Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC qQdLhnXFzJNCngCHYBJVW7b S0066-782X2022000700046 abc.20220371 10.36660/abc.20220371 Minieditorial A Pandemia de COVID-19 e a Doença Cardiovascular no Brasil: Aprendendo com os Dados 0000-0002-1051-9434 Cesena Fernando 1 Cenocor Guarulhos SP Brasil Cenocor, Guarulhos, SP – Brasil Correspondência: Fernando Cesena • Cenocor – Rua Dr. Ramos de Azevedo, 159, sala 1510. CEP 07012-020, Guarulhos, SP – Brasil E-mail: cesenaf@gmail.com 11 07 2022 07 2022 119 1 46 47 This is an open-access article distributed under the terms of the Creative Commons Attribution License Palavras-chave COVID-19 Doenças Cardiovasculares Mortalidade Mortalidade Hospitalar

A Organização Mundial da Saúde (OMS) estima quase 15 milhões de mortes em excesso associadas à COVID-19 no mundo em 2020 e 2021, definidas como a diferença entre o número total de mortes (por todas as causas) e o número de mortes esperadas se não houvesse pandemia.1

No Brasil, a OMS estima 99 e 220 mortes em excesso associadas à pandemia de COVID-19 por 100.000 habitantes em 2020 e 2021, respectivamente.1 Isso se traduziria em cerca de 680.000 mortes a mais nos dois primeiros anos da pandemia, ou seja, dezenas de milhares a mais do que as mortes por COVID-19 oficialmente relatadas no período. Muitas dessas mortes em excesso estão relacionadas à subnotificação devido à falta de testes ou a diagnósticos incorretos (mortes verdadeiras por COVID-19 atribuídas a outras condições). Outros eventos fatais foram por outras causas e de alguma forma indiretamente associados à pandemia, como as mortes por doenças não tratadas adequadamente devido ao sistema de saúde sobrecarregado. Considerando que as doenças cardiovasculares (DCV) são a principal causa de morte no Brasil,2 é crucial desvendar o impacto da COVID-19 nas estatísticas de DCV.

Nesse contexto, Armstrong et al.,3 analisando dados de hospitais públicos no Brasil, relatam que o número de óbitos hospitalares por DCV em 2020 foi apenas 1,58% inferior ao esperado com base na média dos anos anteriores. No entanto, a taxa de letalidade hospitalar por DCV aumentou 13,3% em todo o ano e 18,8% de março a dezembro.3

Esses achados estão de acordo com outros estudos que relataram, durante a pandemia, redução no número de pacientes que procuram atendimento médico, diminuição das internações e procedimentos por DCV, pacientes hospitalizados mais graves e, consequentemente, aumento da letalidade hospitalar por DCV.4–10 É importante ressaltar que um achado repetidamente relatado é um aumento desconfortável nas mortes domiciliares.11–13 Portanto, agora está claro que a pandemia impactou substancialmente o cuidado com DCV no Brasil.

Quais são os aprendizados deste diagnóstico? Em primeiro lugar, espera-se que os médicos tenham aprendido que há casos em que a investigação, intervenção ou hospitalização não podem ser adiadas. Em segundo lugar, há um grande espaço para educar os pacientes sobre os sinais de alerta de condições graves, como síndrome coronariana aguda e acidente vascular cerebral, minimizando as mortes em casa devidas ao medo do paciente de ir ao hospital. Terceiro, suavizar as consequências da pandemia só é possível com um sistema de saúde bem preparado que possa responder rapidamente às demandas do surto sem comprometer o atendimento de outras doenças mortais. O Brasil não está acostumado a desastres naturais ou pandemias, e muitos subestimaram os danos potenciais do vírus. Agora nós temos a oportunidade de aprender com a experiência, como os países asiáticos fizeram com a epidemia de SARS em 2003, e melhor nos prepararmos para futuros eventos catastróficos.

Após a fase mais crítica, pré-vacinação, da pandemia, a atenção agora se volta para outra preocupação: até que ponto o cancelamento de consultas e procedimentos médicos forçados pela pandemia afetará as DCV? O controle inadequado dos fatores de risco e as intervenções realizadas tardiamente podem adicionar outra camada ao impacto da pandemia de COVID-19 nos desfechos das DCV. O monitoramento contínuo da situação é necessário e provavelmente será abordado por estudos futuros.

Outro aspecto relevante é reconhecer que os efeitos da pandemia não são uniformes na comunidade. Marinho et al.,14 encontraram um excesso de mortalidade de 26,3% (23,3%-29,3%) entre pretos/pardos no Brasil em 2020, enquanto esse número foi de 15,1% (14,1%-16,1%) em brancos.14 Em Belo Horizonte-MG, o excesso de mortalidade em 2020 aumentou à medida que o Índice de Vulnerabilidade à Saúde piorou.15 Além disso, Brant et al. relataram que o aumento de óbitos domiciliares por DCV em Belo Horizonte-MG em 2020 foi mais acentuado em indivíduos mais vulneráveis socialmente.13 Identificar os subgrupos mais afetados é estratégico para definir alvos prioritários para intervenções de saúde pública e evitar o perigoso caminho de aumento das desigualdades em saúde.

Nas últimas décadas, observamos um declínio contínuo da mortalidade por DCV ajustada por idade no Brasil, embora essa queda tenha se atenuado nos últimos anos.2 Ainda não está claro se a pandemia modificará substancialmente essa tendência. No entanto, a mudança no padrão de internações por DCV e o aumento inaceitável de óbitos domiciliares não podem ser assistidos passivamente sem perplexidade. É hora de aprender com os dados e agir para minimizar os impactos da pandemia nos desfechos das DCV.

Minieditorial referente ao artigo: Excesso de Mortalidade Hospitalar por Doenças Cardiovasculares no Brasil Durante o Primeiro Ano da Pandemia de COVID-19

 Referências World Health Organization.(WHO)- 2022 Global excess deaths associated with COVID-19, January 2020 - December 2021 [online] Available at: <https://www.who.int/data/stories/global-excess-deaths-associated-with-covid-19-january-2020-december-2021> [Accessed 20 May 2022] 1 World Health Organization.(WHO)- 2022. Global excess deaths associated with COVID-19, January 2020 - December 2021. [online] Available at: <https://www.who.int/data/stories/global-excess-deaths-associated-with-covid-19-january-2020-december-2021> [Accessed 20 May 2022]. Oliveira GMM Brant LCC Polanczyk CA Malta DC Biolo A Nascimento BR Cardiovascular Statistics - Brazil 2021 Arq Bras Cardiol 2022 118 1 115 373 10.36660/abc.20200812 2 Oliveira GMM, Brant LCC, Polanczyk CA, Malta DC, Biolo A, Nascimento BR, et al. Cardiovascular Statistics - Brazil 2021. Arq Bras Cardiol. 2022;118(1):115-373. doi: 10.36660/abc.20200812 Armstrong AC Santos LG Leal TC Paiva JPS Silva LF Santana GBA In-Hospital Mortality from Cardiovascular Diseases in Brazil during the First Year of The COVID-19 Pandemic Arq Bras Cardiol 2022 119 1 37 45 3 Armstrong AC, Santos LG, Leal TC, Paiva JPS, Silva LF, Santana GBA, et al. In-Hospital Mortality from Cardiovascular Diseases in Brazil during the First Year of The COVID-19 Pandemic. Arq Bras Cardiol. 2022; 119(1):37-45. Jardim TV Jardim FV Jardim LMV Coragem JT Castro CF Firmino GM Jardim PCBV Changes in the Profile of Emergency Room Patients during the COVID-19 Outbreak in a General Hospital Specialized in Cardiovascular Care in Brazil Arq Bras Cardiol 2021 116 1 140 143 10.36660/abc.20200595 4 Jardim TV, Jardim FV, Jardim LMV, Coragem JT, Castro CF, Firmino GM, Jardim PCBV. Changes in the Profile of Emergency Room Patients during the COVID-19 Outbreak in a General Hospital Specialized in Cardiovascular Care in Brazil. Arq Bras Cardiol. 2021;116(1):140-3. doi: 10.36660/abc.20200595 Silva PGMB Dutra AAF Manfredi AB Sampaio PPN Correa CM Griz HB Setta D Furlan V Reduction in the Number of Patients with Suspected and Confirmed Acute Coronary Syndrome during the early months of the Covid-19 Pandemic: Analysis of a Brazilian Network Arq Bras Cardiol 2021 116 5 1003 1006 10.36660/abc.20200873 5 Silva PGMB, Dutra AAF, Manfredi AB, Sampaio PPN, Correa CM, Griz HB, Setta D, Furlan V. Reduction in the Number of Patients with Suspected and Confirmed Acute Coronary Syndrome during the early months of the Covid-19 Pandemic: Analysis of a Brazilian Network. Arq Bras Cardiol. 2021;116(5):1003-6. doi: 10.36660/abc.20200873 Normando PG Araujo JA Filho Fonseca GA Rodrigues REF Oliveira VA Hajjar LA 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 10.36660/abc.20200821 6 Normando PG, Araujo-Filho JA, Fonseca GA, Rodrigues REF, Oliveira VA, Hajjar LA, et a. Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil. Arq Bras Cardiol. 2021;116(3):371-80. doi: 10.36660/abc.20200821 Lisboa LA Mejia OAV Arita ET Guerreiro GP Silveira LMVD Brandão CMA Impact of the First Wave of the COVID-19 Pandemic on Cardiovascular Surgery in Brazil: Analysis of a Tertiary Reference Center Arq Bras Cardiol 2022 118 3 663 666 10.36660/abc.20210235 7 Lisboa LA, Mejia OAV, Arita ET, Guerreiro GP, Silveira LMVD, Brandão CMA, et al. Impact of the First Wave of the COVID-19 Pandemic on Cardiovascular Surgery in Brazil: Analysis of a Tertiary Reference Center. Arq Bras Cardiol. 2022;118(3):663-6. doi: 10.36660/abc.20210235 Costa R Silva KRD Saucedo SCM Silva LA Crevelari ES Nascimento WTJ Impact of the COVID-19 Pandemic on Cardiac Implantable Electronic Devices Procedures in a Tertiary Referral Center Arq Bras Cardiol 2021 117 4 765 769 10.36660/abc.20201378 8 Costa R, Silva KRD, Saucedo SCM, Silva LA, Crevelari ES, Nascimento WTJ, et al. Impact of the COVID-19 Pandemic on Cardiac Implantable Electronic Devices Procedures in a Tertiary Referral Center. Arq Bras Cardiol. 2021;117(4):765-9. doi: 10.36660/abc.20201378 Cerci RJ Vitola JV Paez D Zuluaga A Bittencourt MS Sierra-Galan LM The Impact of COVID-19 on Diagnosis of Heart Disease in Latin America an INCAPS COVID Sub-analysis Arq Bras Cardiol 2022 118 4 745 753 10.36660/abc.20210388 9 Cerci RJ, Vitola JV, Paez D, Zuluaga A, Bittencourt MS, Sierra-Galan LM, et al. The Impact of COVID-19 on Diagnosis of Heart Disease in Latin America an INCAPS COVID Sub-analysis. Arq Bras Cardiol. 2022;118(4):745-53. doi: 10.36660/abc.20210388 Nascimento BR Brant LCC Castro ACT Froes LEV Ribeiro ALP Teixeira RA Reduction in Hospital Admissions Associated with Coronary Events during the COVID-19 Pandemic in the Brazilian Private Health System: Data from the UNIMED-BH System Rev Soc Bras Med Trop 2021 54 e01742021 10.1590/0037-8682-0174-2021 10 Nascimento BR, Brant LCC, Castro ACT, Froes LEV, Ribeiro ALP, Teixeira RA, et al. Reduction in Hospital Admissions Associated with Coronary Events during the COVID-19 Pandemic in the Brazilian Private Health System: Data from the UNIMED-BH System. Rev Soc Bras Med Trop. 2021;54:e01742021. doi: 10.1590/0037-8682-0174-2021 Brant LCC Nascimento BR Teixeira RA Lopes MACQ Malta DC Oliveira GMM Ribeiro ALP Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities Heart 2020 106 24 1898 1905 10.1136/heartjnl-2020-317663 11 Brant LCC, Nascimento BR, Teixeira RA, Lopes MACQ, Malta DC, Oliveira GMM, Ribeiro ALP. Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities. Heart. 2020;106(24):1898-905. doi: 10.1136/heartjnl-2020-317663 Guimarães NS Carvalho TML Machado-Pinto J Lage R Bernardes RM Peres ASS Increased Home Death Due to Cardiopulmonary Arrest in Times of COVID-19 Pandemic Arq Bras Cardiol 2021 116 2 266 271 10.36660/abc.20200547 12 Guimarães NS, Carvalho TML, Machado-Pinto J, Lage R, Bernardes RM, Peres ASS, et al. Increased Home Death Due to Cardiopulmonary Arrest in Times of COVID-19 Pandemic. Arq Bras Cardiol. 2021;116(2):266-71. doi: 10.36660/abc.20200547 Brant LCC Pinheiro PC Ribeiro ALP Machado IE Correa PRL Santos MR Cardiovascular Mortality During the COVID-19 Pandemics in a Large Brazilian City: A Comprehensive Analysis Glob Heart 2022 17 1 11 11 10.5334/gh.1101 13 Brant LCC, Pinheiro PC, Ribeiro ALP, Machado IE, Correa PRL, Santos MR, et al. Cardiovascular Mortality During the COVID-19 Pandemics in a Large Brazilian City: A Comprehensive Analysis. Glob Heart. 2022;17(1):11. doi: 10.5334/gh.1101 Marinho MF Torrens A Teixeira R Brant LCC Malta DC Nascimento BR Racial disparity in excess mortality in Brazil during COVID-19 times Eur J Public Health 2022 32 1 24 26 10.1093/eurpub/ckab097 14 Marinho MF, Torrens A, Teixeira R, Brant LCC, Malta DC, Nascimento BR, et al. Racial disparity in excess mortality in Brazil during COVID-19 times. Eur J Public Health. 2022;32(1):24-6. doi: 10.1093/eurpub/ckab097 Passos VMA Brant LCC Pinheiro PC Correa PRL Machado IE Santos MR Higher mortality during the COVID-19 pandemic in socially vulnerable areas in Belo Horizonte: implications for vaccine prioritization Rev Bras Epidemiol 2021 24 e210025 10.1590/1980-549720210025 15 Passos VMA, Brant LCC, Pinheiro PC, Correa PRL, Machado IE, Santos MR, et al. Higher mortality during the COVID-19 pandemic in socially vulnerable areas in Belo Horizonte: implications for vaccine prioritization. Rev Bras Epidemiol. 2021;24:e210025. doi: 10.1590/1980-549720210025 Short Editorial The COVID-19 Pandemic and Cardiovascular Disease in Brazil: Learning from the Data 0000-0002-1051-9434 Cesena Fernando 1 Guarulhos SP Brazil Cenocor, Guarulhos, SP – Brazil Mailing Address: Fernando Cesena • Cenocor – Rua Dr. Ramos de Azevedo, 159, sala 1510. Postal Code 07012-020, Guarulhos, SP – Brazil E-mail: cesenaf@gmail.com Keywords COVID-19 Cardiovascular Diseases Mortality Hospital Mortality

The World Health Organization (WHO) estimates nearly 15 million excess deaths associated with COVID-19 in the world in 2020 and 2021, defined as the difference between the total number of deaths (from all causes) and the number of expected deaths if there was no pandemic.1

In Brazil, the WHO estimates 99 and 220 excess deaths associated with the COVID-19 pandemic per 100,000 inhabitants in 2020 and 2021, respectively.1 This would translate into around 680,000 excess deaths in the first two years of the pandemic, i.e., tens of thousands higher than the officially reported COVID-19 deaths in the period. Many of these excess deaths are related to sub notification due to lack of testing or misdiagnosis (true deaths from COVID-19 assigned to other conditions). Other fatal events were from other causes and somehow indirectly associated with the pandemic, such as the deaths from illnesses not properly treated due to the overwhelmed health system. Considering that cardiovascular disease (CVD) is the main cause of death in Brazil,2 it is crucial to unravel the impact of COVID-19 on CVD statistics.

In this context, Armstrong et al.,3 analyzing data from public hospitals in Brazil, report that the number of in-hospital deaths due to CVD in 2020 was only 1.58% lower than expected based on the average of previous years. However, the in-hospital case fatality rate due to CVD increased by 13.3% in the whole year and by 18.8% from March to December.3

These findings are in agreement with other studies that reported, during the pandemic, a reduction in the number of patients seeking medical care, a decrease in CVD hospitalizations and procedures, more severely diseased hospitalized patients, and consequently an increase in hospital lethality due to CVD.4–10 Importantly, a repeatedly reported finding is an uncomfortable increase in home deaths.11–13 Therefore, it is now clear that the pandemic has substantially impacted CVD care in Brazil.

What are the takeaways from this diagnosis? First, physicians are expected to have learned that there are cases where the investigation, intervention, or hospitalization cannot be postponed. Second, there is a large room to educate patients about warning signs of severe conditions, such as acute coronary syndrome and stroke, minimizing the home deaths due to patient fear of going to the hospital. Third, smoothing the consequences of the pandemic is only possible with a well-prepared health system that can rapidly respond to the outbreak's demands while not compromising the care of other deadly diseases. Brazil is not used to natural disasters or pandemics, and many underestimated the potential damage of the virus. Now we have the opportunity to learn from the experience as Asian countries did from the SARS epidemic in 2003 and better prepare ourselves for future catastrophic events.

After the most critical, pre-vaccination phase of the pandemic, the attention now shifts to another concern: to which extent will the cancellation of medical consultations and procedures forced by the pandemic affect CVD? Suboptimal risk factor control and interventions carried out late may add another layer to the impact of the COVID-19 pandemic on CVD outcomes. Continuous monitoring of the situation is needed and will probably be addressed by future studies.

Another relevant aspect is to acknowledge that the effects of the pandemic are not uniform in the community. Marinho et al.14 found an excess mortality rate of 26.3% (23.3%-29.3%) among blacks/browns in Brazil in 2020, while this number was 15.1% (14.1%-16.1%) in whites.14 In Belo Horizonte-MG, the excess mortality in 2020 increased as the Health Vulnerability Index worsened.15 Also, Brant et al. reported that the increase in CVD home deaths in Belo Horizonte-MG in 2020 was more pronounced in more socially vulnerable individuals.13 Identifying the most affected subgroups is strategic for defining priority targets for public health interventions and avoiding the dangerous path of increasing health inequalities.

In the last decades, we have observed a continuous decline in the age-adjusted CVD mortality in Brazil, although this decrease has attenuated in the last years.2 It is not yet clear whether the pandemic will substantially modify this trend. Nevertheless, the change in the pattern of hospitalizations for CVD and the unacceptable increase in home deaths cannot be passively watched without perplexity. It is time to learn from the data and act to minimize the impacts of the pandemic on CVD outcomes.

Short Editorial related to the article: In-Hospital Mortality from Cardiovascular Diseases in Brazil during the First Year of The COVID-19 Pandemic