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Cardiovascular mortality in Brazil during the COVID-19 pandemic: a comparison between underlying and multiple causes
L C C Brant1, P C Pinheiro2, L G Passaglia2
1School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
Insights
During the COVID-19 pandemic, cardiovascular disease (CVD) mortality in Brazil did not change when listed as the underlying cause of death. However, CVD deaths increased when considered as multiple causes, indicating misclassification and higher out-of-hospital fatalities.
Area of Science:
- Public Health
- Epidemiology
- Cardiovascular Medicine
Background:
- The COVID-19 pandemic has significantly altered global mortality patterns, with notable impacts on cardiovascular disease (CVD) deaths.
- Misclassification of causes of death may contribute to observed changes in CVD mortality during the pandemic.
- Understanding these changes is crucial for accurate public health surveillance and response.
Purpose of the Study:
- To evaluate the impact of the COVID-19 pandemic on cardiovascular disease (CVD) mortality in Brazil.
- To compare CVD mortality trends using underlying causes (UCs) versus multiple causes (MCs) of death.
- To identify factors contributing to potential discrepancies in CVD mortality reporting.
Main Methods:
- Ecological time-series study analyzing age-standardized death rates for CVD in Brazil from epidemiological week 10/2020 to 39/2021.
- Data sourced from the Mortality Information System, classifying CVD using ICD-10 codes as UC or MC.
- Comparison of observed versus expected CVD mortality rates (2017-2019 baseline) using risk ratios (RiRs) and 95% confidence intervals (CIs).
Main Results:
- CVD mortality as an underlying cause showed no significant change (RiR = 1.00) compared to expected rates.
- A significant increase in out-of-hospital mortality (RiR = 1.18) and deaths from ill-defined causes (RiR = 1.43) was observed.
- CVD mortality as a multiple cause increased by 10% (RiR = 1.10), particularly in the North and Central West regions, among men, and older adults (≥60 years).
Conclusions:
- While underlying cause of death for CVD remained stable, multiple cause coding revealed a pandemic-associated increase in Brazil.
- Increased out-of-hospital deaths, potential misclassification, and competing causes of death likely explain the observed rise in MCs.
- These findings highlight the importance of comprehensive cause-of-death data analysis for understanding pandemic's true impact on CVD.
Objectives:
The COVID-19 pandemic has differentially impacted cardiovascular disease (CVD) mortality worldwide. Causes of death misclassification may be one of the reasons. We evaluated the impact of the pandemic on CVD mortality in Brazil, comparing underlying causes (UCs) and multiple causes (MCs) of death.
Study Design:
Ecological time-series study.
Methods:
An ecological, time-series study was conducted analysing age-standardised death rates for CVD, from epidemiological week (EW) 10/2020 to 39/2021, using data from the Mortality Information System, Brazil. CVD was defined using the International Classification of Diseases (ICD-10) coding, if reported as UC or MC of death. Observed and expected data (mean for the same EW, 2017-2019) were compared. Risk ratios (RiRs) were analysed, and 95% confidence intervals (CIs) were calculated.
Results:
Age-standardised mortality rate for CVD as UC of death was 165.8 (95%CI: 165.4-166.3) per 100,000 inhabitants, similar to what was expected (165.6/100,000, 95%CI: 165.2-166.1, RiR = 1.00). There was increased out-of-hospital mortality (RiR = 1.18; 95%CI: 1.17-1.19) and deaths of ill-defined causes (RiR = 1.43; 95%CI: 1.42-1.44). The increase in out-of-hospital deaths was more pronounced in the North (RiR = 1.33; 95%CI 1.30-1.36) region, with a less resilient health system. Conversely, as MCs of death, there was a 10% increase in CVD mortality (observed: 243.2 [95%CI: 242.7-243.7], expected: 221.6 [95%CI: 221.1-222.1] per 100,000). An increase also occurred in the North and Central West regions (RiR = 1.16; 95%CI: 1.15-1.18), among men (RiR = 1.11; 95%CI: 1.11-1.12) and individuals aged ≥60 years (RiR = 1.11; 95%CI: 1.10-1.11).
Conclusions:
During the pandemic, mortality rates for CVD as MCs of death increased in Brazil, whereas as UC mortality rates did not change. Higher out-of-hospital mortality, misclassification, and competing causes of death may explain this pattern.
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