key: cord-0943880-n8wfu8bz
authors: Jain, Shashank; Workman, Virginia; Ganeshan, Raj; Obasare, Edinrin R.; Burr, Alicia; DeBiasi, Ralph M.; Freeman, James V.; Akar, Joseph; Lampert, Rachel; Rosenfeld, Lynda E.
title: ENHANCED ECG MONITORING OF COVID-19 PATIENTS
date: 2020-05-06
journal: Heart Rhythm
DOI: 10.1016/j.hrthm.2020.04.047
sha: ee42806d9d780ba4a36ec94a0ebe907249ba6626
doc_id: 943880
cord_uid: n8wfu8bz

Abstract Background Many of the drugs being used in the treatment of the ongoing pandemic coronavirus disease 2019 (COVID-19) are associated with QT prolongation. Expert guidance supports ECG monitoring to optimize patient safety. Objective To establish an enhanced process for ECG monitoring of patients being treated for COVID-19. Methods We created an SBAR (Situation Background Assessment Recommendation Tool) identifying the indication for ECGs in COVID-19 patients, and tagged these ECGs to ensure prompt over reading and identification of those with QT prolongation (QTc >470 ms for QRS < 120 ms, QTc > 500 ms for QRS > 120 ms). This triggered a phone call from the electrophysiology service to the primary team to provide management guidance and a formal consultation if requested. Results During a 2-week period we reviewed 2006 ECGs, corresponding to 524 unique patients, of whom 103 (19.7%) met SBAR defined criteria for QT prolongation. When compared to those without QT prolongation, these patients were more often in the intensive care unit (58.3% vs 35.4%) and more likely to be intubated (31.1 vs 18.1%). Fifty patients with QT prolongation (48.5%) had electrolyte abnormalities, 98 (95.1%) were on COVID-19 related QT prolonging medications, and 62 (60.2%) were on 1-4 additional non COVID-19 related QT prolonging drugs. Electrophysiology recommendations were given to limit modifiable risk factors. No patient developed torsade de pointes. Conclusion This process functioned efficiently, identified a high percentage of patients with QT prolongation, and led to relevant interventions. Arrhythmias were rare. No patient developed torsade de pointes.

supported the use of ECG monitoring to identify QT prolongation in COVID-19 patients 76 being treated with these drugs. We describe the process we instituted to facilitate such 77 monitoring and the outcome of our screening.

Recognizing the importance of the timely identification of ECG abnormalities, most 80 specifically QT prolongation, in patients being treated for COVID-19, we initiated a 81 hospital wide protocol designed to optimize ECG monitoring of these patients. This Table I . Among 122 the patients that were COVID-19 positive, those with QT prolongation were more likely 123 to spend time in the intensive care unit (ICU) (58.3% vs 36.5%, p = .000), and were 124 more likely to be intubated (31.1% vs 19.7%, p = .014) than those without this finding 125 ( The ongoing COVID-19 pandemic has caused us to modify our usual care pathways to 162 provide the best possible care to the most patients, often with suboptimal resources.

The medications being used clinically with hopes of improving outcomes in patients The SBAR we used for screening patients was developed at our institution early in our 179 COVID-19 experience, and was designed to find a compromise between safety and the 180 need for frequent ECGs before we were routinely using validated telemetry or remote While we think it is likely that many factors contributed to the low incidence of clinical 195 arrhythmias in our patients we cannot rule out that our interventions, which improved 196 electrolyte management and helped identify other QT prolonging medications, many of 197 which were then discontinued, played a role in the return of the QTc toward baseline 198 values and the low incidence of torsade de pointes. We also hope that they gave support to the treating teams to continue therapy, when this was felt to be indicated. 200 We do know that mitigating multiple simultaneous insults to the ion channels involved in 201 myocardial repolarization, most specifically IKr, may be protective 11 . Other reasons for 202 the low incidence of torsade de pointes may be the safeguarding effects of relative 203 sinus tachycardia or other unidentified factors.

Although we believe our process functioned well, we recognized early on that the Our study has several limitations, including those of a single center retrospective study. In an effort to provide optimal care in the setting of the current COVID-19 pandemic we 226 developed a system to rapidly and efficiently review the ECGs of these patients, identify 227 those with QT prolongation, and provide electrophysiologic guidance to the treating 228 teams. While we did identify a high prevalence of QT prolongation in this population, Figure 3 Box plot of QTc intervals for initial ECG, peak value and final ECG. Compared 247 to initial ECG, QTc was significantly longer at peak (470.6 ± 35.9 ms vs 520.6 ± 36.7 248 ms; P = .000). Compared to Peak QTc, there was a significant decrease in QTc by the 249 final ECG (520.6 ± 36.7 ms vs 478.9 ± 31.0 ms; P = .000). There was also a difference 250 noted between the initial QTc and the final QTc (470.6 ± 35.9 ms vs 478.9 ± 31.1 ms; P 251 = .026). QTc = corrected QT interval' ECG = Electrocardiogram. Values are presented as mean ± 1SD or as n (%). Hypomagnesemia was defined as a value less than 2.0 302 mEq/L and hypokalemia was defined as a value less than 4.0 mEq/L 

COVID-19: a recommendation to examine the effect of Toxicol

Considerations for Drug 440 Interactions on QTc in Exploratory COVID-19 (Coronavirus Disease

SARS-CoV-2, COVID-19 and inherited 443 arrhythmia syndromes. Heart Rhythm

Urgent Guidance 446 for Navigating and Circumventing the QTc Prolonging and Torsadogenic 447

Potential of Possible Pharmacotherapies for COVID-19

Inpatient Use of Ambulatory Telemetry 450

Monitors for COVID-19 Patients Treated with Hydroxychloroquine and/or

Am Coll Cardiol

Acknowledgements: We wish to thank Kristie Lavorgna, Wendy Bruni, and the other 376 ECG Staff whose hard work and commitment to patient care made this process