key: cord-0847954-ejpx1zpv
authors: Dagher, Lilas; Shi, Hanyuan; Zhao, Yan; Wetherbie, Andrew; Johnsen, Erik; Sangani, Deep; Nedunchezhian, Saihariharan; Brown, Margo; Miller, Peter; Denson, Joshua; Schieffelin, John; Marrouche, Nassir
title: New‐onset atrial arrhythmias associated with mortality in black and white patients hospitalized with COVID‐19
date: 2021-04-16
journal: Pacing Clin Electrophysiol
DOI: 10.1111/pace.14226
sha: 271e7d051dbe97c3408db38568d0619de1da8398
doc_id: 847954
cord_uid: ejpx1zpv

BACKGROUND: Specific details about cardiovascular complications, especially arrhythmias, related to the coronavirus disease of 2019 (COVID‐19) are not well described. OBJECTIVE: We sought to evaluate the incidence and predictive factors of cardiovascular complications and new‐onset arrhythmias in Black and White hospitalized COVID‐19 patients and determine the impact of new‐onset arrhythmia on outcomes. METHODS: We collected and analyzed baseline demographic and clinical data from COVID‐19 patients hospitalized at the Tulane Medical Center in New Orleans, Louisiana, between March 1 and May 1, 2020. RESULTS: Among 310 hospitalized COVID‐19 patients, the mean age was 61.4 ± 16.5 years, with 58,7% females, and 67% Black patients. Black patients were more likely to be younger, have diabetes and obesity. The incidence of cardiac complications was 20%, with 9% of patients having new‐onset arrhythmia. There was no significant difference in cardiovascular outcomes between Black and White patients. A multivariate analysis determined age ≥60 years to be a predictor of new‐onset arrhythmia (OR = 7.36, 95% CI [1.95;27.76], p = .003). D‐dimer levels positively correlated with cardiac and new‐onset arrhythmic event. New onset atrial arrhythmias predicted in‐hospital mortality (OR = 2.99 95% CI [1.35;6.63], p = .007), a longer intensive care unit length of stay (mean of 6.14 days, 95% CI [2.51;9.77], p = .001) and mechanical ventilation duration(mean of 9.08 days, 95% CI [3.75;14.40], p = .001). CONCLUSION: Our results indicate that new onset atrial arrhythmias are commonly encountered in COVID‐19 patients and can predict in‐hospital mortality. Early elevation in D‐dimer in COVID‐19 patients is a significant predictor of new onset arrhythmias. Our finding suggest continuous rhythm monitoring should be adopted in this patient population during hospitalization to better risk stratify hospitalized patients and prompt earlier intervention.

In the face of the global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) virus, a large body of evidence points toward a significant impact of the virus on the cardiovascular system. 1, 2 The reported rates of myocardial injury among Coronavirus Infectious Disease of 2019 (COVID-19) patients, defined by an abnormal level of troponin, varied between 10% and 28%. 3, 4 Many reports demonstrated myocarditis 5 and heart failure events associated with COVID-19. One of the first studies to report the rate of arrhythmias includes 138 COVID-19 hospitalized patients from Wuhan and shows an incidence of 16.7% in their cohort. 6 Although arrhythmic complications have already been reported in several studies, details regarding the type of arrhythmia and its impact on hospi- In this study, we sought to characterize cardiovascular and arrhythmic complications in COVID-19 hospitalized patients in New Orleans stratified by race groups, define predictive factors for cardiac and arrhythmic complications during COVID-19 hospitalization, and determine the impact of new-onset atrial arrhythmias on hospitalization outcomes.

This retrospective observational study was conducted using medical records of patients hospitalized for COVID-19 at Tulane Medical Center in New Orleans, Louisiana, United States, between March 1, 2020

and May 1, 2020, and who were either treated and discharged or died during hospitalization. All patients had confirmed SARS-CoV-2 infection by positive polymerase chain reaction of a nasopharyngeal swab testing in accordance with CDC guidelines. This study was approved by the institutional ethics board of Tulane University School of Medicine (no. 2020−463). Given the retrospective and de identified nature of the data in this study, informed consent was waived. 

All data were included as study variables to characterize hospitalized was used for these analyses, and p-value of < .05 was considered statistically significant.

Three-hundred ten patients were admitted for a COVID-19 infection and either discharged or died after hospitalization from March 1, 2020

to May 1, 2020 in our center. Baseline characteristics of the overall population, as well as stratified by race, are shown in Table 1 

Overall, 62 (20%) COVID-19 hospitalized patients suffered from cardiac complications ( ischemic cerebrovascular accident (7) . There was no difference in the incidence of cardiovascular complications and new-onset arrhythmia between Black and White patients ( Table 2 ).

In 

In a multivariate analysis including 10 

We demonstrated an incidence of 20% of cardiac complications includ- a massive release of cytokines that can promote arrhythmogenic pathways. 12 Also, in the state of hyperinflammatory response, coronary atherosclerotic plaques are prone to rupture leading to acute cardiac injury and increased susceptibility for arrhythmias. Another possibility is related to a direct viral injury to the myocardium mimicking the presentation of viral myocarditis, as the virus has been consistently detected within myocardial cells. 13, 14 A variety of the abovementioned pathophysiological pathways associated with the COVID-19 infection could explain the notable incidence of new-onset arrhythmias.

In our regression model, an age of 60 years or older was a significant predictor of cardiac outcomes and new-onset arrhythmias. The association between age and COVID-19 hospitalization and cardiovascular outcomes has been proven across multiple studies. Our finding confirm previously published data from both Bhatla et al. 9 and Colon et al., 10 as both studies found age to be associated with the incidence of cardiac arrhythmia. In the University of Pennsylvania study, 9 after multivariate adjustment, only age (OR 1.05) and heart failure (OR 5.61) were independently associated with incident AF. We also confirmed the lack of association with sex, race, BMI, diabetes, and hypertension. 9 Moreover, in our cohort, the presence of previous cardiac disease was not predictive of new-onset arrhythmia, which highlights the role of the virus and its accompanying high inflammatory burden in inducing cardiac electrical remodeling regardless of previous underlying disease.

In our population, abnormal D-dimer at presentation was associ- 

New-onset atrial arrhythmia, mainly AF, patients was an independent predictor of increased in-hospital mortality in COVID-19 patients.

The development of atrial arrhythmias during hospitalization also increased ICU length of stay and mechanical ventilation days. While we found that atrial arrhythmias increased by almost seven times the risk of mortality, Bhatla et al. 9 showed similar results where incident AF was associated with six times the risk of in-hospital mortality in a univariate analysis, although it did not remain significant after multivariate adjustment. New onset of atrial arrhythmia in this population could be an indicator of a severe inflammatory response induced by the virus, explaining its strong predictive value for inhospital mortality, length of ICU admission and mechanical ventilation.

On the other hand, patients who develop atrial arrhythmia would be at higher risk of cardiac decompensation and/or ischemic events, worsening their hospitalization outcomes and prognosis. Thus, we highlight the importance of cardiac rhythm monitoring for further risk stratification.

Black individuals have been shown to be disproportionately hit by the 

Limitations of this study include that analyses were conducted from a single center serving a large urban population, which may affect generalizability of results. In addition, telemetry was not technically reviewed by the study team, and was up to the discretion of the inpatient teams to classify and identify arrhythmia and complications. Moreover, complete laboratory testing was not performed in all patients. Additionally, a history of cardiac arrhythmia was based on a review of electronic health records, thus previous AF episodes in patients with new-onset AF during hospitalization cannot be definitely ruled out. Finally, the analysis was based on data from electronic medical records, which is subject to entry errors and missing data. Nevertheless, this study provides a comprehensive epidemiologic analysis of hospitalized Black versus White patients as well as it highlights novel findings of the effect of new-onset atrial arrhythmias on mortality and severity of clinical outcomes. 

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New-onset atrial arrhythmias associated with mortality in black and white patients hospitalized with COVID-19

The authors declare that there is no conflict of interest.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Lilas Dagher MD https://orcid.org/0000-0003-0660-318XHanyuan Shi MD https://orcid.org/0000-0001-6977-6569