ABC | Volume 115, Nº2, August 2020

Original Article Malta et al. Cardiovascular Disease Mortality in SIM and GBD Arq Bras Cardiol. 2020; 115(2):152-160 rates decreased from 263.9 to 172.0 deaths per 100,000 inhabitants. The GBD 2017 estimated rates decreased from 248.8 to 178,0 deaths per 100,000 inhabitants. However, it is worth noting that, from 2015 to 2017, the GBD estimated rates increased, and this increase was also observed in the Corrected SIM rates from 2015 to 2016. When assessing the percentage variations in the standardized CVD mortality rates from 2000 to 2017 by each state and the Federal District, there was a difference in the Crude SIM data, with stabilization in the rates or their increase (of as much as 115%) in most Northern and Northeastern states. That pattern is observed neither in the Corrected SIM data nor in the GBD Study data, whose rates showed a reduction in all Brazilian states and the Federal District (Figure 5, Table 2). Discussion This study compares three different methods to estimate the historical series of CVD mortality in Brazil from 2000 to 2017, which decreased, except for the period from 2015 onwards, when there was an increase in the GBD estimated rates and stability in the Corrected SIM rates. The estimates of the Corrected SIM and GBD were similar, especially after 2006, when the quality of the SIM improved. The Crude SIM showed an increase in the rates of the Northern and Northeastern states, while the Corrected SIM and GBD showed a reduction in the rates of all states and the Federal District in the period. Cardiovascular diseases are the number one cause of death globally 13 and in Brazil, 5,14 corresponding to one third of all deaths. All regions showed a decline in mortality due to chronic non communicable diseases (CNCDs). The CVDs and their complications have a high impact on the loss of productivity in the workplace and in the family income, resulting in a US$ 4.18 billion deficit in the Brazilian economy from 2006 to 2015. 15 Studies conducted in several countries have shown a reduction in the incidence of CVDs and in CVD mortality since the 1960s. 16,17 In Brazil, that reduction occurred later, in the 1990s. 5,14 Over the years, SIM has been improved, having its coverage increased and the quality of the reports of underlying causes of death in death certificates refined. These advances have resulted from the efforts of the Brazilian Ministry of Health in partnership with states and municipalities to improve death data collection by the SIM. Some examples are the 2005 Project to Reduce Ill-Defined Causes and the Projects to Reduce Regional Inequalities and Child Mortality in the Northeastern states and the ‘Legal Amazonia’ region. 18 It is worth noting the Project of Active Search for Death Data, which enabled the definition of methodologies to redistribute underreported deaths. 19,20 Those corrections are essential for the accurate interpretation and comparability of historical series in different regions of Brazil. It is worth noting the important reduction in the percentage of ill-defined causes of death in the SIM, which results from the improvement in the quality of healthcare services and the increase in healthcare coverage, especially the advance of the family healthcare team to inner areas of the country. 5 In addition, the differences between the Corrected SIM and the GBD Study 2017 can be explained by the percentage of the codes of unspecific causes, named ‘garbage code’ in the international literature. 8 Although the Figure 4 – Standardized cardiovascular disease mortality rates according to the Crude and Corrected SIM and the GBD Study 2017. Brazil, 2000 to 2017. Sources: SIM and Brazil GBD Study 2017. 156