Covid-19 Pandemic and Cardiac Arrhythmia

Dr M Belhameche*

Corresponding Author: Dr M Belhameche, GHEF Marne le vallée Rhythmology Unit.

Copy Right: © 2022 Dr M Belhameche, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: May 28, 2022

Published Date: June 10, 2022

Introduction

The Covid -19 pandemic, has affected the whole world.

The clinic manifestations are primarily respiratory with an acute respiratory distress syndrome (ARDS).

But this virus can affect different organs including the heart with rhythmic complications.

Epidemiology: (54)
This pandemic has affected more than 500 million people worldwide. And was responsible for the deaths of more than 6 million.

Incidence of cardiac arrhythmia (2,3,8,32)

• The incidence of rhythm and conduction disorders during Covid-19 infection is estimated at 17% ( 11% if it's the Omicron virus)  of hospitalized patients. It is 44% of patients hospitalized in intensive care unit (ICU) .

• Atrial fibrillation represents the most frequent arrhythmia with more than 50% depending on the series (40 to 70%). After these are ventricular arrhythmia with an average frequency of 15%,  and in the third  conductive disorders.

Number of events according intensive care unit (ICU) hospitalization or non (ICU):

(2,3,,15,18,24,25,32)

Arrhythmias are very frequent hospitalization in intensive care, testifying to the seriousness of their existence during this condition. Here is a study byAssociation of intensive care unit (ICU) status and cardiac arrhythmias. The odds ratios (and 95% confidence intervals) of ICU admission and specified cardiac arrhythmias are depicted. The dashed vertical red line represents an odds ratio 5 1. Unadjusted models have a blue marker. Multivariable models (black marker) were adjusted for age, sex, race, body mass index, heart failure, coronary heart disease, diabetes, hypertension, chronic kidney disease, and hydroxychloroquine treatment. NSVT 5 non sustained ventricular tachycardia.

Prognosis of cardiac arrhythmia in patient with covid-19:

The prognosis is poor if an arrhythmia is associated with covid-19. these arrhythmias are a marker of the severity of the viral attack linked to several mechanisms.

• According to the series, mortality can reach 80%, especially in ICU patients.
• Direct attack by the virus (myocarditis or pericarditis).

Indirect harm :

• Severe hypoxemia (ARDS).
• Severe inflammatory reaction(cytokine storm).

Hydroelectrtolytic disorder and or medications.

Risk of death according to age in Covid-19:(21,40,41,44).
The mortality rate is higher in the age group between 50 and 70 years. It is between 16% (16 patients out of 102) in the age group 50 to 60 years and 26% (23 patients out of 89) in the age group between 60 and 70 years.

Evolution of the disease after infection with the virus and Cardiac arrhythmia mecanisme. (15,18)

Once infected by the virus, there are 3 evolutionary phases in the mechanism of the appearance of complications, in particular cardiac arrhythmias.

1. phase of contact with the virus of 5 days.

2. Phase of onset of respiratory disorders with 5-day hypoxemia.
3. Inflammatory phase with cytokine storm with multi-organ damage lasting 5 days.

Inflammatory mechanism ( cytokine storm):(9,10,12,13,14,18,21,26,32,39).

There are two mechanisms

• A direct mechanism or direct attack by the pulmonary and myocardial virus (fibroblast and myocytes).

An indirect inflammatory mechanism through cytokines. This inflammation can trigger a cytokine storm with hepatic and central nervous system damage as described in this table.

Electrocardiographic aspects:(15,16,36,37,46,47)

Sinus dysfunction (bradycardia).

Sinus tachycardia.

Supra ventricular tachycardia.

Atrial fibrillation or atrial flutter.

Ventricular premature complexes and nonsustained VT.

Conduction disturbances (AVB/BBB).

Polymorphic ventricular tachycardia (torsade de pointe).

Unstable ventricular tachycardia or ventricular fibrillation.

Management of arrhythmias: (16,18,19,20)

The management of cardiac arrhythmias linked to covid 19 is no different from those in patients without covid. There are, however, a few additional means to consider:

   - Treatment of hypoxemia.

   - Treatment of fever.

   - Treatment of electrolyte disorders related to vomiting and diarrhea.

   - Consider antibiotic treatment responsible for QT prolongation.

   - Specific considerations for management cardiac arrhythmia :

• Rate control for management minimise the risck of QTc prolongation.
• Implantation temporary pace maker for bradycardie or atrioventricular block.
• External electric shock sometimes ciculatory assitance (ECMO) to better oxygenate the patient and put the heart at rest.
• The medical treatment  is the same as for non-Covid.

Conclusion

• Heart rhythm disorders are common in infection with the covid 19 virus.
• There mechanism is multifactorial.
• Their prognosis is poor with a high mortality rate testifying to the seriousness of the infection.
• Their management is the same apart from a few considerations.

References

 1.Covid-19 et maladies cardiovasculaires : des liaisons dangereuses Communique? de l’Académie nationale de médecine 28 février 2022

2. Management mecanisme epidemiology Arrhythmias in the COVID-19 patient Michael P. Lavelle, MD,1 Amar D. Desai, BS, MPH,1 Elaine Y. Wan, MD, FACC, FAHA, FHRS Heart Rhythm O2, Vol 3, No 1, February 2022

3. COVID-19 and cardiac arrhythmias Anjali Bhatla, BA,*1 Michael M. Mayer and All epidemiology, prognostic, toutes les courbes UCU et mortalite

4. Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination  PCORnet, United States, January 2021–January 2022 Jason P. Block, MD1

5. US Department of Health and Human Services/Centers for Disease Control and Prevention Vaccination

6.  Boehmer TK, Kompaniyets L, Lavery AM, et al. Association between COVID-19 and myocarditis using hospital-based administrative data— United States, March 2020–January 2021. MMWR Morb Mortal Wkly Rep 2021;70:1228–32. PMID:34473684 https://doi.org/10.15585/ mmwr.mm7035e5

7. Barda N, Dagan N, Ben-Shlomo Y, et al. Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting. N Engl J Med 2021;385:1078–90. PMID:34432976 https://doi.org/10.1056/ NEJMoa2110475

8. Forrest CB, McTigue KM, Hernandez AF, et al. PCORnet® 2020: current state, accomplishments, and future directions. J Clin Epidemiol 2021;129:60–7. PMID:33002635 https://doi.org/10.1016/j. jclinepi.2020.09.036

9. Yousaf AR, Cortese MM, Taylor AW, et al.; MIS-C Investigation Authorship Group. Reported cases of multisystem inflammatory syndrome in children aged 12-20 years in the USA who received a COVID-19 vaccine, December, 2020, through August, 2021: a surveillance investigation. Lancet Child Adolesc Health 2022;S2352- 4642(22)00028-1. PMID:35216660 https://doi.org/10.1016/ S2352-4642(22)00028-1

10. Feldstein LR, Rose EB, Horwitz SM, et al.; Overcoming COVID-19 Investigators; CDC COVID-19 Response Team. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020;383:334–46. PMID:32598831 https://doi.org/10.1056/ NEJMoa2021680

11. Klein NP, Lewis N, Goddard K, et al. Surveillance for adverse events after COVID-19 mRNA vaccination. JAMA 2021;326:1390–9. PMID:34477808 https://doi.org/10.1001/jama.2021.15072

12. Witberg G, Barda N, Hoss S, et al. Myocarditis after Covid-19 vaccination in a large health care organization. N Engl J Med 2021;385:2132–9. PMID:34614329 https://doi.org/10.1056/NEJMoa2110737

13. Oster ME, Shay DK, Su JR, et al. Myocarditis cases reported after mRNA-based COVID-19 vaccination in the US from December 2020 to August 2021. JAMA 2022;327:331–40. PMID:35076665 https:// doi.org/10.1001/jama.2021.24110

14. Vidula MK, Ambrose M, Glassberg H, et al. Myocarditis and other cardiovas- cular complications of the mRNA-based COVID-19 vaccines. Cureus 2021; 13:e15576.

15. Gupta MD, Qamar A, MP G, et al. Bradyarrhythmias in patients with COVID-19: a case series. Indian Pacing Electrophysiol J 2020;20:211–212.

16. Lakkireddy DR, Chung MK, Gopinathannair R, et al. Guidance for cardiac electro- physiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Car- diology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Heart Rhythm 2020; 17:e233–e241.

17. Manolis AS, Manolis AA, Manolis TA, et al. COVID-19 infection and cardiac arrhythmias. Trends Cardiovasc Med 2020;30:451–460.

18. Shao F, Shuang X, Ma X, et al. In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation 2020;151:18–23

19. Mitacchione G, Schiavone M, Gasperetti A, Forleo GB. Ventricular tachycardia storm management in a COVID-19 patient: a case report. Eur Heart J Case Rep 2020;4:1–6

20. Manolis AS, Manolis AA, Manolis TA, et al. COVID-19 infection and cardiac arrhythmias. Trends Cardiovasc Med 2020;30:451–460.

21. Bisaccia G, Ricci F, Recce V, et al. Post-acute sequelae of COVID-19 and car- diovascular autonomic dysfunction: what do we know? J Cardiovasc Dev Dis 2021;8:156.

22.Johansson M, Stahlberg M, Runold M, et al. Long-haul post-COVID-19 symp- toms presenting as a variant of postural orthostatic tachycardia syndrome: the Swedish experience. JACC Case Rep 2021;3:573–580.

23.Etheridge SP, Asaki SY. COVID-19 infection and corrected QT interval prolongation-collateral damage from our newest enemy. JAMA Netw Open 2021;4:e217192.

24. Arrhythmias in the COVID-19 patient Michael P. Lavelle, MD,1 Amar D. Desai, BS, MPH,1 Elaine Y. Wan, MD, FACC, FAHA, FHRS From the Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, (Heart Rhythm O2 2022;3:8–14) Columbia University, New York, New York.

25. Prospective arrhythmia surveillance after a COVID-19 diagnosis Dewland TA, et al. Open Heart 2022;9:e001758. doi:10.1136/openhrt-2021-001758

26. Nishiga M, Wang DW, Han Y, et al. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol 2020;17:543–58.

27. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061–9.

28. Bhatla A, Mayer MM, Adusumalli S, et al. COVID-19 and cardiac arrhythmias. Heart Rhythm 2020;17:1439–44.

29. Colon CM, Barrios JG, Chiles JW, et al. Atrial arrhythmias in COVID-19 patients. JACC Clin Electrophysiol 2020;6:1189–90.

30. Cardiac arrhythmias in COVID-19: Mechanisms, outcomes and the potential role of proarrhythmia M Europace 2021 Volume 23 Supplement 3 Merino JL.; Caro J.; Rey JR.; Castrejon S.; Martinez-Cossiani M. University Hospital La Paz, Madrid, Spain Chemaly

32.  Fiorina Annales de Cardiologie et d’Ange?iologie 69 (2020) 376–379

33. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020;5(7):802–10.

 34.  Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020, http://dx.doi.org/10.1001/jamacardio.2020.3557 [Article sous presse. Consulte? le 26 aou?t 2020. Disponible sur : https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC7385689/].

 35. Madjid M, Connolly AT, Nabutovsky Y, Safavi-Naeini P, Razavi M, Mil- ler CC. Effect of high influenza activity on risk of ventricular arrhythmias requiring therapy in patients with implantable cardiac defibrillators and cardiac resynchronization therapy defibrillators. Am J Cardiol 2019;124(1): 44–50.

 36. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus – infected pneumonia in Wuhan, China. JAMA 2020;323(11):1061–9. 2020;142

37. Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ. Urgent gui- dance for navigating and circumventing the QTc-prolonging and torsa- dogenic potential of possible pharmacotherapies for coronavirus disease 19 (COVID-19). Mayo Clin Proc 2020, http://dx.doi.org/10.1016/j.mayocp 

 38. Lazzerini PE, Boutjdir M, Capecchi PL. COVID-19, arrhythmic risk, and inflam- mation: mind the gap ! Circulation 2020;142(1):7–9.

 39. Walters TE, Kalman JM, Patel SK, Mearns M, Velkoska E, Burrell LM. Angio- tensin converting enzyme 2 activity and human atrial fibrillation: increased plasma angiotensin converting enzyme 2 activity is associated with atrial fibrillation and more advanced left atrial structural remodelling. Europace 2017;19(8):1280–7.

40. COVID-19: Cardiac Arrhythmias Hussein Taqi BCS Online Resources

41. Kuck KH. Arrhythmias and sudden cardiac death in the COVID-19 pandemic. Herz 2020 doi: 10.1007/s00059-020- 04924-0

44. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395(10229):1054-62. doi: 10.1016/S0140-6736(20)30566-3

 45. Mehra MR, Desai SS, Kuy S, et al. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med 2020 doi: 10.1056/NEJMoa2007621

46. Fried JA, Ramasubbu K, Bhatt R, et al. The Variety of Cardiovascular Presentations of COVID-19. Circulation 2020 doi: 10.1161/CIRCULATIONAHA.120.047164

47/Goyal P, Choi JJ, Pinheiro LC, et al. Clinical Characteristics of Covid-19 in New York City. N Engl J Med 2020 doi: 10.1056/ NEJMc2010419

48/Seecheran R, Narayansingh R, Giddings S, et al. Atrial Arrhythmias in a Patient Presenting With Coronavirus Disease-2019 (COVID-19) Infection. J Investig Med High Impact Case Rep 2020;8:2324709620925571. doi: 10.1177/232470962092 5571

49. Adlan A. Sympathetic nervous system dysfunction in rheumatoid arthritis: brief overview 2019 [Available from: http://www.brainimmune.com/sympathetic-nervous-system-dysfunction-rheumatoid-arthritis/ accessed 30/05/2020

50. Adlan AM. Inflammation and Heart Rate-corrected QT Interval: Evidence for a Potentially Reversible Cause of Sudden Death in Patients with Rheumatoid Arthritis? J Rheumatol 2018;45(12):1609-10. doi: 10.3899/jrheum.180921

51. Kapoor A, Pandurangi U, Arora V, et al. Cardiovascular risks of hydroxychloroquine in treatment and prophylaxis of COVID-19 patients: A scientific statement from the Indian Heart Rhythm Society. Indian Pacing Electrophysiol J 2020;20(3):117-20. doi: 10.1016/j.ipej.2020.04.003

52. Tindale AH, S. Use of Hydroxychloroquine and Azithromycin for treatment of COVID-19 and its relation to QTc prolongation 2020 [Available from: https://www. britishcardiovascularsociety.org/resources/ editorials/articles/hydroxychloroquine-azithromycin-treatment-covid-19-qtc-prolongation accessed 30/05/2020.]

53. Hussein TAQI BMJ British cardiovascular society. 2021

54. COVID-19 POINT E?PIDE?MIOLOGIQUE Sante public France19 mai 2022 / N°116