texto em 
Inglês (pdf)
Artigo em XML
Referências do artigo
Tradução automática
Permalink
INTRODUCTION
Stroke is a cerebrovascular pathology characterized by an immediate neurological deficit due to an ischemic or hemorrhagic brain injury1. It is one of the main causes of death and disability worldwide, affecting millions of people annually2,3. This condition causes a significant burden on health systems and social resources, requiring effective prevention, treatment, and rehabilitation interventions4,5.
The occurrence and mortality of stroke vary according to age groups, with higher incidence and mortality generally observed as age increases6. Sex, race, and family history are also non-modifiable risk factors for the disease6,7. Additionally, individuals with diabetes, hypertension, obesity, dyslipidemia, a high degree of physical inactivity, smoking, alcohol abuse, and stress are more susceptible to suffering a stroke6,7.
Each year, about 17 million cases of stroke occur globally3. Estimates suggest that 1 in 4 people will suffer a stroke during their lifetime8. Annually, more than 6 million deaths from stroke are reported, with most associated with ischemic stroke9. These figures highlight the significant mortality burden attributed to stroke and underscore the importance of effective preventive measures and treatments to mitigate this global impact3.
In Latin America, stroke also has a high incidence and is among the leading causes of death3. Given this scenario, in recent decades there has been an advance in Brazil’s stroke control policies10. However, despite the downward trend in the mortality rate in recent years, this decline is not evenly distributed across all regions of the country11,12.
Brazilian states with better economic development show a similar downward trend, while the same results are not evident in poorer territories13,14. There is speculation that socioeconomic differences and differences in access to health services in different states may influence the number of deaths from stroke.
The state of Amazonas has a low level of socioeconomic development and faces significant health challenges15,16. The vast geographic extension, low demographic density, limited regionalization of health care, and the scarcity of economic resources contribute to disparities in access to health services15. These conditions can compromise the effectiveness of prevention measures, diagnosis, and adequate treatment of pathologies such as stroke15,17. Despite this, the literature lacks studies that evaluate the epidemiology of stroke in the state. Therefore, this study aims to analyze stroke mortality in the adult population of Amazonas state between 2000 and 2021.
METHODS
Study design
The study is an ecological time-series analysis based on secondary data from the adult population of Amazonas, Brazil, from 2000 to 2021.
Location and population studied
The study considered data related to the population aged 20 to 80 years or older, residing in Amazonas, Brazil, from 2000 to 2021. Amazonas, located in the Northern region, is the largest state in Brazil by territorial extension, covering 1,559,255.881 km2. It has a population of 3,941,175 inhabitants and a population density of 2.53 inhabitants/km2 16.
Data source and extraction
All data were extracted from the database of the Department of Health Information and Informatics of the Unified Health System (DATASUS) of the Ministry of Health for the place of residence from 2000 to 2021 for the total population and stratified by sex and age group. The DATASUS information is publicly and freely accessible.
The population data used in this study came from the “Study of Population Estimates by municipality, sex, and age from 2000 to 2021” prepared by the Ministry of Health based on the Brazilian Population Census of 2022. These data are available through the DATASUS database at the following address: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popsvsbr.def.
Stroke mortality data were extracted from the DATASUS website at the following address: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/nito.def. All death information incorporated into DATASUS originates from the Mortality Information System of the Ministry of Health.
Study variable
The study variable was death due to the cause of stroke occurring in residents of the state of Amazonas. Stroke was defined by the codes I60 (subarachnoid hemorrhage), I61 (intracerebral hemorrhage), I63 (cerebral infarction), and I64 (unspecified as ischemic or hemorrhagic), according to the International Classification of Diseases version 10. The occurrence of stroke has been determined for the entire population and stratified by sex (male and female) and age group (20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, and 80 years or older) for the calendar years between 2000 and 2021.
Statistics analysis
Data on stroke deaths for the total population, age groups, and sex were acquired using the file transfer system from the Department of Health Information and Informatics of the Unified Health System database to a comma-separated values (CSV) file format.
For each year from 2000 to 2021, the mortality rate per 100,000 inhabitants and the sex-specific mortality rate ratio were determined using Microsoft Office Excel. The mortality rate was obtained by dividing the number of deaths by the specific population, and the result was multiplied by 100,000. The sex-specific mortality rate ratio was estimated by dividing the male mortality rate by the female mortality rate annually18.
Prais-Winsten regression was employed to analyze the trend of stroke mortality rates from 2000 to 2021 using Stata 17. The dependent variable was the mortality rate per 100,000 inhabitants, and the independent variable was the year. Analyses were conducted for the general population, with stratification by sex and age group: 20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, and 80 years and older. Autocorrelation was estimated using the adjusted Durbin-Watson method.
Annual percent change (APC) was calculated for each age group following procedures suggested by Antunes and Cardoso19. Briefly, dependent variables were initially logarithmically transformed. The Prais-Winsten regression was then used to estimate beta values and respective 95% confidence intervals (CI). Subsequently, APC and respective 95% confidence intervals (CI) were calculated using the formula: (-1 + 10β estimado) X 100. Models with p-values equal to or less than 5% were considered statistically significant.
RESULTS
Table 1 presents the number of deaths and mortality rates from stroke in the adult population of the state of Amazonas, Brazil, from 2000 to 2021. The year 2021 saw the highest number of deaths in the analyzed historical series, with a total of 851 deaths, including 422 in males and 429 in females. The mortality rate in 2021 was the highest between 2015 and 2021, reaching 31,84. The highest mortality rate observed during the entire period occurred in 2014, at 33,45.
Table 1 : Number of deaths and mortality rate from stroke in the adult population of the State of Amazonas, Brazil, from 2000 to 2021
| Deaths | Mortality rate* | Mortality Rate Ratio: Male / Female | |||||
|---|---|---|---|---|---|---|---|
| All | Male | Female | All | Male | Female | ||
| 2000 | 446 | 222 | 224 | 31.73 | 31.49 | 31.98 | 0.98 |
| 2001 | 449 | 235 | 214 | 30.72 | 32.06 | 29.38 | 1.09 |
| 2002 | 422 | 221 | 201 | 27.79 | 29.02 | 26.55 | 1.09 |
| 2003 | 410 | 208 | 202 | 26.01 | 26.31 | 25.70 | 1.02 |
| 2004 | 429 | 224 | 205 | 26.24 | 27.33 | 25.14 | 1.09 |
| 2005 | 475 | 217 | 258 | 28.05 | 25.56 | 30.55 | 0.84 |
| 2006 | 510 | 275 | 235 | 29.11 | 31.32 | 26.89 | 1.16 |
| 2007 | 472 | 229 | 243 | 26.07 | 25.24 | 26.91 | 0.94 |
| 2008 | 575 | 299 | 276 | 30.76 | 31.93 | 29.59 | 1.08 |
| 2009 | 522 | 244 | 278 | 27.07 | 25.27 | 28.88 | 0.88 |
| 2010 | 559 | 303 | 256 | 28.12 | 30.45 | 25.79 | 1.18 |
| 2011 | 615 | 324 | 291 | 30.06 | 31.67 | 28.45 | 1.11 |
| 2012 | 650 | 350 | 300 | 30.89 | 33.30 | 28.49 | 1.17 |
| 2013 | 633 | 324 | 309 | 29.26 | 30.01 | 28.51 | 1.05 |
| 2014 | 744 | 386 | 358 | 33.45 | 34.82 | 32.10 | 1.08 |
| 2015 | 715 | 370 | 345 | 31.27 | 32.49 | 30.06 | 1.08 |
| 2016 | 653 | 331 | 322 | 27.79 | 28.30 | 27.28 | 1.04 |
| 2017 | 649 | 339 | 310 | 26.87 | 28.22 | 25.53 | 1.11 |
| 2018 | 645 | 323 | 322 | 25.99 | 26.19 | 25.80 | 1.02 |
| 2019 | 685 | 361 | 324 | 26.90 | 28.54 | 25.29 | 1.13 |
| 2020 | 674 | 360 | 314 | 25.83 | 27.78 | 23.90 | 1.16 |
| 2021 | 851 | 422 | 429 | 31.84 | 31.81 | 31.87 | 1.00 |
Source: Developed by the authors, 2024, from the database; * Mortality rate per 100,000.
Except in the years 2000, 2005, 2007, 2009, and 2021, men consistently exhibited higher mortality rates than women. The most significant disparity between the sexes occurred in 2010 when the male mortality rate was 18% higher. Additionally, for most years evaluated, the number of deaths was higher among males compared to females (table 1).
In 2021, the highest number of deaths occurred in five age groups: 20-29 years, 50-59 years, 60-69 years, 70-79 years, and 80 years or older. During this period, the highest number of deaths within specific age groups throughout the historical series was observed, with 289 deaths among individuals aged 80 years or older. This age group consistently showed predominance in absolute deaths, except from 2000 to 2004 and in 2006 and 2008 (table 2).
Table 2 : Number of deaths by age group from stroke in the adult population of the State of Amazonas, Brazil, from 2000 to 2021
| Age groups | |||||||
|---|---|---|---|---|---|---|---|
| 20 - 29 age | 30 - 39 age | 40 - 49 age | 50 - 59 age | 60 - 69 age | 70 - 79 age | 80 years old and over | |
| 2000 | 5 | 19 | 58 | 72 | 94 | 99 | 99 |
| 2001 | 8 | 15 | 43 | 77 | 97 | 111 | 98 |
| 2002 | 5 | 17 | 36 | 72 | 94 | 104 | 94 |
| 2003 | 5 | 17 | 41 | 73 | 76 | 99 | 99 |
| 2004 | 4 | 15 | 45 | 65 | 99 | 107 | 94 |
| 2005 | 7 | 23 | 48 | 74 | 90 | 114 | 119 |
| 2006 | 8 | 20 | 58 | 61 | 90 | 140 | 133 |
| 2007 | 6 | 18 | 42 | 72 | 79 | 124 | 131 |
| 2008 | 11 | 12 | 50 | 89 | 110 | 152 | 151 |
| 2009 | 7 | 19 | 50 | 74 | 87 | 128 | 157 |
| 2010 | 4 | 21 | 50 | 93 | 102 | 139 | 150 |
| 2011 | 4 | 16 | 52 | 93 | 105 | 157 | 188 |
| 2012 | 7 | 28 | 53 | 91 | 124 | 168 | 179 |
| 2013 | 5 | 25 | 54 | 103 | 109 | 142 | 195 |
| 2014 | 8 | 28 | 67 | 112 | 139 | 182 | 208 |
| 2015 | 11 | 24 | 51 | 88 | 137 | 157 | 247 |
| 2016 | 11 | 25 | 53 | 103 | 112 | 153 | 196 |
| 2017 | 11 | 23 | 56 | 89 | 116 | 144 | 210 |
| 2018 | 6 | 24 | 54 | 71 | 119 | 163 | 208 |
| 2019 | 6 | 20 | 68 | 100 | 127 | 169 | 195 |
| 2020 | 7 | 22 | 60 | 90 | 123 | 148 | 224 |
| 2021 | 14 | 23 | 63 | 104 | 142 | 216 | 289 |
Source: Developed by the authors, 2024, from the database.
The mortality rate increased with advancing age, being particularly pronounced in age groups above 60 years, with an even more significant value in individuals over 80 years old. Temporal analysis revealed periods of both increase and decrease in the mortality rate over time. In 2015, there was a notable peak in the mortality rate among individuals aged 80 and older (figure 1).
Figure 1 : Stroke Mortality Rate by Age Group in the Adult Population of Amazonas state, Brazil, 2000 to 2021
Only individuals aged 80 years or older showed an increasing trend, with an APC (Annual Percentage Change) of 2.34% (95% CI: 0.18; 4.54). In contrast, in the age groups of 40 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years, a reduction in the mortality rate was observed over the historical series, with the most significant decrease occurring among individuals aged 50 to 59 years, with an APC of -6.27% (95% CI: -8.40; -4.09). Regarding the total population, other age groups, and sex, the APC of the mortality rate remained stationary (table 3).
Table 3 : Annual percentage variation of stroke mortality rate by sex and age group in the population of Amazonas State, Brazil, from 2000 to 2021
| Beta | p | APC | (CI 95%) | Interpretation | |
|---|---|---|---|---|---|
| All | -0.00045 | 0.909 | -0.10 | (-1.94 ; 1.77) | Stationary |
| Sex | |||||
| Male | 0.00101 | 0.787 | 0.23 | (-1.52 ; 2.01) | Stationary |
| Female | -0.00189 | 0.629 | -0.43 | (-2.26 ; 1.42) | Stationary |
| Grupo Etário | |||||
| 20 – 29 age | 0.01027 | 0.492 | 2.39 | (-4.57 ; 9.86) | Stationary |
| 30 – 39 age | -0.01137 | 0.089 | -2.58 | (-5.52 ; 0.44) | Stationary |
| 40 - 49 age | -0.02108 | ≤ 0.001 | -4.74 | (-6.81 ; -2.61) | Decreasing |
| 50 - 59 age | -0.02811 | ≤ 0.001 | -6.27 | (-8.40 ; -4.09) | Decreasing |
| 60 - 69 age | -0.02269 | ≤ 0.001 | -5.09 | (-6.76 ; -3.39) | Decreasing |
| 70 - 79 age | -0.01357 | ≤ 0.001 | -3.08 | (-4.66 ; -1.47) | Decreasing |
| 80 years old and over | 0.01004 | 0.035 | 2.34 | (0.18 ; 4.54) | Increasing |
Source: Developed by the authors, 2024, from the database. APC: Annual percentage variation
DISCUSSION
The mortality rate remained stable for both sexes in the age groups 20-29 years and 30-39 years, as well as for the total population. In contrast, there was an increase in the mortality rate among those aged 80 years old and over, while the other age groups showed a decrease. The male-to-female mortality rate ratio was consistently higher for men. The highest mortality rates occurred in the age groups 60 years and older. Between 2015 and 2021, the highest mortality rate occurred in 2021.
There is a global trend of decreasing stroke mortality rates20. In the Southern and Southeastern regions of Brazil, between 2008 and 2018, there was a decrease in mortality rates13. A study that evaluated the trend of stroke mortality rates in Brazil from age 30 onwards, between 2000 and 2009, showed a reduction in mortality rates for individuals aged 30-39 years21. However, our study found that mortality rates remained stable for the total population and for the age groups 20-29 and 30-39, and increased for individuals over 80 years old in Amazonas.
The high stroke mortality rate in the state of Amazonas results from significant health challenges experienced by the population. Centralization of services in Manaus, lack of access to specialized services in remote areas, shortage of qualified healthcare professionals, and structural inequities in the healthcare system undermine the regionalization process15. These factors may limit longitudinal monitoring of individuals, which is crucial for preventing and treating modifiable risk factors associated with stroke22,23. Additionally, they prolong access times to emergency services, potentially increasing the number of deaths23.
Our results also revealed a higher stroke mortality rate among men compared to women in most years. Roni et al.24 evaluated stroke mortality in the state of Pará and found a significant difference between sexes, with stroke mortality rates often higher among men. The causes of this disparity are multifaceted and may include social and cultural factors25.
Advanced age is a risk factor for stroke mortality20. As observed in this study, numerous other research studies have shown higher mortality rates in age groups above 60 years11,26. This phenomenon can be explained by a combination of physiological factors related to aging itself and the presence of chronic diseases in this population27.
Franceschi et al.27 emphasize that aging is associated with chronic inflammation, structural and functional changes in blood vessels, oxidative stress, and mitochondrial dysfunction. Additionally, there is a higher prevalence of diabetes, hypertension, and heart disease among While the stroke mortality rate remained stable for the general population, individuals aged 80 years and older experienced a high number of total deaths and a growing trend in stroke mortality. This highlights the necessity for interventions and healthcare strategies aimed at stroke prevention and management, particularly among the elderly. These factors may contribute to a greater susceptibility to stroke.
Similarly to our findings, Djaló et al.28 observed that the stroke mortality rate in 2021 exceeded the rate of the previous four years in Pernambuco. This increase can explained by the development of the COVID-19 pandemic, which negatively impacted patients with less severe strokes due to delays in hospital care, changes in treatment organization, ICU overload, and lower adherence to protocols29,30. Additionally, some studies suggest an increase in stroke incidence associated with COVID-19, although further research is needed to clarify the pathophysiology of this relationship31.
The motivation for this research stemmed from the scarcity of studies on the epidemiological parameters of stroke in the state of Amazonas. Stroke is one of the leading causes of death and disability in Brazil and worldwide. The population of Amazonas faces unique challenges in accessing healthcare, which likely contributes to the high mortality rates in the region.
A stationary temporal trend was observed in the mortality rate for the general population, whereas individuals aged 80 years and older showed an increasing trend. These findings underscore the need for specific interventions and public policies to control stroke in the state, especially among elderly individuals aged 80 years and older.
The limitations of this study include the potential for errors, underreporting, and delays in data recording, which could influence the findings. However, it is crucial to note that the registration procedures in the Mortality Information System are standardized and conducted by trained professionals, minimizing the likelihood of mistakes32. Moreover, the robustness of the data mitigates the potential impacts of underreporting and delayed registrations.
Continuing to monitor the assessed indicators in the state and conducting new research to investigate the underlying factors behind the observed outcomes is imperative. Including other variables such as pre-existing medical conditions, family history of cardiovascular diseases, socioeconomic status, and access to healthcare is crucial for a more comprehensive evaluation. Future studies can explore these variables for a more detailed analysis of stroke mortality rates in Amazonas state.
CONCLUSION
This study showed a stable trend in mortality rates for the total population and the age groups 20-29 years and 30-39 years. However, individuals aged over 80 years showed an increasing trend in mortality rates. Most deaths occurred in individuals over 60 years old. Additionally, a disparity between sexes was evident, with men often exhibiting higher mortality rates.
Moving forward, closely monitoring these trends and developing specific public health strategies for vulnerable groups, especially elderly, is essential to reduce mortality in these populations. Furthermore, ongoing research into factors contributing to these disparities can help formulate more effective policies to improve the health and longevity of the population.
