key: cord-0834487-t7votjuu
authors: Martínez-Mateo, Virgilio; Fernández-Anguita, Manuel José; Paule, Antonio
title: Electrocardiographic signs of acute right ventricular hypertrophy in patients with COVID-19 pneumonia: A clinical case series.
date: 2020-07-21
journal: J Electrocardiol
DOI: 10.1016/j.jelectrocard.2020.07.007
sha: 8ccfb014395b3686af57b0deb539f3d779eacc4e
doc_id: 834487
cord_uid: t7votjuu

This paper reports 6 cases of patients affected by coronavirus disease 2019 bilateral pneumonia with associated acute respiratory distress associated and signs of acute right ventricular hypertrophy on electrocardiography despite the absence of acute pulmonary embolism or signs of severe pulmonary hypertension on transthoracic echocardiography. These cases suggest a possible connection between acute elevated right ventricular afterload and acute respiratory distress in patients affected by SARS-CoV-2.

J o u r n a l P r e -p r o o f

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) resulting in significant morbidity and mortality. This major morbidity and mortality are largely due to acute viral pneumonitis that evolves to acute respiratory distress syndrome (ARDS).

Reports suggest that among those infected with SARS-CoV-2, up to 20% develop severe disease requiring hospitalization 1 , and up to 40% cases are associated with ARDS 2 . On the other hand, right ventricular (RV) overload and RV failure are common in patients who develop ARDS 3 . However, until now, the incidence and prognostic implications of this phenomenon have not been well described in patients with ARDS secondary to COVID-19 pneumonia. We present a clinical case series of 6 patients affected by COVID-19 bilateral pneumonia and ARDS associated with signs of acute J o u r n a l P r e -p r o o f

The basal characteristics of the patients are described in Table 1 . All patients were admitted to the hospital between March 15, 2020, and April 10, 2020, with a diagnosis of SARS-CoV-2 bilateral pneumonia, acute respiratory failure and radiology signs of ARDS. In all cases, electrocardiographic signs of RVH and RV overload were detected.

Specifically, incomplete or complete right bundle branch block (RBBB) and the S I Q III pattern were the most frequent signs detected (5 of 6 patients), followed by inverted T waves in the right precordial leads ( Figure 1A ). Other signs, such as enlargement of the (Table 1 ). In all cases, PE was excluded by computed tomography. All patients were managed with hydroxychloroquine, lopinavir/ritonavir, azithromycin, ceftriaxone, low-molecularweight heparin and high doses of prednisone. Indeed, oxygenation with high-flow systems was required in all cases to meet oxygenation goals, although invasive mechanical ventilation was not required in any of them. Unfortunately, 2 patients died during admission due to septic shock, and 4 patients were discharged after verifying radiological improvement of pneumonia and oxygenation parameters. In the follow-up, a new ECG register and TTE study could be performed in 3 patients one month Journal Pre-proof J o u r n a l P r e -p r o o f after discharge (Table 2) . ECG signs of RVH and mild dilatation of the right cavities were still present in all cases despite improvement in the values of sPAP ( Figure 1B ).

RVH results from increased RV afterload from PH or other heart, lung, or sleep disorders, which are associated with significant morbidity and mortality 4 .

Electrocardiography, although specific, lacks sensitivity for a diagnosis of RVH 5 . The current recommended AHA criteria for RVH by surface ECG are based on older studies with small study populations of severe RVH from advanced cardiopulmonary disease 4 .

However, recent studies have demonstrated that the ECG screening criteria for RVH are not sufficiently sensitive or specific for the screening of mild RVH in adults without clinical cardiovascular disease 4 . In patients with ARSD secondary to acute lung injury, RHV and RV failure are common and are predictors of mortality 3 . However, ECG findings of RVH in this setting have not been used for prognostic objectives, although they provide evidence of advanced disease that may be difficult to manage in critically ill patients 6 . In our cases, the presence of ECG signs of RVH was a predictor of dilatation of the RV in TTE and a hallmark of severity of COVID-19 pneumonia severity. Indeed, the S I Q III pattern was the most frequent sign detected, a finding important because this pattern is usually also found in patients with massive PE. In fact, it is known that COVID-19-affected patients have a heightened inflammatory state that increases their thrombotic risk, specially of venous thromboembolic events and EP 7 . In light of this, althouhg detection of a S I Q III pattern is probably secondary to increased J o u r n a l P r e -p r o o f Tricuspid Annular Plane Systolic Excursion; sPAP: systolic pulmonary artery pressure.

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