Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is involved in a global outbreak affecting millions of people who manifest a variety of symptoms. Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is increasingly associated with cardiovascular complications requiring hospitalizations; however, the mechanisms underlying these complications remain unknown. Nitric oxide (NO) and hydrogen sulfide (H 2 S) are gasotransmitters that regulate key cardiovascular functions. Methods Blood samples were obtained from 68 COVID-19 patients and 33 controls and NO and H 2 S metabolites were assessed. H 2 S and NO levels were compared between cases and controls in the entire study population and subgroups based on race. The availability of gasotransmitters was examined based on severity and outcome of COVID-19 infection. The performance of H 2 S and NO levels in predicting COVID-19 infection was also analyzed. Multivariable regression analysis was performed to identify the effects of traditional determinants of gasotransmitters on NO and H 2 S levels in the patients with COVID-19 infection. Results Significantly reduced NO and H 2 S levels were observed in both Caucasian and African American COVID-19 patients compared to healthy controls. COVID-19 patients who died had significantly higher NO and H 2 S levels compared to COVID-19 patients who survived. Receiver-operating characteristic analysis of NO and H 2 S metabolites in the study population showed free sulfide levels to be highly predictive of COVID-19 infection based on reduced availability. Traditional determinants of gasotransmitters, namely age, race, sex, diabetes, and hypertension had no effect on NO and H 2 S levels in COVID-19 patients. Conclusion These observations provide the first insight into the role of NO and H 2 S in COVID-19 infection, where their low availability may be a result of reduced synthesis secondary to endotheliitis, or increased consumption from scavenging of reactive oxygen species.

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A 37-year-old gentleman with no significant past medical history presented to the emergency department with a two-week history of progressively worsening shortness of breath. Vital signs were stable on arrival and initial physical exam was remarkable for a high pitched early diastolic decrescendo murmur at the left lower sternal border. Further physical examination revealed bounding carotid pulses (consistent with Corrigan’s sign), and a systolic contraction and diastolic dilation of pupil (consistent with Landolfi’s sign). Brachial artery was noted to be tortuous and prominently pulsatile with a bruit audible on auscultation, consistent with locomotor brachii (panel A). Upon further evaluation using point of care ultrasound, diastolic flow reversal and double bruit (both systolic and diastolic) on compression, were noted on spectral Doppler tracing (panel B). Transthoracic echocardiography showed bicuspid aortic valve with flail leaflet and severe eccentric aortic insufficiency; thereby confirming the diagnosis of aortic regurgitation. The patient eventually underwent a surgical aortic valve replacement with mechanical valve.

Importance: Coronavirus disease 2019 is associated with a variety of arrhythmias. However, there are limited data regarding bradyarrhythmias and cardiac pauses in COVID-19. Objective: The objective was to characterize significant cardiac pauses in critically ill COVID-19 patients. Design: This was a case series of 26 consecutive patients with confirmed COVID-19 at an academic medical center in Shreveport, Louisiana. Setting: The study was conducted in the intensive care unit (ICU) and step-down ICU. Participants: Patients were either on mechanical ventilation or high-flow oxygen by nasal cannula. Main Outcomes and Measures: Demographic, clinical, laboratory, and medication data were analyzed. Continuous telemetry monitoring was utilized to record number, type, and duration of bradyarrhythmic events as well as their risk determinants. Results: The median age of the 26 patients was 49.5 years (range 33–78). Fifteen (57.7%) were men. Incidence of significant bradycardia and cardiac pauses, defined as an event, occurred in 11 (42.3%) patients. The median age of patients with an event was 57 years (range 33–66) and 5 (45.5%) were men. The average pause duration was 6.77 s with a range of 1.6–30 s. Five of 11 (45.5%) patients had high-grade atrioventricular (AV) nodal block. One patient required temporary pacemaker insertion for complete heart block and recurrent asystole arrests. A trend toward higher troponin I level in bradyarrhythmia patients was noted (mean troponin I was 2.72 ng/mL, [standard deviation] 4.48) compared to patients without event(s) (mean 0.42 ng/mL 0.52, P = 0.07). Conclusions and Relevance: Significant bradycardic events in critically ill patients with COVID-19 occurred in 42.3% of patients. This is the first case series of such events in COVID-19 patients. Increased awareness of these findings could affect management techniques and call for enhanced monitoring of such patients.