ABC | Volume 114, Nº6, June 2020

Case Report Ritt et al. COVID-19 and cardiac collateral damage Arq Bras Cardiol. 2020; 114(6):1172-1075 attendance upon arrival at the hospital may be optimized by internal movement and protocol, time to arrival at the hospital depends almost exclusively on patients’ perception and evaluation of symptoms. The SARS-CoV-2 pandemic has introduced other perspectives to this pathological approach, considering the potential risk of contamination in a hemodynamic environment, with procedures that may require more invasiveness, with inadequate environment for controlling the spread of the virus and guaranteeing the safety of healthcare professionals. 3 A recent publication from the epicenter of the pandemic weighs the possibility of thrombolytic therapy for confirmed cases with respiratory symptoms of the disease. 4 The reported case illustrates another scenario within the SARS-CoV-2 pandemic, which is as concerning as the pandemic itself. Previously published studies during other viral epidemics have suggested an increase in the occurrence of myocardial infarction, with a greater propensity for inflammation and plaque instability, 5 and this also appears to be the rationale for SARS-CoV-2 infection. 6 Nonetheless, reports in different world centers point to a reduction in the frequency of hospital admission due to infarction, with an observational study indicating a 40% decrease in attendance for STEMI, with a slight increase in the rate of thrombolysis. 7 This paradoxical decline may be associated with a reduction in the number of patients seeking emergency care units, faced with fear generated by the pandemic, eventual doubts regarding symptoms associated with ACS and SARS-CoV-2 infection, and logistical issues related to healthcare caused by the collapse of the healthcare system. In our service, for instance, 21 patients were attended in the emergency room following the protocol for chest pain between March 20 and April 8, 2020; this is compatible with a 74% relative reduction with respect to the same period in 2019 and a 72% relative reduction with respect to the same period in 2018. A case series from a single center for attending AMI in Hong Kong demonstrated a significant delay in providing care to these patients in comparison with a historical series from the previous year, with an increase in median time for all indicators of quality of care analyzed, especially time from onset of symptoms to first medical contact (318 minutes, IIQ 75 – 458 vs. 82.5 minutes, IIQ 32.5 – 195). 8 Suspension of angiotensin converting enzyme inhibitors/ angiotensin receptor blockers and risk of events The patient in question had suspended use of ARB of his own accord. Although we cannot define a causal nexus between this suspension and the occurrence of AMI, it is known that discontinuation of anti-hypertensive medications may contribute to greater occurrence of ACS. 9 The type 2 angiotensin-converting enzyme (ACE-2) appears to be involved in the internalization mechanism of SARS-CoV-2 on the tissue level. This information has led to speculation that users of angiotensin-converting enzyme inhibitors (ACEI) or ARB may have a greater likelihood of becoming infected due to ACE-2 upregulation. There are no published clinical data to prove this relationship apart frommechanistic observation, except the theoretical rationale. 10 Experimental models in animals have shown inconsistent effects of ACEI and ARB on levels of ACE-2 or its tissue activity. 11 Furthermore, cross- sectional studies in the fields of heart failure, atrial fibrillation, aortic stenosis, and coronary disease 12 resulted in similar ACE-2 plasma activity, regardless of whether ACEI and ARB were used or not. In addition to this, plasma levels of ACE-2 may not be reliable markers of the membrane-bound form, and there is a lack of evidence that modification of ACE-2 levels or tissue activity favor the penetration of SARS-CoV-2. In this scenario, the world’s leading cardiology societies have published informational updates, unanimously advising people to the maintain the use of these medications, given that the risk of rebound high blood pressure or decompensation of heart failure could lead to greater potential harm. 13 It is worth underscoring that some preliminary studies have even suggested that these medications may have a protective effect, reducing pulmonary inflammation. 14 Conclusion At this time, when everyone is concerned with the potential risks of the COVID-19 pandemic, we need to be aware and alert the population not to underestimate symptoms that are suggestive of cardiovascular events or risks related to delays in seeking emergency medical care. The direct harm of COVID-19 is at the center of media discussions and scientific publications, but the potential cardiovascular collateral damage related to delayed medical care in patients with acute vascular events should not go neglected. Author contributions Conception and design of the research: Ritt LEF, Viana MS, Darzé ES; Acquisition of data, Analysis and interpretation of the data and Writing of the manuscript: Ritt LEF, Viana MS, Feitosa GF, Oliveira AM, Souza FS, Darzé ES; Statistical analysis: Ritt LEF, Viana MS; Critical revision of the manuscript for intellectual content: Ritt LEF, Viana MS, Feitosa GF, Souza FS, Darzé ES. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors. 1074