Epidemiological Profile and Comparison of Mortality Due to Stroke and Atrial Fibrillation in Brazil Over the Past 26 YearsAbstract
Background: Atrial fibrillation (AF) stands out as the most prevalent arrhythmia, and its incidence increases with age. Stroke ranks as the second leading cause of mortality in Brazil and represents the primary contributor to global disability.
Objective: Considering the severity of these conditions, this study seeks to elucidate the epidemiological landscape of AF and stroke-related deaths in Brazil from 1996 to 2022.
Methods: The following variable were analyzed in the study - geographic region, federative state, age demographics, gender distribution, year of mortality, race/ethnicity, educational attainment, and place of death. This research adopted a descriptive approach through a retrospective, exploratory, epidemiological analysis of data sourced from the Mortality Information System (SIM) accessible through the Department of Health Informatics of the Brazilian Unified Health System (DATASUS) website.
Results: Over the 26-year period, 1,201,327 deaths from AF and stroke were registered in Brazil. These deaths were mostly caused by stroke (94.5%) and were more concentrated in the southeast region, where the highest number of doctors capable of identifying and notifying these deaths are also concentrated.
Conclusion: This study claims for a paradigm shift in disease control strategies and underscores the imperative of bolstering the efficacy of public health policies to address the huge impact of stroke and AF-related mortality on population health.
Keywords: Atrial Fibrillation; Stroke; Mortality
Introduction
Characterized by a complete disorganization of atrial electrical activity, atrial fibrillation (AF) results in a loss of atrial systole, with a typical electrocardiographic pattern. This abnormal atrial electrical activity may be caused by several mechanisms including hemodynamic, electrophysiological, autonomic and structural factors, atrial tachycardias, ectopic beats, along with genetic polymorphism1-12 AF is the most common sustained arrhythmia in clinical practice, and patients may vary from asymptomatic to fleeting symptoms, which complicates the diagnosis. Consequently, thrombotic phenomena and even atherosclerotic processes occur, leading to a fourfold increase in the risk of developing a stroke associated with AF.1
Stroke can manifest in two forms: hemorrhagic, with blood extravasation within or around parenchymal and subarachnoid structures, respectively, and ischemic, with vessel occlusion and subsequent difficulty in nutrient and oxygen supply. Regarding risk factors, both diseases share modifiable and non-modifiable ones. Non-modifiable factors include age, sex, and race, while modifiable factors encompass systemic arterial hypertension, smoking, diabetes mellitus, and obesity.2,7
According to the Brazilian Stroke Society (SBAVC), stroke, which until the mid-2010s was the second leading cause of death in Brazil, has held the first position for the past five years. The disease has surpassed heart attack as the leading cause of death in the country, a reversal of the situation observed in the Western world.4
Therefore, attention to the five characteristic signs and symptoms of stroke - such as numbness or weakness of the face, leg, or arm muscles; dizziness, difficulty walking, or loss of balance; headache without apparent cause; sudden changes in vision in one or both eyes; and sudden onset of confusion - is essential for early diagnosis.8 Similarly, symptoms such as palpitations, dizziness, dyspnea, and chest pain, confirmed by an altered electrocardiogram, assist in the early detection of stroke, especially in elderly and cardiac patients with AF.10
In summary, given the global and national relevance of both conditions, the objective of our study is to evaluate the correlation between the epidemiological profile of AF and stroke in Brazil from 1996 to 2022. This aims to assist in the remodeling of disease control actions, improvement of population quality of life, and formulation of scientific parameters regarding the main affected regions of Brazil.
Objective
This study aims to delineate the epidemiological profile of deaths due to AF and stroke in Brazil from 1996 to 2022 in terms of geographical region, federative state, age group, sex, year of death, race/ethnicity, education level, and place of occurrence in order to characterize the trend and magnitude of these diseases in the country.
Methods
This was an exploratory, retrospective, epidemiological study of descriptive nature, utilizing data obtained from the Mortality Information System (SIM) available on the website of the Department of Health Informatics of the Brazilian Unified Health System (DATASUS). Notifications of deaths due to atrial flutter and fibrillation and unspecified stroke (hemorrhagic and ischemic) in Brazil between 1996 and 2022 were selected. Descriptive and analytical analyses of the data were performed, and results were organized into tables. The variables studied included geographic region, federative state, age group, sex, year of death, race/ethnicity, ICD-10 category, and place of occurrence (e.g. in the hospital, at home, others).
The following variables were excluded from the study: region/federative unit, ICD-10 chapters, ICD-10 groups, cause-ICD-BR-10, ill-defined cause, year/month of death, month of death, education level, OPS age group, detailed age group, age group under one year, and marital status.
Information was collected on April 17, 2024. Since the data are available in the public domain, this study did not require analysis by the Ethics Committee. The authors declare no conflicts of interest.
Limitations include possible underreporting and incomplete/incorrect filling of data (database).
Results
Upon examining the data between 1996 and 2022, we observed a steady increase in the number of deaths due to flutter and AF each year (Table 1). In 1996, 686 cases were recorded, while in 2022, 5688 cases were recorded, representing an increase of 729.2%. Conversely, there was a non-linear decrease in the number of deaths from stroke over the years. However, it is noteworthy that in 1996, there were 48,055 cases recorded compared to 35,982 in 2022, corresponding to a decrease of 25.1%.
Distribution of the number of deaths from atrial flutter and AF and stroke (not specified as hemorrhage or infarction) by year of death from 1996 to 2022 in Brazil
Over the 26-year period there were a total of 1,201,327 deaths from the I48 (atrial flutter) and I64 (stroke) categories, with deaths due to stroke accounting for 1,135,332 (94.5%) of the total.
In terms of deaths attributed to atrial flutter and AF, Table 2 indicates a higher incidence in the Southeast region (36,143 cases), followed by the south (14,388 cases), northeast (9,315 cases), midwest (4,144 cases), and north regions (2,005 cases). Regarding deaths due to stroke, the Southeast region also exhibited a higher incidence (477,341 cases), followed by the northeast (350,270 cases), south (181,258 cases), north (69,977 cases), and midwest regions (56,486 cases). It is of note that the concentration of physicians was the highest in the southeast region of Brazil - 303,886 physicians (52%) in 2022 – as illustrated in the Central Illustration.
Distribution of deaths from atrial flutter and AF and stroke (not specified as hemorrhage or infarction) by geographic region in Brazil from 1996 to 2022 and comparison with the number of physicians per region in 2022; *Data for the year 2022 taken from Scheffer M. et al.11
Distribution of deaths from atrial flutter and AF and unspecified stroke (not specified as hemorrhage or infarction) by region of Brazil from 1996 to 2022 and comparison with the number of physicians per region of Brazil in 2022
Distribution of deaths from atrial flutter and AF and stroke (not specified as hemorrhage or infarction) by federative state of Brazil, from 1996 to 2022
Regarding mortality due to atrial flutter and AF by federative state, the state of São Paulo leads with 17,512 cases, followed by the states of Minas Gerais (8,864), Rio de Janeiro (8,510), Rio Grande do Sul (6,363 cases), and Paraná (5,460 cases). São Paulo is also the number one state in mortality due to stroke, with 199,410 cases, followed by Rio de Janeiro (133,926 cases), Minas Gerais (122,466 cases), Bahia (96,576 cases), and Paraná (76,973 cases).
Concerning gender, it is possible to observe in Table 4 that most cases of deaths due to atrial flutter/AF occurred among women (57.4%, n=37,868).
Distribution of deaths from atrial flutter and AF and stroke (not specified as hemorrhage or infarction) by gender, from 1996 to 2022 in Brazil
Similarly to what was observed for mortality due to the ICD-10 category (atrial flutter and AF and unspecified stroke), the predominant age group in both cases is the elderly. Thus, mortality due to atrial flutter/AF in individuals aged above 60 years accounts for 91.7% of cases in this category (Tabe 5). Concerning mortality due to stroke, the elderly group (≥60 years)_accounted for 84.1% – when summing the age intervals of 60 to 69 years (209,414), 70 to 79 years (328,197), and 80 years or older (417,583) of the total cases.
Distribution of deaths from atrial flutter and AF and stroke (not specified as hemorrhage or infarction) by age, from 1996 to 2022 in Brazil
In relation to the race/ethnicity criterion, deaths from atrial flutter and AF and unspecified stroke (ICD-10) occurred, in decreasing order, among whites, browns/mixed race, blacks, yellows, and indigenous people. White race accounted for 64.8% (42,748 cases) of deaths from atrial flutter/AF, and 44.5% (505,455 cases) of deaths from unspecified stroke (Table 6).
Distribution of deaths from atrial flutter and AF, and stroke (not specified as hemorrhage or infarction) by race/ethnicity, from 1996 to 2022 in Brazil
Finally, upon analyzing the place of occurrence of the deaths from atrial flutter, AF and stroke, the location of the highest incidence of deaths from these conditions was the hospital (73.6%; 884,302 cases), followed by domicile (20.9%; 251,501 cases) (Table 7). The number of cases declared as unknown corresponded to 5,835 cases (0.5%).
Distribution of deaths from atrial flutter and AF, and unspecified stroke as hemorrhagic and ischemic by location of occurrence, from 1996 to 2022 in Brazil.
Conclusion
This study describes the epidemiological profile of people who died from AF and stroke over between 1996 and 2022 in Brazil. Based on the analysis of data obtained from SIM 94.5% were caused by stroke and 5.5% of deaths by atrial flutter and AF. However, there was an increase in the number of deaths from atrial flutter or AF and a slight decrease in the number of deaths due to stroke during this period in Brazil. It is worth noting that the prevalence of AF was accompanied by an increase in morbidity and mortality attributed to the disease, with a notable increased risk of stroke in patients with the arrhythmia.
Furthermore, the southeast region had the highest number of deaths for both diagnoses, and the state of São Paulo was the most affected. Regarding the epidemiological profile of the victims, most of them were white, and older. Females outnumbered males in cases of atrial flutter and AF, while males outnumbered females in cases of stroke.
This study provides epidemiological characteristics, as well as geographic distribution and risk factors deaths from AF and stroke over the past 26 years in Brazil, contributin to remodeling of public policies.
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Sources of Funding
There were no external funding sources for this study.
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Study Association
This study is not associated with any thesis or dissertation work.
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Ethics Approval and Consent to Participate
This article does not contain any studies with human participants or animals performed by any of the authors.
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Edited by
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Editor responsible for the review:
Ricardo Alkmim Teixeira
Publication Dates
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Publication in this collection
02 Dec 2024 -
Date of issue
2024
History
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Received
15 Aug 2024 -
Reviewed
19 Aug 2024 -
Accepted
14 Oct 2024
Source: MS/SVS/CGIAE - Mortality Information System – SIM.