COVID-19 and cardiac arrhythmias: a global perspective on arrhythmia characteristics and management strategies

Abstract

Background Cardiovascular and arrhythmic events have been reported in hospitalized COVID-19 patients. However, arrhythmia manifestations and treatment strategies used in these patients have not been well-described. We sought to better understand the cardiac arrhythmic manifestations and treatment strategies in hospitalized COVID-19 patients through a worldwide crosssectional survey. Methods The Heart Rhythm Society (HRS) sent an online survey (via SurveyMonkey) to electrophysiology (EP) professionals (physicians, scientists, and allied professionals) across the globe. The survey was active from March 27 to April 13, 2020. Results A total of 1197 respondents completed the survey with 50% of respondents from outside the USA, representing 76 countries and 6 continents. Of respondents, 905 (76%) reported having COVID-19-positive patients in their hospital. Atrial fibrillation was the most commonly reported tachyarrhythmia whereas severe sinus bradycardia and complete heart block were the most common bradyarrhythmias. Ventricular tachycardia/ventricular fibrillation arrest and pulseless electrical activity were reported by 4.8% and 5.6% of respondents, respectively. There were 140 of 631 (22.2%) respondents who reported using anticoagulation therapy in all COVID-19-positive patients who did not otherwise have an indication. One hundred fifty-five of 498 (31%) reported regular use of hydroxychloroquine/chloroquine (HCQ) + azithromycin (AZM); concomitant use of AZM was more common in the USA. Sixty of 489 respondents (12.3%) reported having to discontinue therapy with HCQ + AZM due to significant QTc prolongation and 20 (4.1%) reported cases of Torsade de Pointes in patients on HCQ/chloroquine and AZM. Amiodarone was the most common antiarrhythmic drug used for ventricular arrhythmia management. Conclusions In this global survey of > 1100 EP professionals regarding hospitalized COVID-19 patients, a variety of arrhythmic manifestations were observed, ranging from benign to potentially life-threatening. Observed adverse events related to use of HCQ + AZM included prolonged QTc requiring drug discontinuation as well as Torsade de Pointes. Large prospective studies to better define arrhythmic manifestations as well as the safety of treatment strategies in COVID-19 patients are warranted.

A case of complete heart block in a COVID-19 infected patient

“…There have only been few reported cases of complete heart block [4,5]. It is difficult to determine if cardiac arrhythmias that are reported in patient cohorts are related to myocarditis, electrolyte abnormalities, or medication side effects as many of the medications administered to treat the infection are associated with arrhythmia [6]. This patient presented with complete heart block and was not given any therapeutics for COVID-19 prior to her hospitalization suggesting a different etiology causing her heart block.…”

“…Cardiac arrhythmias have been reported in association with cardiac injury [2,4,5]. In a large physician survey predominantly involving electrophysiologists, sinus bradycardia and complete heart block were the most observed bradyarrhythmia in hospitalized patients [6]. The exact mechanism as to how COVID-19 causes cardiac injury remains unclear.…”

Arrhythmia in COVID-19

“…Atrial fibrillation was the most common cardiac arrhythmia observed in patients with COVID-19 infection according to one survey [27]. The mechanisms that might cause atrial fibrillation in these patients are possibly due to systemic infection, direct viral cardiomyocyte injury, hypoxemia, and susceptibility of the population due to advanced age and their comorbidities, and, finally, sympathetic nervous system overactivity [28].…”

Tyrosine Kinase Inhibitors Play an Antiviral Action in Patients Affected by Chronic Myeloid Leukemia: A Possible Model Supporting Their Use in the Fight Against SARS-CoV-2

“…The efficacy of chloroquine and hydroxychloroquine, which act as immunomodulating agents by modifying the pH of endocytic vesicles (so blocking the first infection phases), is a matter of debate. Indeed, several studies focused their attention on the increased risk of prolongation of QTc and possible onset of arrhythmias that these compounds, especially in combination with antibiotics, seem to induce (13). On the other hand, a meta-analysis conducted on nine different studies sustained the efficacy of these drugs (14).…”