key: cord-0931440-2njlkupa
authors: Centurión, Osmar Antonio
title: Wide QRS complex and left ventricular lateral repolarization abnormality: The importance of ECG markers on outcome prediction in patients with COVID-19
date: 2021-04-21
journal: Am J Med Sci
DOI: 10.1016/j.amjms.2021.04.005
sha: 23c78d2ee7ef01a9c7af9e55ccd82c1f165fafed
doc_id: 931440
cord_uid: 2njlkupa

nan

caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Up to November 5, 2020 , this disease resulted in considerable morbidity and mortality worldwide with 47,596,852 laboratory-confirmed cases and 1,216,357 deaths.

Most of the studies that reported myocardial involvement were based on elevated serum cardiac biomarkers, while others on cardiac magnetic resonance imaging. [1] [2] [3] It was reported recently that there is also evidence of direct viral damage of the myocardium causing acute myocarditis detected by histological studies. This was manifested as myocardial edema and acute myocardial injury with the presence of SARS-CoV-2 on electron microscopy. 6 Electrocardiogram (ECG) abnormalities commonly seen in cardiac injury are ST elevation and PR depression. Other ECG abnormalities that can be observed in acute cardiac injury include new-onset bundle branch block, QT prolongation, pseudoinfarct pattern, premature ventricular complexes, bradyarrhythmias and ventricular tachycardia (VT). 1 In this issue of the American Journal of The Medical Sciences, Sonsoz MR, et al. 7 demonstrated that two simple ECG parameters can be associated with markers of Patients with primary composite endpoint were more likely to have wide QRS complex (>120 ms) and lateral ST-T segment abnormality. Multivariable Cox regression showed increasing odds of primary composite endpoint associated with acute cardiac injury (odds ratio 3.14, 95% CI 1.26 -7.99; P = 0.016), and QRS duration longer than >120 ms (odds ratio 3.62, 95% CI 1.39 -9.380; P = 0.008). Patients with wide QRS complex (>120 ms), and abnormalities of lateral ST-T segment had significantly higher median level of troponin T and pro-BNP than patients without. Therefore, the authors concluded that the presence of wide QRS duration and lateral ST-T segment abnormalities were associated with worse clinical outcome and higher levels of myocardial injury biomarkers in hospitalized patients with COVID-19. 7 The development of ECG abnormalities in the LV lateral wall in the study patients of Sonsoz MR, et al. 7 Acute cardiac injury manifested by increased blood levels of cardiac troponin value greater than the 99th percentile reference limit, several electrocardiographic abnormalities, or myocardial dysfunction, seems to be prevalent in hospitalized patients with COVID-19. Shi S, et al. 5 recently reported abnormal ECG findings compatible with myocardial ischemia, namely, T wave depression and inversion, STsegment depression, and Q-waves in patients with COVID-19 during the period of elevated cardiac biomarkers. In-hospital mortality was found to be more than 6-fold higher in patients with elevated cardiac Troponin T levels which persisted after adjustment for baseline characteristics and medical comorbidities. 5 Therefore, it is reasonable to assume that initial measurement of cardiac biomarkers immediately after hospitalization for SARS-CoV-2 infection may help identifying a subset of patients with possible cardiac injury and, thereby, predict the progression of COVID-19 towards a worse outcome. It remains to be proven whether the SARS-CoV-2-mediated myocardial damage will have long-term detrimental effects on cardiac function and survival. Hence, follow up data on survivors is required to improve evaluation of the long-term clinical outcomes.

It is not surprising to read the important findings of Sonsoz MR, et al. 7 since wide QRS complex was already previously associated with increased mortality risk in patients without COVID-19 (8-10). Ukena C, et al. 8 reported in patients with suspected miocarditis unrelated to COVID-19 that a QRS width greater than 120 ms in duration was associated with greater risk of cardiac death or need for heart transplantation [8] . Kalra PR, et al. 9 investigated the optimal QRS duration that separates patients with HF into those with a relatively benign versus a poor prognosis. Patients with a QRS ≥ 0.12 s had a three-fold increased risk for the combined end point of death or transplantation. Moreover, it has been shown that a wide QRS complex predisposes HF patients to VT, and it was found to be an independent risk factor for VT inducibility in the multivariate analysis. In fact, the risk of inducible VT increased by 2.4% for each 1 ms increase in QRS duration. 10 As Sonsoz MR, et al. 7 

Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

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

Potential mechanisms of cardiac injury and common pathways of inflammation in patients with COVID-19

Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

Myocardial localization of coronavirus in COVID-19 cardiogenic shock

Prognostic electrocardiographic parameters in patients with suspected myocarditis

Clinical characteristics and survival of patients with chronic heart failure and prolonged QRS duration

Usefulness of QRS prolongation in predicting risk of inducible monomorphic ventricular tachycardia in patients referred for electrophysiologic studies