Excess of Cardiovascular Deaths During the COVID-19 Pandemic in Brazilian Capital Cities
Authors: Brant Luisa C. C. , Nascimento Bruno R. , Teixeira Renato , Lopes Marcelo Antônio C. Q. , Malta Deborah C. , Oliveira Gláucia Maria M. , Ribeiro Antonio Luiz P. 
Published: June 2020

AbstractIntroductionDuring the COVID-19 pandemic, excess mortality has been reported, while hospitalizations for acute cardiovascular events reduced. Brazil is the second country with more deaths due to COVID-19. We aimed to evaluate excess cardiovascular mortality during COVID-19 pandemic in 6 Brazilian capital cities.MethodsUsing the Civil Registry public database, we evaluated total and cardiovascular excess deaths, further stratified in ACS, stroke and unspecified cardiovascular deaths in the 6 Brazilian cities with greater number of COVID-19 deaths (São Paulo, Rio de Janeiro, Fortaleza, Recife, Belém, Manaus). We compared data from epidemiological weeks 12 to 22 of 2020, with the same period in 2019. We also compared the number of hospital and home deaths during the period.ResultsThere were 69,328 deaths and 17,877 COVID-19 deaths in the studied period and cities for 2020. Cardiovascular mortality increased in most cities, with greater magnitude in the Northern capitals. However, while there was a reduction in ACS and stroke in the most developed cities, the Northern capitals showed an increase of these events. For unspecified cardiovascular deaths, there was a marked increase in all cities, which strongly correlated to the rise in home deaths (r=0.86, p=0.01).ConclusionThe excess cardiovascular mortality was greater in the less developed cities, possibly associated with healthcare collapse. ACS and stroke deaths decreased in the most developed cities, in parallel with an increase in unspecified cardiovascular and home deaths, presumably as a result of misdiagnosis. Conversely, ACS and stroke deaths increased in cities with a healthcare collapse.Clinical PerspectiveWhat is already known about this subject?During the pandemic, beyond deaths due to confirmed COVID-19, there seems to be an increase in the total number of deaths compared to previous years in Brazil. Excess mortality may have occurred due to identified or not COVID-19 or other causes, being an objective and comparable metric for healthcare evaluation.What does this study add?In the 6 Brazilian capitals with higher numbers of deaths due to COVID-19, the impact of the pandemic in the excess all-cause and cardiovascular deaths was noticeable, especially in regions where health systems collapsed, which are the most socioeconomically deprived. In the other capital cities, the decreasing number of deaths associated with well-defined events (ACS and stroke) paralleled with more frequent undefined cardiovascular and home deaths.How might this impact on clinical practice?Investments should be prioritized to areas where the pandemic resulted in health system collapse. During periods of social distancing, campaigns and strategies to increase the population’s awareness of cardiovascular care, health promotion practices, seeking services in the case of acute signs and symptoms, should be prioritized by governments.The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article to be published in HEART editions and any other BMJPGL products to exploit all subsidiary rights.