key: cord-0791265-5w71i2vu
authors: Zuin, Marco; Rigatelli, Gianluca; Roncon, Loris; Zuliani, Giovanni
title: Mortality risk in COVID-19 patients with right bundle branch block
date: 2021-07-02
journal: Rev Esp Cardiol (Engl Ed)
DOI: 10.1016/j.rec.2021.06.014
sha: f750bed1466b15fb744533b23654e4bf59b055c4
doc_id: 791265
cord_uid: 5w71i2vu

nan

Riesgo de mortalidad en pacientes con COVID-19 con bloqueo de rama derecha

To the Editor, Recent analyses have demonstrated that COVID-19 patients with pre-existing cardiovascular risks and/or comorbidities have a higher risk of death in the short-term period. However, the prognostic role of right bundle branch block (RBBB) in these patients has not yet been evaluated. The Aaim of this study was manuscript is to perform a brief meta-analysis on the prognostic impact of RBBB oin short-term mortality in of COVID-19 patients. The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The MEDLINE and Scopus databases were systematically searched for articles, published in English language, from the inception of the COVID-19 pandemic (January 2020) through 1 May 2021 using the following Medical Subject Heading (MESH) terms: "COVID-19" AND "Arrhythmias" OR "Right bundle branch block". Inclusion criteria were: a) studies enrolling participantssubjects with a confirmed diagnosis of COVID-19; b) providing data on the presence/absence of RBBB among survivors (S) and nonnon-survivors (NS), allowing us to calculate an unadjusted odds ratio (OR) when not provided; and c) reporting all-cause mortality by the presence or absence or RBBB. We excluded Ccase reports, review articles, editorials/letters, and case series with less than 10 participants, randomized controlled trials and studies including duplicate populations and investigations evaluating the electrocardiographic consequences of specific COVID-19 therapy were excluded. References from the included studies were screened to potentially identify other investigations meeting the inclusion criteria. Ethical approval and informed consent were not required as the study did not directly enrol human participantssubjects. The quality of the included studies was graded using the Newcastle-Ottawa quality assessment scale (NOS). Mortality risk data were pooled using the Mantel-Haenszel random effects models with odds ratios (OR) as the effect measure with 95% confidence intervals (CI).

Heterogeneity among studies was assessed using Higgins and Thompson I 2 statistic where I 2 values J o u r n a l P r e -p r o o f correspond to the following levels of heterogeneity: low (< 25%), moderate (25%-75%) and high (> 75%). The presence of potential publication bias was verified by visual inspection of the funnel plot.

Due to the low number of the included studies (< 10), small-study bias was not examined as our analysis was underpowered to detect such bias. A predefined sensitivity analysis (leave-one-out analysis) was performed removing 1 study at a the time, to evaluate the stability of our results. All meta-analyses were conducted using Comprehensive Meta-Analysis software, version 3 (Biostat, United States). The Iinitial search resulted in 2049 articles (951 in PubMed and 1098 in Scopus, respectively). After we removed ing duplicates (n = 885) and applyied ng our inclusion criteria, 6 studies, 1-6 enrolling 1904 patients (mean age 64.7 years old, 1176 males) were included in the analysis. All the investigations were resulted to be of high quality according to the NOS. The most frequent comorbidities were arterial hypertension and diabetes mellitus. Conversely, the prevalence of heart failure, coronary artery disease and chronic obstructive pulmonary disease were not systematically reported in the reviewed investigations, making impossible a comprehensive evaluation impossible (table 1). The Mmortality rate was 17.0% (n = 324). RBBB was presents in 150 COVID-19 participantssubjects (7.8 % of cases). On pooled analysis, RBBB was significantly associated with a higher risk of death in the shortterm period (OR, 2.96; 95%CI, 2.04-4.30; P ≤ .0001; I 2 = 0%) (figure 1A). Visual inspection of the relative funnel plot did not revealed no significant evidence of publication bias (figure 1B). Sensitivity analysis slightly changed the combined OR, which remained statistically significant across a range from 2.38 (95%CI,1.48-3.84) to 3.24 (95%CI, 2.16-4.85), suggesting that no single study had an undue impact on the study outcome. The results of present analysis suggest a higher mortality risk in COVID-19 patients with RBBB. We decided to analyzse the impact onr RBBB since several different analyses have demonstrated that right ventricular dysfunction is frequently observed in in COVID-19 patients and is associated with a poor prognosis. 1, 6 Because Being RBBB is an electrocardiographic singn of right ventricular strain and considering that right ventricular dysfunction is generally due to pulmonary micro-embolic events in COVID-19 patients, we hypothesized suppose that this conduction J o u r n a l P r e -p r o o f disturbance may be related towith a worst prognosis. However, we cannot exclude the possibility that those patients with more severe infection most frequently had RBBB.

Unfortunately, we were unable it was not possible to assess whether if RBBB was already present before COVID-19 infection or whether it might it may be due to a secondary right ventricular overload caused determined by pulmonary micro-or macro-thrombotic events, or pre-existing pulmonary disease, or ventilatory support. Furthermore, none of the reviewed investigations made a distinction make a distinction between complete and incomplete RBBB or as well as for the setting of hospitalization (ie,.e., Intensive care unit or general wards). Moreover, the reported presented ORs were are unadjusted for potential confounders and, despite the meta-regression performed, this aspect limited our final conclusions. Therefore, our results must be cautiously interpreted and considered preliminary. Further larger clinical studies are needed to confirm our preliminary results and also to determine the potential pathophysiological mechanisms underlying this relationship. 

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