2439.1 (2023.3;2978.4) 78.8 (65.8;94.9) -48 (-53.7;-42)
Espírito Santo 2628.8 (2295.3;3051.6) 109.2 (96.1;125.8) 2974.6 (2426.3;3661.6) 70.1 (57.1;86.3) -35.8 (-42;-29.9)
Goiás 4735.6 (4205.1;5429.8) 128 (114.7;145.2) 5840.8 (4903.6;7144.8) 79.8 (67.3;97.3) -37.7 (-43.5;-31.5)
Maranhão 7473 (5921.2;9327.9) 142.1 (116.4;171.6) 4842.9 (3887.8;6116.6) 63.2 (51;79.3) -55.6 (-64.4;-46.3)
Mato Grosso 1828.6 (1579.2;2132.2) 101.6 (88.5;117.3) 2466 (1996.8;3072) 66.9 (54.5;82.8) -34.2 (-40.9;-27.8)
Mato Grosso do Sul 1669 (1402.1;1974.2) 104.5 (90.1;121.8) 2109.8 (1733.1;2612.1) 71.2 (58.6;87.9) -31.8 (-38.6;-24.4)
Minas Gerais 19249.1 (17181.8;21938.6) 130.8 (117.6;148) 18154.8 (15183.7;21952.5) 76.5 (63.5;92.8) -41.5 (-47.4;-35.5)
Pará 3950.3 (3349.3;4663.4) 91.5 (78.6;107.5) 5808.4 (4645;7300.4) 65.9 (53.3;82) -27.9 (-34.8;-20.8)
Paraíba 3916.4 (3288.8;4699.1) 125.1 (106.1;147.5) 3123.4 (2541.7;3837.2) 70.6 (57.5;86.9) -43.5 (-52;-34.8)
Paraná 10399.6 (9331.5;11680) 136.1 (123.1;152.3) 10256.3 (8682.8;12479.2) 81.7 (68.6;99.4) -40 (-45.5;-33.8)
Pernambuco 7748.4 (6752.1;8887.8) 110.2 (95.9;126.4) 8150.9 (6836.5;9867.3) 78.7 (66.2;95.3) -28.5 (-34.6;-22.1)
Piauí 2106.2 (1603.1;2601.3) 83.8 (66;103.3) 2139 (1699.7;2745.7) 58.6 (46.7;75.1) -30.1 (-40.3;-17.3)
Rio de Janeiro 14806.5 (13066.6;16943.4) 113.9 (100.9;129.8) 13785.8 (11373.1;17049.6) 70.7 (58;88) -37.9 (-43.9;-31.8)
Rio Grande do Norte 2163 (1817.4;2559.8) 94.3 (79.8;111.1) 2852.8 (2365.9;3507.2) 75.4 (62.7;92.4) -20.1 (-28.4;-10.9)
Rio Grande do Sul 8371.7 (7163.3;9922.7) 94.4 (81.5;110.9) 7857.9 (6265.8;9956.8) 62 (48.9;78.6) -34.4 (-40.8;-27.9)
Rondônia 1066 (924.3;1232.7) 113.4 (100;129.4) 1317 (1055;1625.9) 73 (58.9;89.6) -35.7 (-43.4;-28.3)
Roraima 153.9 (127.6;187.4) 88.8 (75.3;105.5) 335.3 (262.1;430.8) 61.7 (48.9;77.9) -30.5 (-38.5;-22.8)
Santa Catarina 4413.5 (3816.7;5148.1) 108.6 (95.7;125) 5283.7 (4296.7;6556.9) 68.4 (55.6;85) -37 (-43.4;-30.6)
São Paulo 39592.8 (35476.3;45103.4) 134.5 (121.5;151.7) 35783 (29557.6;44123.8) 70.9 (58.2;87.7) -47.3 (-53.3;-41.3)
Sergipe 1627.5 (1401.2;1913.6) 114.8 (100.3;133) 1870.6 (1561.8;2277.1) 77 (64.6;93.1) -33 (-40.2;-26.3)
Tocantins 891.8 (595.4;1118.1) 109.4 (80.7;133.7) 1181.6 (973.8;1459.3) 72.9 (60.4;89.7) -33.3 (-44.6;-15.9)
B.2.5- Non-rheumatic valvular heart disease
Acre 76.6 (68.6;89.8) 34.6 (31.1;41) 231.2 (202.9;258.1) 34.9 (30.4;39) 1.1 (-16.5;14.5)
Alagoas 435.5 (385.3;565.4) 27.1 (24;35.1) 1122.2 (1002.4;1359.9) 34.4 (30.7;41.5) 26.9 (7.9;43.8)
Amapá 60 (41.1;66.2) 43.9 (31;48.5) 276 (187.7;307.7) 48.3 (32.6;53.9) 10 (-7.8;24.5)
Amazonas 383.1 (320.1;430.5) 35.8 (30.9;40.2) 1120.8 (942.5;1248.8) 36.4 (30.5;40.4) 1.7 (-10.3;14)
Bahia 2839.9 (2502.2;3279.7) 35.1 (31.1;40.7) 4949.5 (4486.8;6140.9) 30.8 (28;38.3) -12.2 (-22.2;12)
Brazil 45589.2 (38652.3;48617.4) 42.9 (36.6;45.8) 89684.3 (75761.8;95891.8) 39.4 (33.2;42.2) -8 (-15.6;-4)
Ceará 979.5 (757.8;1644.8) 21.4 (16.6;36) 2601.6 (2333.2;3343) 26.2 (23.5;33.6) 22.2 (-13.9;51.7)
Distrito Federal 475.3 (369.5;517.4) 53 (41.8;57.3) 1026.2 (904.4;1164.8) 40.2 (35.3;45.4) -24.1 (-32.1;-7.6)
Espírito Santo 954.5 (637.9;1049.7) 53.2 (36.8;58.2) 1994.2 (1441.6;2200) 46.7 (33.9;51.6) -12.2 (-19.7;-3.4)
Goiás 1044.4 (870.5;1136.7) 40.3 (34;43.8) 2513.9 (2156.8;2780.7) 36.3 (31.4;40.2) -10 (-17;-1)
Maranhão 841.7 (638.4;1353.6) 27.4 (21;44.5) 1646 (1410.8;2450.2) 24.5 (21;36.5) -10.4 (-24;7.8)
Mato Grosso 448.3 (391.9;502.9) 39.1 (34.6;43.8) 1235 (1068.3;1378.4) 37.4 (32.3;41.7) -4.3 (-15.6;7.1)
Mato Grosso do Sul 518 (401.4;571.5) 45.4 (35.9;49.7) 1237.3 (960.8;1368.1) 43.2 (33.7;47.7) -4.9 (-15.2;6.1)
Minas Gerais 4805.1 (4079.6;5198.5) 41.1 (35.6;44.6) 9545.6 (7991.5;10392.3) 38 (31.9;41.5) -7.7 (-17.5;-0.1)
Pará 871.1 (775.6;1053.9) 31.3 (28.2;38.5) 2471.2 (2222.8;2874.6) 33.9 (30.5;39.6) 8.3 (-6.6;20.6)
Paraíba 485 (382.9;858.3) 19.9 (15.8;34.8) 978.9 (818.3;1667.4) 21.5 (17.9;36.6) 8.1 (-11.5;28.3)
Paraná 3211.1 (2218.8;3517.2) 54.6 (38.2;59.6) 6327.7 (4281.6;6982.9) 49.8 (33.6;55) -8.8 (-18.1;-1.4)
Pernambuco 2014.5 (1698.1;2212.9) 38.6 (33.3;42.7) 4112.2 (3493.4;4518.3) 41 (34.7;44.9) 6.1 (-4.3;16.3)
Piauí 381.9 (291.7;687.1) 23.2 (18.1;41) 879.2 (770.3;1289.3) 24.2 (21.2;35.5) 4.3 (-18.9;27.5)
Rio de Janeiro 4639.3 (4053.3;5965.9) 41.8 (37.1;54.1) 7855.6 (7028.2;9622.4) 37.1 (33.3;45.6) -11.2 (-18.7;-3.6)
Rio Grande do Norte 446.7 (374.6;658.4) 25.3 (21.2;37) 1205.9 (1082.5;1495.1) 31.9 (28.6;39.6) 26.3 (-7.3;51.8)
Rio Grande do Sul 4017.2 (2844.8;4352.4) 53.9 (38.7;58.5) 7588.9 (4941.1;8430.1) 51.9 (34.2;57.5) -3.7 (-19.7;5.2)
Rondônia 221.1 (193.3;264.1) 39.1 (34.9;46.8) 524.4 (452.9;662.3) 33.5 (29;41.7) -14.5 (-25.9;-1.6)
Roraima 32 (27.8;41.7) 35.3 (30.8;48.9) 120.3 (104;161.8) 31.5 (27.3;41) -10.9 (-28.3;7.3)
Santa Catarina 1766.7 (1153.7;1937.8) 58.3 (37.4;63.9) 3758.7 (2515;4171.6) 49.2 (32.4;54.7) -15.6 (-22.8;-7.7)
São Paulo 13252 (9281.2;14232.8) 54.6 (39;58.4) 23226.5 (18142.4;25116.5) 44.9 (35.1;48.6) -17.7 (-24.1;-10.8)
Sergipe 218.2 (184.3;330.5) 22.6 (19.1;34.2) 615.9 (541.8;879.7) 27.4 (24.2;39.1) 21.2 (1.3;39)
Tocantins 170.7 (124.4;233.6) 33.3 (26.2;46.2) 519.5 (455.3;586.8) 35.4 (31.1;40) 6.4 (-24;35.7)
B.2.5.1- Non-rheumatic calcific aortic valve disease
Acre 40.5 (30;46.2) 19.1 (14.6;21.7) 133.9 (112.7;168.1) 20.8 (17.7;25.7) 9 (-10.8;51.7)
Alagoas 189.8 (160.5;241.4) 12.2 (10.4;15.3) 625.7 (549.3;827.4) 19.4 (17.1;25.3) 58.6 (33.4;93.9)
Amapá 32.1 (18.2;37) 24.9 (14.5;28.3) 161.6 (122.6;192) 29.4 (21.7;34.5) 17.8 (-0.4;68.2)
Amazonas 231.6 (136.2;266.9) 22.4 (13.8;25.4) 739.3 (617.9;840) 24.4 (20.1;27.5) 9.1 (-6.7;58.5)
Bahia 1658.3 (1011.9;1940.1) 20.9 (13.1;24.3) 3000.9 (2707.6;3816.1) 18.8 (16.9;23.9) -10.4 (-27;61.2)
Brazil 26502.4 (19395.6;28697.2) 25.4 (19.1;27.4) 56930.9 (50545.9;65681.9) 25.1 (22.1;28.7) -1.2 (-9.1;24.2)
Ceará 429.8 (315.7;695.5) 9.6 (7.1;15.5) 1451.9 (1234;2158.8) 14.7 (12.5;21.7) 52.5 (18.4;95)
Distrito Federal 271.8 (234.1;332.2) 32.1 (27.4;38.2) 655.9 (552.3;920.4) 26.3 (22.3;36.6) -18.1 (-30.1;8.5)
Espírito Santo 488.7 (313.1;557) 28.5 (18.8;32.2) 1182.1 (959.5;1371.1) 27.8 (22.4;32) -2.4 (-15.2;28.3)
Goiás 589.3 (415.1;674) 23.7 (17;26.7) 1582.9 (1418.5;1838.7) 23 (20.6;26.6) -3 (-15.7;29.8)
Maranhão 377.9 (295.1;491.2) 12.6 (10;16.7) 951.9 (812.4;1361.8) 14.3 (12.2;20.4) 13.4 (-5.9;44.1)
Mato Grosso 243.7 (182.5;280.4) 22.4 (17.3;25.6) 749.8 (666.3;912.9) 23 (20.5;27.7) 2.6 (-12.2;37)
Mato Grosso do Sul 302.3 (199.2;348.4) 27.5 (18.3;31.2) 806 (658.2;903.3) 28.3 (23;31.6) 2.8 (-12;39)
Minas Gerais 2808.8 (1974.5;3167.3) 24.5 (17.8;27.4) 6005.2 (5096.3;6815.2) 23.9 (20.4;27.2) -2.5 (-13.6;22.8)
Pará 423.2 (333.3;485.2) 16 (13;18.4) 1351.8 (1171.1;1746.7) 19 (16.5;24.4) 18.6 (1.6;53.1)
Paraíba 206.3 (155.1;396.3) 8.6 (6.5;16.2) 547.1 (426.1;1049) 12 (9.3;23.1) 40.1 (11.5;73.1)
Paraná 1874.7 (1154.1;2123.9) 32.9 (20.9;36.9) 4232.1 (3003.5;4719) 33.4 (23.7;37.2) 1.4 (-9;23.8)
Pernambuco 965.9 (746.3;1081.1) 19 (15.1;21.3) 2374.9 (2111.6;2875.8) 23.8 (21.2;28.7) 25.5 (9.4;53.7)
Piauí 152.4 (113.5;255.6) 9.6 (7.3;16.1) 449.8 (369.5;734.1) 12.4 (10.2;20.3) 29.1 (2.6;69.1)
Rio de Janeiro 2651.5 (2230.2;3550.9) 24.2 (20.8;33) 5140.9 (4615.8;7109.1) 24.2 (21.8;33.6) 0 (-10.3;18.3)
Rio Grande do Norte 241.5 (194.2;300.7) 13.8 (11.2;17.3) 750.5 (657;955.2) 19.9 (17.4;25.4) 43.9 (15.2;93.5)
Rio Grande do Sul 2457.2 (1619.1;2728) 33.6 (22.2;37.2) 5106.1 (3487.4;5690.3) 34.8 (23.9;38.6) 3.8 (-6.2;22.4)
Rondônia 121.9 (90.7;143.3) 22.8 (17.7;26.2) 317.1 (262.3;435) 20.6 (17.2;27.3) -9.8 (-28;26.9)
Roraima 20.4 (14.5;23.9) 23.2 (17.5;26.6) 82.2 (68.4;107.1) 22.1 (18.7;27.4) -4.7 (-23.2;36.4)
Santa Catarina 1071.1 (587;1233.8) 36.6 (19.9;41.7) 2571.3 (1727.2;2869.9) 33.9 (22.4;37.9) -7.3 (-17.4;18.6)
São Paulo 8484.5 (5317.1;9384.8) 35.5 (23.3;39.1) 15357.3 (13142.4;17600.3) 29.7 (25.2;33.9) -16.2 (-26;10.5)
Sergipe 93.2 (75.2;149.4) 9.9 (8;15.8) 324.7 (258.7;557.4) 14.6 (11.7;24.7) 47.2 (20.2;81.9)
Tocantins 74 (53.8;103.7) 15.3 (11.9;21) 278.2 (234.9;375.9) 19.2 (16.3;25.7) 25.8 (-2.9;66.6)
B.2.5.2- Non-rheumatic degenerative mitral valve disease
Acre 30 (25.2;46) 13.1 (10.9;20.6) 75.1 (60.5;90.7) 11.2 (8.9;13.4) -14.8 (-45.7;3.5)
Alagoas 220.5 (183.7;311.8) 13.5 (11.2;19) 444.4 (356.2;522.7) 13.4 (10.8;15.8) -0.1 (-29.4;20.1)
Amapá 23.8 (19.6;30.9) 16.6 (14;21.9) 91.8 (53.3;112.4) 15.6 (9.2;19) -6 (-44.1;13.9)
Amazonas 136 (113;215.8) 12.2 (10.1;19.4) 331.9 (263.6;401.4) 10.6 (8.4;12.7) -13.3 (-43;4.9)
Bahia 1104.1 (905.1;1731.5) 13.3 (10.9;21.1) 1828.7 (1488.1;2227.1) 11.3 (9.2;13.8) -14.9 (-42.1;2.9)
Brazil 17936 (15500.4;22621.4) 16.4 (14.4;20.8) 30580.8 (20064.3;34729.6) 13.4 (8.8;15.2) -18.7 (-43.4;-9.3)
Ceará 493.4 (278.6;898.4) 10.7 (6.1;19.1) 1052.9 (767.3;1230.3) 10.6 (7.7;12.4) -1.2 (-43.9;35.8)
Distrito Federal 190.7 (115.1;218.4) 19.7 (12.4;22.5) 339.3 (159.2;421.1) 12.8 (6.2;15.9) -35.1 (-59.2;-22.7)
Espírito Santo 443.7 (279.5;557.8) 23.6 (15.4;29.7) 762.6 (387;901.9) 17.7 (9.1;21) -24.9 (-45.7;-13.2)
Goiás 424.4 (369.9;542.4) 15.6 (13.6;20) 855.1 (613.7;989.7) 12.2 (8.9;14.2) -21.6 (-43.6;-8.5)
Maranhão 385.9 (203.6;833) 12.5 (6.8;26.7) 582.5 (380.8;1068.8) 8.6 (5.7;15.7) -31 (-45.2;-11)
Mato Grosso 190.4 (160.8;242.1) 15.7 (13.3;20.6) 447.5 (286.6;524.3) 13.3 (8.7;15.7) -14.8 (-44.4;3.3)
Mato Grosso do Sul 204.1 (169.1;260.1) 17 (14.4;21.8) 406.4 (251.7;480.2) 14.1 (8.8;16.6) -17.4 (-46;-0.6)
Minas Gerais 1890.6 (1645.4;2507.9) 15.8 (13.9;21.1) 3353.1 (2245.4;3860.9) 13.3 (9;15.3) -15.7 (-44.4;-0.2)
Pará 404.9 (333.3;563.2) 14 (11.7;19.8) 983 (706.3;1136.6) 13.3 (9.6;15.4) -5.5 (-35.3;12.4)
Paraíba 237.4 (142.8;443.7) 9.7 (5.9;17.8) 370 (265.7;569.3) 8.1 (5.8;12.5) -16.5 (-38.4;3.1)
Paraná 1268 (887.1;1627.5) 20.6 (14.9;26.9) 1968.9 (1084.3;2414.3) 15.4 (8.5;18.9) -25.5 (-48;-13.3)
Pernambuco 999.8 (786.7;1162.9) 18.8 (15.1;22) 1641.1 (1077;1887.1) 16.2 (10.7;18.7) -13.7 (-34;-1.5)
Piauí 195.7 (108.4;388.3) 11.8 (6.8;22.7) 376.3 (274.4;508.7) 10.3 (7.5;14) -12.3 (-42.4;17.5)
Rio de Janeiro 1909.1 (1454.4;2345.8) 16.9 (13;20.8) 2593.4 (1731.6;3056.8) 12.3 (8.2;14.5) -27.2 (-47.3;-16.1)
Rio Grande do Norte 183.1 (118.7;339.9) 10.3 (6.7;18.9) 401.6 (333.7;489.9) 10.6 (8.8;12.9) 3 (-38.3;45.6)
Rio Grande do Sul 1483.2 (1058.6;1927.1) 19.4 (13.9;25.2) 2354.6 (1214.6;2951.9) 16.1 (8.4;20.2) -16.7 (-46.7;-2.1)
Rondônia 87 (71.6;132.9) 14.6 (12.1;22.1) 172.4 (133;219) 10.9 (8.5;13.5) -25.6 (-47.3;-7.7)
Roraima 9.1 (6.4;21.2) 10 (7.1;23) 27 (19.8;52.4) 7 (5.2;12.6) -30.3 (-53.4;-10)
Santa Catarina 664.1 (474.2;931.5) 20.8 (14.7;29.9) 1126.1 (625.8;1436.1) 14.5 (8.2;18.8) -30.2 (-50.8;-18.5)
São Paulo 4562.6 (3474.3;6176.4) 18.3 (14.3;24.5) 7528.5 (4049.6;8857.7) 14.5 (7.8;17) -20.8 (-50.7;-5.8)
Sergipe 111.2 (75.5;172) 11.4 (7.8;17.5) 256 (187.3;305.8) 11.3 (8.3;13.7) -0.9 (-32.9;20.8)
Tocantins 83.2 (52.6;126.5) 15.7 (10.1;24) 210.5 (142.8;246.4) 14.2 (9.7;16.6) -9.5 (-49.6;31)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

– A: Age-standardized mortality rates attributable to Rheumatic Heart Disease in Brazil in 1990 – 2017. B: Crude mortality rates attributable to Rheumatic Heart Disease in Brazil in 1990 – 2017. C: Proportional mortality (%) attributable to Rheumatic Heart Disease in the Brazilian population in 1990 – 2017. Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

Data derived from Global Burden of Disease Study 2017 (GBD 2017).236

– Number of prevalent cases and age-standardized prevalence of atrial fibrillation and flutter, per 100 000 inhabitants, in 1990 and 2017, with percent change, by sex, in Brazil and Brazilian Federative Units
Both Sexes Female Male
Brazil and Federative Units 1990 (95% UI) 2017 (95% UI) Percent change (95% UI) 1990 (95% UI) 2017 (95% UI) Percent change (95% UI) 1990 (95% UI) 2017 (95% UI) Percent change (95% UI)
Acre 585.2 (482.8;692.5) 600.8 (493.1;714.2) 2.7 (7.1;-2) 487.9 (408.1;569.3) 508.3 (427;596.5) 4.2 (10.3;-2.2) 669.8 (540.1;806.8) 697.2 (555;849.8) 4.1 (10.6;-2.5)
Alagoas 426.1 (308.3;568) 428.7 (312.2;556.5) 0.6 (5.9;-5) 320.2 (221.7;432.7) 322.5 (225.4;434.5) 0.7 (7.5;-6.3) 546.6 (398.9;735.7) 562.5 (421.5;734.3) 2.9 (10.7;-5.3)
Amapá 673.7 (580.9;766.1) 696.7 (600.5;800.2) 3.4 (7.3;-0.5) 538.9 (464;616.7) 559.2 (483.3;643.2) 3.8 (8.8;-1.3) 816.7 (703.6;936.5) 848.1 (726.9;976.7) 3.8 (10.1;-1.8)
Amazonas 482.5 (375.5;610.5) 503 (385.7;636.4) 4.3 (9.9;-0.4) 349.6 (257.3;461.3) 360.5 (264.6;476.8) 3.1 (9.9;-3.1) 620 (490.9;766.8) 655.3 (510;813) 5.7 (13;-0.7)
Bahia 447.3 (332.2;579.6) 469.7 (346.1;606.8) 5 (10.1;0.1) 336.9 (242.4;445.2) 359.7 (258.1;475.1) 6.8 (13.6;-0.5) 574.2 (436.2;733.4) 605.7 (454;772.5) 5.5 (14;-1.6)
Brazil 619 (515.5;727.6) 640.9 (537;751) 3.5 (5.3;1.7) 499.3 (417.9;586.5) 522.1 (439.9;610.1) 4.6 (7;2.3) 758.9 (630;893.1) 786.9 (656.6;925) 3.7 (5.9;1.4)
Ceará 470.1 (361.8;598.3) 481.7 (368.6;612.8) 2.5 (7.1;-1.9) 338.8 (242.3;450.9) 348.8 (250.2;463.5) 2.9 (9.6;-3.7) 618.3 (486.1;767.3) 645.7 (505.6;803.7) 4.4 (10.7;-2.2)
Distrito Federal 649.2 (560.8;745.1) 665.2 (569.5;769.2) 2.5 (7.2;-1.6) 528.1 (456.8;602.9) 547.3 (468.8;629.1) 3.6 (9.8;-1.9) 796.8 (686.4;920.9) 824.8 (698.9;968.1) 3.5 (10.7;-2.1)
Espírito Santo 483.6 (371.6;608.6) 505 (386.6;644.5) 4.4 (9.4;-0.7) 381 (295.8;478.9) 401.9 (311.9;509.7) 5.5 (13.1;-0.8) 597 (453;756.4) 629.5 (479.9;809) 5.4 (12.5;-0.9)
Goiás 487.3 (378.1;605.3) 511.8 (397.7;643.5) 5 (10.8;-0.1) 438.8 (359.7;524.3) 461.1 (377.2;557.3) 5.1 (12;-1.8) 533.3 (381.5;695.6) 568.7 (412.3;754.8) 6.6 (14.8;-1.1)
Maranhão 377.7 (251.2;546.2) 351.4 (234.6;502) -7 (-1.9;-13.4) 300.6 (197.9;439.7) 281.1 (185.6;398.6) -6.5 (0.1;-14.7) 467.9 (312.4;676.6) 432.4 (290.1;621.1) -7.6 (0.1;-16)
Mato Grosso 537.9 (432.1;652) 558.1 (443.3;686) 3.8 (8.6;-1.1) 456.4 (381.1;543.6) 477.2 (393.2;572.4) 4.6 (11.2;-1.6) 607.2 (471.4;759.2) 637.4 (491.4;812.9) 5 (11.6;-1.8)
Mato Grosso do Sul 678.5 (588.7;774.3) 690.4 (594.9;796.2) 1.8 (6.6;-2.3) 532.6 (459.2;608.8) 551.4 (477.8;631.7) 3.5 (9.7;-1.9) 815.8 (706.7;938.3) 845.2 (719.9;986) 3.6 (10.2;-2.2)
Minas Gerais 716.3 (620.7;815.9) 732.2 (646.8;820.9) 2.2 (7.8;-2.6) 554.1 (476.8;635) 565.7 (498.8;638.4) 2.1 (9;-3.9) 907.1 (783.5;1034.5) 930.7 (822.7;1040.7) 2.6 (9;-2.9)
Pará 426.2 (310.8;561) 434.7 (314;575.1) 2 (7.4;-3.1) 312 (218.4;434.1) 309.5 (215.6;429.8) -0.8 (6.5;-7.7) 549.8 (406.6;719.6) 569.2 (416;743) 3.5 (9.7;-3.5)
Paraíba 507.8 (405.5;622) 527.4 (418.9;650.3) 3.9 (8.1;-0.2) 417.8 (341.3;505.7) 438.5 (352.9;531.2) 5 (11;-1.2) 610.3 (472.6;762.7) 640.1 (498.3;810.1) 4.9 (11.5;-1.8)
Paraná 588.3 (488.1;692.4) 607.7 (502.3;721.1) 3.3 (7.6;-0.9) 493.9 (418.7;573.1) 514.7 (434.7;602.9) 4.2 (10;-2) 686.9 (554.8;827.8) 719 (576.4;870.9) 4.7 (12.5;-1)
Pernambuco 422.7 (304.4;559.1) 442 (317.7;588.2) 4.6 (10.1;-0.4) 335.9 (238.6;447.7) 354.9 (255.2;473.6) 5.7 (14;-1.6) 528.9 (379.7;703.9) 558.1 (400.4;750.7) 5.5 (11.9;-1.7)
Piauí 429.2 (311.3;569) 437.6 (318.1;577.5) 2 (7.4;-2.4) 322 (227.4;434.3) 327.8 (229.5;439.6) 1.8 (9.4;-5.2) 550.2 (408.1;719.3) 568.7 (417.2;750.2) 3.4 (9.7;-2.6)
Rio de Janeiro 723.3 (626.3;827) 742.4 (646.8;845.8) 2.6 (6.6;-1.4) 567.3 (487;652.3) 585 (506.3;671.8) 3.1 (8.3;-2.2) 934.3 (812;1071.9) 956.7 (831.5;1094.2) 2.4 (8.2;-3.3)
Rio Grande do Norte 458.2 (345.8;587) 467.1 (346.5;603.8) 1.9 (7.6;-3.1) 337.9 (242.7;446.4) 347.7 (247;466.6) 2.9 (11.2;-4.7) 592.8 (458.7;744.5) 617 (468.6;789.3) 4.1 (11;-3)
Rio Grande do Sul 509.1 (399;629.9) 534.9 (418.9;668) 5.1 (9.5;0.3) 435.5 (351.1;526.3) 456.5 (367.2;558.1) 4.8 (11.9;-1.6) 604.9 (449;773) 635.8 (476.4;823.5) 5.1 (11.8;-0.9)
Rondônia 515.5 (408.2;637) 529.1 (416;655) 2.6 (7.3;-2.3) 436.6 (357.1;521.5) 455.1 (371.5;547.6) 4.2 (11.1;-2.2) 580.5 (446;741.2) 601.5 (453.1;767.6) 3.6 (10.8;-3)
Roraima 702.9 (609.8;804.9) 741.4 (646.1;844.4) 5.5 (9.5;1.6) 523.1 (451.2;603.1) 562.9 (488.7;641.4) 7.6 (13.8;2) 843.5 (728.4;969) 909.8 (793.3;1039.6) 7.9 (13.4;2.4)
Santa Catarina 617.1 (516.7;722.4) 641.9 (539.1;754.4) 4 (8.5;-0.2) 561.6 (482.9;640.9) 582.5 (504;667.2) 3.7 (9.4;-2.4) 679.5 (544.4;820.5) 711.7 (566.7;873) 4.7 (11.1;-1.6)
São Paulo 849.8 (736.7;972.7) 865.6 (753.4;984.3) 1.9 (6.1;-1.9) 702.6 (605.4;807.1) 726.4 (629.4;832.9) 3.4 (9.7;-1.6) 1028.3 (890.9;1176.3) 1042.9 (903.6;1190.2) 1.4 (6.8;-4.1)
Sergipe 518.5 (419.8;629.8) 536.3 (436.6;654.6) 3.4 (8.5;-1.3) 390.7 (312.6;481.3) 408.3 (322.8;515.6) 4.5 (11.9;-2.6) 669.2 (543.8;805.3) 699.4 (570.4;847.3) 4.5 (10.9;-1.6)
Tocantins 613.3 (518.7;713.7) 632.8 (532.1;743) 3.2 (8.2;-1.6) 448.1 (372.1;527.4) 465.7 (385.1;557.3) 3.9 (9.7;-1.4) 765.1 (651.1;890.6) 794.5 (668.7;927.2) 3.8 (10.3;-2.9)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

– Number of deaths and age-standardized mortality rate due to atrial fibrillation and flutter, per 100 000 inhabitants, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017
Number of deaths (95% UI) Mortality rate (95% UI) Number of deaths (95% UI) Mortality rate (95% UI) Percent change (95% UI)
Acre 4 (4;5) 4.9 (4.5;5.5) 22 (20;24) 4.5 (4.1;4.8) -8.6 (-18.4;-0.9)
Alagoas 35 (33;41) 3.5 (3.3;4.1) 119 (112;135) 4.1 (3.8;4.7) 16.1 (4.2;26.2)
Amapá 3 (3;3) 5.8 (5.4;6.5) 18 (16;19) 5.3 (4.7;5.6) -9.6 (-20.2;-2.2)
Amazonas 19 (17;22) 3.9 (3.7;4.7) 87 (82;96) 4 (3.8;4.5) 3.2 (-11.6;13)
Bahia 236 (219;265) 4.2 (3.9;4.8) 719 (675;798) 4.3 (4.1;4.8) 2.3 (-6.1;10.2)
Brazil 2649 (2428;2836) 4.7 (4.4;5.1) 10059 (9390;10698) 4.8 (4.5;5.2) 2.5 (-2.9;7.3)
Ceará 128 (117;149) 3.5 (3.2;4.1) 404 (380;443) 3.9 (3.6;4.3) 10.9 (-1.7;21.9)
Distrito Federal 13 (12;14) 6.4 (6.1;7) 97 (88;108) 7.6 (6.8;8.4) 19.8 (5.5;32.9)
Espírito Santo 41 (37;44) 6.2 (5.7;6.7) 169 (157;188) 4.5 (4.1;5) -28.3 (-33.7;-21)
Goiás 43 (38;46) 4.9 (4.5;5.2) 226 (206;246) 4.3 (3.9;4.6) -13.7 (-20.1;-5.6)
Maranhão 85 (55;101) 4.9 (3;5.8) 305 (219;342) 5.1 (3.6;5.7) 4.1 (-6.7;26.3)
Mato Grosso 18 (16;21) 4.1 (3.8;5.1) 99 (92;111) 4.4 (4.1;4.9) 5.6 (-8.3;16.1)
Mato Grosso do Sul 24 (22;26) 5.1 (4.7;5.5) 110 (103;122) 4.8 (4.5;5.3) -6.6 (-13.3;2.2)
Minas Gerais 279 (253;294) 5.2 (4.7;5.4) 1144 (1058;1223) 4.6 (4.3;4.9) -11.5 (-17.2;-4.6)
Pará 63 (59;71) 4.5 (4.2;5) 258 (232;279) 4.6 (4.1;5) 2.5 (-8.3;11.9)
Paraíba 74 (69;85) 3.8 (3.5;4.3) 196 (179;222) 3.9 (3.6;4.5) 4.1 (-8.4;16.3)
Paraná 123 (115;137) 5.4 (5.1;5.9) 516 (487;575) 4.9 (4.6;5.5) -8.3 (-14.2;-2)
Pernambuco 135 (127;151) 4.7 (4.5;5.3) 402 (377;446) 4.3 (4;4.8) -9 (-15.1;-2.3)
Piaui 43 (39;51) 4.1 (3.7;5) 138 (129;157) 3.8 (3.5;4.3) -9.1 (-20.7;0.5)
Rio de Janeiro 290 (266;306) 5.3 (4.9;5.6) 1052 (972;1124) 5.2 (4.8;5.6) -0.2 (-6.7;6.5)
Rio Grande do Norte 60 (54;67) 4.1 (3.7;4.6) 169 (158;188) 4.2 (3.9;4.6) 1.5 (-8.4;12.4)
Rio Grande do Sul 183 (168;195) 4.9 (4.5;5.2) 698 (655;761) 4.9 (4.6;5.3) 0.5 (-6.6;7.6)
Rondônia 5 (5;6) 4.5 (4.2;5) 45 (41;52) 4.3 (3.8;4.9) -5.4 (-16.1;6.2)
Roraima 1 (1;2) 7.7 (7;9.2) 11 (10;13) 6.6 (5.8;7.4) -14.5 (-30.2;-1.2)
São Paulo 637 (571;670) 5.8 (5.2;6.1) 2605 (2372;2755) 5.8 (5.3;6.2) 1.2 (-6.3;8.4)
Santa Catarina 69 (64;74) 5.2 (4.8;5.6) 312 (293;340) 5.1 (4.8;5.6) -1.3 (-8.7;6.5)
Sergipe 27 (25;31) 3.6 (3.4;4.1) 81 (75;87) 4 (3.7;4.4) 11.4 (-0.8;21.6)
Tocantins 10 (9;12) 7.1 (6.4;8.3) 55 (50;60) 4.4 (4;4.8) -37.4 (-46.5;-30.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation .285

– Number of deaths and age-standardized mortality rate due to atrial fibrillation and flutter, per 100 000 inhabitants, for males, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017
Number of deaths (95% UI) Mortality rate (95% UI) Number of deaths (95% UI) Mortality rate (95% UI) Percent change (95% UI)
Acre 2.4 (2;2.9) 5.2 (4.5;6.3) 9.9 (7.4;11) 4.3 (3.2;4.7) -18.5 (-36;-6.3)
Alagoas 16.8 (14.9;21.8) 3.9 (3.5;5.1) 43.9 (36;51) 3.6 (3;4.2) -6.8 (-25.1;7.4)
Amapá 1.4 (1.2;1.7) 5.3 (4.7;6.9) 8 (5.9;8.9) 5.7 (4.2;6.3) 7.2 (-22.4;24.4)
Amazonas 9 (8;12.5) 4.1 (3.7;5.9) 37.1 (31.5;44.3) 3.8 (3.2;4.5) -8.9 (-31.4;6.1)
Bahia 106.6 (93.5;133.7) 4.5 (3.9;5.6) 300.3 (246.4;345.5) 4.5 (3.7;5.2) 2 (-12.8;14.6)
Brazil 1134.1 (952.8;1309.1) 4.7 (4.1;5.6) 3773.7 (3076.2;4312) 4.6 (3.8;5.2) -3.5 (-12.9;1.8)
Ceará 60.8 (52.3;85.1) 3.7 (3.2;5.2) 150.3 (124.7;172.3) 3.6 (3;4.1) -3.7 (-27.5;14.2)
Distrito Federal 5.1 (4.4;6.3) 5.8 (5;6.9) 33.1 (27.6;44.6) 6.5 (5.5;8.3) 12.6 (-5.3;28.7)
Espírito Santo 18.7 (15.5;21.5) 6 (5;7.1) 68.3 (59.6;85.4) 4.5 (3.9;5.6) -25.5 (-35.5;-12.6)
Goiás 19.6 (15.7;22.2) 3.6 (2.8;4) 104.4 (86.7;121.5) 4.3 (3.6;5.1) 20.7 (5.6;36.8)
Maranhão 37.7 (28.4;47.6) 6 (4.1;7.9) 152.5 (121.6;180.5) 6.1 (4.8;7.2) 0.5 (-17.7;21.6)
Mato Grosso 9.7 (8.6;13.3) 4.5 (3.9;6.5) 45.7 (39.9;56.6) 4 (3.5;4.9) -12.1 (-31.4;2)
Mato Grosso do Sul 12 (10;13.7) 4.8 (3.9;5.4) 46.7 (37.9;53) 4.5 (3.7;5.2) -4.6 (-15;4.9)
Minas Gerais 117.9 (91.5;129.6) 4.9 (3.8;5.3) 448.6 (360.9;504.4) 4.4 (3.6;5) -8.8 (-18.3;5.3)
Pará 27.4 (24.5;34.2) 4.4 (3.9;5.6) 118.4 (98.2;138.8) 4.7 (3.8;5.5) 6.5 (-11.5;21.6)
Paraíba 34.5 (30.2;43.6) 3.7 (3.2;4.6) 73.6 (58.5;86.4) 3.7 (3;4.4) 1.3 (-16.8;20)
Paraná 56.9 (48.1;67.9) 5.1 (4.3;6.1) 207 (179.8;248.3) 4.7 (4.1;5.6) -7.7 (-19.6;2.2)
Pernambuco 60.6 (51.5;72.6) 5 (4.2;5.9) 146.5 (118.1;165.8) 4 (3.2;4.5) -19.1 (-30.3;-10.8)
Piauí 21.7 (18.5;31.3) 5.2 (4.4;7.7) 51.5 (41.7;59.5) 3.3 (2.7;3.8) -36.2 (-55.3;-22.8)
Rio de Janeiro 111.5 (86.2;124.2) 5.4 (4.3;6.1) 348.2 (286.2;400.2) 4.9 (4.1;5.7) -9.5 (-20.4;2.3)
Rio Grande do Norte 28.1 (25.1;36.5) 4.4 (3.9;5.6) 64.6 (52.2;74.5) 4 (3.2;4.6) -7.7 (-27.1;6.6)
Rio Grande do Sul 72.6 (59.1;83.3) 5.2 (4.2;6) 244.4 (205.8;288.7) 4.8 (4;5.6) -8 (-20.4;2.1)
Rondônia 3.1 (2.7;3.7) 4.9 (4.1;5.7) 21.6 (18;25.5) 4 (3.3;4.7) -18.7 (-32.2;-4.5)
Roraima 0.7 (0.6;0.9) 7.4 (6.4;10.2) 5.2 (3.5;6.1) 5.6 (3.7;6.6) -24.1 (-55.7;-2.4)
Santa Catarina 29 (23.2;33.3) 4.9 (3.9;5.6) 111.5 (95.9;136.1) 4.6 (3.9;5.5) -6.4 (-21.3;9.3)
São Paulo 253.3 (189.4;278.3) 5.4 (4.1;6) 877.3 (668.2;969.6) 5.2 (4;5.8) -4.1 (-16.6;9.7)
Sergipe 12.1 (10.9;15.6) 3.8 (3.4;4.8) 29.6 (24;33.9) 3.7 (3;4.3) -1.3 (-19.8;13.2)
Tocantins 5 (4.3;7) 6.7 (5.6;10.1) 25.5 (19.7;28.6) 4.1 (3.1;4.5) -39.9 (-59.5;-25)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

– Number of deaths and age-standardized mortality rate due to atrial fibrillation and flutter, per 100 000 inhabitants, for females, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017
Number of deaths (95% UI) Mortality rate (95% UI) Number of deaths (95% UI) Mortality rate (95% UI) Percent change (95% UI)
Acre 2.1 (1.9;2.2) 4.7 (4.3;5) 12.1 (11;13.8) 4.7 (4.3;5.4) 0.1 (-12.3;20.5)
Alagoas 18.6 (17.2;20.4) 3.3 (3;3.6) 74.9 (68.7;87) 4.4 (4;5.1) 33.7 (18.1;51.9)
Amapá 1.8 (1.6;1.9) 6.2 (5.7;6.6) 9.8 (8.9;10.9) 5 (4.6;5.6) -19.1 (-28.5;-6.7)
Amazonas 9.5 (8.8;10.3) 3.8 (3.5;4) 50.3 (46.4;55.1) 4.2 (3.9;4.7) 13 (1.5;26.5)
Bahia 129.5 (119;141.4) 4.1 (3.8;4.5) 419 (386.8;470) 4.1 (3.8;4.6) 1 (-10.1;14.6)
Brazil 1515 (1453.7;1558) 4.7 (4.5;4.9) 6285.3 (6014.2;6615.7) 5 (4.8;5.2) 5.4 (0;12.3)
Ceará 67.3 (55.6;76.4) 3.4 (2.8;3.8) 253.8 (235.8;280.5) 4.1 (3.8;4.5) 21.2 (2.5;55.8)
Distrito Federal 7.9 (7.4;8.5) 6.8 (6.3;7.5) 64.3 (55.9;72) 8 (6.9;9) 17.8 (-4.1;36.2)
Espírito Santo 22.2 (21.1;23.4) 6.3 (5.9;6.6) 100.3 (91.8;109.2) 4.4 (4;4.8) -29.8 (-36.4;-22.7)
Goiás 23.4 (21.9;24.8) 6.4 (6;6.8) 121.8 (112.8;132.6) 4.2 (3.9;4.6) -34.1 (-39.9;-27.8)
Maranhão 47.5 (19.2;62) 4.6 (1.8;6) 152.1 (84.2;183) 4.5 (2.5;5.4) -2.7 (-16.2;44.7)
Mato Grosso 7.9 (7.1;8.8) 3.8 (3.4;4.2) 53 (48.6;58.4) 4.7 (4.3;5.2) 23.7 (7;43.6)
Mato Grosso do Sul 12.3 (11.7;13) 5.4 (5.1;5.7) 63.5 (58.3;71.8) 5 (4.5;5.6) -8.2 (-16.6;3.4)
Minas Gerais 161 (153.7;169.7) 5.3 (5.1;5.6) 695.6 (644.5;746.7) 4.7 (4.3;5) -12.6 (-19.7;-5.3)
Pará 35.7 (33;38.6) 4.5 (4.2;4.8) 139.2 (126.4;151.5) 4.5 (4.1;4.9) -0.5 (-10.9;10.8)
Paraíba 40 (36.6;44) 3.9 (3.5;4.2) 122.3 (108.1;146.1) 4.1 (3.6;4.8) 5.2 (-10.7;27.9)
Paraná 66 (62.6;70.3) 5.6 (5.3;6) 309.3 (287.2;338.3) 5 (4.7;5.5) -10 (-16.8;-2)
Pernambuco 74.4 (69.4;82.4) 4.6 (4.3;5) 255.8 (234.3;293.1) 4.5 (4.1;5.1) -2.1 (-10.7;9)
Piauí 21.2 (17.8;24.3) 3.5 (3;4.1) 86.9 (80.1;99) 4 (3.7;4.6) 14.2 (-2.7;46.6)
Rio de Janeiro 178.9 (169.9;190.3) 5.2 (4.9;5.5) 703.5 (652;753.2) 5.3 (5;5.7) 3.5 (-4.7;12.5)
Rio Grande do Norte 31.7 (27.6;35.2) 4 (3.4;4.4) 104.6 (95.4;119) 4.2 (3.8;4.8) 7.2 (-7.4;35.9)
Rio Grande do Sul 110 (104.6;115.1) 4.7 (4.5;5) 454 (421.1;488) 4.9 (4.6;5.3) 3.6 (-4.2;12)
Rondônia 2 (1.8;2.2) 4.1 (3.8;4.5) 23.7 (20.5;28.3) 4.5 (3.9;5.4) 9.7 (-6.2;28.3)
Roraima 0.5 (0.5;0.6) 7.8 (7.1;8.7) 6.1 (5.1;7.7) 7.3 (6.1;9.2) -6.5 (-26.1;18.5)
Santa Catarina 39.8 (37.7;42.4) 5.4 (5.1;5.7) 200.6 (185.2;217.9) 5.4 (5;5.9) 0.7 (-8;10.2)
São Paulo 384 (366;404.7) 5.9 (5.6;6.2) 1728 (1597.3;1849.2) 6.1 (5.7;6.6) 3.3 (-4.6;11.7)
Sergipe 14.7 (13.6;16) 3.5 (3.2;3.8) 51 (46.9;55.6) 4.2 (3.9;4.6) 20 (5.5;34.7)
Tocantins 5 (4.2;5.6) 7.3 (6;8.4) 29.9 (27.3;33.6) 4.8 (4.4;5.4) -34.3 (-44.6;-13.8)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

– Number of DALYs and age-standardized DALY rates due to atrial fibrillation and flutter, per 100 000 inhabitants, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017
Number of DALYs (95% UI) DALY Rate (95% UI) Number of DALYs (95% UI) DALY Rate (95% UI) Percent change (95% UI)
Acre 140.3 (113.7;174.5) 95.2 (79;115.3) 542.9 (445.2;660.8) 99.2 (82.4;119.4) 4.2 (-2.5;9.6)
Alagoas 909.3 (730.5;1123.5) 72.4 (59.1;88.5) 2456 (2031.2;2952.7) 82.7 (68.8;99.8) 14.3 (5.6;21.9)
Amapá 93.7 (76;114.6) 108.7 (91.2;129.2) 499.4 (411.6;598.4) 114.8 (96.3;135.5) 5.6 (-0.8;10.9)
Amazonas 560.7 (445.6;698.8) 80.3 (65.3;98.1) 2138.5 (1735.6;2644.7) 86 (70.9;104.7) 7 (-2.3;13.8)
Bahia 5285.8 (4366.4;6397.1) 81.3 (67.7;97.7) 13791.8 (11451.4;16610.3) 87.7 (72.8;105.1) 7.9 (1.8;14.3)
Brazil 79208.5 (64514;96525.8) 99 (82.3;118.9) 226809.7 (187976.8;272166.3) 103.6 (86.3;123.8) 4.6 (1.7;7.2)
Ceará 3014.4 (2422;3741.1) 75.8 (61.3;93.5) 8054.1 (6619.6;9756.6) 81.9 (67.2;99.4) 8.1 (0.8;15.1)
Distrito Federal 543.8 (441.9;662.7) 115.2 (98.8;135.3) 2469.3 (2043.2;2968.8) 121.7 (104.3;143.6) 5.6 (-0.4;12.4)
Espírito Santo 1099.3 (895.3;1344.2) 92 (77.3;109.3) 3570.3 (2938.2;4327.6) 88 (73;106.3) -4.3 (-9.7;2)
Goiás 1394.8 (1125.9;1736.9) 88.5 (74.3;106.4) 5412.9 (4410.7;6618) 87.9 (72.8;106.9) -0.7 (-6;4.2)
Maranhão 1889.2 (1401.3;2435) 82.3 (59.9;105.9) 5041.4 (3929.4;6224.5) 82.1 (63.9;101) -0.3 (-8.1;9.3)
Mato Grosso 598.8 (479.5;750) 88.1 (72.5;107.8) 2612.4 (2125.1;3202.6) 93.2 (76.9;113.4) 5.7 (-1.8;12.3)
Mato Grosso do Sul 826.2 (672.8;1002.9) 106.5 (89.4;126.4) 2822.2 (2306.6;3401.7) 107.2 (88.5;128.2) 0.7 (-4.2;5.9)
Minas Gerais 9413 (7638.3;11547.3) 108.3 (90.1;129.8) 27059.3 (22340.6;32657.7) 108.2 (89.5;130.4) -0.1 (-5;4.7)
Pará 1539.4 (1262.2;1889.2) 81.5 (67.9;98.9) 5393.3 (4478.1;6529.9) 87.8 (73.5;105.3) 7.7 (-0.5;15.3)
Paraíba 1821.5 (1468.3;2223.4) 80.9 (65.7;98.4) 4007.5 (3263.1;4821.6) 86.5 (70.3;104.3) 6.9 (-0.9;14.3)
Paraná 3979.9 (3220;4841.8) 99.3 (83.5;118.5) 12001.8 (9814.5;14534.6) 99.9 (82.5;120) 0.6 (-4.5;5.2)
Pernambuco 3220.7 (2629.5;3992.3) 80.7 (67.7;97.7) 7977.1 (6643;9724) 83.5 (69.8;101.6) 3.5 (-2.1;8.8)
Piauí 1028.8 (830.3;1272.4) 78.1 (63.8;95.4) 2789.9 (2291.5;3412.7) 77.8 (64;95) -0.4 (-9.6;6.5)
Rio de Janeiro 9520.4 (7787.9;11658.2) 111.4 (93.3;133.4) 24316.8 (20202.2;29195.3) 115 (95.9;137.6) 3.2 (-1.1;7.7)
Rio Grande do Norte 1263.4 (1031.4;1535.4) 80.1 (65.7;96.9) 3165.6 (2620.9;3796.6) 84.7 (70.1;101.5) 5.8 (-1;13)
Rio Grande do Sul 5078.4 (4134.3;6186.3) 89.5 (74.8;107.2) 13838.5 (11505.8;16723.4) 93.9 (78.3;113) 5 (-0.4;10.1)
Rondônia 253.4 (200.9;317.6) 90.3 (75.1;109.6) 1179 (948.7;1453.8) 89.7 (73.1;108.8) -0.7 (-9.2;6.7)
Roraima 56.1 (44.6;69.3) 126.8 (106.6;149.8) 348.9 (280.1;430.2) 121.6 (100.7;145.4) -4.1 (-14.3;4.4)
Santa Catarina 2181.6 (1779.3;2657.9) 102 (85.4;121.3) 7392.7 (6024.1;8973) 103.4 (85.4;123.9) 1.3 (-4.1;6.7)
São Paulo 22477.6 (18132.5;27717.9) 126.9 (105.3;152.6) 64766.7 (53494.2;78258.7) 129.7 (107.8;155.7) 2.2 (-1.9;6.8)
Sergipe 669 (542.7;814.8) 81.1 (66.1;98.5) 1828.2 (1484.9;2230) 88.9 (72.8;108.1) 9.6 (2;16.3)
Tocantins 349.1 (280.8;431.7) 109.5 (92.1;130.9) 1333.2 (1097.2;1609.2) 100.5 (83.2;120.9) -8.2 (-17.2;-1.2)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

– Number of DALYs and age-standardized DALY rates due to atrial fibrillation and flutter, per 100 000 inhabitants, for males, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017 Percent change (95% UI)
Number of DALYs (95% UI) DALY Rate (95% UI) Number of DALYs (95% UI) DALY Rate (95% UI)
Acre 82.4 (64.8;104.4) 103.4 (83.4;127.4) 285.5 (225.7;358.6) 105.6 (83.6;130.8) 2.1 (-9.8;11)
Alagoas 499.5 (389.5;638.7) 85 (67.3;107.9) 1190.5 (947.6;1474.1) 90.7 (72.7;112.3) 6.7 (-5.5;16.7)
Amapá 51.1 (40;63.7) 118 (95.2;144.5) 271.4 (214;333.8) 130.5 (104.5;157) 10.6 (-3;20.7)
Amazonas 329.6 (252.8;421.6) 94 (74.1;118) 1188.9 (930.8;1511.3) 97.5 (77.3;121.8) 3.7 (-9.4;13)
Bahia 2825.4 (2259;3508.4) 93.6 (75.8;114.9) 7090.6 (5714.9;8706.2) 103.8 (83.9;126.9) 10.8 (0.8;20.6)
Brazil 41514.9 (32715.2;51721.2) 111.1 (89.5;136.9) 110643.1 (88439.8;136579.6) 115.1 (92.9;141.4) 3.6 (-1.4;6.8)
Ceará 1685.5 (1306.6;2141) 90 (70.3;113.6) 4062.6 (3213.5;5079.7) 94.3 (74.8;117.5) 4.8 (-9.7;15.1)
Distrito Federal 279.4 (219.3;350.7) 121.6 (100;148) 1168.9 (907.8;1460.2) 129.5 (104.1;159.2) 6.5 (-3.6;16.9)
Espírito Santo 599.5 (468.5;752.8) 102.1 (82.7;126.1) 1800.5 (1424.3;2230.4) 99.9 (79.9;123) -2.1 (-9.8;6.8)
Goiás 751.4 (581.6;960.7) 85.2 (67.9;107.5) 2773.6 (2210.3;3516.4) 95.5 (77.1;119.9) 12.1 (3.3;20.3)
Maranhão 1002.8 (794.7;1292) 97.2 (76.4;124.3) 2672.9 (2147.4;3307.8) 95.8 (77.1;117.9) -1.4 (-12.1;9.3)
Mato Grosso 361.1 (280.9;464.2) 97.1 (77.2;122.4) 1416.9 (1121.4;1780.2) 98 (78;122.3) 0.9 (-10.9;10.3)
Mato Grosso do Sul 481.8 (382.6;600.1) 116.5 (94.2;143.5) 1485.7 (1183.7;1835.7) 118.9 (95.7;145.8) 2 (-5;8.3)
Minas Gerais 5075.7 (3941.5;6388.2) 123.2 (98.4;152.2) 13931.2 (11083.4;17144.6) 124.9 (100.2;152.9) 1.4 (-5.6;8.7)
Pará 848 (666.8;1072.3) 92 (73.9;114.8) 3030.6 (2434.6;3752.2) 102.1 (83.5;125.9) 11 (-0.9;21.2)
Paraíba 959.6 (751.8;1199.7) 89.6 (70.4;112.2) 1908.7 (1508.1;2391.4) 96.4 (76.2;120.1) 7.6 (-3.9;19.3)
Paraná 2155.1 (1663;2723.3) 106.1 (85.2;131) 5923.6 (4690.3;7392.9) 109.3 (87.5;134.3) 3 (-4.7;10.2)
Pernambuco 1666.7 (1313.2;2134) 92.1 (74.4;115.9) 3745.8 (2945.1;4730.6) 92.8 (73.4;117.1) 0.8 (-8.9;8.4)
Piauí 576.9 (446.6;737.6) 95.2 (74.8;122.4) 1384.7 (1098.5;1744.7) 85.8 (68.1;107.6) -9.9 (-26.6;0.8)
Rio de Janeiro 4817.5 (3787.4;6124) 130.7 (106;161.9) 11413.5 (9010.4;14162.3) 132.1 (105.6;162.3) 1.1 (-6.1;7.9)
Rio Grande do Norte 693 (547.8;864.6) 93.1 (74.1;115.7) 1566.9 (1250.7;1936.6) 97.1 (77.6;119.6) 4.3 (-9.9;14.5)
Rio Grande do Sul 2490.2 (1952.9;3132) 100.7 (81.3;123.8) 6341.6 (5040.4;7933.5) 103.5 (83.6;128.3) 2.8 (-6;10)
Rondônia 162 (126.2;207.2) 99.7 (81.4;123.1) 641.9 (500.4;812.1) 94.9 (75.2;118.3) -4.9 (-14.9;5)
Roraima 37.3 (29;46.7) 140.1 (113.5;170.8) 206.6 (161.2;261.9) 132.4 (105.1;163.7) -5.5 (-24.5;7.6)
Santa Catarina 1083.7 (847.3;1362.7) 106.2 (85.8;130.2) 3431.7 (2674.2;4328.4) 107 (85.2;133.9) 0.8 (-8.3;9.9)
São Paulo 11426.4 (8857.6;14374.4) 139.5 (111.1;173.2) 30035.6 (23857;37379.4) 140.2 (112.5;172.2) 0.5 (-6.5;7.5)
Sergipe 360.2 (280.2;450.3) 95.4 (74.6;119) 913.8 (721.5;1145.2) 101.8 (81.3;126.9) 6.7 (-4.6;16.1)
Tocantins 213.1 (162.9;269.7) 120.8 (96.4;150) 758.9 (602.2;940.5) 111.6 (89.1;137.6) -7.6 (-24.8;3.3)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

– Number of DALYs and age-standardized DALY rates due to atrial fibrillation and flutter, per 100 000 inhabitants, for females, in 1990 and 2017, with percent change, in Brazil and Brazilian Federative Units
1990 2017 Percent change (95% UI)
Number of DALYs (95% UI) DALY Rate (95% UI) Number of DALYs (95% UI) DALY Rate (95% UI)
Acre 57.9 (47.4;70.5) 86.1 (72.7;102.9) 257.4 (215.1;306.5) 92.9 (77.9;110.2) 7.9 (-0.3;18.8)
Alagoas 409.8 (338.1;497) 61.8 (51.4;75) 1265.4 (1065.7;1512.4) 76 (64.2;90.7) 23 (11;37.8)
Amapá 42.6 (35.6;51.1) 99.4 (85;116.6) 227.9 (189.3;270.1) 101.1 (84.9;118.6) 1.6 (-6.7;11.1)
Amazonas 231.1 (189.1;286.3) 67.1 (56.5;81.1) 949.6 (793.8;1139.7) 74.8 (62.7;88.8) 11.4 (2.8;20.8)
Bahia 2460.4 (2058.7;2986.8) 70.7 (59.5;85.1) 6701.3 (5667.8;8010.2) 74.7 (62.9;89.5) 5.6 (-2.8;15)
Brazil 37693.5 (31770.2;45054.9) 88.6 (76.2;103.9) 116166.6 (98895.8;135791.7) 93.7 (79.8;109.5) 5.8 (2.4;9.7)
Ceará 1329 (1065.5;1653.3) 63.3 (51;78.8) 3991.4 (3369.5;4733.9) 71.4 (60.1;85.2) 12.8 (0.7;31.8)
Distrito Federal 264.4 (221.2;315.2) 109.1 (94.7;125) 1300.4 (1089.6;1554.4) 113.9 (96.7;132.4) 4.4 (-7.5;15.1)
Espírito Santo 499.9 (418.4;598.1) 82.4 (71.3;96.2) 1769.9 (1488;2115) 78 (65.7;93) -5.3 (-11.9;1.5)
Goiás 643.3 (529.2;783.9) 92.3 (80.3;107) 2639.3 (2200.5;3167.7) 81.1 (68.2;96.8) -12.2 (-18.5;-5.6)
Maranhão 886.4 (483.4;1176.4) 72.3 (38.6;96) 2368.5 (1549.5;2987.1) 71.1 (46.4;89.5) -1.8 (-12.9;25)
Mato Grosso 237.7 (192.1;291.2) 78.2 (64.8;94.1) 1195.4 (994.5;1433.5) 88.1 (74.1;103.9) 12.7 (3.3;24)
Mato Grosso do Sul 344.4 (290.2;410.1) 95.3 (82.6;111.1) 1336.5 (1121.2;1582.5) 96.4 (81.4;113.9) 1.2 (-5.8;9.8)
Minas Gerais 4337.2 (3603.5;5206.8) 95 (81.1;111.6) 13128.1 (11052.7;15567.4) 93.7 (78.7;111.3) -1.3 (-7.3;4.6)
Pará 691.4 (579.5;847.2) 71.2 (60.2;85.5) 2362.7 (2004;2820.5) 74.2 (63.4;87.9) 4.2 (-4.6;13.7)
Paraíba 861.9 (711.9;1040.7) 73.2 (61.1;87.8) 2098.8 (1736.5;2506.6) 78.4 (64.5;94) 7.1 (-4;21.5)
Paraná 1824.7 (1515.5;2188.5) 92.4 (79.6;107.7) 6078.2 (5072;7195.1) 91.6 (76.9;107.9) -0.9 (-6.8;5.3)
Pernambuco 1554 (1305.2;1877.1) 71.4 (61;84.8) 4231.3 (3587.3;5077.2) 76.1 (64.6;91) 6.6 (-0.4;14.6)
Piauí 451.9 (362.3;565.1) 64.6 (52.1;80.5) 1405.3 (1184.9;1674.4) 70.6 (59.4;84.4) 9.2 (-2.9;28)
Rio de Janeiro 4703 (3930;5630.4) 97 (82.5;114.7) 12903.3 (10976.9;15227.6) 101.6 (86.2;120) 4.7 (-1.2;11)
Rio Grande do Norte 570.4 (472.9;691.2) 68.7 (57;82.9) 1598.7 (1346;1893.9) 74.5 (62.2;88.8) 8.4 (-3.2;27.5)
Rio Grande do Sul 2588.2 (2156.8;3097.6) 81.1 (69.1;95.9) 7496.9 (6386.8;8904.7) 86 (72.8;102.1) 5.9 (0;12.8)
Rondônia 91.4 (72.4;113.5) 79.2 (66.7;94.3) 537.1 (434.2;655.1) 84.2 (68.9;101.2) 6.3 (-4.1;18.8)
Roraima 18.8 (15.1;22.9) 108.9 (92.8;126.8) 142.3 (114.4;173.6) 108.9 (89.6;130.4) 0 (-14.6;17.9)
Santa Catarina 1097.9 (912.9;1328.2) 97.8 (83.5;116.1) 3961 (3331.6;4682.9) 99.3 (83.9;116.5) 1.5 (-4.6;8.4)
São Paulo 11051.2 (9167;13335.7) 115.9 (98;137.3) 34731.2 (29277.5;41069.7) 120.4 (101.6;142.3) 3.9 (-1.4;9.9)
Sergipe 308.8 (258.3;371.5) 69 (58;82.6) 914.3 (770.8;1097.2) 78.3 (65.9;93.7) 13.3 (4.5;23.3)
Tocantins 136 (110.1;166.5) 96.4 (80.4;114.7) 574.3 (479.9;679.9) 89 (74.9;105.6) -7.7 (-18.2;8.4)
Source: Global Burden of Disease Study 2017, Institute for Health Metrics and Evaluation.285

Data derived from Global Burden of Disease Study 2017 (GBD 2017).285

Data derived from Global Burden of Disease Study 2017 (GBD 2017).285

Data derived from Global Burden of Disease Study 2017 (GBD 2017).285

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.