Cardiovascular Mortality during the COVID-19 Pandemics in a Large Brazilian City: a Comprehensive Analysis (preprint)

Introduction: The impact of COVID-19 pandemics on cardiovascular diseases (CVD) may be caused by health system reorganization and/or collapse, or from changes in the behaviour of individuals. In Brazil, municipalities were empowered to define regulatory measures, potentially resulting in diverse effects on CVD morbimortality. Objective: To analyse the impact of COVID-19 pandemics on CVD outcomes in Belo Horizonte (BH), the 6th greater capital city in Brazil, including: mortality, mortality at home, hospitalizations, intensive care unit utilization, and in-hospital mortality; and the differential effect according to sex, age range, social vulnerability, and pandemics phase. Methods: Ecological study analysing data from the Mortality and Hospital Information System of BH residents aged [≥]30 years. CVD was defined as in Chapter IX from ICD-10. Social vulnerability was classified by a composite socioeconomic index as high, medium and low. The observed age-standardized rates for epidemiological weeks 10-48, 2020, were compared to the expected rates (mean of 2015-2019). Wilcoxon rank-sum test was used to test differences, and risk ratios with their 95% confidence intervals were calculated. National demographic estimates was used to calculate rates. Results: We found no changes in CVD mortality rates (RiR 1.01, 95%CI 0.96-1.06). However, CVD deaths occurred more at homes (RiR 1.32, 95%CI 1.20-1.46) than in hospitals (RiR 0.89, 95%CI 0.79-0.99), as a result of a substantial decline in hospitalization rates, even though proportional in-hospital deaths increased. The rise in home deaths was greater in older adults and in had an increasing gradient in those more socially vulnerable (RiR 1.45); for high (RiR 1.45), medium (RiR 1.32) and low vulnerability (RiR 1.21). Conclusion: The greater occurrence of CVD deaths at home, in parallel with lower hospitalization rates, suggests that CVD care was disrupted during the COVID-19 pandemics, which more adversely affected older and more socially vulnerable individuals, exacerbating health inequities in BH.

Excess of Cardiovascular Deaths During the COVID-19 Pandemic in Brazilian Capital Cities (preprint)

IntroductionDuring 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 (Sao Paulo, Rio de Janeiro, Fortaleza, Recife, Belem, 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 PerspectiveO_LIWhat 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. C_LIO_LIWhat 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. C_LIO_LIHow 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 populations 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. C_LI