ARTICLE IN PRESS

Analyses of Mortality and Prevalence of Cerebrovascular

Disease in Colombia, South America (2014-2016): A Cross-
Sectional and Ecological Study

Nicolas Yanez, MD, MS,* Juan Nicolas Useche, MD,† Hernan Bayona, MD,‡
Alexandra Porras, PhD,* and Gabriel Carrasquilla, PhD*

Background: Stroke is the second cause of death and the first cause of disability
worldwide. However, although numerous reports regarding stroke epidemiology
in Latin America have been published, they differ widely in terms of employed
methods and end points. This is the first of a series of articles that describes the epi-
demiology of stroke and other cerebrovascular diseases (CVD) in the nation, as
well as their correlation with recognized risk factors and social variables. Methods:
Descriptive analyses were performed using the Colombian vital registration system
and social security information system as primary data sources. Rates and ratios
were calculated, corrected for under-registration, and standardized. Secondary
analyses were made using data from national surveys and government organiza-
tions on hypertension, diabetes mellitus, sedentarism, obesity, tobacco and alcohol
consumption, and unsatisfied basic needs. Factorial multivariate multiple regres-
sion analyses were performed to evaluate correlations. Concentration curves and
indices were calculated to evaluate for inequities in the distribution of events.
Results: Global CVD had a national mortality rate and a prevalence ratio of 28 and
142 per 100,000 persons, respectively. Nontraumatic intracranial hemorrhage had
the highest mortality rate (ie, 15 per 100,000), while cerebral infarction and transi-
tory cerebral ischemia had the highest prevalence ratios (ie, 28 and 29 per 100,000,
respectively). Hypertension and tobacco use were the most relevant risk factors for
most of the simple and multiple models, and cerebral amyloid angiopathy and non-
pyogenous intracranial venous thrombosis were the disease categories with the
most socially unequal distribution of deaths and cases (ie, concentration indices of
.34 and .29, respectively). Conclusions: CVDs are a cause for concern in Colombia
and a marker of healthcare inequality and social vulnerability. Nationwide control
of risk factors such as hypertension and tobacco use, as well as the design and con-
duct of public policy focused on the vulnerable and medically underserved regions
and on standardizing mandatory CVD registries might ease its burden.
Key Words: Stroke—cerebrovascular disorders—mortality—prevalence—
socioeconomic factors—epidemiology
© 2020 Elsevier Inc. All rights reserved.

From the *Master of Science in Epidemiology Program, Universidad El Bosque, Bogota D.C, Colombia; †Department of Diagnostic Imaging, Hos-
pital Universitario Fundaci
on Santa Fe de Bogot
a, Bogota D.C, Colombia; and ‡Department of Neurology, Hospital Universitario Fundaci
on Santa
Fe de Bogot
a, Carrera 7 No. 117 15, Bogota D.C, Colombia.
Received June 27, 2019; revision received December 17, 2019; accepted January 25, 2020.
Sources of Funding: There are no funding sources to disclose. NY, as the corresponding author, had access to all the data in the study and had
final responsibility for the decision to submit for publication.
Address correspondence to Nicolas Yanez, MD, MS, Master of Science in Epidemiology Program, Universidad El Bosque, Carrera 9 No. 131A-02
Edificio Fundadores, Piso 5, Bogota D.C, Colombia. E-mail: nyanez@unbosque.edu.co.
1052-3057/$ - see front matter
© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104699

Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104699 1
 ARTICLE IN PRESS
2 N. YANEZ ET AL.
Introduction
In 2015, neurological disorders were the largest cause
group of disability-adjusted life years (DALYs) and the sec-
ond largest behind cardiovascular diseases in terms of
global deaths, accounting for 10.2% of DALYs and 16.8%
of deaths, respectively.1 Stroke, in particular, accounted for
almost half of the total DALYs and more than two-thirds
of the deaths among all neurological disorders analyzed in
the Global Burden of Diseases, Injuries, and Risk Factor
2015 Study (GBD 2015 Study).1 However, despite substan-
tial decreases in mortality rates from stroke and communi-
cable neurological disorders in the last 3 decades, there
have been significant increases in the absolute number of
cases, deaths, and DALYs associated to stroke and other
neurological conditions.2,3 This situation is even more con-
cerning when some studies predict that the number of
stroke events, at least for the United States, will more than
double in 2050 as compared to those that occurred in 2010.4
The GBD 2015 study also showed a statistically signifi-
cant increase in the proportional contribution of stroke-
related DALYs and deaths in developing countries, a trend
on the one hand explained by the widening gap in stroke
prevention and management between developed and
developing countries and on the other hand conditioned
by the effects of the epidemiologic and demographic transi-
tions.5,6 During the past decades, the countries of Latin
America have been the focus of social changes that have
led to a slowing in population growth, an increase in urban
dwelling, and the steadily aging of their populations.7 This
has led to a gradual increase in the frequency of noncom-
municable disease risk factors to the point of almost herald-
ing an imminent cardiovascular disease epidemic.8 As is
the case in most countries, hypertension, smoking, diabetes
mellitus, physical inactivity, obesity, and atrial fibrillation
have been identified as the leading risk factors for stroke in
Latin America by several studies, including the CARMELA
(Cardiovascular Risk Factor Multiple Evaluation in Latin
America) and INTERSTROKE (Risk Factors for Ischemic
and Intracerebral Hemorrhagic Stroke in 22 Countries)
studies.9-12 Additionally, conditions such as Chagas dis-
ease, which is associated with cardiomyopathy, arrhyth-
mias, and cardioembolic events in almost a third of the
cases, have also been recently recognized as important
region and country-specific risk factors.13 However, the
study of risk factors is not sufficient to adequately compre-
hend the causal network that determines health outcomes.
Socioeconomic status, employment, housing, environmen-
tal exposures, and the fulfillment of basic needs are exam-
ples of social determinants of health that have been
historically compromised in Latin American countries and
which have been related to worse outcomes and quality of
life in patients with stroke.14-16
In light of the above, there has been an increased interest
in the study of stroke, its risk factors and social determi-
nants for the guidance of public health policies in Latin
America. In keeping with this spirit, this paper is the first
of a series that describes and characterizes the epidemiol-
ogy and burden of stroke and other cerebrovascular dis-
eases (CVDs), as well as the cost-effectiveness of the
treatment options offered in the health benefits plan of the
nation’s social security system. The research portrayed in
this article had 2 objectives: (1) to estimate the mortality
and prevalence of CVDs, including stroke, in Colombia,
with stratification according to age, sex, and geographic
location; and (2) to describe the correlation between the
estimated measures of frequency with hypertension, diabe-
tes mellitus, dyslipidemia, physical inactivity, obesity, and
tobacco and alcohol use, as well as with unsatisfied basic
needs (UBN). This report adheres to the STROBE guide-
lines for transparent reporting of observational studies.17,18
Methods
This cross-sectional study is divided in 2 phases: (1)
descriptive analyses of mortality and prevalence and (2)
secondary analyses of their correlations with risk factors
and sociodemographic variables for the Colombian popu-
lation for which data were available during the 2014-2016
time period. An exploratory review of the literature was
performed in order to identify the International Classifica-
tion of Diseases (ICD-10) codes to be used for the study
and to define the categories of disease analysis (Table 1).
Primary Descriptive Analyses of Mortality and
Prevalence
Primary data for mortality were obtained from the
Colombian national vital registration system operated by
the National Administrative Department of Statistics
(DANE, in Spanish) and publicly available at their official
website.19 An individual identification number was
assigned for each registry in the crude anonymized data-
base and the age variables were recodified to a new 5-year
age interval variable. Causes of death (CoD) were codified
to each category of disease analysis according to the ICD-
10 rules for selection of underlying CoD.20 If an underlying
cause was senility or an ill-defined condition, the sequence
of the other multiple causes was analyzed in order to deter-
mine if an ICD-10 code of interest was the actual CoD. Reg-
istries where then recodified to reflect the change in CoD.
Garbage code redistribution was performed according to
the published literature.21-23 As reported by Truelsen et al,
there is a significant proportion of stroke-related deaths
assigned to ill-defined codes.24 In an attempt to adequately
portray the burden of stroke-related deaths in order to
inform decision-makers and the general population, regis-
tries with I64 as CoD were redistributed to the ischemic or
nonischemic categories according to the 5-year age interval
proportions in the well-codified registries. Specifically,
there were 10,728 registries that had I64 as CoD for the
3 years under analysis. About 78% (8277) was redistributed
 ARTICLE IN PRESS
CEREBROVASCULAR DISEASE EPIDEMIOLOGY IN COLOMBIA 3

Table 1. Categories of disease analysis and associated ICD-10 codes for mortality and prevalence estimations

Mortality
Disease category ICD-10 codes
1 Global CVD Comprised of disease categories 2-9
2 Cerebral arteritis in infectious and parasitic A18.8, A32.8, A52.0, I68.1
diseases
3 Cerebral amyloid angiopathy E85.0-9, I68.0
4 Vascular dementia F01.0-9
5 Nontraumatic intracranial hemorrhage I60-9, I69.0, I67.0-1, I61.0-9, I69.1, I62.0-9, I69.2
6 Cerebral infarction I63.0-9, I69.3, G45.0-9, R41.3, G46.0-8, I65.0-9, I66.0-9, I67.2-6
7 Cerebral arteritis in other diseases M32.1, I67.7, I68.2
8 Congenital malformations of the cerebral cir- Q28.0-9
culatory system
9 Other cerebrovascular diseases I67.8-9, I68.8, I69.8

Prevalence
Disease category ICD-10 codes
1 Global CVD Comprised of disease categories 2-17
2 Cerebral arteritis in infectious and parasitic A18.8, A32.8, A52.0, I68.1
diseases
3 Cerebral amyloid angiopathy E85.0-9, I68.0
4 Vascular dementia F01.0-9
5 Nontraumatic intracranial hemorrhage I60-9, I61.0-9, I62.0-9
6 Cerebral infarction I63.0-9, G46.0-8
7 Cerebral arteritis in other diseases M32.1, I67.7, I68.2
8 Congenital malformations of the cerebral cir- Q28.0-9
culatory system
9 Transient cerebral ischemic attack G45.0-9, R41.3
10 Occlusion and stenosis in the cerebral circula- I65.0-9, I66.0-9
tory system without infarction
11 Dissection of cerebral arteries without rupture I67.0
12 Cerebral aneurysm without rupture I67.1
13 Cerebral atherosclerosis and progressive vas- I67.2-3
cular leukoencephalopathy
14 Hypertensive encephalopathy I67.4
15 Moyamoya disease I67.5
16 Nonpyogenic thrombosis of the intracranial I67.6
venous system
17 Other cerebrovascular diseases I67.8-9, I68.8, I69.8
Abbreviations: ICD, International Classification of Diseases; CVD, cerebrovascular diseases.

to the nontraumatic intracranial hemorrhage disease cate-
gory, while 22% (2350) was redistributed to the cerebral
infarction disease category. The total counts of registries
that were redistributed accounted for a 35% and a 32% of
the total registries within each disease category, respec-
tively. Mortality counts were adjusted for completeness of
death registration using the Bennett-Horuichi method. As
the last published Colombian population census was per-
formed in 2005, the population projections for the years
2014, 2015, and 2016 were used to calculate the mortality
rates per 5-year age interval, sex, geographic region, and
year of death.25 Crude mortality rates were age adjusted
using the Colombian census of 2005 as the standard popu-
lation and mid-p gamma confidence intervals were calcu-
lated.26 After assessing for goodness of fit, Poisson
regression was performed for each disease category per
year and region to assess for statistical significance and var-
iance of time trends. Direct standardization and confidence
interval calculation were done in Epidat (Version 4.2,
Xunta de Galicia, Spain, 2016) while choropleths were
made using Epi Info (Version 7.2.2.2, Centers for Disease
Control and Prevention, Atlanta, Georgia, 2016). No choro-
pleths were made for disease categories for which meas-
ures of position could not be computed.
In Colombia, social security information system is the
technological platform that records every contact an indi-
vidual may have with the social security system. Health
professionals and institutions are required to upload the
details of the event with information regarding the
patient’s main diagnosis and demographics, as well as the
type and characteristics of the event. As such, it is the pri-
mary means to quantify various health variables in
 ARTICLE IN PRESS
4 N. YANEZ ET AL.
Colombia. Primary data for prevalence were obtained
from the health services provision cube available through
a real-time secure SQL Server Analysis Services connec-
tion with social security information system, which
required previous training performed by the Health and
Social Protection Ministry. The total number of cases for
each disease category was calculated as the sum of all the
patients that used social security services on a given year
and had an ICD-10 code of interest as the main diagnosis
of the event. Registries with I64 as main diagnosis where
recodified to either ischemic or nonischemic disease cate-
gories according to the age, sex, and year-specific propor-
tions published by the GBD study and available at the
GBD Compare website.27 Prevalence ratios were calcu-
lated in a similar fashion to mortality rates to produce
estimates for 5-year age intervals, sex, geographic region,
social security insurance regime, year, and disease cate-
gory. The same statistical adjustments and means of
results presentation described previously for mortality
were used for prevalence.
Secondary Analyses of Risk Factors and
Sociodemographic Variables
Secondary analyses were made to assess the correla-
tion between the mortality rates and prevalence ratios
with risk factors and sociodemographic variables, using
multiple national data sources. Data on the prevalence of
hypertension and diabetes mellitus were obtained from
the Colombian Fund of High Cost Diseases.28 Data on
obesity and physical activity were obtained from the
National Nutrition Situation Survey (ENSIN, in Spanish)
conducted in 2010.29 Data on tobacco and alcohol use
were obtained from the National Study of Psychoactive
Substance Use conducted in 2013.30 As multiple out-
comes were being investigated, a multivariate multiple
regression analysis was performed to investigate the
relationships between the disease categories and the risk
factors previously described across the 3 years under
study. Factorial multivariate analysis of variance was
used as a proxy to individual ordinary least squares
(OLS) regression. P values lower than .05 for overall
model tests were deemed as statistically significant. For
independent variables that were not statistically signifi-
cant, tests were performed to evaluate for hypotheses
regarding nondifference across outcomes. As the disease
category global CVD is a “summary” category, it was
not included in this model and was instead analyzed
separately. Stata/IC (Version 15.1, StataCorp, College
Station, TX, 2019) was used for these analyses. Data on
UBN were obtained from estimations available in the
official website of DANE.31 Inequities in the distribution
of mortality and prevalence according to UBN were
assessed with concentration curves and quantified with
concentration indices for each disease category. These
analyses were performed using Epidat.
Results
Crude and age-adjusted region-specific mortality rates
and prevalence ratios for the 3 years of study are shown
in eTables 1 and 2. Unless otherwise noted, and because
most estimated measures were similar across the years
under study, the tables and figures used as examples cor-
respond to the most recent year of analysis (2016).
Mortality
Mortality counts varied greatly between disease catego-
ries. Infectious cerebral arteritis, cerebral amyloid angiop-
athy, and congenital malformations, each had mortality
counts of zero for half or more of the geographic regions
under the period of study, which translated in low mortal-
ity rates for these disease categories (eTable 3) Mortality
rates increased exponentially with age for all disease cate-
gories, except for noninfectious cerebral arteritis, which
plateaued at ages 25-74 (ie, around .0017 per 1000), and
congenital malformations, which was highest in the
4 years of age or less group (ie, .0018 per 1000). Although
male and female rates were similar for most disease cate-
gories, females had significantly higher mortality rates
due to non-infectious cerebral arteritis (eFigures 1-9).
Age-adjusted mortality rates varied greatly according to
geographic location. For global CVD, rates higher than the
third quartile (ie, .31 per 1000) were mostly observed along
the southern edge of the Eastern Andean Range and the
Amazon region bordering Peru. Nontraumatic intracranial
hemorrhage had a similar geographic distribution with the
addition of the northern Pacific region. Cerebral infarction,
however, had higher rates along a horizontal stretch com-
prised by the Central Andean Range and bordering Pacific
and Llanos regions as well as the Amazonian territories up
to the Brazilian border (Fig 1 and eFigures 10-12).
Prevalence
In contrast to mortality counts, only the Moyamoya dis-
ease category had zero prevalent cases for half or more of
the geographic regions under the period of study (eTable 4).
Similar to mortality rates, prevalence ratios increased expo-
nentially with age for most disease categories. Infectious
cerebral arteritis had a biphasic presentation peaking at the
35-39 and 80 or more age groups (ie, .021 and .028 per 1000,
respectively). Although Moyamoya disease ratios were the
lowest of every disease category, they were also distributed
in a biphasic manner peaking at both extremes of age (ie,
.002 and .003, respectively). Nonpyogenic intracranial
venous thrombosis ratios were highest in females aged 25-
34 (ie, .016 to .021 per 1000) but remained relatively constant
after 40 years of age (ie, around .011 per 1000). Females had
consistently higher ratios of cerebral amyloid angiopathy,
noninfectious cerebral arteritis, and unruptured cerebral
aneurysms. The highest ratios occurred in the first case at
the 60-64 (ie, .076 per 1000) age group, in the second at the
 ARTICLE IN PRESS
CEREBROVASCULAR DISEASE EPIDEMIOLOGY IN COLOMBIA 5

Figure 1. Global CVD mortality rate and prevalence ratio (x 1,000) geographic distribution in Colombia (2016). Abbreviation: CVD, cerebrovascular diseases.

30-59 age group (ie, around .4 per 1000), and in the third at
the 70-74 age group (ie, .44 per 1000) (eFigures 13-29).
Disease distribution according to age-adjusted preva-
lence ratios varied significantly from mortality distribution.
Global CVD was more frequent in the Caribbean and the
north-Andean regions (ie, higher than 1.88 per 1000). The
regions with highest nontraumatic intracranial hemorrhage
and cerebral infarction ratios were scattered along the
southern Pacific region bordering Ecuador with a few foci
in the Andean region. Compared to mortality geographic
 ARTICLE IN PRESS
6 N. YANEZ ET AL.

Table 2. Simple and multivariate OLS regression results for global CVD measures and the risk factors under study in Colombia (2014-2016)

Simple OLS regression

Mortality Risk factor Coefficient Robust t P value 95% Confidence R2
standard interval
error
Hypertension .0011294 .0002479 4.56 .0000 .0006377 - .0016212 .2154
Diabetes mellitus .0012335 .0007954 1.55 .1240 .0003444 - .0028115 .0504
Overweight .0001289 .0001429 .9 .3690 .0004124 - .0001546 .0098
and obesity
Tobacco use .000281 .0001591 1.77 .0800 .0005967 - .0000347 .0207
Alcohol use .0001682 .0001031 1.63 .1060 .0000363 - .0003728 .0133
Prevalence
Hypertension .0148504 .0016004 9.28 .0000 .0116752 - .0180257 .4826
Diabetes mellitus .0090447 .0082938 1.09 .2780 .0074099 - .0254993 .0351
Overweight .0030324 .0010884 2.79 .0060 .0051918 to .0008731 .0703
and obesity
Tobacco use .0026891 .001568 1.71 .0890 .0004219 - .0058 .0246
Alcohol use .0013393 .0009034 1.48 .1410 .000453 - .0031317 .0109
Multiple OLS regression
Mortality
Hypertension .0011741 .0002337 5.02 .000 .0007104 - .0016378
Tobacco use .0005216 .000146 3.57 .001 .0008113 to .0002318
Alcohol use .0001537 .0000684 2.25 .027 .0000179 - .0002895
Model parameters: F = 15.68, P value = .0000, R2 = .2745
Abbreviations: CVD, cerebrovascular diseases; OLS, ordinary least squares.

Figure 2. Global CVD and UBN concentration curve for mortality rates and prevalence ratios (x 1,000) in Colombia (2016). Abbreviations: CVD, cerebrovascu-
lar diseases; UBN, unsatisfied basic needs.

analysis, additional choropleths could be constructed, Secondary Analyses

including infectious and noninfectious cerebral arteritis,
vascular dementia, congenital malformations, transitory
cerebral ischemia, and hypertensive encephalopathy,
among others. Their respective geographic distributions
are available in eFigures 30-40.
No individual-level source of information for the esti-
mation of risk factor measures was available, as such,
prevalence ratios retrieved from multiple data sources
were used (eTable 5).
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CEREBROVASCULAR DISEASE EPIDEMIOLOGY IN COLOMBIA 7

Table 3. Concentration indices for concentration curves relating
disease categories rates and ratios with UBN in Colombia (2016)
Mortality Disease category
rates
Global CVD
Infectious cerebral arteritis
Cerebral amyloid angiopathy
Vascular dementia
Nontraumatic intracranial
hemorrhage
Cerebral infarction
Noninfectious cerebral arteritis
Congenital malformations
Other CVD
Prevalence
ratios
Global CVD
Infectious cerebral arteritis
Cerebral amyloid angiopathy
Vascular dementia
Non-traumatic intracranial
hemorrhage
Cerebral infarction
Noninfectious cerebral arteritis
Congenital malformations
Transitory cerebral ischemia
Occlusion and stenosis of (pre)
cerebral arteries
Unruptured cerebral artery
dissection
Unruptured cerebral aneurysm
Cerebral vascular atherosclerosis
and leukoencephalopathy
Hypertensive encephalopathy
Moyamoya disease
Nonpyogenous intracranial
venous thrombosis
Other CVD
Abreviations: CVD, cerebrovascular diseases; UBN, unsatisfied
basic needs.
noninfectious cerebral arteritis had a statistically significant
correlation with hypertension and overweight and obesity,
but in multiple analysis the correlation with overweight and
Concentration obesity disappeared and was replaced by alcohol use. These
index
and other multivariate simple and multiple regression results
.007 for mortality rates are described in eTables 6 and 7.
.176 Arterial hypertension and overweight and obesity were
.343 the only statistically significant risk factor for prevalence
.33 ratios of global CVD with R2 values of .48 and .7, respec-
.011 tively. In the case of infectious cerebral arteritis ratios, for
the 3 statistically significant risk factors found in simple and
.034
multiple analyses (ie, hypertension, diabetes mellitus, and
.068
.052 overweight and obesity), only hypertension was found to
.043 have a positive correlation. These risk factors were also asso-
ciated with cerebral amyloid angiopathy in simple analysis;
however, in multiple analysis hypertension was no longer
.092 significant. For vascular dementia ratios, diabetes mellitus
.04 was statistically significant only in simple regression models,
.176 while hypertension and tobacco use were significant in both.
.23 Hypertension was the only risk factor which showed a posi-
.03 tive statistically significant correlation with both, nontrau-
matic intracranial hemorrhage and cerebral infarction. These
.065
and other multivariate simple and multiple regression
.181
.18 results for prevalence ratios are described in eTables 8 and 9.
.077 Regarding the social variable UBN, on the one hand, fol-
.144 lowing visual inspection of the concentration curves con-
structed for mortality rates, cerebral amyloid angiopathy
.218 and vascular dementia show the most socially unequal dis-
tribution of deaths, with corresponding concentration indi-
.182 ces of .343 and .33. The other disease categories had either
.161 low divergence from or transected the identity line. On the
other hand, the majority of concentration curves con-
.086
structed for prevalence diverged from the identity line,
.068
with nonpyogenous intracranial venous thrombosis,
.294
unruptured cerebral artery dissection, and unruptured
.059 cerebral aneurysm having the highest concentration indices
(ie, .294, .218, and .182, respectively) Concentration curves
and their corresponding indices are available in Figure 2
and eFigures 41-64, and Table 3, respectively.

In simple OLS analysis, arterial hypertension was the only

statistically significant risk factor for mortality rates of global
CVD with an R2 value of .22. For multiple OLS analysis and
after backward elimination, only the model of hypertension
and tobacco and alcohol use was statistically significant with
an R2 value of .27. However, tobacco had a negative relation-
ship with global CVD mortality rates (Table 2). Infectious
cerebral arteritis, cerebral amyloid angiopathy, nontraumatic
intracranial hemorrhage, and congenital malformations mor-
tality rates had no statistically significant correlation with any
risk factor. Although vascular dementia mortality rates were
positively associated with hypertension, diabetes mellitus,
tobacco and alcohol use in simple OLS regression, only the
model with hypertension and tobacco use was statistically
significant. Cerebral infarction had a statistically significant
correlation only with hypertension. In simple regression,
Discussion
The term CVD encompasses a wide range of pathological
entities that affect the arteries of the brain. Historically, it has
been used interchangeably with stroke mainly because,
atleast in terms of prevalence and mortality, it is the most
socially important disease of the group. However, although
most recent international collaborations (ie, GBD and INTER-
STROKE groups, among others) and some countries in Latin
America (ie, Brazil, Argentina, and Chile) have studied and
reported measures for stroke subtypes, this trend has not
been as evident in Colombia.3,5,10,23 In this fashion, the sparse
nationally published CVD literature available has focused on
stroke as a group and has not explored entities such as cere-
bral arteritis, cerebral angiopathy, or congenital malforma-
tions.32-35 As such, the results of this study provide an
 ARTICLE IN PRESS
8 N. YANEZ ET AL.
update, based on the best available data, of measures of dis-
ease mortality and frequency as well as their correlation to
widely recognized risk factors.
Although CVD mortality rates keep in line with published
available literature and have shown a tendency to decrease
over time, the same cannot be said for prevalence ratios.36 For
most disease categories prevalent cases appear to concentrate
on the central wealthy urban regions while mortality is high-
est on the medically underserved and impoverished regions,
situation especially apparent to nontraumatic intracranial
hemorrhage. Access to medical services and prompt and
appropriate healthcare are essential factors that influence
mortality of any cause. Moreover, in addition to treatment
options such as intravenous thrombolytics, endovascular
management, or surgical techniques (ie, craniotomy and ven-
triculostomy) not being widely available, nonexisting or mal-
functional prehospital evaluation and notification systems are
responsible for the transportation of cases to the nearest
healthcare institutions instead of the most appropriate ones.
These situations compound to existing social vulnerabilities
making CVD and stroke prevention and management issues
that should be addressed from an intersectorial point of view.
Even though it is logical that hypertension and tobacco
use were the risk factors with strongest measures of corre-
lation, it is not likely that any risk factor under study could
exert a protective effect on stroke and other CVDs. This
was the case for overweight and obesity and for alcohol
use and could have been the result of unmeasured and
uncontrolled ambient confounding. As such, models con-
taining any such variables must be regarded with caution.
Social inequity analyses can be performed in a number of
ways with several possible variables. The UBN index
focuses on poor housing conditions and may not be as sensi-
tive as the multidimensional poverty index in assessing true
poverty and social disparity. However, updated and region-
ally disaggregated multidimensional poverty index meas-
urements were not available for Colombia for the period
under study, and thus the UBN was used as a proxy. Given
that prevalence is most likely determined by intrinsic and
extrinsic (un)modifiable risk factors while actual mortality is
most likely influenced by access to prompt and appropriate
healthcare, it is not surprising that high-cost and difficult-to-
manage diseases, such as cerebral amyloid angiopathy and
vascular dementia, have the most socially unequal distribu-
tion of deaths. Access to appropriate healthcare services is
restricted in medically underserved regions, which in turn
harbor low-income populations that cannot afford transpor-
tation or out-of-pocket expenses. High-income population,
in contrast, might be appropriately managed and would
eventually die due to other causes.
It is important to note that the population projections
used in this study were those constructed based on the
2005 Colombian census. However, according to prelimi-
nary analyses of the 2018 census, the total Colombian
population was overestimated in such projections, a
situation which most likely would have cause an underes-
timation of the real estimated measures.
This study has several limitations. First, the data sources
for the estimations of mortality rates and prevalence ratios
were based on the national vital registration and sanitary
event reporting systems. Miss-classification of disease out-
comes and inappropriate selection of ICD-10 codes are just 2
examples of inadequate coding behavior that is widespread
across the nation. As most analyzed disease categories
required either special equipment or training to be diagnosed
it is highly likely that rural and medically underserved
regions either failed to identify them or mistook them for
other entities. This is especially true for some uncommon
entities used in the prevalence analyses. Second, although
vital registration certificates may state CVD as CoD, there is
no way to ascertain the time between event onset and actual
death. In a similar fashion, there is no way to distinguish
first-time ever from recurrent events, which results in the
measurement of aggregate measures of disease mortality
and prevalence. This is especially true for stroke, as it has
been established that disease mortality is highest during the
first month after the event and that the epidemiology of
recurrent events varies significantly from first-time ever
strokes. Third, given the emphasis on ascertaining differen-
ces between geographic regions, true mixed effects modeling
would have been a more appropriate method for evaluating
correlations. However, data on independent variables were
only available at an aggregated regional level, without any
measures of dispersion or uncertainty that could be used to
assess for inter- and intraclass variability. Fourth, ecological
cross-sectional studies have serious difficulties in quantifying
correlation measures and could be fraught with bias if con-
founding is not adequately addressed. Moreover, informa-
tion on risk factors were extracted from multiple sources
which, in turn, varied greatly in methods of data acquisition.
Nevertheless, the results of this study are the most up-to-
date epidemiological measures for stroke and other CVDs in
Colombia and underscore the importance of creating and
maintaining a national stroke and CVD registry, of regular
and reliable national individual-level noncommunicable dis-
ease risk factor assessment, and of focusing transectorial
public health policies for CVD control on the medically
underserved regions and socially vulnerable populations.
Acknowledgments
N.Y. prepared the first draft. A.P. and G.C. reviewed and
edited the first draft and final versions of the manuscript. All
authors reviewed all subsequent drafts, reviewed results, and
approved the final version of the manuscript.
Disclosures
The authors have nothing to disclose.
 ARTICLE IN PRESS
CEREBROVASCULAR DISEASE EPIDEMIOLOGY IN COLOMBIA
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