ABC | Volume 114, Nº6, June 2020

Viewpoint Acute Coronary Syndromes in the Current Context of the Covid-19 Pandemic Raphael Boesche Guimarães, 1 Breno Falcão, 2,3 Ricardo Alves Costa, 4,5 Marcelo Antônio Cartaxo Queiroga Lopes, 6 Roberto Vieira Botelho, 7 Ricardo Petraco, 8 Rogério Sarmento-Leite 1,9,1 0 Instituto de Cardiologia, 1 Porto Alegre, RS - Brazil Hospital de Messejana, 2 Fortaleza, CE - Brazil Hospital Universitário Walter Cantídeo, 3 Fortaleza, CE - Brazil Instituto Dante Pazzanese de Cardiologia, 4 São Paulo, SP - Brazil Hospital Sírio-Libanês, 5 São Paulo, SP - Brazil Hospital Alberto Urquiza Wanderley, 6 João Pessoa, PB - Brazil Instituto do Coração do Triângulo, 7 Uberlândia, MG - Brazil Imperial College London, 8 Londres, Inglaterra Hospital Moinhos de Vento Porto Alegre, 9 RS - Brazil Universidade Federal de Ciências da Saúde de Porto Alegre, 10 Porto Alegre, RS - Brazil Introduction COVID-19, initially described at the end of 2019 in China, may present as atypical pneumonia and severe respiratory failure. 1 Classified in February 2020 as a pandemic 2 by the World Health Organization (WHO), COVID-19 has had major clinical, social, political and economic implications. Society as a whole has had to adapt to a new reality, forcing hospitals to rewrite their routine practices and clinical pathways. Specific measures have had to be put in place to prevent hospital transmission of the infection. Also, dedicated COVID units have been set up and infection control protocols implemented. Finally, additional human, material and financial resources have been allocated in order to provide patients with the best possible care, without compromising the safety of healthcare workers. Social isolation as a way of containing the spread of the disease may have helped, in some places, to “flatten the curve”, preventing the collapse of healthcare systems. However, the duration of the pandemic, as well as the precise risk of transmission are still largely unknown. Typical symptoms of COVID-have been described 3,4 and most infected patients present with mild viral syndromes. As a result, and as part of social distancing measures, patients are recommended to seek hospital care only in case of severe symptoms. This policy has, on the other hand, has generated a widespread reluctance by the population to go to hospitals, for fear of being exposed to the virus in healthcare settings. As a result, diagnosis, treatment and prognosis of several other clinical conditions have been unintentionally impacted. This applies to cardiology and, particularly, to Acute Coronary Syndromes (ACS), a phenomenon described globally. 5 Furthermore, individuals who are over 60 years old and those with previous cardiovascular or respiratory disorders are more likely to develop severe forms of COVID-19, with increased cardiovascular compromise during the infection course, such as myocarditis, type II infarctions and thromboembolic phenomena. 6,7 International Experiences Experiences shared from countries in which the COVID-19 infection wave preceded ours indicate important associations between COVID-19 and cardiovascular disease. COVID-19 patients with established cardiovascular disease and those with hypertension and diabetes represent about 40% of the severe cases and have a worse prognosis. 8 These groups have a much higher fatality rate – 7.3-10.5% compared to 2.3% for the general population 9 . Cardiac manifestations attributed to COVID-19 have also been reported, with arrhythmias occurring in 16.7% and acute myocardial injury in up to 7% of hospitalized cases. 10,11 In addition to these direct associations, the “side effects” of the COVID-19 pandemic in the care of acute coronary syndromes have generated concern. There was a sharp drop in the search for cardiac emergency room care by patients with ACS, possibly related to the fear of contracting infections in the hospital environment, which can result in underdiagnosis and inadequate treatment, with risk of death and long-term morbidity. 12,13 In addition, delays in primary angioplasty have been reported, with complications of late-presenting myocardial infarction having been described. 14 National campaigns targeted to raise awareness of ACS symptoms have been put in place internationally, advising patients to seek help quickly in case of suspected cardiac emergencies. 15 Telemedicine is a facilitating tool for such complex COVID-19 circumstances, as it has the potential to allow the physician to remotely recognize suspected symptoms of acute coronary syndrome and guide the patient to seek care immediately. In addition, it allows pre-hospital diagnosis of Mailing Adress: Rogério Sarmento-Leite • Instituto de Cardiologia - Avenida Princesa Isabel, 395. Postal code 90620-000, Porto Alegre, RS – Brazil rsl.sarmento@gmail.com Manuscript rcivd April 21, 2020, revisd manusript April 24, 2020, acptd April 29, 2020 Keywords Acute Coronary Syndrome/complications; Coronavirus; COVID-19; Pandemics; Acute Myocardial Infarction/ prevention and control; Telemedicine/trends; Quarantine. DOI: https://doi.org/10.36660/abc.20200358 1067