key: cord-0841941-g5rvzqq6 authors: Pietro, Riccardo Di; Calcagno, Simone; Biondi-Zoccai, Giuseppe; Versaci, Francesco title: Is COVID-19 the deadliest event of the last century? date: 2021-05-17 journal: Eur Heart J DOI: 10.1093/eurheartj/ehab083 sha: 71e5c2d4618fd0aa7285a36f1f8a51f56dcded47 doc_id: 841941 cord_uid: g5rvzqq6 nan Cicero's quote poignantly embodies history as a life. Despite the passing of more than 2000 years, this statement is still relevant today. Indeed, according to people born in the second half of the 20th century, the most grievous cause of loss of lives was Second World War (World War II, WWII), with 75 million deaths between 1939 and 1945 ( Figure 1 ). 1 But this global war was not the worst cause of fatalities of the last century ( Table 1) . Before WWII, in 1918, the Spanish flu due to the H1N1 virus was the deadliest pandemic in human history. 2 Its death toll is typically estimated to be between 50 and 100 million during only 12 months, divided in four main waves. It is true that there have been other pandemics since 1918, but none of them as disastrous as the Spanish flu. From these pandemics the world learned several lessons and measures to deal with them, including social distancing, wearing masks, avoiding public gatherings, caring for health care professionals, quarantine, and isolation. 3 Luckily, after WWII, there were no more global conflicts, and this time lapse could be due to the awareness of state leaders of the necessity of avoiding a world conflict, especially after the advent of nuclear weapons. Evidently, a current war would express a human madness of even greater magnitude than the ones from the past. Until 2019, it was thought that the lessons of the H1N1 pandemic had provided us appropriate knowledge for the management of new pandemics, just like what happened in 2003 with severe acute respiratory syndrome (SARS). Yet, 2020 clearly invalidated this theory. On 31 December 2019, the Wuhan Municipal Health Commission in Wuhan City, Hubei Province, China, reported a cluster of pneumonia cases (including seven severe cases) of unknown aetiology, with a common reported link to Wuhan Huanan Seafood Wholesale Market, a wholesale fish and live animal market ( Figure 2) : it was the beginning of a new pandemic. 4 The International Committee on Taxonomy of Viruses announced severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) to be the name of the new virus on 11 February 2020 and, on the same date, the World Health Organization (WHO) announced that the disease caused by the novel coronavirus would be named COVID-19 (COronaVIrus Disease 19). 5 It took 3 months, more than 148 000 total cases of COVID-19 and more than 4000 deaths before WHO explicitly stated that COVID-19 should be characterized as a pandemic. From March 2020, governments have decided independently for the use of patient isolation, social distancing, face masks, and local/ regional/national lockdowns in order to contain and mitigate the diffusion of SARS-COV2. In April 2020, the New England Journal of Medicine highlighted the risk of transmission with aerosols and fomites, and WHO provided clear recommendations for masks in healthcare and community settings. Nevertheless, in 12 months of pandemic due to SARS-COV2, the world counts more than 100 million cases and almost 3 million deaths. 6 It would seem that the most frequent cause of deaths since December 2019 is COVID-19, given its high contagiousness and capability to cause severe disease, especially in the elderly and the frail. 7 Despite the dreadfulness of infectious diseases, other factors also continue to heavily impact on the global burden of disease. For instance, environmental changes and social conditions have increased the prevalence of what once were relatively obscure ailments, e.g. myocardial infarction and lung cancer, and according to the latest data from WHO, cardiovascular disease (CVD) is still the first cause of death globally, taking an estimated 18 million lives every year: more than any war or pandemic! In the current COVID-19 era, mass media are encouraging 'stay-athome' policies, with healthcare systems reducing elective procedures and surgeries. Collectively, such strategies have resulted in an important decrease in the number of patients admitted for non-COVID-19 conditions. Accordingly, reductions in admissions for acute STelevation myocardial infarction (STEMI) have been evident, together with increases in out-of-hospital cardiac arrests and late presentations of STEMI (including those complicated by cardiogenic shock, apical thrombus, or wall rupture) ( Figure 3) . 8, 9 There are a lot of COVID-19related reasons that may explain the declining incidence of STEMI, both in a positive and negative way. For instance, favourable lifestyle changes may include remote work and education, with lower stress burden. Most importantly, lockdowns have dramatically reduced industrial activities, traffic, and pollution, an established precipitant of STEMI. 10 Lastly, closure of restaurants and non-essential services may possibly have improved diets by controlling salt intake, decreasing consumption of fried foods, and increased uptake of fruits and vegetables. Conversely, patient fear of contracting COVID-19 in hospitals may force individuals to stay at home even when symptomatic, forcibly underestimating their symptoms. Despite these arguments, to date, there are no conclusive data to definitively explain the reduction in hospital admissions for acute coronary syndromes, and clarifying whether this is expression of prevention or consequence of an indirect increase in deaths from CVD. The latter scenario would unfortunately make the COVID-19 pandemic even more cruel than we currently know. Similarly, the post-COVID-19 era (hopefully foreseeable given the ongoing vaccination campaign) remains difficult to predict, especially in terms of impact on and of CVD. In conclusion, the winner for the worst massacre award of the last 100 years is not yet known. Only history will reveal it, being the teacher of life for the umpteenth time. Two faces of death: fatalities from disease and combat in America's principal wars, 1775 to present Mortality burden of the 1918-1919 influenza pandemic in Europe Post-COVID-19 precautions based on lessons learned from past pandemics: a review SARS-CoV-2 and COVID-19: facing the pandemic together as citizens and cardiovascular practitioners WHO Director-General's opening remarks at the media briefing on COVID-19 -11 COVID-19 Dashboard by the Center for Systems Science and Engineering Extracorporeal membrane oxygenation for critically ill patients with coronavirus-associated disease 2019: an updated perspective of the European experience ST-elevation myocardial infarction in the COVID-19 era Indolfi C; Societ a Italiana di Cardiologia and the CCU Academy Investigators Group. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era Air pollution, climate changes and cardiovascular diseases: a nightmare threesome Conflict of interest: G.B.-Z. has consulted for Cardionovum, Bonn, Germany, Innovheart, Milan, Italy, Meditrial, Rome, Italy, and Replycare, Rome, Italy.