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PLoS One. 2019 Jan 10;14(1):e0210502. doi: 10.1371/journal.pone.0210502. eCollection 2019.

The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access.

Author information

Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America.
Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
Department of Medicine, Centro Universitario Inga, Maringa, Brazil.
Panamerican Health Organization, Brasilia, Brazil.
Department of Computer Science, Pontifical University Catholic of Parana, Curitiba, Brazil.
Data Processing Department, State University of Maringa, Maringa, Brazil.
Department of Medicine, State University of Maringa, Maringa, Brazil.



Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality.


Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables.


The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.

Conflict of interest statement

The authors have declared that no competing interests exist.

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