Editorial comment
Strategies for reducing cardiovascular mortality should go beyond control of classic risk factors
As estratégias para a redução da mortalidade cardiovascular devem ir além do controlo dos clássicos fatores de risco
Marcus Vinícius Bolívar Malachias
Faculdade Ciências Médicas de Minas Gerais, Fundação Educacional Lucas Machado, Belo Horizonte, MG, Brazil
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(A) Mortality from circulatory system diseases in 2013 and MHDI in 2000; (B) mortality from hypertensive diseases in 2013 and MHDI in 2000; (C) mortality from cerebrovascular diseases in 2013 and MHDI in 2000.</p> <p id="spar9010" class="elsevierStyleSimplePara elsevierViewall">CSDs: circulatory system diseases; CBVDs: cerebrovascular diseases; FUs: federative units; HYPDs: hypertensive diseases; MHDI: Municipal Human Development Index. North region FUs – AC: Acre; AM: Amazonas; AP: Amapá; PA: Pará; RO: Rondônia; RR: Roraima; TO: Tocantins. Northeast FUs – AL: Alagoas; BA: Bahia; CE: Ceará; MA: Maranhão; PB: Paraíba; PE: Pernambuco; PI: Piauí; RN: Rio Grande do Norte; SE: Sergipe. Midwest region FUs – DF: Federal District; GO: Goiás; MS: Mato Grosso do Sul; MT: Mato Grosso. Southeast region FUs – ES: Espírito Santo; MG: Minas Gerais; RJ: Rio de Janeiro; SP: São Paulo. South region FUs – PR: Paraná; RS: Rio Grande do Sul; SC: Santa Catarina.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paolo Blanco Villela, Carlos Henrique Klein, Gláucia Maria Moraes de Oliveira" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Paolo Blanco" "apellidos" => "Villela" ] 1 => array:2 [ "nombre" => "Carlos Henrique" "apellidos" => "Klein" ] 2 => array:2 [ "nombre" => "Gláucia Maria Moraes" "apellidos" => "de Oliveira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217420491930087X" "doi" => "10.1016/j.repce.2018.07.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491930087X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117306327?idApp=UINPBA00004E" "url" => "/08702551/0000003800000003/v3_201911300707/S0870255117306327/v3_201911300707/en/main.assets" ] "asociados" => array:1 [ 0 => array:20 [ "pii" => "S0870255117306327" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.07.007" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1359" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2019;38:205-12" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 837 "formatos" => array:3 [ "EPUB" => 95 "HTML" => 568 "PDF" => 174 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Socioeconomic factors and mortality due to cerebrovascular and hypertensive disease in Brazil" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "212" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Fatores socioeconômicos e mortalidade por doenças cerebrovasculares e hipertensivas no Brasil" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3097 "Ancho" => 1573 "Tamanyo" => 247902 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mortality rates from selected causes in 2013 and Municipal Human Development Index in 2000 in Brazilian federative units. (A) Mortality from circulatory system diseases in 2013 and MHDI in 2000; (B) mortality from hypertensive diseases in 2013 and MHDI in 2000; (C) mortality from cerebrovascular diseases in 2013 and MHDI in 2000.</p> <p id="spar9010" class="elsevierStyleSimplePara elsevierViewall">CSDs: circulatory system diseases; CBVDs: cerebrovascular diseases; FUs: federative units; HYPDs: hypertensive diseases; MHDI: Municipal Human Development Index. North region FUs – AC: Acre; AM: Amazonas; AP: Amapá; PA: Pará; RO: Rondônia; RR: Roraima; TO: Tocantins. Northeast FUs – AL: Alagoas; BA: Bahia; CE: Ceará; MA: Maranhão; PB: Paraíba; PE: Pernambuco; PI: Piauí; RN: Rio Grande do Norte; SE: Sergipe. Midwest region FUs – DF: Federal District; GO: Goiás; MS: Mato Grosso do Sul; MT: Mato Grosso. Southeast region FUs – ES: Espírito Santo; MG: Minas Gerais; RJ: Rio de Janeiro; SP: São Paulo. South region FUs – PR: Paraná; RS: Rio Grande do Sul; SC: Santa Catarina.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paolo Blanco Villela, Carlos Henrique Klein, Gláucia Maria Moraes de Oliveira" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Paolo Blanco" "apellidos" => "Villela" ] 1 => array:2 [ "nombre" => "Carlos Henrique" "apellidos" => "Klein" ] 2 => array:2 [ "nombre" => "Gláucia Maria Moraes" "apellidos" => "de Oliveira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217420491930087X" "doi" => "10.1016/j.repce.2018.07.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491930087X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117306327?idApp=UINPBA00004E" "url" => "/08702551/0000003800000003/v3_201911300707/S0870255117306327/v3_201911300707/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Strategies for reducing cardiovascular mortality should go beyond control of classic risk factors" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "214" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Marcus Vinícius Bolívar Malachias" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Marcus Vinícius" "apellidos" => "Bolívar Malachias" "email" => array:1 [ 0 => "mbolivar@uol.com.br" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculdade Ciências Médicas de Minas Gerais, Fundação Educacional Lucas Machado, Belo Horizonte, MG, Brazil" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "As estratégias para a redução da mortalidade cardiovascular devem ir além do controlo dos clássicos fatores de risco" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiovascular disease (CVD), especially myocardial infarction and stroke, is the leading cause of death worldwide.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> In Portuguese-speaking countries (PSCs), ischemic heart disease is the leading cause of death, followed by cerebrovascular disease, with the exception of Mozambique and São Tomé and Príncipe, where this order is reversed.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> It has been demonstrated that the most important risk factors for CVD in the PSCs are hypertension and diet.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The paper by Villela et al. published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> reveals that mortality due to CVD, especially cerebrovascular and hypertensive disease, is inversely related to the Human Development Index (HDI) of Brazil's federative units (the 26 states plus the Federal District of the capital, Brasilia), and to supplementary health coverage (private health insurance), probably reflecting the impact of socioeconomic inequality.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Brazil, with its area of 8.5 million km<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a>, more than 207 million inhabitants, and 27 federative units, is the largest PSC, and presents enormous social, economic, cultural, ethnic and geographical diversity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> These inequalities indicate that there is not in fact one single Brazil but many, and there are similar disparities between the PSCs, which, although they share the same history of colonization and the same language, have extremely diverse socioeconomic levels and health indicators.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Some regions of Brazil present high levels of socioeconomic development, such as the Federal District, which has a similar HDI to that of Portugal, but economically poor states such as Alagoas, Maranhão and Piauí have HDIs closer to those of Cape Verde, East Timor and Equatorial Guinea.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,3,5,6</span></a> Although there no Brazilian regions with HDIs as low as PSCs such as Mozambique and Guinea-Bissau,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5,6</span></a> the demonstration of a correlation between cardiovascular mortality in Brazil and its socioeconomic indicators<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3,6</span></a> should be a stimulus for improving our understanding of the determinants of CVD that go beyond the classic risk factors, a task that is relevant not only for Brazil or the PSCs, but for the whole world.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The Prospective Urban and Rural Epidemiological (PURE) study, which assessed healthy lifestyles among individuals with CVD in 628 urban and rural communities in 17 countries, demonstrated that the prevalence of risk factors is highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries. However, although the risk factor burden was lowest in low-income countries, the rates of major CVD and death were substantially higher in low-income than in high-income countries.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In addition, it has been shown that the availability and use of medication, such as that established for secondary prevention of cardiovascular disease, is alarmingly low worldwide, but predominantly in low-income regions. In many countries with the lowest use, pro-rich inequality is greatest.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The challenge of containing the progress of CVD is complex. It has been established that many different factors need to be controlled,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> including behavioral (smoking, diet, physical activity), biological (hypertension, hypercholesterolemia, diabetes), psychosocial (depression, anxiety, acute and chronic life stressors, lack of social support), health systems (access to care, screening, diagnosis, quality of care), environmental (pollution control, water treatment), intersectoral (tobacco control policies, agricultural policies, food labeling), and information (health education, multilevel communication).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The recently published First Brazilian Registry of Hypertension<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> show that the results of the various hypertension control strategies in the country have been good, with 60.6% of patients treated in tertiary cardiology centers meeting target blood pressure levels (below 140/90<span class="elsevierStyleHsp" style=""></span>mmHg), although it does not reflect the entire hypertensive population of the country. Even so, mortality from CVD in Brazil remains alarmingly high.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The path to improving global cardiovascular health involves multiple and complex strategies, but as demonstrated in the article by Villela et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> assessing conditions in Brazil, it appears above all to involve reducing regional inequalities and improving the social and economic conditions of the population.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "World Health Organization (WHO). 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 4 | 11 |
| 2024 Outubro | 36 | 34 | 70 |
| 2024 Setembro | 33 | 23 | 56 |
| 2024 Agosto | 33 | 33 | 66 |
| 2024 Julho | 34 | 33 | 67 |
| 2024 Junho | 21 | 20 | 41 |
| 2024 Maio | 39 | 17 | 56 |
| 2024 Abril | 24 | 26 | 50 |
| 2024 Maro | 27 | 22 | 49 |
| 2024 Fevereiro | 27 | 20 | 47 |
| 2024 Janeiro | 25 | 30 | 55 |
| 2023 Dezembro | 18 | 19 | 37 |
| 2023 Novembro | 24 | 26 | 50 |
| 2023 Outubro | 7 | 15 | 22 |
| 2023 Setembro | 19 | 18 | 37 |
| 2023 Agosto | 20 | 20 | 40 |
| 2023 Julho | 14 | 6 | 20 |
| 2023 Junho | 23 | 12 | 35 |
| 2023 Maio | 28 | 30 | 58 |
| 2023 Abril | 18 | 6 | 24 |
| 2023 Maro | 30 | 22 | 52 |
| 2023 Fevereiro | 23 | 27 | 50 |
| 2023 Janeiro | 16 | 14 | 30 |
| 2022 Dezembro | 32 | 14 | 46 |
| 2022 Novembro | 38 | 30 | 68 |
| 2022 Outubro | 28 | 24 | 52 |
| 2022 Setembro | 27 | 28 | 55 |
| 2022 Agosto | 19 | 40 | 59 |
| 2022 Julho | 26 | 35 | 61 |
| 2022 Junho | 20 | 26 | 46 |
| 2022 Maio | 23 | 39 | 62 |
| 2022 Abril | 21 | 27 | 48 |
| 2022 Maro | 27 | 31 | 58 |
| 2022 Fevereiro | 16 | 25 | 41 |
| 2022 Janeiro | 15 | 22 | 37 |
| 2021 Dezembro | 14 | 26 | 40 |
| 2021 Novembro | 20 | 42 | 62 |
| 2021 Outubro | 25 | 46 | 71 |
| 2021 Setembro | 22 | 30 | 52 |
| 2021 Agosto | 22 | 31 | 53 |
| 2021 Julho | 15 | 20 | 35 |
| 2021 Junho | 18 | 24 | 42 |
| 2021 Maio | 29 | 28 | 57 |
| 2021 Abril | 42 | 24 | 66 |
| 2021 Maro | 46 | 24 | 70 |
| 2021 Fevereiro | 39 | 18 | 57 |
| 2021 Janeiro | 85 | 14 | 99 |
| 2020 Dezembro | 29 | 8 | 37 |
| 2020 Novembro | 24 | 17 | 41 |
| 2020 Outubro | 21 | 12 | 33 |
| 2020 Setembro | 21 | 13 | 34 |
| 2020 Agosto | 14 | 7 | 21 |
| 2020 Julho | 21 | 7 | 28 |
| 2020 Junho | 19 | 14 | 33 |
| 2020 Maio | 28 | 8 | 36 |
| 2020 Abril | 32 | 11 | 43 |
| 2020 Maro | 21 | 11 | 32 |
| 2020 Fevereiro | 110 | 22 | 132 |
| 2020 Janeiro | 59 | 12 | 71 |
| 2019 Dezembro | 21 | 11 | 32 |
| 2019 Novembro | 24 | 6 | 30 |
| 2019 Outubro | 21 | 9 | 30 |
| 2019 Setembro | 64 | 9 | 73 |
| 2019 Agosto | 18 | 6 | 24 |
| 2019 Julho | 49 | 20 | 69 |
| 2019 Junho | 52 | 28 | 80 |
| 2019 Maio | 79 | 52 | 131 |
| 2019 Abril | 21 | 16 | 37 |
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