Clinical and cardiac characteristics of COVID‐19 mortalities in a diverse New York City Cohort

Abstract

Introduction Electrocardiographic characteristics in COVID‐19‐related mortality have not yet been reported, particularly in racial/ethnic minorities. Methods and Results We reviewed demographics, laboratory and cardiac tests, medications, and cardiac rhythm proximate to death or initiation of comfort care for patients hospitalized with a positive SARS‐CoV‐2 reverse‐transcriptase polymerase chain reaction in three New York City hospitals between March 1 and April 3, 2020 who died. We described clinical characteristics and compared factors contributing toward arrhythmic versus nonarrhythmic death. Of 1258 patients screened, 133 died and were enrolled. Of these, 55.6% (74/133) were male, 69.9% (93/133) were racial/ethnic minorities, and 88.0% (117/133) had cardiovascular disease. The last cardiac rhythm recorded was VT or fibrillation in 5.3% (7/133), pulseless electrical activity in 7.5% (10/133), unspecified bradycardia in 0.8% (1/133), and asystole in 26.3% (35/133). Most 74.4% (99/133) died receiving comfort measures only. The most common abnormalities on admission electrocardiogram included abnormal QRS axis (25.8%), atrial fibrillation/flutter (14.3%), atrial ectopy (12.0%), and right bundle branch block (11.9%). During hospitalization, an additional 17.6% developed atrial ectopy, 14.7% ventricular ectopy, 10.1% atrial fibrillation/flutter, and 7.8% a right ventricular abnormality. Arrhythmic death was confirmed or suspected in 8.3% (11/133) associated with age, coronary artery disease, asthma, vasopressor use, longer admission corrected QT interval, and left bundle branch block (LBBB). Conclusions Conduction, rhythm, and electrocardiographic abnormalities were common during COVID‐19‐related hospitalization. Arrhythmic death was associated with age, coronary artery disease, asthma, longer admission corrected QT interval, LBBB, ventricular ectopy, and usage of vasopressors. Most died receiving comfort measures.

Electrocardiographic manifestations of COVID-19

“…Of the inferior leads, lead III frequently demonstrates the most obvious findings due to it direct imaging of the right ventricular muscle mass. Over 8% of deaths may be due to dysrhythmias in the setting of COVID-19 [ 39 ].…”

“…Both sinus tachycardia and atrial fibrillation are independent predictors of illness severity, myocardial injury, and poor outcomes in COVID-19 [ 40 ]. One study conducted in New York hospitals found atrial fibrillation/flutter was present in 14.3% of patients at admission and occurred in 10.1% of patients during hospitalization [ 39 ]. Another study found atrial fibrillation/flutter to be present in 22% of critically ill patients requiring mechanical ventilation [ 32 ].…”

“…Patients hospitalized with COVID-19 are at increased risk of cardiac arrest, but the rhythms associated with cardiac arrest vary in the inpatient population. A study focusing on hospitalized patients in New York City noted that asystole occurred most often, followed by PEA and then pulseless VT/VF [ 39 ]. Another study found 9 patients out of 700 experienced cardiac arrest, with only one having a shockable rhythm [ 57 ].…”

“…QT interval prolongation is associated with more critical illness requiring ICU admission, as well as cardiac injury and mortality [ 61 , 69 ]. Left and right bundle branch blocks may occur in up to 12% of patients at the time of admission or during hospitalization [ 32 , 39 ]. Significant QT interval prolongation may lead to torsade des pointes.…”

The State of Atrial Fibrillation in 2020

“…Recently, Abrams et al reported characteristics associated with mortalities during the initial phase of the pandemic in New York City. 5 Of the 133 patients among 1,258 total study participants who died, 14.3% presented with AF and an additional 10.1% subsequently developed AF during their hospital stay. This high incidence of AF in patients who ultimately experienced poor outcomes is consistent with reports suggesting that cardiac involvement in disease in general is associated with a poor prognosis.…”