key: cord-326945-fvgc33qx
authors: Babapoor-Farrokhran, Savalan; Alzubi, Jafar; Khraisha, Ola; Mainigi, Sumeet K.
title: Cardiac Arrhythmias in the Era of COVID-19 Pandemic
date: 2020-09-11
journal: Trends Cardiovasc Med
DOI: 10.1016/j.tcm.2020.09.001
sha: 
doc_id: 326945
cord_uid: fvgc33qx

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Coronavirus disease-19 (COVID-19) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has quickly spread across the world since it was officially reported in Wuhan, China in Dec 2019 and emerged as a global pandemic leading to significant morbidity, mortality, economic affliction, and social disruption. Cardiac injury is one of the known complications of COVID-19 through various mechanisms [1] . Cardiac injury increases the risk of critical illness, morbidity, and mortality. It also increases the risk of cardiac arrhythmias. Current understanding of the impact of COVID-19 on arrhythmias is still in its infancy. However, it continues to evolve as new data from reliable studies emerge [2] . Cardiac arrhythmias are more common in critically ill COVID-19 patients. The exact mechanisms that could result in arrhythmogenesis is not completely known yet, but hypoxia caused by pulmonary disease, myocarditis, exaggerated host immune response, myocardial ischemia, electrolyte imbalance, and medication side effects have been proposed as a potential cause [3] .

Manolis and colleagues [4] in this issue of Trends in Cardiovascular Medicine summarize current knowledge regarding arrhythmic complications of COVID-19 and discuss potential mechanisms. They further touch upon treatment, management, and monitoring strategies for COVID-19 patients. Different cardiac rhythm disturbances of COVID-19 have been reported so far. Amongst them sinus tachycardia is the most common due to multiple causes including systemic infection, fever, respiratory failure, and pain. Sinus bradycardia, on the other hand, has been observed in a few studies emphasizing the need for close monitoring of these patients.

Bradycardia has been suggested as a warning sign of the onset of a serious cytokine storm suggesting that inflammatory injury of the sinus node is likely the contributing factor. The presence of right bundle branch block, intraventricular block, premature atrial contractions, or abnormal PR interval behavior (paradoxical prolongation or lack of shortening) increased mortality [5] .

According to one survey, atrial fibrillation (AF) was the most commonly encountered cardiac arrhythmia in COVID-19 patients [6] . The authors discuss the impact of national lockdown on the rate of AF diagnosis, reporting a significant drop in registered new-onset AF cases during the pandemic [7] . Their guidance on management of atrial fibrillation is similar as Additionally, the article discusses the common incidence of acute myocardial injury in COVID-19 patients, which can be a potential substrate for ventricular arrhythmia. The authors note that in comparison to the year prior there was an increased incidence of out-of-hospital cardiac arrest observed during the pandemic [8] . While the correlation between the increase in cardiac arrest and COVID-19 infections is high, this increase may be attributable to delayed routine cardiac care and apprehension of seeking medical attention during the lockdown. A recent study showed increased incidence of stress-induced cardiomyopathy during the pandemic, a condition that is well-known for its predisposition for life-threatening arrhythmias [9] .

Unfortunately, treatments for acute COVID-19 infection that have been attempted can also have detrimental cardiac effects. The authors describe the QT prolonging effects of several therapies, particularly macrolides and hydroxychloroquine, and the need for close monitoring of QT interval in those patients receiving these medications. These potentially pro-arrhythmic changes can occur through direct effects of treatment, drug-drug interactions, or uncovering of silent genetic variants of congenital QT syndrome. Although serial electrocardiograms (ECG) have been used traditionally to monitor QTc, outpatient cardiac telemetry has emerged as an alternative method. New QT detection algorithms on mobile cardiac outpatient telemetry systems, and consumer heart rate and even oximetry monitors will likely change the approach for Ultimately, hindsight and retrospective analysis of the cardiac impact of COVID-19 will tell us if the standard treatments used for treating arrhythmias in other individuals were beneficial or detrimental to coronavirus patients. Particular focus on evaluating the safety of antiarrhythmic drugs, different anticoagulants, or clinical factors that influence management is paramount. Until we have more data, clinicians will have to apply clinical judgment when treating these patients.

Myocardial injury and COVID-19: Possible mechanisms

COVID-19 and cardiac arrhythmias

Involvement of cardiovascular system as the critical point in coronavirus disease 2019 (COVID-19) prognosis and recovery

Covid-19 infection and cardiac arrhythmias

Behavior of the PR interval with increasing heart rate in patients with COVID-19

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

Newonset atrial fibrillation: incidence, characteristics, and related events following a national COVID-19 lockdown of 5.6 million people

Out-of-hospital cardiac arrest during the COVID-19 pandemic

Incidence of Stress Cardiomyopathy During the Coronavirus Disease