key: cord-0860272-p10c3k9b
authors: Peltzer, Bradley; Manocha, Kevin K.; Ying, Xiaohan; Kirzner, Jared; Ip, James E.; Thomas, George; Liu, Christopher F.; Markowitz, Steven M.; Lerman, Bruce B.; Safford, Monika M.; Goyal, Parag; Cheung, Jim W.
title: Arrhythmic Complications of Patients Hospitalized With COVID-19: Incidence, Risk Factors, and Outcomes
date: 2020-09-15
journal: Circ Arrhythm Electrophysiol
DOI: 10.1161/circep.120.009121
sha: 43bc6b529e48e72a9e59e38a2f482c5ed2fd3403
doc_id: 860272
cord_uid: p10c3k9b

nan

D uring the course of the coronavirus disease 2019 pandemic, cardiovascular manifestations have been recognized as an important complication among patients hospitalized with the disease. Arrhythmias have been reported to occur in 7% to 16.7% of hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. 1, 2 However, the incidence of specific types of arrhythmias and its outcomes among patients with COVID-19 have not been well-described. We sought to define the incidence of and risk factors for arrhythmias among patients hospitalized with COVID-19 and to evaluate its association of arrhythmias with outcomes including mortality.

We studied all patients with COVID-19 who were admitted consecutively to New York-Presbyterian/ Weill Cornell Medicine and New York-Presbyterian/ Lower Manhattan Hospital between March 3 and April 6, 2020. This study was approved by the Weill Cornell Medicine Institutional Review Board. Requirements for informed consent for the study were waived due to the retrospective nature of the study. The data, analytic methods, and study materials that support the findings of this study are available from the corresponding author upon reasonable request. All cases of COVID-19 were confirmed through real-time reverse-transcriptase polymerase chain reaction assays on nasopharyngeal swabs. Using REDCap, patient data were manually abstracted from New York-Presbyterian electronic health records to develop a COVID-19 registry, as previously described. 3 Demographics and comorbid conditions were abstracted.

Hypoxia on presentation was defined as use of supplemental oxygen in the emergency department within 3 hours of presentation. Hospitalization events, medication usage, and laboratory values through May 10, 2020, were reviewed.

The primary outcome of the study was 30-day allcause mortality. Arrhythmias were identified by review of all electrocardiograms and telemetry data obtained during hospitalization. All patients admitted with COVID-19 were placed on telemetry and 82.8% patients underwent at least one ECG. Arrhythmias were defined as atrial fibrillation (AF), atrial flutter, supraventricular tachycardia (VT), frequent premature ventricular contractions (defined as either ≥2 premature ventricular contractions on a 6 second 12-lead ECG recording or ≥10 premature ventricular contractions per minute on telemetry recording), VT, ventricular fibrillation (VF) and atrioventricular block (second degree or higher). The χ 2 test, Student t test, and Wilcoxon rank-sum test were used. Multivariable logistic regression analysis was used to identify predictors of arrhythmias and of 30-day mortality.

A total of 1053 consecutive patients were included in the study analysis. As of May 10, 2020, 723 (68.6%) patients were discharged, 146 (13.9%) were still hospitalized, and 184 (17.5%) had died. The median length of follow-up was 7 (interquartile range [IQR], 3-18; range, 0-62) days. Arrhythmias were identified in 270 (25.6%) of patients. Overall, AF/atrial flutter was identified in 166 (15.8%) patients (with 101 [9.6%] being newly diagnosed). Frequent premature ventricular contractions were seen in 137 (13.0%) patients. VT or VF was found with 27 (2.6%) patients which included 7 (0.7%) patients with nonsustained VT only, 13 (1.2%) with sustained VT, 9 (0.9%) with polymorphic VT, and 8 (0.8%) with VF. Atrioventricular block (second degree or greater) was seen in 4 (0.4%) patients. The clinical characteristics, imaging findings, and outcomes of the cohort stratified by the presence or absence of arrhythmias are summarized in the Table. Compared with patients without arrhythmias, patients with arrhythmias were older with a higher proportion of males and whites, and significantly more comorbidities. On multivariable regression analysis, age (adjusted odds ratio [aOR], 1.04; P<0.001), male sex (aOR, 2.49; P<0.001), prior history of AF (aOR, 6.03; P<0.001), and hypoxia on presentation (aOR, 2.17; P<0.001) were independently associated with the occurrence of any arrhythmia.

Compared with patients without arrhythmias, patients with arrhythmias more frequently had abnormal chest radiographs. Among 146 (13.9%) patients who underwent echocardiographic imaging, there were no significant differences in left ventricular ejection fraction or proportion of patients with left or right ventricular dysfunction between patients with and without arrhythmias. Overall, compared with patients without arrhythmias, the arrhythmia group had significantly higher peak levels of cardiac troponin I (median, 0.12 [IQR, 0.04-0.56] versus 0 [0-0.05] ng/mL), C-reactive protein (32. There are several limitations to the study. This is a retrospective study with data obtained via chart abstraction, which may be subject to error or interpretation. Variations in telemetry monitoring systems across hospital units may have led to possible underdetection of arrhythmias in some cases. Because this study focused on in-hospital outcomes, out-of-hospital deaths following discharge for COVID-19 were not examined.

In this analysis of arrhythmic complications of over 1000 consecutive patients hospitalized with COVID-19, atrial fibrillation/flutter was seen in over 15% of patients with >60% of these occurring in patients without any prior history of AF while VT/VF occurred in <3% of patients. Age, male sex, and hypoxia on presentation were independently associated with the occurrences of arrhythmias. The presence of arrhythmias tracked with markers of disease severity and elevated markers of myocardial injury, inflammation, and fibrinolysis. Although there are likely myriad factors that lead to COVID-19-associated arrhythmias, our findings suggest that arrhythmias may predominantly be a marker of COVID-19 severity. Further studies to elucidate the mechanisms of COVID-19-associated arrhythmias and to assess whether treatments targeting SARS-CoV-2 infection and its associated inflammatory response can reduce arrhythmia occurrence are warranted. 

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected Pneumonia in Wuhan, China

Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19)

Clinical characteristics of covid-19 in New York city

Echocardiographic findings Decreased LVEF <50%, n/total n (%)

Lowest LVEF during hospitalization, %, median

ARB, angiotensin receptor blocker; ICU, intensive care unit; IQR, interquartile range; LVEF, left ventricular ejection fraction

RRT, renal replacement therapy

We thank the following Weill Cornell Medicine medical students for their contri-