Are my Values Different from Yours? The Value of Coronary Artery Disease Invasive Care in Brazil

Abstract

Coronary Artery Disease (CAD) has been consistently associated with the leading cause of death and disability in most western industrialized countries since the mid-1950s. Although it still has a major impact on the health of society in these countries, CAD rates have considerably decreased in recent decades. 1There are significant differences in the prevalence of CAD, as different world regions face varying stages of this epidemic. An epidemiological transition model for cardiovascular disease describes a series of stages starting from a population profile with low life expectancy and cardiovascular diseases mainly due to infectious diseases and malnutrition, which is a pattern commonly observed in developing countries. As the economic and public health development improves the population's nutrition and decreases infectious disease rates, life expectancy increases, and the pattern and rates of cardiovascular disease are changed. In the last phase, commonly seen in high-income countries, life expectancy increases, and degenerative cardiovascular diseases at advanced age predominate. Variable rates of incidence, prevalence, and mortality reflect the different levels of risk factors, other concurrent causes of death, and the availability of resources to fight cardiovascular disease.2 Despite large variations in the number of revascularization procedures in different countries, the number of interventions does not seem to be related to the incidence of CAD. 3The increase in the number of interventional procedures for myocardial revascularization (angioplasty and surgery) in the last 20 years performed by the Unified Health System (SUS) in Brazil follows this second CAD epidemic wave in developing countries and may help to rethink the model of care that we will need to build in the next decades for our society.The more expressive growth in the number of angioplasties in relation to surgeries in SUS is also paralleled by different countries worldwide in the same period. The use of angioplasty has increased rapidly over the past 20 years in most of the Organization for Economic Cooperation and Development (OECD) countries, surpassing myocardial revascularization surgery as the preferred method for revascularization in the mid-1990s.3 On average, in OECD countries, angioplasty now accounts for 78% of all revascularization procedures and exceeds 85% in France, Spain, and Israel.3 In Brazil, 66% of myocardial revascularization procedures performed by SUS in 2015 were carried out by transcatheter approach.Dissimilarly, following the last stage of this epidemic, US hospitals observed a significant reduction in the number of myocardial revascularization surgeries and a non-significant reduction (stabilization) in the number of angioplasties performed in the first decade of the 21 st century, during which time more hospitals performed both procedures, reducing the average volume of each institution, which can have a negative impact on the quality, safety and costs associated with these interventions. 4 These observations ha...