ABC | Volume 114, Nº6, June 2020

Editorial Fernandes Covid-19: difficulties and prospects Arq Bras Cardiol. 2020; 114(6):988-991 1. Nussbaumer-StreitB,MayrV,DobrescuAI,ChapmanA,PersadE,KleringsI,etal. Quarantinealoneorincombinationwithotherpublichealthmeasurestocontrol COVID-19:arapidreview.CochraneDatabaseSystRev.2020;4(4):CD013574. 2. Wikipedia. List of countries by hospital beds. [Cited in 2020 Apr 20] Available from: https://en.wikipedia.org/wiki/List_of_countries_by_hospital_beds. 3. Eich B B. https://docs.google.com/spreadsheets/d/1zC3kW1sMu0sjnT_ vP1sh4zL0tF6fIHbA6fcG5RQdqSc/htmlview#gid=0. 2020. 4. BrebanR,VardavasR,BlowerS.Theoryversusdata:howtocalculateR0?PLoS One. 2007;2(3):e282. 5. Murray CJ. Forecasting COVID-19 impact on hospital bed-days, ICU-days, ventilator-days and deaths by US state in the next 4 months. medRxiv. 2020 Mar. 30. 6. Dana S, Simas AB, Filardi BA, Rodriguez RN, Valiengo LLC, Gallucci-Neto J. Brazilian modeling of COVID-19 (BRAM-COD): a Bayesian Monte Carlo approach for COVID-19 spread in a limited data set context. medRxiv. 2020 May 17. 7. Worldometer.CoronavirusCases;2020.[citado20abr.2020].Disponívelem: https://www.worldometers.info/coronavirus/coronavirus-cases/. 8. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 inWuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. 9. YaoH, Lu X, ChenQ, Xu K, Chen Y, Cheng L, et al. . Patient-derivedmutations impact pathogenicity of SARS-CoV-2. medRxiv. 2020 Apr. 23. 10. Ministério da Saude. Painel Coronavírus. Rio de Janeiro, DF: Ministério da Saúde;2020.[citado20abr.2020].Disponívelem: https://covid.saude.gov.br/ . 11. Brasil.PortaldaTransparência[Internet].EspecialCOVID-19.PainelRegistral; 2020.[citado20abr.2020].Disponívelem: https://transparencia.registrocivil. org.br/especial-covid. 12. Fiocruz. Info Gripe [Internet]. Rio de Janeiro: Fiocruz; 2020. [citado 20 abr. 2020]. Disponível em: http://info.gripe.fiocruz.br/. 13. Lai S, Ruktanonchai NW, Zhou L, Prosper O, LuoW, Floyd JR, et al. Effect of non-pharmaceutical interventions to contain COVID-19 in China. Nature. 2020.[Epub ahead of print]. 14. Lopes B. Milton Friedman, a história de um lápis: A perspectiva e a lição que talvez passou despercebido; 2018. [citado 20 abr. 2020]. Disponível em: https://medium.com/@brunolopes_61254/milton- friedman-a-hist%C3%B3ria-de-um-l%C3%A1pis-a-perspectiva-e-a- li%C3%A7%C3%A3o-que-talvez-passou-despercebido-500de4c7a84a. 15. Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage. Eur Heart J. 2020;41(19):1852-3. 16. BalkM, Gomes HB, Quadros AS, Saffi MAL, Leiria TLL. Comparative analysis between transferred and self-referred STEMI patients undergoing primary angioplasty. Arq Bras Cardiol. 2019;112(4):402-7. 17. Oliveira LMSM, Costa IMNBC, Silva DGD, Silva JRSS, Barreto-Filho JAS, Almeida-Santos MA, et al. Readmission of patients with acute coronary syndrome and determinants. Arq Bras Cardiol. 2019;113(1):42-9. 18. McQueenie R, Ellis DA, McConnachie A, Wilson P, Williamson AE. Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study. BMC Med. 2019;17(1):2. References the population concerned and without proper preparation. The decision of what to do and at what point in the pandemic is crucial so that we do not turn the goal of saving lives into a merely appealing pitch with consolidated results that result in more deaths than lives saved. The second and third order effects that occur in any therapy can often be more harmful than the treatment itself, especially when it is carried out without proper planning. Very common in situations where centralization tries to simplify extremely complex processes that involve multiple chains (as we have in a famous example of pencil making), 14 the final effect can be exactly the opposite of what we are pursuing. And here we have several situations where an unnecessary extension of confinement measures can lead to a greater number of deaths than from the disease itself. As of writing this, the number of deaths from Covid-19 in Brazil is about 10,000 patients and we have almost 45 days of isolation. Due to an expected 30% reduction in primary angioplasty surgeries, increased transfer times and rehospitalizations due to untreated acute coronary syndromes, 15–17 an excess of cardiovascular deaths of over 3,000 is estimated in this period. Missing outpatient visits of various specialties increases the risk of death by up to 1.5 times, adding to this excess another 9,000 unnecessary deaths. 18 The 1% increase in unemployment or the drop in Gross Domestic Product alone is associated with an increase in deaths of up to 1.63 times in the economically active population, adding another 3,500 excess deaths to this amount. 19 Mortality calculations due to failure of therapies for neoplasms and misdiagnoses in Brazil do not yet exist, but in the USA and England, excess deaths were estimated at 34,000 and 6,000 respectively. 20 All of these deaths are associated with several causes, mainly due to the lack of timely access to overburdened healthcare systems solely focused on one cause of mortality. These will be the invisible deaths of the pandemic and isolation because they were not predicted as the side effects to single-point measures. What will come in the next weeks and months is beyond the views expressed here and will depend, to a great extent, on how we will choose to defuse this health crisis, sooner or later. Expensive spending on chronic diseases is likely to increase dramatically in the coming months, 21 overburdening a government already in debt. Unemployment and declining income will lead many Brazilians to migrate to a Public Healthcare System already burdened from the demand repressed over these months. At the same time, other solutions to increase the efficiency of the systems will be improved as they have been in this short period of time, such as digital prescriptions and telemedicine. 22 This increase in medical productivity can partly alleviate these increases in demand and costs, making our healthcare system to demonstrate the resilience and effectiveness that has made us to witness a mortality per million up to 10 times less than other European countries at the same stage of the disease, despite all our difficulties. What we do know is that we will be ready for new challenges, as optimists have always surprised us as to how human inventiveness is capable of overcoming obstacles. 990