Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBCTXvqPFmSZCdvK9trq5TzRhB00381S0066-782X2021000400381abc.2021011310.36660/abc.20210113MinieditorialEventos Cardiovasculares Evitáveis: Um Sério Efeito Colateral da Pandemia de COVID-190000-0002-1051-9434CesenaFernando H. Y.Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – BrasilCorrespondência: Fernando Cesena • Hospital Israelita Albert Einstein, Avenida Brasil, 953. CEP 01431-000, São Paulo, SP – Brasil, E-mail: fernando.cesena@einstein.br, cesenaf@gmail.com230420210320211163381382This is an open-access article distributed under the terms of the Creative Commons Attribution LicensePalavras-chaveCOVID-19BetacoronavírusPandemiaInfarto do MiocárdioInsuficiência CardíacaDoenças Cardiovasculares/mortalidadeVacinação
Logo após o início da pandemia de COVID-19, um sentimento geral surgiu entre os médicos: muitos pacientes teriam desfechos desfavoráveis devido à demora na procura por serviços médicos por medo de contaminação. Pacientes com infarto agudo do miocárdio, insuficiência cardíaca descompensada ou acidente vascular cerebral (AVC) permaneceriam em casa ou iriam para o hospital tardiamente. A investigação de doenças possivelmente graves como o câncer seria adiada. Além disso, o colapso do sistema de saúde seria um fator contribuinte para o cuidado inadequado de doenças outras que não a COVID-19.
Levou alguns meses para que os pesquisadores coletassem dados sobre as nuances desse fenômeno. Diversas publicações têm confirmado as expectativas, lançando luz sobre um aspecto que deve ser discutido e divulgado.
Nesse contexto, este número da ABC publica uma análise do impacto dos primeiros meses da pandemia sobre o número de procedimentos médicos, internações e óbitos intra-hospitalares por doenças cardiovasculares no âmbito do serviço público de saúde brasileiro.1 Os números esperados para março a maio de 2020, baseados nas tendências de 2016 a 2019, foram confrontados com os números observados durante a pandemia. Os principais resultados indicam que o número de procedimentos, cirurgias, internações e óbitos hospitalares foi muito inferior ao esperado. Os autores descrevem uma redução de 15% nas internações por doenças cardiovasculares. Os óbitos hospitalares por doenças cardiovasculares também diminuíram, mas não na mesma proporção (-8%). Como consequência, a letalidade intra-hospitalar aumentou 9%.1
O número reduzido de procedimentos cardíacos e internações hospitalares devido a urgências cardiovasculares é compatível com outros relatos do Brasil e de outros países.2–4 Essa observação, por si só, não seria um problema se desfechos relevantes como óbitos, insuficiência cardíaca pós-infarto do miocárdio e incapacidades pós-AVC não tivessem aumentado. Infelizmente, não é o caso. Brant et al.5 publicaram uma análise abrangente do excesso de mortalidade cardiovascular de março a maio de 2020 nas seis capitais brasileiras com maior número de óbitos por COVID-19. Os autores encontraram um excesso no total de óbitos cardiovasculares na maioria das cidades, principalmente devido a causas cardiovasculares não especificadas, que foram correlacionadas com um aumento nos óbitos domiciliares.5
As questões relacionadas às consequências indiretas e nocivas da pandemia não se restringem às doenças cardiovasculares. Várias publicações têm destacado demanda reduzida por serviços oncológicos e menor número de exames diagnósticos e procedimentos terapêuticos para o câncer durante a pandemia.6–9
Portanto, os danos colaterais da pandemia de COVID-19 são claros e alarmantes, e estratégias para minimizar eventos evitáveis devem ser desenvolvidas e implementadas. Isto é especialmente verdadeiro no contexto das doenças cardiovasculares, principal causa de óbitos no mundo e no Brasil.10
Obviamente, a solução ideal é controlar a própria pandemia, o que leva tempo e dependerá do sucesso do programa de vacinação, que está sempre ameaçado pelo surgimento de novas variantes do coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2). Enquanto a transmissão comunitária do vírus estiver em níveis elevados, outras iniciativas podem ajudar.
Em primeiro lugar, é obrigatório alertar os médicos e pacientes para o perigo de delongas no diagnóstico e no tratamento de doenças cardiovasculares, malignidades e outros processos patológicos. Os médicos devem dominar a tarefa frequentemente difícil de equilibrar os benefícios e riscos de encaminhar pacientes para procedimentos diagnósticos e internações hospitalares. O correto discernimento sobre a urgência depende de um misto de educação continuada, capacitação e bom senso. Campanhas públicas voltadas para leigos também podem ser úteis.
Em segundo lugar, os serviços de saúde devem estar preparados para minimizar os riscos aos pacientes e profissionais de saúde durante a pandemia. As sociedades médicas têm o papel de orientar os profissionais de saúde para a realização de procedimentos com segurança, como a Sociedade Brasileira de Cardiologia tem feito por meio da emissão de documentos com recomendações específicas.11–13 Hospitais de referência e ensino também podem contribuir compartilhando suas experiências e protocolos que podem ser utilizados por centros menores.14
Em terceiro lugar, devemos tirar proveito do atendimento de saúde remoto para preencher parcialmente a lacuna de acesso restrito à assistência médica nestes tempos de pandemia. Uso inteligente da telemedicina,15 visitas da equipe de saúde e coleta de sangue em domicílio, bem como teletransmissão do eletrocardiograma são alguns exemplos de práticas que podem ser adotadas.
Em conclusão, agora está claro que os impactos da pandemia de COVID-19 vão muito além dos óbitos por pneumonia viral e aspectos socioeconômicos. Os pacientes estão mais relutantes e têm adiado investigações médicas, em grande parte devido ao medo de serem infectados pelo SARS-CoV-2. Embora compreensíveis do ponto de vista do paciente, essas atitudes apresentam riscos elevados, principalmente quando se trata de doenças cardiovasculares e câncer. Esforços devem ser feitos para limitar os eventos evitáveis e para minimizar as consequências trágicas dessa pandemia em curso ou outras tragédias que possam nos atingir futuramente.
Minieditorial referente ao artigo: Redução na Hospitalização e Aumento na Mortalidade por Doenças Cardiovasculares durante a Pandemia da COVID-19 no Brasil
ReferencesNormandoPGAraujoJAFilhoFonsecaGARodriguesREFOliveiraVAHajjarLAReduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in BrazilArq Bras Cardiol202111633713801. Normando PG, Araujo-Filho JA, Fonseca GA, Rodrigues REF, Oliveira VA, Hajjar, LA, et al. Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil. Arq Bras Cardiol. 2021; 116(3):371-380.MafhamMMSpataEGoldacreRGairDCurnowPBrayMCOVID-19 pandemic and admission rates for and management of acute coronary syndromes in EnglandLancet2020396102483813892. Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet. 2020;396(10248):381-9.AlmeidaALCSantoTMDEMelloMSSCedroAVLopesNLRibeiroAPMRRepercussions of the COVID-19 pandemic on the care practices of a Tertiary HospitalArq Bras Cardiol202011558628703. Almeida ALC, Santo TMDE, Mello MSS, Cedro AV, Lopes NL, Ribeiro APMR, et al. Repercussions of the COVID-19 pandemic on the care practices of a Tertiary Hospital. Arq Bras Cardiol. 2020;115(5):862-70.De RosaSSpaccarotellaCBassoCCalabroMPCurcioAFilardiPPReduction of hospitalizations for myocardial infarction in Italy in the COVID-19 eraEur Heart J20204122208320884. De Rosa S, Spaccarotella C, Basso C, Calabro MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020;41(22):2083-88.BrantLCCNascimentoBRTeixeiraRALopesMACQMaltaDCOliveiraGMMExcess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital citiesHeart202010624189819055. Brant LCC, Nascimento BR, Teixeira RA, Lopes MACQ, Malta DC, Oliveira GMM, et al. Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities. Heart. 2020;106(24):1898-905.LaiAGPaseaLBanerjeeAHallGDenaxasSChangWHEstimated impact of the COVID-19 pandemic on cancer services and excess 1-year mortality in people with cancer and multimorbidity: near real-time data on cancer care, cancer deaths and a population-based cohort studyBMJ Open20201011e0438286. Lai AG, Pasea L, Banerjee A, Hall G, Denaxas S, Chang WH, et al. Estimated impact of the COVID-19 pandemic on cancer services and excess 1-year mortality in people with cancer and multimorbidity: near real-time data on cancer care, cancer deaths and a population-based cohort study. BMJ Open. 2020;10(11):e043828.MorrisEJAGoldacreRSpataEMafhamMFinanPJSheltonJImpact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based studyLancet Gastroenterol Hepatol2021631992087. Morris EJA, Goldacre R, Spata E, Mafham M, Finan PJ, Shelton J, et al. Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study. Lancet Gastroenterol Hepatol. 2021;6(3):199-208.AraujoSEALealACentroneAFYTeichVDMalheiroDTCyprianoASImpact of COVID-19 pandemic on care of oncological patients: experience of a cancer center in a Latin American pandemic epicenterEinstein (Sao Paulo)2020122119eAO62828. Araujo SEA, Leal A, Centrone AFY, Teich VD, Malheiro DT, Cypriano AS, et al. Impact of COVID-19 pandemic on care of oncological patients: experience of a cancer center in a Latin American pandemic epicenter. Einstein (Sao Paulo). 2020 Dec 21;19:eAO6282.RiemannSSpeckIGerstackerKBeckerCKnopfACollateral damage of the COVID-19 pandemic: an alarming decline in critical procedures in otorhinolaryngology in a German university hospitalEur Arch Otorhinolaryngol2020121517Epub ahead of print9. Riemann S, Speck I, Gerstacker K, Becker C, Knopf A. Collateral damage of the COVID-19 pandemic: an alarming decline in critical procedures in otorhinolaryngology in a German university hospital. Eur Arch Otorhinolaryngol. 2020 Dec 15;1-7. [Epub ahead of print].OliveiraGMMBrantLCCPolanczykCABioloANascimentoBRMaltaDCCardiovascular statistics - Brazil 2020Arq Bras Cardiol2020115330843910. 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.GrossmanGBSelleraCACHossriCACCarreiraLTFAvanzaACJrAlbuquerquePFPosition statement of the Brazilian Society of Cardiology Department of Exercise Testing, Sports Exercise, Nuclear Cardiology, and Cardiovascular Rehabilitation (DERC/SBC) on activities within its scope of practice during the COVID-19 pandemicArq Bras Cardiol2020115228429111. Grossman GB, Sellera CAC, Hossri CAC, Carreira LTF, Avanza Jr AC, Albuquerque PF, et al. Position statement of the Brazilian Society of Cardiology Department of Exercise Testing, Sports Exercise, Nuclear Cardiology, and Cardiovascular Rehabilitation (DERC/SBC) on activities within its scope of practice during the COVID-19 pandemic. Arq Bras Cardiol. 2020;115(2):284-91.CostaIBSDRochitteCECamposCMBarberatoSHOliveiraGMMLopesACQCardiovascular imaging and interventional procedures in patients with novel coronavirus infectionArq Bras Cardiol2020115111112612. Costa IBSD, Rochitte CE, Campos CM, Barberato SH, Oliveira GMM, Lopes ACQ, et al. Cardiovascular imaging and interventional procedures in patients with novel coronavirus infection. Arq Bras Cardiol. 2020;115(1):111-26.BittencourtMSGenerosoGMeloPHMCPeixotoDMirandaEJFPMesquitaETStatement - protocol for the reconnection of cardiology services with patients during the COVID-19 pandemic - 2020Arq Bras Cardiol2020115477679913. Bittencourt MS, Generoso G, Melo PHMC, Peixoto D, Miranda EJFP, Mesquita ET, et al. Statement - protocol for the reconnection of cardiology services with patients during the COVID-19 pandemic - 2020. Arq Bras Cardiol. 2020;115(4):776-99.ChamiéDOliveiraFBragaSCostaJRSiqueiraDAAStaicoRAdapted catheterization laboratory practices during the COVID-19 pandemic: The Instituto Dante Pazzanese de Cardiologia ProtocolArq Bras Cardiol2020115355856814. Chamié D, Oliveira F, Braga S, Costa JR, Siqueira DAA, Staico R, et al. Adapted catheterization laboratory practices during the COVID-19 pandemic: The Instituto Dante Pazzanese de Cardiologia Protocol. Arq Bras Cardiol. 2020;115(3):558-68.NascimentoBRBrantLCCastroACTFroesLEVRibeiroALPCruzLVImpact of a large-scale telemedicine network on emergency visits and hospital admissions during the coronavirus disease 2019 pandemic in Brazil: Data from the UNIMED-BH systemJ Telemed Telecare202010251357633X2096952915. Nascimento BR, Brant LC, Castro ACT, Froes LEV, Ribeiro ALP, Cruz LV, et al. Impact of a large-scale telemedicine network on emergency visits and hospital admissions during the coronavirus disease 2019 pandemic in Brazil: Data from the UNIMED-BH system. J Telemed Telecare. 2020 Oct 25;1357633X20969529.Short EditorialAvoidable Cardiovascular Events: A Serious Side Effect of the COVID-19 Pandemic0000-0002-1051-9434CesenaFernando H. Y.Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP – BrazilMailing Address: Fernando Cesena • Hospital Israelita Albert Einstein, Avenida Brasil, 953. Postal Code 01431-000, São Paulo, SP – Brazil, E-mail: fernando.cesena@einstein.br, cesenaf@gmail.comKeywordsCOVID-19BetacoronavirusPandemicsMyocardial InfarctionHeart FailureCardiovascular Diseases/mortalityVaccination
Soon after the beginning of the COVID-19 pandemic, a general feeling arose among the doctors: many patients would have poor outcomes due to delays in seeking medical services for fear of infection. Patients with acute myocardial infarction, decompensated heart failure or stroke would stay at home or go to the hospital late in the course of the event. Investigation of potentially serious diseases, such as cancer, would be postponed. Besides, healthcare collapse would prove to be a contributor to inadequate care of non-COVID-19 diseases.
It took some months for the researchers to gather data on the nuances of this phenomenon. Several publications have confirmed the expectations, shedding light on an aspect that must be discussed and disseminated.
In this context, this issue of ABC publishes an analysis of the impact of the first months of the pandemic on the number of medical procedures, hospital admissions, and in-hospital deaths due to cardiovascular diseases in the setting of the Brazilian public healthcare service.1 The numbers expected for March to May 2020, based on the trends from 2016 to 2019, were confronted with the numbers observed during the pandemic. The main results indicate that the number of procedures, surgeries, hospital admissions, and in-hospital deaths was much lower than expected. The authors describe a 15% decrease in hospital admissions due to cardiovascular diseases. In-hospital deaths due to cardiovascular diseases also dropped, but not to the same extent (-8%). As a consequence, in-hospital mortality increased by 9%.1
The reduced number of cardiac procedures and hospital admissions due to cardiovascular urgencies is consistent with other reports from Brazil and other countries.2–4 This observation, per se, would not be a problem if relevant outcomes, such as deaths, post-myocardial infarction heart failure and post-stroke disabilities had not increased. Unfortunately, this is not the case. Brant et al.5 have published a comprehensive analysis of excess cardiovascular mortality from March to May 2020 in the six Brazilian capitals with the highest number of COVID-19 fatalities. The authors found an excess in total cardiovascular deaths in most cities, especially due to unspecified cardiovascular causes, which were correlated with an increase in home deaths.5
Concerns about indirect, harmful consequences of the pandemic are not restricted to cardiovascular diseases. Several publications have highlighted a reduced demand for cancer services, and a lower number of diagnostic exams and therapeutic procedures for cancer during the pandemic.6–9
Therefore, the collateral damage of the COVID-19 pandemic is clear and alarming, and strategies to minimize avoidable events must be developed and implemented. This is especially true in the setting of cardiovascular diseases, the leading cause of death in the world and in Brazil.10
Obviously, the ideal solution is to control the pandemic itself, which takes time and will depend on the success of the vaccination program, which is always threatened by the emergence of new variants of the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2). As long as the community transmission of the virus is at high levels, other initiatives may help.
Firstly, it is mandatory to make doctors and patients aware of the danger of delaying diagnosis and treatment of cardiovascular diseases, malignancies, and other pathological processes. Physicians should master the frequently hard task of balancing the benefits and risks of referring patients to diagnostic procedures and hospital admissions. The correct discernment on the urgency depends on a mixture of continuing education, training, and common sense. Public campaigns targeting lay people may also be useful.
Secondly, healthcare services must be prepared to minimize risks to patients and healthcare professionals during the pandemic. Medical societies have a role in guiding the health providers to safely perform procedures, such as the Brazilian Society of Cardiology has done by issuing documents with specific recommendations.11–13 Teaching, reference hospitals can also contribute by sharing their experience and protocols that may be used by smaller centers.14
Thirdly, we should take advantage of remote healthcare to partially fill the gap of restricted access to medical assistance in these pandemic times. Intelligent use of telemedicine,15 home visits by the health team, blood collection at home, and electrocardiogram teletransmission are some examples of practices that may be performed.
In conclusion, it is now clear that the impacts of the COVID-19 pandemic go far beyond deaths due to viral pneumonia and socio-economic aspects. Patients are more reluctant and have postponed medical investigations, largely due to the fear of being infected with SARS-CoV-2. Although understandable from the patient’s perspective, these attitudes pose high risks, especially when it comes to cardiovascular diseases and cancer. Efforts must be made to limit preventable events and to minimize the tragic consequences of this ongoing pandemic or other disasters that might affect us in the future.
Short Editorial related to the article: Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil