ABSTRACT

Objective:

to estimate the prevalence and investigate the sociodemographic, health, and lifestyle factors associated with the self-reported diagnosis of Cardiovascular Disease (CVD) in the adult Brazilian population.

Methods:

Data from the National Health Survey (PNS 2019) were analyzed. The presence of CVD was self-reported through the question: “Has any doctor ever given you a diagnosis of heart disease?”. Sociodemographic factors, health conditions, and lifestyle were evaluated. For data analysis, Poisson Regression with robust variance was used.

Results:

5.3% (95%CI 5.04–5.57) of Brazilian adults reported CVD, of which, 29.08% (95%CI 27.04–31.21) underwent coronary artery bypass surgery or angioplasty and 8.26% (95%CI 7.09–9.6) reported severe limitation in usual activities due to CVD. The factors associated with CVD were advanced age; being male; white race/color; complete middle school and incomplete high school education; have health insurance; self-assessing health as regular or bad/very bad; self-reported hypertension, high cholesterol, and diabetes; being a former smoker; consuming fruits and vegetables as recommended; not consuming alcohol in excess; and not practicing leisure-time physical activity.

Conclusions:

CVD is associated with sociodemographic, health, and lifestyle factors. It is important to support public policies, programs, and goals for the reduction of cardiovascular diseases in Brazil, especially in the most vulnerable groups.

Keywords:
Cardiovascular diseases; Risk factors; Health surveys; Brazil

INTRODUCTION

Cardiovascular diseases (CVD) are the main cause of mortality in Brazil and worldwide, in addition to causing increased morbidity, premature mortality, disabilities, loss of quality of life, and direct and indirect costs to health¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... .

According to estimates from the Global Burden of Disease (GBD) study, globally, the prevalent cases of CVD increased significantly between 1990 and 2019, from 271 million to 523 million, respectively²2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020; 76(25): 2982-3021. https://doi.org/10.1016/j.jacc.2020.11.010
https://doi.org/10.1016/j.jacc.2020.11.0... . There was also an increase in the number of deaths from CVD from 12.1 million in 1990 to 18.6 million in 2019. In addition, global trends for years lived with disability (YLD) are growing, having doubled over these years, from 17.7 to 34.4 million²2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020; 76(25): 2982-3021. https://doi.org/10.1016/j.jacc.2020.11.010
https://doi.org/10.1016/j.jacc.2020.11.0... . In Brazil, the scenario is similar, CVD has been the leading cause of death since the 1990s³3. Institute for Health Metrics and Evaluation. GBD compare, viz hub. Institute for Health Metrics and Evaluation [Internet]. 2019 [cited on May 27, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare/
https://vizhub.healthdata.org/gbd-compar... . There was an increase in mortality, from 270,000 in 1990 to 400,000 deaths in 2019, which corresponds to 48% of the total deaths³3. Institute for Health Metrics and Evaluation. GBD compare, viz hub. Institute for Health Metrics and Evaluation [Internet]. 2019 [cited on May 27, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare/
https://vizhub.healthdata.org/gbd-compar... . These diseases are also the leading causes of disability-adjusted life years (DALY) lost. In 1990, they caused 7,006,214 DALYs, and in 2019, there was an increase to 8,861,401 (27% of the total DALY)³3. Institute for Health Metrics and Evaluation. GBD compare, viz hub. Institute for Health Metrics and Evaluation [Internet]. 2019 [cited on May 27, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare/
https://vizhub.healthdata.org/gbd-compar... .

The increase in CVD is related to the aging of the population and classic risk factors such as high blood pressure, diabetes, dyslipidemia, obesity, sedentary lifestyle, smoking, inadequate diet, stress, and family history¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... . Furthermore, sociodemographic, ethnic, cultural, dietary, and behavioral issues are strong predictors of causality, morbidity, and premature mortality and may also explain the differences in CVD burden among populations and their trends over the years¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... .

To prevent CVD, it is necessary to strengthen protection and health promotion measures, especially those that promote healthy lifestyle habits, access to measures for primary and secondary prevention of CVD, associated with the treatment of cardiovascular events¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... . In addition, monitoring, surveillance of risk factors, and integrated actions should be priorities to face these diseases, as they allow, based on evidence, the development of more cost-effective strategies⁴4. Malta DC, Cezário AC, Moura L, Morais Neto OL, Silva Junior JB. A construção da vigilância e prevenção das doenças crônicas não transmissíveis no contexto do Sistema Único de Saúde. Epidemiol Serv Saúde 2006; 15(3): 47-65. http://doi.org/10.5123/S1679-49742006000300006
http://doi.org/10.5123/S1679-49742006000... . The importance of social and economic policies is also highlighted, with a view to reducing inequalities and guaranteeing universal and equal access to health actions and services⁵5. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Fiscal austerity measures hamper noncommunicable disease control goals in Brazil. Cien Saude Colet 2018; 23(10): 3115-122. https://doi.org/10.1590/1413-812320182310.25222018.
https://doi.org/10.1590/1413-81232018231... ,⁶6. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... .

A study carried out in Brazil, in 2013, showed a higher occurrence of CVD in females, aged people, people with hypertension, diabetes, dyslipidemia, overweight, obesity, and unhealthy behaviors such as smoking and physical inactivity⁷7. Gonçalves RPF, Haikal DSA, Freitas MIF, Machado ÍE, Malta DC. Self-reported medical diagnosis of heart disease and associated risk factors: National Health Survey. Rev Bras Epidemiol 2019; 22(Suppl 2): E190016.SUPL2. https://doi.org/10.1590/1980-549720190016.supl.2
https://doi.org/10.1590/1980-54972019001... . However, there has been a trend toward an increase in the prevalence of CVD⁸8. Fundação Oswaldo Cruz. Painel de Indicadores de Saúde – Pesquisa Nacional de Saúde [Internet]. 2021 [cited on July 06, 2021]. Available at:https://www.pns.icict.fiocruz.br/painel-de-indicadores-mobile-desktop/
https://www.pns.icict.fiocruz.br/painel-... and changes in the behavior of some risk factors⁶6. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... ,⁸8. Fundação Oswaldo Cruz. Painel de Indicadores de Saúde – Pesquisa Nacional de Saúde [Internet]. 2021 [cited on July 06, 2021]. Available at:https://www.pns.icict.fiocruz.br/painel-de-indicadores-mobile-desktop/
https://www.pns.icict.fiocruz.br/painel-... . A study showed that, between 2006 and 2014, there was a reduction in smokers and an increase in obesity, consumption of fruits and vegetables, physical activity, and alcohol use. However, as of 2015, the scenario changed, with a reduction in the consumption of fruits and vegetables, stability in the practice of physical activity and an increase in alcohol abuse⁶6. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... . It should be noted that, from mid-2014, there were economic and political crises in Brazil and austerity policies were implemented, such as the approval of Constitutional Amendment No. 95 (EC95)⁹9. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Emenda Constitucional no 95, de 15 de dezembro de 2016. Altera o ato das disposições constitucionais transitórias, para instituir o novo regime fiscal, e dá outras providências. Diário Oficial da União, 2016. Available at:http://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc95.htm
http://www.planalto.gov.br/ccivil_03/con... , which resulted in a decrease in investments in social and health policies, increased inequalities, in addition to reducing the supply of health goods and services, worsening comorbidities and impacting on mortality rates¹⁰10. Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3(4): e000829. https://doi.org/10.1136/bmjgh-2018-000829
https://doi.org/10.1136/bmjgh-2018-00082... ,¹¹11. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Coletiva 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,¹²12. Doniec K, Dall’Alba R, King L. Brazil’s health catastrophe in the making. Lancet 2018; 392(10149): 731-2. https://doi.org/10.1016/S0140-6736(18)30853-5
https://doi.org/10.1016/S0140-6736(18)30... ,¹³13. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Fiscal austerity measures hamper noncommunicable disease control goals in Brazil. Cien Saude Coletiva 2019; 23(10): 3115-22. https://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/10.1590/1413-81232018231... .

In this sense, it is necessary to monitor the prevalence of CVD and their risk factors in Brazilian adults, especially in a scenario of political, economic, and social instability. Therefore, the present study aimed to estimate the prevalence and investigate the sociodemographic, health, and lifestyle factors associated with self-reported diagnosis of CVD in the adult Brazilian population.

METHODS

Cross-sectional study with data from the 2019 National Health Survey (Pesquisa Nacional de Saúde – PNS), which is a population-based survey, representative of the Brazilian population, carried out by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE) in partnership with the Ministry of Health (MoH)¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020 [cited on May 27, 2021]. Available at:https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza... .

The 2019 PNS target population consisted of individuals aged 15 years old or older, residing in permanent private households. The sample consisted of three-stage clusters, with the census tracts being the primary unit, the households the secondary, and one resident aged 15 years old or older the tertiary. Households and residents were selected by simple random sampling. The minimum size defined for the sample was 108,525 households, and the final sample had 94,114 households with an interview carried out, with a response rate of 93.6%¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020 [cited on May 27, 2021]. Available at:https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza... . For the analysis of the present study, individuals under 18 years of age were excluded, totaling 88,531 individuals. Further details on the PNS methodology can be found in previous publications¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020 [cited on May 27, 2021]. Available at:https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza... ,¹⁵15. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5): e2020315. https://doi.org/10.1590/S1679-49742020000500004
https://doi.org/10.1590/S1679-4974202000... .

The diagnosis of CVD was self-reported and evaluated by the question: “Has a doctor ever given you the diagnosis of a heart disease, such as a heart attack, angina, heart failure or any other?”. Individuals who answered “YES” to this question were considered as having CVD.

For individuals who reported a diagnosis of CVD, the following conditions were evaluated: age at first diagnosis of CVD; performing saphenous bypass surgery or catheterization with stent placement or angioplasty; degree of limitation in usual activities due to heart disease; care for CVD (diet; regular physical activity; regular use of medication; regular follow-up with a health professional).

To describe the data, proportions and 95% confidence intervals (95%CI) were calculated. In the verification of possible factors associated with CVD, the prevalence ratio (PR), obtained through Poisson regression with robust variance, was used as a measure of association. Variables with a p-value <0.20 in the crude analyses were included in the multivariate model. In the final model, factors associated with variables with a value of p≤0.05 were considered.

All analyzes were performed by the Data Analysis and Statistical Software (Stata), version 14, using the survey module that considers post-stratification weights.

The PNS 2019 was approved by the National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa – CONEP) of the MoH, under opinion number 3.529.376. Adult participation in the research was voluntary and information confidentiality was guaranteed¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020 [cited on May 27, 2021]. Available at:https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza... . The PNS 2019 data are available for public access and use in the IBGE repository (https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=download0s).

RESULTS

88,531 individuals over 18 years of age were evaluated. Of these, 5.3% (95%CI 5.0–5.6) reported a medical diagnosis of CVD. The mean age at first medical diagnosis of CVD was 46.7 years (95%CI 45.6–47.9). Among adults who reported CVD, 29.1% (95%CI 27.0–31.2) had undergone bypass surgery or angioplasty and 8.3% (95%CI 7.1–9.6) reported severe limitation in usual activities by CVD. With regard to health care given to CVD, 43.7% reported dieting, 26.2% practicing LPA, 69.1% using medication, and 69.9% having regular follow-up with a health professional (Supplementary material 1).

Table 1 shows the prevalence of CVD according to sociodemographic characteristics, health conditions, and lifestyle. There was a higher prevalence of CVD among women (5.6%); people over 60 years of age (13.1%); individuals with low education (7.8%); white color/race (6.1%); who receive from 3 to 5 MW (6.1%); residents of the Southern Region (6.8%). As for health and behavioral characteristics, the highest prevalence of CVD was among those who have health insurance (6.2%); self-evaluation their health as bad or very bad (17.1%); people with hypertension (13.6%), diabetes (15.4%), high cholesterol (13.4%), obesity (7.0%); former smokers (7.9%); with recommended consumption of fruits and vegetables (7.2%); who do not abuse alcohol intake (5.9%); who do not have high salt intake (5.4%); who are not physically active at leisure (6.1%).

In the multivariate model, it was observed that the highest prevalence of CVD is associated with 60 years of age or more (PR=2.8; 95%CI 1.8–4.4); complete middle school to incomplete high school (PR=1.2; 95%CI 1.0–1.4); having health insurance (PR=1.4; 95%CI 1.2–1.6); self-evaluated health as regular (PR=2.0; 95%CI 1.8–2.3) or bad/very bad (PR=3.1; 95%CI 2.7–3.6); hypertension (PR=2.3; 95%CI 2.0–2.5), high cholesterol (PR=1.7; 95%CI 1.5–1.9) and diabetes (PR=1.2; 95%CI 1,1–1.3); consumption of fruits and vegetables (PR=1.2; 95%CI 1.1–1.4); being a former smoker (PR=1.2; 95%CI 1.1–1.3). On the other hand, being female (PR=0.8; 95%CI 0.7–0.9), of brown (PR=0.8; 95%CI 0.7–0.9) or black race/color (PR=0.8; 95%CI 0.7-0.9), abusive use of alcohol (RP=0.7; 95%CI 0.6-0.9), and practice of LPA (PR=0.8; 95%CI 0.7–0.9) were associated with a lower prevalence of CVD (Table 2).

DISCUSSION

This study identified that approximately 1 in 20 Brazilian adults had CVD, showing that self-reported diagnosis of the disease was frequent in the country. About a third had undergone coronary artery bypass graft surgery and/or coronary angioplasty and about a tenth reported severe limitation. Factors positively associated with CVD were: advanced age; complete middle school and incomplete high school education; health insurance; self-rating health as regular or bad/very bad; self-reported hypertension, high cholesterol, and diabetes; being a former-smoker; consuming fruits and vegetables as recommended. On the other hand, the lowest prevalence of CVD were among women, those of brown and black color/race; those who consume alcohol abusively and practice LPA.

In the present study, in the bivariate analysis, women had a higher prevalence of CVD, however, in the multivariate model, there was a higher prevalence of CVD in men. Although some studies show higher prevalence of CVD in women¹⁸18. Appelman Y, van Rijn BB, Haaf MET, Boersma E, Peters SAE. Sex differences in cardiovascular risk factors and disease prevention. Atherosclerosis. 2015; 241(1): 211-8. https://doi.org/10.1016/j.atherosclerosis.2015.01.027
https://doi.org/10.1016/j.atherosclerosi... ,¹⁹19. Vogel B, Acevedo M, Appelman Y, Merz CNB, Chieffo A, Figtree GA, et al. The Lancet women and cardiovascular disease commission: reducing the global burden by 2030. Lancet 2021; 397(10292): 2385-438. https://doi.org/10.1016/S0140-6736(21)00684-X
https://doi.org/10.1016/S0140-6736(21)00... , most studies point to higher risk factors, such as smoking, inadequate diet²⁰20. Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3): 713-25. https://doi.org/10.1590/1413-81232015203.16182014
https://doi.org/10.1590/1413-81232015203... –²²22. Cardoso LSM, Gomes CS, Moreira AD, Bernal RTI, Ribeiro ALP, Malta DC. Fruit and vegetable consumption, leisure-time physical activity and binge drinking in Belo Horizonte, Brazil, according to the Health Vulnerability Index. Rev Bras Epidemiol 2021; 24 (suppl 1): e210013. https://doi.org/10.1590/1980-549720210013.supl.1
https://doi.org/10.1590/1980-54972021001... , measured hypertension²³23. Malta DC, Santos NB, Perillo RD, Szwarcwald CL. Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013. Sao Paulo Med J 2016; 134(2): 163-70. doi: 10.1590/1516-3180.2015.02090911
10.1590/1516-3180.2015.02090911... , among men, which has been explained by behavioral and cultural issues and greater access to health services, health care and adherence to promotion and prevention practices among women²⁴24. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... –²⁶26. Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados à procura por serviços de saúde numa perspectiva relacional de gênero. Ciênc Saúde Coletiva 2014; 19(4): 1263-74. https://doi.org/10.1590/1413-81232014194.01242013
https://doi.org/10.1590/1413-81232014194... . Furthermore, the mortality rate, loss of healthy years of life, and disability due to CVD are higher among men³3. Institute for Health Metrics and Evaluation. GBD compare, viz hub. Institute for Health Metrics and Evaluation [Internet]. 2019 [cited on May 27, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare/
https://vizhub.healthdata.org/gbd-compar... ,¹⁸18. Appelman Y, van Rijn BB, Haaf MET, Boersma E, Peters SAE. Sex differences in cardiovascular risk factors and disease prevention. Atherosclerosis. 2015; 241(1): 211-8. https://doi.org/10.1016/j.atherosclerosis.2015.01.027
https://doi.org/10.1016/j.atherosclerosi... ,²⁷27. Brant LCC, Nascimento BR, Passos VMA, Duncan BB, Bensenõr IJM, Malta DC, et al. Variations and particularities in cardiovascular disease mortality in Brazil and Brazilian states in 1990 and 2015: estimates from the Global Burden of Disease. Rev Bras Epidemiol 2017; 20(Suppl 01): 116-28. https://doi.org/10.1590/1980-5497201700050010”
https://doi.org/10.1590/1980-54972017000... . Thus, higher prevalence of CVD among men is considered consistent with the literature.

As in other studies²2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020; 76(25): 2982-3021. https://doi.org/10.1016/j.jacc.2020.11.010
https://doi.org/10.1016/j.jacc.2020.11.0... ,⁷7. Gonçalves RPF, Haikal DSA, Freitas MIF, Machado ÍE, Malta DC. Self-reported medical diagnosis of heart disease and associated risk factors: National Health Survey. Rev Bras Epidemiol 2019; 22(Suppl 2): E190016.SUPL2. https://doi.org/10.1590/1980-549720190016.supl.2
https://doi.org/10.1590/1980-54972019001... ,²⁸28. Oliveira GMM, Brant LCC, Polanczyk CA, Biolo A, Nascimento BR, Malta DC, et al. Cardiovascular statistics – Brazil 2020. Arq Bras Cardiol 2020; 115(3): 308-439. https://doi.org/10.36660/abc.20200812
https://doi.org/10.36660/abc.20200812... , this study identified higher prevalence of CVD with increasing age, with greater magnitude in the age group aged 60 years old or more. The association between advancing age and progressive increase in CVD is supported in the literature, especially by the inherent alterations of senescence²⁹29. Massa KHC, Duarte YAO, Chiavegatto Filho ADP. Analysis of the prevalence of cardiovascular diseases and associated factors among the elderly, 2000-2010. Cien Saude Colet 2019; 24(1): 105-14. https://doi.org/10.1590/1413-81232018241.02072017
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https://doi.org/10.1016/j.jacc.2017.01.0... . In addition, the progression of longevity can also provide longer exposure to risk factors such as pollution, smoking, unhealthy diet, and sedentary lifestyle³¹31. Costantino S, Paneni F, Cosentino F. Ageing, metabolism and cardiovascular disease. J Physiol 2016; 594(8): 2061-73. https://doi.org/10.1113/JP270538
https://doi.org/10.1113/JP270538... , which may contribute to the development of CVD³²32. World Health Organization. WHO methods for life expectancy and healthy life expectancy [Internet]. Geneva: World Health Organization; 2014 [cited on May 27, 2021]. Available at:https://www.who.int/healthinfo/statistics/LT_method_1990_2012.pdf
https://www.who.int/healthinfo/statistic... . Furthermore, aged people use health services more often, which can contribute to the diagnosis of CVD²⁵25. Szwarcwald CL, Stopa SR, Damacena GN, Almeida WS, Souza Júnior PRB, Vieira MLFP, et al. Mudanças no padrão de utilização de serviços de saúde no Brasil entre 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1): 2515-28.https://doi.org/10.1590/1413-81232021266.1.43482020
https://doi.org/10.1590/1413-81232021266... ,³³33. Louvison MCP, Lebrão ML, Duarte YAO, Santos JLF, Malik AM, Almeida ES. Inequalities in access to health care services and utilization for the elderly in São Paulo, Brazil. Rev Saude Publica 2008; 42(4): 733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,³⁴34. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saude Publica 2017; 51(suppl 1): 3s. https://doi.org/10.1590/S1518-8787.2017051000074
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The lower prevalence of CVD in black and brown people remained in line with the results of studies with PNS data from 2013⁷. Although they have been presented as a protective factor, it is important to highlight the existence of ethnic-racial disparities in cardiovascular health³⁵35. Pool LR, Ning H, Lloyd-Jones DM, Allen NB. Trends in racial/ethnic disparities in cardiovascular health among US adults from 1999-2012. J Am Heart Assoc 2017; 6(9): e006027. https://doi.org/10.1161/JAHA.117.006027
https://doi.org/10.1161/JAHA.117.006027... , in which black individuals have higher mortality risk than white ones³⁶36. Lockwood KG, Marsland AL, Matthews KA, Gianaros PJ. Perceived discrimination and cardiovascular health disparities: a multisystem review and health neuroscience perspective. Ann N Y Acad Sci 2018; 1428(1): 170-207. https://doi.org/10.1111/nyas.13939
https://doi.org/10.1111/nyas.13939... . In Brazil, socioeconomic and cultural disparities can lead to differences in risk factors according to race/color²⁰20. Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3): 713-25. https://doi.org/10.1590/1413-81232015203.16182014
https://doi.org/10.1590/1413-81232015203... . A study identified the highest occurrence of cardiovascular risk factors in blacks and browns, such as hypertension, worse dietary patterns, and physical inactivity²⁰20. Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3): 713-25. https://doi.org/10.1590/1413-81232015203.16182014
https://doi.org/10.1590/1413-81232015203... . Thus, the possible explanations for the results of the present study are due to the greater access of the white population to health services, providing more opportunities for CVD diagnoses²⁵25. Szwarcwald CL, Stopa SR, Damacena GN, Almeida WS, Souza Júnior PRB, Vieira MLFP, et al. Mudanças no padrão de utilização de serviços de saúde no Brasil entre 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1): 2515-28.https://doi.org/10.1590/1413-81232021266.1.43482020
https://doi.org/10.1590/1413-81232021266... and more use of therapeutic procedures to define the presence of CVD, and also due to the effect of the bias of survival, with the occurrence of fatal events in blacks and browns, reinforcing the importance of studies in the country to elucidate this issue in most vulnerable populations.

Although improvements in the access to the Unified Health System (Sistema Único de Saúde – SUS) have taken place throughout Brazil, in this study, individuals with health insurance had a higher prevalence of CVD. It is known that the use of the service is determined by a need perceived by the user, arising from their health situation or prior knowledge of the disease³⁷37. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... . Thus, the data described here may reflect the greater ease of access to medical diagnosis by the population with health insurance. It is noteworthy that, in the PNS carried out in 2013, individuals without health insurance, with or without chronic non-communicable diseases (NCDs), also had a lower prevalence of use of services, hospitalization, and medical consultation³⁷37. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... ,³⁸38. Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6): 1751-62. doi: 10.1590/1413-81232018236.06022018
10.1590/1413-81232018236.06022018... . These findings reinforce the need for investments in the SUS, to remedy these differences in social segments of the population³⁷37. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... .

The current study showed that individuals with bad/very bad self-rated health had a higher prevalence of CVD. The data found in this research corroborate previous studies in which most individuals with CVD reported a worse perception of their health status⁷7. Gonçalves RPF, Haikal DSA, Freitas MIF, Machado ÍE, Malta DC. Self-reported medical diagnosis of heart disease and associated risk factors: National Health Survey. Rev Bras Epidemiol 2019; 22(Suppl 2): E190016.SUPL2. https://doi.org/10.1590/1980-549720190016.supl.2
https://doi.org/10.1590/1980-54972019001... ,³⁹39. Pavão ALB, Werneck GL, Campos MR. Self-rated health and the association with social and demographic factors, health behavior, and morbidity: a national health survey. Cad Saude Publica 2013; 29(4): 723-34. PMID: 23568302. The poor self-rated health indicator is a strong predictor of morbidity and mortality and worse health outcomes⁴⁰40. Sousa JL, Alencar GP, Antunes JLF, Silva ZP. Markers of inequality in self-rated health in Brazilian adults according to sex. Cad Saude Publica 2020; 36(5): e00230318. https://doi.org/10.1590/0102-311X00230318
https://doi.org/10.1590/0102-311X0023031... . It is noteworthy that this indicator produces a self-classification of the individual and also shows their understanding and perception of the disease, considering signs and symptoms, severity, risks, disabilities, and impacts on their physical, mental, and social well-being⁴¹41. Barros MBA, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saude Publica 2009; 43(Suppl 2): 27-37. https://doi.org/10.1590/S0034-89102009000900005
https://doi.org/10.1590/S0034-8910200900... . Studies show a positive association between self-assessment and regular and poor self-perception with CVD⁴²42. Theme Filha MM, Souza Junior PRB, Damacena GN, Szwarcwald CL. Prevalence of chronic non-communicable diseases and association with self-rated health: National Health Survey, 2013. Rev Bras Epidemiol 2015; 18(Suppl 2): 83-96. https://doi.org/10.1590/1980-5497201500060008
https://doi.org/10.1590/1980-54972015000... ,⁴³43. Arruda GO, Santos AL, Teston EF, Cecilio HPM, Radovanovic CAT, Marcon SS. Association between self-reported health and sociodemographic characteristics with cardiovascular diseases in adults. Rev Esc Enferm USP 2015; 49(1): 61-8. https://doi.org/10.1590/S0080-623420150000100008
https://doi.org/10.1590/S0080-6234201500... . Thus, individuals with CVD had 2.5 times the chance of evaluating their health status as bad⁴²42. Theme Filha MM, Souza Junior PRB, Damacena GN, Szwarcwald CL. Prevalence of chronic non-communicable diseases and association with self-rated health: National Health Survey, 2013. Rev Bras Epidemiol 2015; 18(Suppl 2): 83-96. https://doi.org/10.1590/1980-5497201500060008
https://doi.org/10.1590/1980-54972015000... ; those with angina, 2.17 times; with heart failure the chance was 5.21 times; and with acute myocardial infarction, 5.77 times⁴³43. Arruda GO, Santos AL, Teston EF, Cecilio HPM, Radovanovic CAT, Marcon SS. Association between self-reported health and sociodemographic characteristics with cardiovascular diseases in adults. Rev Esc Enferm USP 2015; 49(1): 61-8. https://doi.org/10.1590/S0080-623420150000100008
https://doi.org/10.1590/S0080-6234201500... .

Self-reported clinical conditions, such as hypertension, diabetes, and high cholesterol, were presented in this study as risk factors for the diagnosis of CVD. The presence of these risk factors causes deleterious effects on the cardiovascular system, with negative impacts on health, reinforcing the multiple causality of CVD⁴⁴44. Glovaci D, Fan W, Wong ND. Epidemiology of diabetes mellitus and cardiovascular disease. Curr Cardiol Rep 2019; 21(4): 21. https://doi.org/10.1007/s11886-019-1107-y.
https://doi.org/10.1007/s11886-019-1107-... –⁴⁷47. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. Available at:https://www.who.int/publications/i/item/9789241506236
https://www.who.int/publications/i/item/... . In hypertension, the risk attributable to a progressive increase in blood pressure is approximately 60% for stroke and 50% for coronary artery disease (CAD)⁴⁵45. Fuchs FD, Whelton PK. High blood pressure and cardiovascular disease. Hypertension 2020; 75(2): 285-92. https://doi.org/10.1161/HYPERTENSIONAHA.119.14240
https://doi.org/10.1161/HYPERTENSIONAHA.... ,⁴⁷47. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. Available at:https://www.who.int/publications/i/item/9789241506236
https://www.who.int/publications/i/item/... . In diabetes, there is an increased risk of mortality from CVD, and the most common cardiovascular manifestations include heart failure, peripheral arterial disease, and CAD⁴⁴44. Glovaci D, Fan W, Wong ND. Epidemiology of diabetes mellitus and cardiovascular disease. Curr Cardiol Rep 2019; 21(4): 21. https://doi.org/10.1007/s11886-019-1107-y.
https://doi.org/10.1007/s11886-019-1107-... . Dyslipidemia, on the other hand, has an increased risk of atherosclerotic CVD⁴⁶46. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021; 26(2): 541-53. https://doi.org/10.1590/1413-81232021262.37102020
https://doi.org/10.1590/1413-81232021262... . In this context, it is imperative to contain modifiable risk factors with the implementation of interventions, such as access to early pharmacological and non-pharmacological treatments²⁹29. Massa KHC, Duarte YAO, Chiavegatto Filho ADP. Analysis of the prevalence of cardiovascular diseases and associated factors among the elderly, 2000-2010. Cien Saude Colet 2019; 24(1): 105-14. https://doi.org/10.1590/1413-81232018241.02072017
https://doi.org/10.1590/1413-81232018241... ,⁴⁸48. Bonotto GM, Mendoza-Sassi RA, Susin LRO. Knowledge of modifiable risk factors for cardiovascular disease among women and the associated factors: a population-based study. Cien Saude Colet 2016; 21(1): 293-302. https://doi.org/10.1590/1413-81232015211.07232015
https://doi.org/10.1590/1413-81232015211... . The importance of preventing these comorbidities is highlighted, not only to improve the living conditions of individuals, but also to reduce the global burden of NCDs in the population²⁹29. Massa KHC, Duarte YAO, Chiavegatto Filho ADP. Analysis of the prevalence of cardiovascular diseases and associated factors among the elderly, 2000-2010. Cien Saude Colet 2019; 24(1): 105-14. https://doi.org/10.1590/1413-81232018241.02072017
https://doi.org/10.1590/1413-81232018241... .

Regarding the lifestyle of the Brazilian population, evidence indicates a proportional increase in CVD due to the growth of the four main risk factors, which include tobacco use, unhealthy diet, physical inactivity, and excessive consumption of alcohol⁴⁷47. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. Available at:https://www.who.int/publications/i/item/9789241506236
https://www.who.int/publications/i/item/... . Although the prevalence of smoking in Brazil has reduced in recent decades, there is still a high burden of disease associated with this risk factor²¹21. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FM, Prates EJS, et al. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45(5): e20180384. https://doi.org/10.1590/1806-3713/e20180384
https://doi.org/10.1590/1806-3713/e20180... ,⁴⁹49. Pinto M, Bardach A, Palacios A, Biz A, Alcaraz A, Rodriguez B, et al. Burden of smoking in Brazil and potential benefit of increasing taxes on cigarettes for the economy and for reducing morbidity and mortality. Cad Saude Publica 2019; 35(8): e00129118. https://doi.org/10.1590/0102-311X00129118
https://doi.org/10.1590/0102-311X0012911... . In the current study, there is a possible explanation for the higher prevalence and positive association between former smokers and CVD, which is related to the fact that these people have stopped smoking due to the medical diagnosis of CVD, adhering to changes in behavior due to received guidance on the harmful effects of smoking¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... , configuring a reverse causality effect. This same effect possibly occurred in relation to the positive association of CVD with alcohol use and in those individuals who had recommended consumption of FV, suggesting a possible change in lifestyle, with an improvement in the dietary pattern and a decrease in alcohol consumption after diagnosis of the disease. This can also demonstrate a greater understanding of the disease and its risks, as well as the importance of adopting healthy habits by the participants to prevent worse clinical outcomes¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... .

An important result of this study was the positive effect of LPA as a protective factor for CVD. Regular physical activity is inversely associated with mortality from all causes (including cardiovascular ones), configures a protective factor for NCDs and contributes to improving quality of life, physical and mental well-being, in addition to helping with weight control¹1. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology - 2019. Arq Bras Cardiol 2019; 113(4): 787-891. https://doi.org/10.5935/abc.20190204
https://doi.org/10.5935/abc.20190204... ,²²22. Cardoso LSM, Gomes CS, Moreira AD, Bernal RTI, Ribeiro ALP, Malta DC. Fruit and vegetable consumption, leisure-time physical activity and binge drinking in Belo Horizonte, Brazil, according to the Health Vulnerability Index. Rev Bras Epidemiol 2021; 24 (suppl 1): e210013. https://doi.org/10.1590/1980-549720210013.supl.1
https://doi.org/10.1590/1980-54972021001... .

Some limitations of the study should be considered, such as the impossibility of establishing a causal relationship, as this is a cross-sectional study. Although the investigation of CVD, which includes cardiac and cerebrovascular pathologies, is frequent in the literature, the present study analyzed only heart diseases. Another point that deserves to be highlighted is the fact that the 2019 PNS collects self-reported information, which may be subject to information bias, generating less accurate estimates. However, it is highlighted that the PNS presents great methodological rigor, and the generalization of the results is safe for national estimates. Furthermore, theoretical criteria were used for the analyses, along with robust statistical methods.

Despite the limitations presented, this study advances in findings on factors associated with CVD with robust survey data and national representativeness in a period after the economic austerity policies. In this sense, it is also relevant as an analysis prior to the COVID-19 pandemic, which will serve as a basis for comparing future studies.

The results showed that the prevalence of CVD was approximately 5% of the Brazilian adult population. CVD was associated with sociodemographic factors (male gender, older age, white race/color, average education level and health insurance), health status (self-assessed health as regular or bad/very bad and diagnosis of hypertension, high cholesterol, and diabetes) and lifestyle (former-smoker, consumption of fruits and vegetables, alcohol use, and physical inactivity). This information can support public policies, programs, and goals to reduce CVD in Brazil, especially in the most vulnerable groups.

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