Although clinical manifestations of COVID-19 are mainly respiratory, the virus also affects other organs, especially the cardiovascular system. The latest research suggests that in some cases, a cardiac arrhythmia occurs. Even health facilities with limited capacities can now quickly implement long-term ECG monitoring to follow up on possible cardiological events, and monitor patients with pre-existing diseases, or recovered ones with mild symptoms.
Cardiovascular complications
The National Health Commission of China (NHC) has reported that among all cases of coronavirus, cardiovascular symptoms were the first manifestation of the disease in many patients1. According to studies, they are associated with poorer outcomes – it has been reported that patients with pre-existing cardiovascular conditions have had the highest morbidity (10.5%) following COVID-19 infection2.
The most common cardiovascular complications include arrhythmias: atrial fibrillation, ventricular tachyarrhythmia, and ventricular fibrillation; cardiac injury, myocarditis, heart failure, pulmonary embolism, and disseminated intravascular coagulation (DIC)3. The etiology of cardiovascular disorders varies from hypoxia, catecholaminergic stress, ACE2 downregulation and activation of the sympathetic nervous system to myocardial inflammation and toxic effects of drugs – all these factors predispose patients to cardiac arrhythmias4.
Studies: supraventricular and ventricular arrhythmias
Hypoxemia caused by COVID-19 can trigger atrial fibrillation (AF), which is one of the most common critical comorbidities. In several studies, the estimated prevalence of AF was 10% in intensive care unit (ICU) patients5. AF may deteriorate cardiac output and is strongly associated with worse outcomes and higher mortality in a group of patients who have tested positive for SARS-CoV-2.
In a published clinical cohort of 138 hospitalized patients with COVID‐19, Wang et. al observed that 16.7% of patients developed arrhythmia. It was the second most severe complication after ARDS (acute respiratory distress syndrome) and was also more frequent in ICU patients (44.4% vs. 6.9%; P < .001)6.
Another study evaluating 148 patients reported that almost one-tenth developed arrhythmia. This concerned 7% of patients who did not require ICU treatment and 44% of intensive care patients. Groups were not divided according to the type of arrhythmia7.
A retrospective, observational study of 85 fatal cases of COVID-19 revealed that most of the patients had noncommunicable chronic diseases (hypertension, diabetes, coronary heart disease) and died of multiple organ failure. Among other complications, 60% of patients developed an arrhythmia. However, malignant arrhythmias have rarely been the cause of death (2.47% of all patients)8.
A study by Colon et al., including 115 patients with COVID-19, revealed that 16.5% of them developed atrial tachyarrhythmia. Arrhythmias were reported in 27.5 % of ICU patients – 12 of them had atrial fibrillation, six patients developed atrial flutter, and there was one patient with atrial tachycardia. The patients in this group tended to be older and had higher concentrations of CRP and D-dimer, but there was no difference in BP values compared to patients without rhythm disorders9. Moreover, there was no correlation between ST-segment abnormalities or high-sensitive troponin level and arrhythmia, which is in contrast to a study by Guo et al. in which patients with elevated TnT levels had more frequent malignant arrhythmias (11.5% vs. 5.2%), including ventricular tachycardia and ventricular fibrillation10.
Based on the results of both studies, there is no doubt that cardiac arrhythmias are often followed by hemodynamic deterioration. Colon et al. showed a relationship between the need for mechanical ventilation and the occurrence of rhythm disorders (p = 0.0002). Furthermore, patients with atrial arrhythmias required significantly longer vasopressor treatment and a higher dose of noradrenaline than others. The duration of atrial tachyarrhythmias was 6.9 + 7.3 days, and the mortality rate was 26.3% (5 patients)9.
Drug side effects can also be a cause of rhythm disorders. Antimalarial drugs chloroquine and hydroxychloroquine have both been tested on COVID-19 patients. Long-term medication of antimalarial drugs may increase depolarization length duration, leading to atrioventricular nodal and/or His system malfunction. Hydroxychloroquine can also induce QT interval prolongation, which can lead to polymorphic VT (torsade de pointes) and even sudden cardiac death4,11. For this reason, all patients, especially those with cardiovascular disorders, renal dysfunction, or electrolyte imbalance, require constant monitoring.
According to studies, antiviral drugs such as remdesivir, lopinavir, and interferon 2b, can also contribute to rhythm disorders12. A published case report showed that significant QT prolongation (620ms) in a patient treated with levofloxacin, hydroxychloroquine, and azithromycin can be successfully managed with intravenous lignocaine13.
Conclusion
A growing number of studies and case reports indicate that COVID-19 infection is associated with rhythm disorders, particularly in patients with several cardiac comorbidities. Advanced inflammation, significant myocardial damage and electrolyte disturbances all exacerbate arrhythmic risk and may worsen the patient’s prognosis. Myocardial biomarkers in all patients need to be controlled because they can be used to estimate the patient’s risk and determine the best treatment option.
Reliable cardiological monitoring for patients with COVID-19
The impact of COVID-19 on the development of cardiovascular diseases requires further study, but the results already available suggest that patients should be regularly tested for arrhythmia. Unfortunately, in reality, it is not always feasible.
Infectious disease hospitals do not always have adequate human resources. In recent months, we have experienced that the capacity of many facilities has been approaching its limits. Due to the rapid spread of coronavirus and the need to protect medical personnel, work automation has been introduced where possible.
AI systems for automatic analysis of ECG records are helpful in the rapid detection of cardiac diseases, including arrhythmia. They save time for manual interpretation and do not require local hardware or software resources. Simply upload an ECG into the cloud-based Cardiomatics system to get the result within seconds.
Given the recent results, ECG analysis is also recommended for recovering patients with mild symptoms who don’t have to be hospitalized. With Cardiomatics, this is accessible in any healthcare facility. Request a trial to see how it works.
Bibliography
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[2] Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. J Am Coll Cardiol. 2020;75(18):2352-71.
[3] Guzik TJ, Mohiddin SA, Dimarco A, Patel V, Savvatis K, Marelli-Berg FM, et al. COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options. Cardiovasc Res. 2020.
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[8] Du Y, Tu L, Zhu P, Mu M, Wang R, Yang P, et al. Clinical Features of 85 Fatal Cases of COVID-19 from Wuhan. A Retrospective Observational Study. Am J Respir Crit Care Med. 2020;201(11):1372-9.
[9] Colon CM BJ, Chiles JW, McElwee SK, Russell DW, Maddox WR,, GN K. Atrial Arrhythmias in COVID-19 Patients. JACC: Clinical Electrophysiology. 2020.
[10] Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020.
[11] Carpenter A, Chambers OJ, El Harchi A, Bond R, Hanington O, Harmer SC, et al. COVID-19 Management and Arrhythmia: Risks and Challenges for Clinicians Treating Patients Affected by SARS-CoV-2. Front Cardiovasc Med. 2020;7:85.
[12] Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-7.
[13] Mitra RL, Greenstein SA, Epstein LM. An algorithm for managing QT prolongation in coronavirus disease 2019 (COVID-19) patients treated with either chloroquine or hydroxychloroquine in conjunction with azithromycin: Possible benefits of intravenous lidocaine. HeartRhythm Case Rep. 2020.