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Global burden of cardiovascular disease
Cardiovascular disease mortality in the Americas: current trends and disparities
  1. Maria de Fatima Marinho de Souza1,
  2. Vilma Pinheiro Gawryszewski1,
  3. Pedro Orduñez2,
  4. Antonio Sanhueza1,
  5. Marcos A Espinal3
  1. 1Health Analysis and Information Project, Pan American Health Organization, Washington, DC, USA
  2. 2Chronic Diseases Project, Pan American Health Organization, Washington, DC, USA
  3. 3Health Surveillance, Diseases Prevention and Control, Pan American Health Organization, Washington, DC, USA
  1. Correspondence to Dr Vilma Pinheiro Gawryszewski, Health Analysis and Information Project, Pan American Health Organization, 525 23rd Street, Washington, DC 20037, USA; gawryszv{at}paho.org

Abstract

Objective To describe the current situation and trends in mortality due to cardiovascular disease (CVD) in the Americas and explore their association with economic indicators.

Design and Setting This time series study analysed mortality data from 21 countries in the region of the Americas from 2000 to the latest available year.

Main Outcomes Measures Age-adjusted death rates, annual variation in death rates. Regression analysis was used to estimate the annual variation and the association between age-adjusted rates and country income.

Results Currently, CVD comprised 33.7% of all deaths in the Americas. Rates were higher in Guyana (292/100 000), Trinidad and Tobago (289/100 000) and Venezuela (246/100 000), and lower in Canada (108/100 000), Puerto Rico (121/100 000) and Chile (125/100 000). Male rates were higher than female rates in all countries. The trend analysis showed that CVD death rates in the Americas declined −19% overall (−20% among women and −18% among men). Most countries had a significant annual decline, except Guatemala, Guyana, Suriname, Paraguay and Panama. The largest annual declines were observed in Canada (−4.8%), the USA (−3.9%) and Puerto Rico (−3.6%). Minor declines were in Mexico (−0.8%) and Cuba (−1.1%). Compared with high-income countries the difference between the median of death rates in lower middle-income countries was 56.7% higher and between upper middle-income countries was 20.6% higher.

Conclusions CVD death rates have been decreasing in most countries in the Americas. Considerable disparities still remain in the current rates and trends.

  • Allied specialities
  • cardiovascular disease
  • circulatory system disease
  • congenital heart disease
  • coronary artery disease
  • emergency medicine
  • epidemiology
  • hypertension
  • inequity
  • infection
  • ischaemic heart disease
  • neurology
  • paediatric cardiology
  • public health
  • quality of care and outcomes
  • stroke
  • trend

https://doi.org/10.1136/heartjnl-2012-301828

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    Introduction

    Cardiovascular disease (CVD) is currently the largest single contributor to global mortality and it is expected to continue for years to come.1 Almost 30% of deaths occurring in low and middle-income countries are attributable to CVD, and more than 80% of CVD-related deaths worldwide now occur in such settings.2 Ageing, smoking, an unhealthy diet and physical inactivity in the context of globalisation and unregulated urbanisation are some of the factors that explain the high prevalence of hypertension, hypercholesterolaemia and diabetes in the Americas,3 ,4 making CVD the number one cause of death in the continent.

    An important decline in mortality due to CVD has been observed in North America, western Europe, and Australia.5–7 In the past 10 years in the Americas a number of countries have committed to fighting CVD due to the implementation of policies addressing risk factors for CVD, strengthening preventive actions, expanding access to care services and setting mortality registries. Mortality trends in CVD might be an excellent indicator of the effectiveness of such actions and policies. Furthermore, finding out about the size and trends of mortality due to CVD is essential for countries to plan properly in order to enhance their prevention and control efforts. The recent United Nations High Level Meeting on Non-Communicable Diseases recommended strengthening surveillance and monitoring systems at the country level as well as the development of a comprehensive global monitoring framework, including a set of indicators to monitor trends and to assess progress made in the implementation of national strategies and plans on non-communicable diseases.8

    Data on trends are widely available for high-income countries of the Americas but not for the majority of middle-income countries. In addition, there is a need to examine recent trends to monitor progress in prevention of CVD in the region. In this paper we present the trends in mortality due to CVD in the countries of the Americas over the period 2000–9 and explore its association with economic indicators in selected countries.

    Methods

    Source of data and case definitions

    The Pan American Health Organization operates the regional mortality database, which comprises deaths registered in national vital registration systems and reported annually to the Pan American Health Organization by national authorities.9 This is the official national statistics that come from death certificates. All the countries, except Canada, provide individual mortality data. At first, the quality of information of each country is evaluated by verifying the integrity and consistency of data in addition to the validation of selected variables (sex, age and underlying cause of death).

    In order to ensure comparability of mortality data among countries some procedures to improve the quality of mortality statistics have been adopted.10 ,11 Some countries face problems regarding the coverage of civil registration systems due to burials without a death certificate, which results in the under-registration of deaths. Another problem is not filling out adequately the underlying cause of death on the death certificate or deaths without medical certifications, which results in a proportion of ill-defined causes of death. Therefore, an algorithm to correct under-registration and ill-defined causes was applied if a country has an estimated proportion of under-registration more than 10%, or a proportion of ill-defined causes more than 10%, or both, according to the methodology.10 ,11 The under-registration of deaths estimated for the region of the Americas for the triennium 2007–9 was 7.3% and ill-defined causes was 3.7%.12 These proportions for each country can be found as supplementary data and also in a specific publication, which is available online only.12 In our study 13 countries were corrected.

    We extracted data (updated in May 2011) from 2000 (unless otherwise specified) to the latest available year, when all countries of the Americas used the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) to code mortality. We selected all deaths whose underlying cause was classified in chapter IX, diseases of circulatory system (I00–I99) of ICD-10. This chapter includes the following subgroup of diseases: ischaemic heart diseases (IHD) (I20–I25), cerebrovascular diseases (I60–I69), hypertensive diseases (I10–I15), heart failure (I50) and cardiac arrest (I46). The last two were used as indicators of the quality of data in this chapter, because they are considered intermediate causes and not the underlying cause of disease.

    A dataset with 15 763 500 deaths from 43 countries was analysed but only information from the 21 largest countries with time series available, representing 95% of the total population of the Americas, are presented here. Data from countries for which a small population and number of deaths would lead to fluctuations in the death rates are not presented, but they were used to calculate the overall death rates for the whole continent (region of the Americas). Population figures available from the United Nations Population Division were used to calculate crude rates (not presented). Age-adjusted death rates were obtained by direct standardisation to the world standard population.13

    To explore the association between the risk of mortality due to CVD and economic status, we used the income group classification developed by the World Bank, which is based on their gross national income per capita: (1) high income, US$12 276 or more; (2) upper middle income, US$3976–12 275; (3) lower middle income, US$1006–3975; and (4) low income, US$1005 or less.14 Four countries (three from North America and one from the non-Latin Caribbean) were classified as high income; 12 countries (11 from Latin America and one from the non-Latin Caribbean) were classified as upper middle income; and six countries (four from Latin America and two from the non-Latin Caribbean) were classified as low middle income. The only country in the Americas classified as a low-income economy was not included in this study due to lack of mortality information.

    As this study analysed anonymous secondary data on mortality, no ethics approval was required.

    Data analysis

    We carried out a trend-series study. First, a descriptive exploratory analysis was performed. Age-standardised death rates were estimated for all the countries with available mortality data from 2000 to the latest year available. A subsequent analysis was undertaken using the regression model, in which the response variable was the logarithm of the age-standardised rates and the covariate was the year. This model allows the estimate of the annual percentage rate variation, CI and p values. Poisson and negative binomial models were also used, but adequate goodness of fit was not obtained. Finally, the median regression model was used in order to study the relationship between age-standardised death rates and income of the countries. This model considers the median of age-standardised death rates in 2000–7 as response variables and dummy variables created from the variable income as covariates. The data were analysed using Tableau V.6.0 software and the statistical program SAS.

    Results

    Current situation of CVD mortality

    The descriptive analysis for the latest available year showed that 1 746 767 deaths due to CVD (ICD-10 I00–I99) were registered in the Americas in 2007, accounting for 33.7% of all deaths. Among this group of diseases, IHD was the leading cause (42.5% overall) followed by cerebrovascular disease (22.2% overall). Hypertensive disease (ICD-10 I10–I15) accounted for 9.2% overall, heart failure (ICD-10 I50) 9.2% overall and cardiac arrest (I46) 1.2% overall. These percentages varied among countries; high-income countries tended to have a higher proportion of IHD. Countries with a high percentage of hypertensive diseases were Ecuador (22.7%), Peru (18.4%) and Guatemala (16.5%). With regard to the quality of information, it is important to point out that 18.9% of CVD deaths in Guatemala were classified as cardiac arrest. In addition, heart failure accounted for 34.1% of CVD deaths in Argentina, 23.4% in El Salvador, 17.2% in Ecuador and 16.1% in Guatemala.

    Table 1 summarises the current situation of CVD, IHD and cerebrovascular diseases age-adjusted mortality in each country by sex and income. The CVD rates varied markedly across countries; the rate in Guyana was 2.7 times higher than in Canada. The highest CVD death rates were observed in Guyana, Trinidad and Tobago, Paraguay, Venezuela and Brazil. On the other hand, Canada, Puerto Rico, Costa Rica, Chile and Peru had the lowest death rates. CVD rates among men were higher than among women in all countries. The risk of a man dying from a CVD in Trinidad and Tobago was 1.8 times higher than that of a woman, but it was 1.1 in El Salvador and Guatemala. The highest death rates in men were observed in Trinidad and Tobago, Guyana, Venezuela, Suriname and Paraguay. Similar results were observed for women, except that Brazil displaced Suriname among the top five.

    View this table:
    Table 1

    Mortality due to cardiovascular diseases (ICD-10 I00–I99) (age-adjusted rates/100 000) by sex and country

    The highest death rates due to IHD were observed in Trinidad and Tobago, Venezuela, Colombia, Guyana and Nicaragua. Men showed a higher risk compared with women in all countries. In Argentina the risk of a man dying from IHD was 2.4 times higher than for a woman. Similar patterns were observed in Chile (2.3) and Canada (2.0). In contrast, the male to female rate ratio was much lower in Cuba (1.3), El Salvador (1.3) and Guyana (1.2). With regard to cerebrovascular disease, the countries with highest death rates for both men and women were Suriname, Guyana, Paraguay, Trinidad and Tobago and Brazil. Table 1 also showed that the death rates in 75% of high-income countries were below the average rate for the region of the Americas. In contrast, just 17% of the lower middle and half of the upper middle-income countries showed rates below the average death rate.

    Trends in CVD mortality

    The CVD age-adjusted death rates in the Americas dropped −19.2% (from 207.8 in 2000 to 167.9/100 000 in 2007), for both men and women. This percentage was slightly higher among women (−20.4%) than among men (−18.2%). In the same period, IHD decreased −24.7% overall and cerebrovascular diseases −21.1% overall. Figure 1 shows the trends in CVD death rates for the selected countries in the Americas over the period 2000 to the latest available year for women, men and overall (rates are available as supplementary data, available online only). Male rates were higher than female rates in all countries during this period and this difference was more marked in Trinidad and Tobago and less marked in El Salvador. Among those classified as high income, the rates showed a steady decline and they were lower than upper middle and lower middle-income countries, except for Trinidad and Tobago, where rates are very high and the decline began in 2004. Mortality among most upper middle-income countries has also been declining steadily. In addition, rates in Mexico (both men and women) and Cuba have been decreasing slightly (just women). No declines were seen in Panama and Suriname. Among lower middle-income countries the rates have been declining only in El Salvador and Nicaragua.

    Figure 1
    Figure 1

    Trends in mortality due to cardiovascular diseases (ICD-10 I00–I99) (age-adjusted rates/100 000). Selected countries in the region of the Americas, 2000 to latest available year.

    Table 2 presents the percentage of variation in the death rates of countries during the study period. In the Americas the rates declined annually by −3.2% (−3.0% among men and −3.4% among women) from 2000 to 2007. Also, the great majority of countries experienced a statistically significant decrease in mortality for both sexes, except in Guatemala (short time series), Guyana, Panama, Paraguay, Suriname and Cuba (just among men). The largest reductions took place in Canada (−4.8%; p<0.001), in the USA (−3.9%; p<0.001) and in Puerto Rico (−3.6%; p<0.001).

    View this table:
    Table 2

    Annual variation (in percentage) in age-adjusted death rates (100 000 population) for cardiovascular diseases (ICD-10 I00-I99) by sex and country

    Disparities

    Table 3 shows the results of the regression model that explores the association between the median of CVD mortality adjusted rates and income groups, across the study period. The risk of death in upper and lower middle-income countries was higher compared with high-income countries. Likewise, the risk of death in lower middle-income countries was higher than that of upper middle-income countries. Similar patterns hold for men and women across the different levels of income. There is a gradient in the difference between the median of death rates across the three income groups. The difference between lower middle-income countries and high income was 56.7% overall (higher among women than men) and between upper middle-income countries and high income 20.6% (not significant among men).

    View this table:
    Table 3

    Median of death adjusted rates (per 100 000) for cardiovascular diseases (ICD-10 I00–I99) across years 2000 to last available year by income group

    Discussion

    As CVD have become a major public health priority globally, monitoring morbidity and mortality of CVD and their risk factors are key components for resource allocation and policy implementation and advocacy. As main findings we found that CVD death rates have been declining in the majority of countries in the Americas over the years, and CVD mortality has disproportionally affected middle-income countries.

    At first, the current death rates in the majority of countries in the Americas (rates below 400/100 000 among men and 270/100 000 among women), compared with standardised data reported by the WHO were less favourable than most countries in western Europe and Australia (rates below 240/100 000 in men and 180/100 000 in women) but more favourable than most countries in Africa and eastern Europe regions (rates above 440/100 000 in men and 370/100 000 in women).1

    In the Americas, our findings showed that the current CVD death rates are markedly higher among upper middle and lower middle-income countries. The social and economic impact of CVD mortality such as increased national health expenditures, losses in the labour force due to premature death and family disruption put these countries at a great risk. In addition, some of them still have to strive to control infectious diseases. In general, populations living in disadvantaged conditions are more exposed to risk factors, greater comorbidities and limited access to healthcare. In Brazil, a survey carried out in 2010 among adults aged 18 years and above showed that the percentage of smokers was 1.8 times higher among those in the less educated group compared with those in the more educated group. In contrast, the consumption of fruits and vegetables and physical activity as recommended was higher in the more educated group compared with the less educated group (1.7 times and 1.7 times, respectively).15 In the USA, people who are not insured have approximately half the probability of having hypertension under control than those who are insured.16

    A promising finding is that death rates have been declining in most countries. It is consistent with previous studies showing that CVD mortality has decreased markedly in high-income countries over the past two decades as well as in middle-income countries such as Cuba and Brazil.1 ,5–7 ,17 ,18 On the other hand, such a decline is not uniform among the different countries, and our results further substantiate the impact of socioeconomic stratification on the risk of CVD mortality: the more disadvantaged income countries had a significantly higher risk of death over the years.

    For IHD mortality three patterns were described: (1) a rise and fall pattern in which death rates increased, peaked and then fell significantly; (2) a rising pattern, in which rates have steadily increased indicating an ongoing epidemic; (3) and a flat pattern, in which IHD death rates have remained relatively low and stable (no epidemics).19 ,20 The first pattern was especially observed in the USA and Canada, where IHD death rates peaked in the 1960s or early 1970s and then they felt precipitously.5 ,19 In our findings these countries keep having a substantial decrease in CVD rates, demonstrating the effectiveness of their strategies for prevention and control. Argentina, Brazil, Chile, Cuba and Panama also experienced a rise-and-fall pattern previously,20 in lower levels, but only in Argentina, Brazil and Chile have the rates been decreasing currently.

    In contrast, from 1970 to 2000, death due to IHD and cerebrovascular diseases were less favourable in some Latin America countries: Costa Rica, Colombia, Ecuador, Mexico and Venezuela showed a rising pattern.20 ,21 Currently, Costa Rica, Colombia, Ecuador and Venezuela have made positive changes since their CVD rates have begun decreasing. Previously, Peru showed very low rates and a flat pattern21; currently the rates continue to be among the lowest in the Americas and they showed a slight decrease.

    The reasons for the observed decline still needs to be better clarified in some Latin America countries. Ford and colleagues5 concluded that approximately 47% of the decrease in coronary disease deaths in the USA was attributable to treatment, while 44% was attributable to the reduction in risk factors such as total cholesterol, blood pressure, smoking and physical inactivity. Beaglehole and Magnus22 pointed out that inappropriate diet and physical inactivity combined with tobacco use was responsible for approximately 75% of new cases of IHD. This emphasises the well-known principle that a large percentage of CVD is preventable. Among the best buy public health interventions are: protecting of people from smoking, promoting a healthy diet and physical activity, reducing salt intake, providing counselling and therapy for people at risk of developing heart attacks and stroke, and banning tobacco and alcohol advertisements.1 ,23 ,24 In addition, investment in the health system, including strengthening primary healthcare, is required for earlier detection and prevention and better outcomes.

    There is a growing interest in addressing the problem of CVD in the Americas. Over the past decade, various countries, such as Argentina, Brazil, Cuba, Panama and Venezuela have implemented national programmes and policies to address the problem.25 Banning smoking in public places was adopted in Canada, Colombia, Ecuador, Guatemala, Panama, Peru and Trinidad and Tobago. Also, some countries have made an effort to measure risk factors at the national level.13 ,25 To bridge the gap between prevention and control of CVD in the Americas it is necessary to strengthen networking among countries, exchanging high cost-effective interventions and evidence-based prevention strategies. For sure, interventions should be adapted taking into account the resources and cultural aspects in each country. In fact, much of the progress made in high-income countries cannot easily be implemented in lower middle-income countries particularly because of infrastructure and resource constraint. At the same time, further research has to be carried out in those countries where no decline was seen.

    The decline in CVD rates is likely to have affected general death rates. From 2000 to 2007, general mortality decreased 8.1% in the Americas, lower than the CVD decrease. Of note, in all high-income countries the decline in CVD rates was higher than general mortality. Among lower middle-income countries just El Salvador and Nicaragua showed this same pattern; however, in Guatemala, Guyana and Paraguay the decline in general mortality was higher than CVD (unpublished data). These countries have probably reached advances in controlling infectious diseases and reducing infant mortality and have differences in population composition compared with high-income countries.

    Some limitations have to be taken into consideration to interpret these findings. First, to compare rates among different countries with different information quality is a challenge. Although the rates were corrected for under-registration of deaths and ill-defined causes, it is possible that these problems might affect rates in some countries, especially the less resourced ones. Second, the classification of the underlying cause of death can vary among countries. For example, Argentina had a high proportion of deaths classified as heart failure, which is considered the ‘end stage of many cardiac and non-cardiac pathological processes’26 and not the underlying cause. Other countries had a high proportion of deaths classified as hypertensive diseases (Ecuador, Peru, Guatemala), which could potentially be cerebrovascular diseases. Therefore, the comparison of rates for these major groups of diseases has to be done carefully. In contrast, the improvement of the quality of data, including better reporting, can increase CVD rates. On the other hand, one of the strengths of this study is to show trend data from countries never shown before such as Guatemala, Guyana, Paraguay and Suriname.

    In conclusion, CVD death rates have been decreasing in most countries in the Americas. However, considerable disparities still remain in the current rates and trends. The reductions in deaths due to infectious diseases and infant mortality and the increase in life expectancy are evidence of the achievements in the region of the Americas. Similar efforts in CVD prevention could make extremely valuable contributions to the worldwide campaign towards the control of non-communicable diseases.

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    Footnotes

    • Competing interests None.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Data sharing statement Age-adjusted death rates per 100 000 population used in our trend analysis and some basic indicators for each country are available for researchers or public health professionals interested in doing any additional studies.