Arq Neuropsiquiat r 2004;62(4):1008-1011
1Depart ment of Int ernal M edicine, School of M edicine, Universit y of Sao Paulo, São Paulo SP, Brazil (USP); 2Division of Int ernal M edicine, Hospit al USP. Dr Lot uf o and Dr Bensenor are recipient s of aw ard grant f rom Conselho Nacional de Pesquisa, Brasília, Brazil. Received 14 April 2004, received in f inal f orm 1 July 2004. Accept ed 7 August 2004.
Dr. Paulo A. Lotufo - Hospital Universitário USP - Avenida Lineu Prestes 2565 - 05508-900 São Paulo SP - Brasil. E-mail: [email protected]
STROKE M ORTALITY IN SÃO PAULO (1997-2003)
A descript ion using t he Tent h Revision of t he
Int ernat ional Classif icat ion of Diseases
Paulo A. Lot uf o
1,2, Isabela M . Bensenor
1ABSTRACT - St roke mort alit y rat es are higher in Brazil w hen compared t o ot her count ries. The cit y of São Paulo has a good syst em of mort alit y surveillance t hat allow us t o describe t he epidemiology of t he st roke in the city. Our aim was to describe the stroke mortality pattern by gender and age characterizing the ischemic/ hemorrhagic rat io. We cat egorized mort alit y dat a by gender and a 10-year age-st rat a f rom 30-39 years-old t o 70-79 years-old. To avoid random variat ions, w e calculat ed t he mean of all deat hs occurred during t he period of 1997 t o 2003. M ort alit y rat es w ere calculat ed using t he populat ion f rom t he Brazilian Nat ional Census occurred in 2000. The proportion of deaths from all types of stroke related to all cardiovascular among w omen w as higher w hen compared t o men, mainly during middle-age. In ot her hand, t he risk of st roke deat h is alw ays higher among men during all ages. Ill-def ined st roke cert if icat ion is more common as under-lying cause of deat h above t he 60 years-old (40 per cent ).Int racerebral hemorrhage w as t he most f requent cause of st roke deat h f or bot h sexes f rom 30 t o 59 years-old. Subarachnoideal hemorrhage w as much more f requent as cause of deat h among w omen t han in men. The rat io bet w een ischemic/hemorrhagic (bot h sub-t ypes) w as 0.59 f or men and 0.56 f or w omen. Concluding, sub-t he magnisub-t ude of hemorrhagic ssub-t roke is ssub-t ill high-er in São Paulo cit y, w it h an special burden t o middle-aged people f or bot h gendhigh-er.
KEY WORDS: cerebrovascular disorders, mort alit y, disease classif icat ion, epidemiology.
M ort alidade pela doença cerebrovascular em São Paulo (1997-2003): descrição ut ilizando a Décim a Classif icação Int ernacional de Doenças
RESUM O - A mort alidade pela doença cerebrovascular (DCV) é ainda elevada no Brasil quando comparada a out ros países. O município de São Paulo t em um sist ema de inf ormação de mort alidade de boa qualidade que nos permit e avaliar a epidemiologia da DCV. O objet ivo do est udo f oi descrever o padrão por gênero e f aixa et ária do dif erent es t ipos de doença DCV. Para essa t aref a, as inf ormações de mort alidade f oram est rat if icadas por gênero e f aixas et árias decenais desde os 30-39 anos de idade at é os 70-79 anos de idade. Para evit ar f lut uações ocasionais, calculou-se a média dos óbit os ocorridos no período de 1997 a 2003.As t axas de mort alidade f oram calculadas usando-se a população det erminada no Censo de 2000. A proporção de mort es por DCV em comparação com o t ot al de óbit os de origem cardiovascular f oi maior ent re as mu-lheres, principalment e na meia idade. Por out ro lado, a dif erença do risco de mort e por ent re homens e mulheres aument ou progressivament e com o avançar da idades, com os homens apresent ando sempre os valores mais elevados. A DCV não especif icada como isquêmica ou hemorrágica f oi a causa mais comum de mort e por DCV a part ir dos 60 anos. No ent ant o, a hemorragia int racerebral f oi a causa mais f reqüent e para ambos os sexos dos 30 aos 59 anos. A hemorragia subaracnoídea f oi causa muit o mais f reqüent e ent re mu-lheres do que em homens. A razão ent re mort es por DCV isquêmica em relação a hemorrágica (ambos sub-t ipos) f oi 0,59 para homens e 0,56 para mulheres. Concluindo, a magnisub-t ude dos sub-t ipos hemorrágicos da DCV é ainda bast ant e elevada em São Paulo quando comparada a de out ros países.
PALAVRAS-CHAVE: doença cerebrovascular, mort alidade, classif icação de doenças, epidemiologia.
Stroke mortality rates are declining in Sao Paulo, Brazil since t he 1980’s1-3. How ever t he burden of
deat hs f rom cerebrovascular disease (CVD) is st ill high in t he cit y of São Paulo as w ell as in ot her Bra-zilian met ropolit an areas1,4In 1996, t he M inist ry of
Healt h of Brazil adopt ed t he 10t hRevision of t he
Arq Neuropsiquiat r 2004;62(4) 1009
t he qualit y of deat h cert if icat ion, due t o t he use of new simple rules t o code CVD. One specif ic quest ion t o st roke epidemiology is t o verif y if using t his new classif icat ion, t he proport ion of ill-def i-ned CVD decreases, w it h more diagnoses of ische-mic and hemorrhagic st roke deat hs.
Considering bot h of f icial healt h st at ist ics and coroner aut opsy services, t he cit y of São Paulo (Brazil) has a complet e and complex syst em of mor-t alimor-t y surveillance mor-t hamor-t allow us mor-t o verif y mor-t he smor-t roke subt ypes’ proport ion by age-st rat a and gender. So, t he aim of t his st udy is t o describe t he dist ri-but ion of t he subt ypes of st roke deat hs according t o age-st rat a and gender.
M ETHOD
M ort alit y dat a w ere obt ained f rom t he cit y of Sao Paulo healt h st at ist ic syst em (PRO-AIM , Programa de Aprimorament o das Inf ormações de M ort alidade), and t hey w ere cat egorized by gender and a 10-year age-st ra-t a (f rom 30-39 years-old ra-t o 70-79 years-old). To avoid ran-dom variat ions, w e used t he mean of all deat hs occurred during t he period of 1997 t o 2003.
M ort alit y rat es w ere calculat ed using t he populat ion f rom t he Brazilian Nat ional Census in 2000. This year w as t he mid-point of t he period 1997-2003. Adjust ment f or age w as obt ained by direct met hod using as st andard t he w hole populat ion of t he cit y of Sao Paulo f rom t he 2000 Census.
RESULTS
Figure 1 show s t he proport ion of deat hs f rom all t ypes of st roke considering all deat hs classif ied as cardiovascular diseases by gender. The propor-t ion of deapropor-t hs f rom spropor-t roke among w omen is high-er when compared to men. This proportion decreas-es in elderly men and w omen compared t o mid-dle-age st rat a. How ever, Figure 2 show s t hat t he gap among t he mort alit y rat es f or st roke bet w een men and w omen are progressively w ider accord-ing t o increasaccord-ing age-st rat a cat egories.
Table 1 show s t hat ill-def ined st roke is t he most common subt ype of deat h cert if icat ion f or st roke for both gender among all people of 30 to 79 years-old w it h a range of 10 t o 40 per cent , due t o t he eldest st rat a. How ever, in t he age-st rat a of 40 t o 59 years-old, int racerebral hemorrhage w as a more f requent cause of t he deat h f or men and w omen. Subarachnoid hemorrhage w as much more f re-quent as a cause of death among women compared t o men. Age-gender specif ic mort alit y rat es (Table 2) are higher among men, except f or subarachnoid hemorrhage. Figure 3 show s t he age-adjust ed
mor-Fig 1. Proportion of stroke deaths among all cardiovascular diseases according to gender and age-strata in Sao Paulo City, 1997-2003.
Fig 2. St roke mort alit y rat es according t o gender and age-st ra-t a in Sao Paulo Cira-t y, 1997-2003.
t alit y rat es considering bot h t ypes of hemorrhag-ic st roke (int racerebral and subarachnoid). The rat io bet w een ischemic/hemorrhagic w as 0.59 f or men and 0.56 f or w omen.
DISCUSSION
The descript ion of st roke mort alit y in t he cit y of São Paulo showed that the most common presen-t apresen-t ion of spresen-t roke deapresen-t h cerpresen-t if icapresen-t ion is spresen-t ill ill-def ined
Table 2. M ort alit y rat es (100,000 inhabit ant s) of st roke subt ypes in São Paulo cit y, 1997-2003.
M ale 30-39 40-49 50-59 60-69 70-79 Tot al
Ill-def ined st roke (I64) 1.2 6.9 28.8 89.2 235.8 30.5
Int racerebral hemorrhage (I61) 5.1 19.2 40.8 58.0 84.7 25.7
Cerebral inf arct ion (I63) 1.3 5.2 18.8 52.4 122.5 17.9
Lat e-ef f ect s of cerebrovascular diseases (I69) 0.2 1.5 7.7 34.8 106.5 11.6
Subarachnoid hemorrhage (I60) 2.5 6.7 10.8 11.8 9.9 6.6
Ot her cerebrovascular diseases (I67) 0.2 0.7 2.0 4.1 10.3 1.7
Ot her non-t rauma-relat ed cerebral hemorrhage (I62) 0.2 0.3 0.7 1.0 4.8 0.7 Female
Ill-def ined st roke (I64) 1.0 5.6 15.5 50.0 151.5 21.9
Int racerebral hemorrhage (I61) 3.8 13.1 23.0 32.0 56.6 17.2
Cerebral inf arct ion (I63) 1.1 3.3 8.5 25.4 83.4 12.1
Subarachnoid hemorrhage (I60) 4.3 11.4 14.4 14.5 17.2 10.3
Lat e-ef f ect s of cerebrovascular diseases (I69) 0.2 0.7 2.9 13.4 59.2 6.8
Ot her cerebrovascular diseases (I67) 0.5 1.3 2.5 4.0 7.5 2.0
Ot her non-t rauma-relat ed cerebral hemorrhage (I62) 0.0 0.1 0.3 0.6 1.2 0.2
1010 Arq Neuropsiquiat r 2004;62(4)
Table 1. Number of deat hs (and percent age) due t o cerebrovascular disease subt ypes (10t h revision of t he int ernat ional classif ica-t ion of diseases) in São Paulo ciica-t y, 1997-2003, according ica-t o gender and age-sica-t raica-t a.
Cause (10-ICD) 30-39 40-49 50-59 60-69 70-79 30-79
M ale N (% ) N (% ) N (% ) N (% ) N (% ) N (% )
Ill-def ined st roke (I64) 68 (11,1) 305 (17,1) 784 (26.3) 1450 (35.5) 2052 (41.0) 4659 (32.2) Int racerebral hemorrhage (I61) 292 (47.7) 841 (47.2) 1111 (37.2) 943(23.1) 737 (14.7) 3924 (27.1) Cerebral inf arct ion (I63) 74 (12.1) 228 (12.8) 513 (17.2) 851 (20.8) 1066 (21.3) 2732 (18.9) Lat e-ef f ect s of cerebrovascular
diseases (I69) 10 (1.6) 68 (3.8) 209 (7.0) 565 (13.8) 927 (18.5) 1779 (12.3) Subarachnoid hemorrhage (I60) 143 (23.4) 295 (16.6) 295 (9.9) 192 (4.7) 86 (1.7) 1011 (7.0) Ot her cerebrovascular
diseases (I67) 12 (2.0) 30 (1.7) 55 (1.8) 67 (1.6) 90 (1.8) 254 (1.8)
Ot her non-t rauma-relat ed
cerebral hemorrhage (I62) 13 (2.1) 13 (0.7) 18 (0.6) 17 (0.4) 42 (0.8) 103 (0.7)
Tot al 612 (100) 1780 (100) 2985 (100) 4085 (100) 5000 (100) 14462 (100)
Female N (% ) N (% ) N (% ) N (% ) N (% ) N (% )
Ill-def ined st roke (I64) 62 (9.1) 283 (15.7) 505 (23.1) 1077 (35.7) 2030 (40.2) 3957 (31.1) Int racerebral hemorrhage (I61) 238 (35.0) 665 (37.0) 751 (34.3) 690 (22.9) 759 (15.0) 3103 (24.4) Cerebral inf arct ion (I63) 71 (10.4) 167 (9.3) 277 (12.7) 547 (18.1) 1118 (22.1) 2180 (17.1) Subarachnoid hemorrhage (I60) 269 (39.6) 581 (32.3) 470 (21.5) 313 (10.4) 231 (4.6) 1864 (14.6) Lat e-ef f ect s of cerebrovascular
diseases(I69) 11 (1.6) 33 (1.8) 94 (4.3) 288 (9.6) 793 (15.7) 1219 (9.6) Ot her cerebrovascular
diseases (I67) 28 (4.1) 65 (3.6) 81 (3.7) 87 (2.9) 101 (2.0) 362 (2.8) Ot her non-t rauma-relat ed
cerebral hemorrhage (I62) 1 (0.1) 5 (0.3) 11 (0.5) 12 (0.4) 16 (0.3) 45 (0.4)
Arq Neuropsiquiat r 2004;62(4) 1011
st roke, independent of t he new crit eria int roduced by t he Tent h Revision of t he Int ernat ional Classi-f icat ion oClassi-f t he Diseases. How ever, t here is a pre-dominance of cases due t o int racerebral hemor-rhage, specially among deat hs occurring at mid-dle-age.
As st at ed by Law lor et . al.5, alt hough st roke and
coronary heart disease have t he same risk f act ors, t here is a dif f erence in geographic, gender, race and age dist ribut ion over t ime. In a seminal paper, they described the secular trends of stroke subtypes (cerebral inf arct ion and bot h t ypes of hemorrhag-ic st rokes) in England and Wales including mort al-it y dat a and inf ormat ion about aut opsy series. The rat io of ischemic t o hemorrhagic st roke obser-ved in 1999 f or men and w omen aged 35-74 years w as 0.38 in cont rast t o 0.56-0.59 observed in our st udy5
M ort alit y st udies did not represent t he only source of dat a t o verif y t he dist ribut ion of st roke subt ypes. In England and Wales, morbidit y st ud-ies from hospital serud-ies and stroke register, revealed a rat io ischemic/hemorrhagic dif f erent f rom mor-t alimor-t y damor-t a, i.e., almosmor-t 2.0.5In t he cit y of São Paulo,
an accurat e post -hoc analysis of hospit alizat ion due t o st roke in a communit y school hospit al dur-ing t he 1990s disclosed that the ratio ischemic/hem-orrhagic among pat ient s admit t ed f rom t he emer-gency w ard w as 2.1 similar t o observed in t he Bri-t ish sBri-t udy.6Ot her series described in Joinville, Sant a
Cat arina show ed a higher rat io (2.8) bet w een ischemic and hemorrhagic.7
In Brazil, t w o aut opsy st udies, one f rom t he ci-t y of São Paulo in ci-t he laci-t e 1990’s, observed ci-t haci-t among aut opsied cases, t he rat io ischemic/hemor-rhagic w as close t o 0.40, a similar value observed during t he 1940s in England.8Ot her series during
t he lat e 1980’s, f rom Port o Alegre, show ed a high-er rat io, almost 0.7, i.e., w it h a prepondhigh-erance of hemorrhagic st roke deat hs9.
M ort alit y st udies using deat h cert if icat ions are an inexpensive, easy and st andardized w ay t o un-derst and st roke epidemiology. How ever, t here is alw ays doubt s about t he qualit y of t he dat a specif -ically for CVD. The World Health Organization spon-sored M ONICA (M onit oring of Trends and Det er-minant s in Cardiovascular Disease) st udy revealed t hat t en of t he previous 21 cent ers enrolled t o creat e a st roke regist er w ere unable t o maint ain t he qualit y of clinical dat a10How ever, t he cit y of
São Paulo has a good syst em of mort alit y dat a, per-mit t ing t o verif y t he presence of dat a inconsist
en-cies and to correct it before data consolidation. Pre-vious st udies of validat ion show ed a qualit y simi-lar t o cit ies in Unit ed Kingdom and t he Unit ed St at es11.
How ever, f or observat ional and clinical t rials, ot her w ays t o classif y st roke subt ypes are more ac-curat e as t he “ Trial of Org 10172 in Acut e St roke Treatment” (TOAST)12and the Oxfordshire
Commu-nit y St roke Project13. These crit eria are have been
creat ed combining clinical, radiographic and an-giographic dat a. Theref ore, t he use of ICD-10 is an useful tool only for epidemiologic and public health purposes.
Concluding, mort alit y dat a classif ied according t o t he 10t hRevision of Int ernat ional Classif icat ion
of Diseases show ed us t he diff erent pat t ern of st ro-ke subt ypes mort alit y according t o gender and age. Hemorrhagic stroke is still an important component of cerebrovascular mort alit y in t he cit y of São Pau-lo, Brazil. Compared t o t he Nint h Revision of t he Int ernat ional Classif icat ion of Diseases, t he Tent h one simplif ies dat a analysis.
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