key: cord-0992065-2pxf6beg
authors: Nathala, Pavani; Salunkhe, Vidyulata; Samanapally, Harideep; Xu, Qian; Furmanek, Stephen; Fahmy, Omar F.; Deepti, Fnu; Glynn, Alex; McGuffin, Trevor; Goldsmith, Dylan C.; Petrey, Jessica; Ali, Tshura; Titus, Derek; Carrico, Ruth; Ramirez, Julio; Antimisiaris, Demetra; Clifford, Sean P.; Pahwa, Siddharth; Roser, Lynn; Kong, Maiying; Huang, Jiapeng
title: Electrocardiographic Features and Outcome Correlations in 124 Hospitalized COVID-19 Patients with Cardiovascular Events
date: 2022-01-13
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2022.01.011
sha: f8d3599f0db537de40b6294a090f536575ad1d9e
doc_id: 992065
cord_uid: 2pxf6beg

Objectives Electrocardiographic (ECG) changes have been associated with COVID-19 severity. However, the progression of ECG findings in COVID-19 patients has not been studied. The purpose of this study was to describe ECG features at different stages of COVID-19 cardiovascular (CV) events and to examine the effects of specific ECG parameters and cardiac-related biomarkers on clinical outcomes in COVID-19. Design Retrospective, cohort study Setting Major tertiary care medical centers and community hospitals in Louisville, KY, USA Participants 124 COVID-19 patients who suffered cardiovascular events during hospitalization. Interventions None Measurements and Main Results 12 lead ECG parameters, biomarkers of cardiac injuries, and clinical outcomes were analyzed with Spearman's correlation coefficients and Kruskal–Wallis one-way ANOVA. Atrial fibrillation/atrial flutter was more frequent in ECG obtained at the time of CV event when compared to admission ECG (9.5% vs. 26.9%; P = .007). Sinus tachycardia was higher in the last available hospital ECG than CV event ECG (37.5% vs. 20.4%; P = .031). Admission ECG QTc was significantly associated with admission troponin levels (R = 0.52, P < .001). The last available hospital ECG showed non-survivors had longer QRS duration than survivors (114.6 vs. 91.2 ms; P = .026), and higher heart rate was associated with longer ICU length of stay (Spearman ρ = 0.339, P = .032). Conclusions In hospitalized COVID-19 patients who suffered cardiovascular events, ECGs at various stages of COVID-19 hospitalization showed significantly different features with dissimilar clinical outcome correlations.

The coronavirus disease 2019 (COVID-19) pandemic continues to be the leading cause of mortality and morbidity around the world with over 229 million infections and over 4.7 million deaths as of September 21, 2021. 1 In the United States alone, over 40 million patients have been infected, and over 670,000 people have died. 2 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel strain of coronavirus that causes COVID-19, is most notably known to cause severe respiratory disease. 3 However, COVID-19 is also known to cause multi-organ dysfunction, with the cardiovascular system being a significant target. [4] [5] [6] [7] Emerging data suggest that cardiac complications occur in as many as 40% of hospitalized patients. 6 Those hospitalized with severe COVID-19 who develop cardiovascular complications have higher mortality, longer length of stay (LOS), and worse prognosis than those who do not experience cardiac complications. 8, 9 A multitude of heart pathologies have been described in association with SARS-CoV-2

infections. Implicated mechanisms of cardiac involvement include: myocardial ischemia secondary to hypoxic state, COVID-19-associated hypercoagulability and resultant microvascular thrombotic complications, cytokine storm, direct viral inflammatory effect, and drug-induced cardiac damage. [10] [11] [12] Electrocardiographic (ECG) changes have been correlated with infection severity. 7, [13] [14] [15] Clinical outcome measures, including admission to intensive care 14 , mechanical ventilation requirement 14 , acute respiratory distress syndrome (ARDS) 7,15-17 , acute renal failure requiring renal replacement therapy 7, 14 , and all-cause mortality 14, 16, 17 were higher in patients with abnormal ECGs.

The Center of Excellence for Research in Infectious Diseases (CERID) recently analyzed 702 adult COVID-19 patients hospitalized between March 2020 and June 2020 in a United States metropolitan area and identified 124 patients who suffered cardiovascular (CV) events. 18 Patients with cardiovascular events had a much higher mortality rate at 45.2% than those without cardiovascular events at 8.7%. 18 The null hypothesis for this project was there is no significant difference between ECGs at admission, CV events and discharge (death or out of hospital). The purpose of this study was to investigate the ECG features in COVID-19 patients who suffered CV events at three distinct phases of hospitalization: upon admission, during the acute CV event, and on approaching discharge or death.

The clinical data used in this study was from the Burden of COVID-19 study, an observational retrospective cohort database maintained by Center of Excellence for Research in Infectious Diseases (CERID) at the University of Louisville. 18, 19, 20 The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies is followed and the checklist is attached in supplemental material. The primary aim was to describe ECG features at different stages of hospitalization during COVID-19 CV events. The secondary aim was to examine the effects of specific ECG parameters and cardiac-related biomarkers on clinical outcomes in COVID-19.

The Burden of COVID-19 Study, including subsequent research using the database, was approved by the University of Louisville Institutional Review Board (# 20-0257). Information from the patients' electronic health records (EHR) was entered into a secure database (REDCap) and is compliant with the Health Insurance Portability and Accountability Act. Patient data is secure through the use of standard data security measures and approved by the IRBs of all participating hospitals to protect and safeguard the private healthcare information of all patients.

Data from 702 adult inpatients hospitalized with COVID-19 from March 9, 2020, to June 20, 2020, at all nine adult hospitals in the Louisville metro area were reviewed. All hospitalized patients with a diagnosis of COVID-19-as defined by a positive reverse transcriptasepolymerase chain reaction (RT-PCR) on the first or the repeat test and/or ground glass opacities on a chest computerized tomography (CT)-met the inclusion criteria for the study. patients seen in the emergency department who were not admitted as a hospital inpatient were excluded from this study.

Data were abstracted from the EHRs of hospitalized patients diagnosed with COVID-19. A comprehensive data abstraction instrument was developed by physicians, nurses, epidemiologists, biostatisticians, public health professionals, and research assistants who were members of the CERID study group. Trained researchers (PN, VS, HS) collected information from the patients' EHRs on COVID-19 test results, past medical history, social history, symptoms of current illness, medications, physical examination, management and therapies, radiologic and laboratory data, clinical course of hospitalization, complications, and outcomes.

Only CV events occurring after admission to the hospital were considered in the analysis. CV events included heart failure, cardiogenic shock, acute myocardial infarction, cardiomyopathy, myocarditis, cardiac arrhythmias (including tachycardia, bradycardia, supraventricular tachycardia, atrial tachycardia, and bundle-branch blocks), cerebrovascular events, pulmonary embolism, pulmonary edema, deep vein thrombosis, and cardiac arrest. Clinical diagnoses of CV events were made independently by individual physicians at each site. We planned to use sensitive cardiac injury/function biomarkers (troponin and B-type natriuretic peptide (BNP)) as short-term outcome measures and mortality, hospital length of stay (LOS), and intensive care unit (ICU) LOS as long-term outcome measures. ECG data assumed normal calibration of ECG paper at 25 millimeters (mm) per second and 1 millivolt (mV) equivalent to 10 millimeters (mm). Results from ECGs were collected from EHRs through abstraction of confirmed 12-lead ECG results by experienced researchers. First ECG was defined as the earliest available ECG in as patient's EHRs upon admission; CV eventtriggered ECG was defined as the ECG within 24 hours of a clinically diagnosed CV event; final ECG was defined as the last recorded ECG before discharge or death.

ECG abnormality was defined as any irregularity in rhythm, left ventricular hypertrophy (LVH), right ventricular hypertrophy (RVH), AV block, or ST changes. Rhythm information from ECGs included sinus rhythm, sinus tachycardia, atrial fibrillation, atrial flutter, atrioventricular (AV) blocks (none, first degree block, second degree type I heart block, second degree type II heart block, third degree heart block), left bundle branch block, and right bundle branch block.

Collected ECG parameters included P-R segment duration (normal range 120-200 ms), QRS duration (normal range 80-100 ms), corrected QT interval (QTc), presence of pathological Qwave (>40ms wide, >2mm deep, or >25% of QRS depth), ST segment elevation and depression indicative of ischemia (voltage >0.1 mV above or below baseline). Other measurements for analysis included evidence of left ventricular hypertrophy (LVH) using Sokolov-Lyon criteria (S wave depth in precordial lead V1 plus tallest R wave height in precordial leads V5-V6 >35 mm) and evidence of right ventricular hypertrophy (RVH) (right axis deviation >90 or 110 ° with larger R and smaller S waves in leads V1 and V2). 21 Laboratory data included the first and highest (peak) levels of troponin as well as BNP and Nterminal pro BNP (NT-pro BNP) levels. Measurements of BNP and NT-pro BNP were converted to one standard unit of measurement for comparison because hospitals used either BNP or NTpro BNP, not both. BNP measurement of 1 picograms per milliliter (pg/mL) is equivalent to 0.289 picomoles per liter (pmol/L) and NT-pro BNP measurement of 1 pg/mL is equivalent to 0.118 pmol/L. 22 

Clinical outcome variables included mortality (date of death and number of days from hospital admission to mortality), hospital LOS, and ICU LOS.

Descriptive statistics were reported; continuous variables were summarized as mean and standard deviation (SD), and categorical variables were summarized as counts and percentages.

To examine the association between ECG parameters and troponin/BNP values, Spearman's correlation coefficients were used to evaluate the association between two continuous variables, and Kruskal-Wallis one way ANOVA was conducted to examine the association between a categorical variable and a continuous outcome variable. 23 To examine whether ECG parameters were associated with mortality (e.g., patients discharged alive or not), Mann-Whitney U tests were used for continuous ECG parameters and Chi-squared tests or Fisher's exact tests for categorical ECG parameters. Generalized mixed effect models were used to examine whether ECG parameters changed over time. In particular, logistic mixed-effect models were used to examine the time effect for categorical ECG parameters, and linear mixed-effect models were used to examine time effect for continuous ECG parameters. 24 In the generalized linear mixed effect models, each subject was considered as a random effect. 

The sample population consisted of 702 hospitalized COVID- 19 (15.3%) had acute worsening of long-term arrhythmia, 7 (5.6%) had cerebrovascular accidents, 8 (6.5%) had pulmonary embolism, 2 (1.6%) had myocarditis, and 6 (4.8%) had deep venous thrombosis (DVT). Pre-existing cardiac co-morbidities in hospitalized COVID-19 patients who suffered CV events and who did not suffer CV events were summarized in Supplemental Table 1 . The group with CV events showed significantly higher incidences of all preexisting cardiac co-morbidities than the group without CV events except DVT. Among the 124 patients, eighty-six patients required ICU care. Fifteen patients received non-invasive mechanical ventilation, and 69 patients needed invasive mechanical ventilation (IMV). Table 1 summarized the ECG parameters in first, CV event-triggered, and final ECGs. Normal sinus rhythm was significantly more common in the first ECG compared to CV event-triggered ECG (59.5% vs. 42.6%; P = .023). Atrial fibrillation or atrial flutter was more frequent in CV event-triggered ECG compared to first ECG (9.5% vs. 26.9%; P = .007). Sinus tachycardia was found to be significantly more frequent in final ECG than in CV event-triggered ECG (37.5% vs. 20.4%; P = .031). Interestingly, we found that QRS duration was significantly longer in CV event-triggered ECG than in final ECG (107.364 ± 30.2 ms vs. 105.59 ± 30.3 ms; P = .047), and the rate of AV block was significantly higher in CV event-triggered ECG than in final ECG (31.5% vs. 17.5%; P = .018). Table   2 ), and a higher heart rate was significantly associated with longer ICU LOS with a Spearman correlation coefficient of 0.339 (P = .032, Supplemental Table 3 ).

First troponin values were compared between patients with and without an ECG abnormality in the first ECG. There were no significant difference in first troponin level among those with and without an ECG abnormality (Table 3) . Supplemental Table 4 showed the correlation coefficients for continuous ECG parameters of the first ECG. QTc was significantly associated with the first troponin levels (R = 0.52, P < .001). Table 4 showed a comparison of peak troponin values between patients with and without ECG abnormality in rhythm, LVH, RVH, AV block, or ST changes. Peak troponin levels of patients with atrial fibrillation or atrial flutter were significantly lower than those with normal sinus rhythm (0.073 ± 0.1 vs. 0.681 ± 1.3; P = .043) ( Table 4 ). There were no significant correlations between peak troponin levels and CV event-triggered ECG parameters (heart rate, P-R interval, QTc and QRS duration, Supplemental Table 5 ).

The effect of the first troponin, peak troponin, and BNP levels on mortality, ICU LOS, and hospital LOS for all 702 patients are summarized in Table 5 Associations of first troponin, peak troponin, and BNP with mortality, ICU LOS, and hospital LOS among the 124 patients with CV events are summarized in Supplemental Table 6 . However, no significant correlations with any of these three main clinical outcomes were observed.

Comprehensive analysis of ECGs in 124 patients who suffered CV events demonstrated distinct features of the first ECG (on admission), CV event-triggered ECG (within 24 hours of CV event), and final ECG (last ECG before discharge or death). Atrial fibrillation/flutter was the most common arrhythmia during CV events, and sinus tachycardia was the most common rhythm in the final ECG. QRS duration was longer, and AV block was more commonly present in the CV event-triggered ECGs.

Two systematic reviews of ECG findings in COVID-19 patients have been published recently. 25,

were the most observed ECG findings, but the relationship with myocardial injuries is debatable.

Garcia-Zamora et al performed a meta-analysis of 28 studies with 12,499 participants and found that the overall prevalence of cardiac arrhythmias was 10.3%, with the most common arrhythmias documented during hospitalization being supraventricular arrhythmias (6.2%), followed by ventricular arrhythmias (2.5%). The incidence of cardiac arrhythmias was higher among critically ill patients (relative risk [ 25, 26 , this study found atrial fibrillation or flutter to be the most common arrhythmia during CV event-triggered ECG (26.9%). However, atrial fibrillation or flutter was much lower on first ECG (9.5%) and final ECG (12.5%). A recent COVID-19 study found atrial fibrillation in 7.0% of the 201 patients at admission, and atrial fibrillation was associated with increased mortality (odds ratio [OR], 12.74; 95% CI, 3.65-44.48; P < .001). 27 Other studies have shown that atrial fibrillation or flutter was the most frequently reported serious arrhythmia 14, 17 , was associated with higher troponin values, and carried a higher mortality rate than other rhythms. 17 In the present study, AV block was also found be significantly higher in CV event-triggered ECG (31.5%) compared to admission or discharge ECGs. Both atrial arrhythmia and AV block could represent direct viral infection of the conduction system, myocardial ischemia/edema, diastolic dysfunction, left ventricular (LV) dysfunction, pulmonary hypertension from ARDS, or pulmonary embolism. For the first ECG, atrial arrhythmia was found to be correlated with shorter hospital and ICU LOS. However, no correlation was found between CV event-triggered or final ECG and either hospital or ICU LOS. One possible explanation could be early mortality with atrial arrhythmia. QRS duration longer than 120 ms was associated with worse clinical outcomes and higher levels of myocardial injury biomarkers in COVID-19. 28 Prolonged QRS could reflect active myocardial injury during CV events caused by the direct impact of SARS-CoV-2 on the cells. 29 A wide QRS complex has been previously associated with increased mortality risk in non-COVID-19 patients. 30, 31, 32 Our findings further confirm the importance of QRS duration in predicting mortality in COVID-19 patients. CV event-triggered ECG demonstrated significantly longer QRS duration than that on the first or final ECGs. Furthermore, this study found that QRS duration on final ECG was significantly longer in non-survivors than survivors among hospitalized COVID-19 patients with CV events.

Among all the parameters reviewed on the first ECGs, only QTc showed a significant correlation with the first troponin. A recent meta-analysis found that the prevalence of QTc > 500 ms was 12.3% in COVID-19 patients. 25 QTc interval prolongation was found to be associated with increased COVID-19 severity and mortality. 33, 34, 35, 36, 37 However, the risk of torsades de pointes was not increased in hospitalized COVID-19 patients who showed a marked prolongation of QTc interval. 38, 39 In our study, we did not find any correlation between ECG parameters and peak troponin levels among CV event-triggered ECGs. This might suggest that the CV eventtriggered ECG parameters are not useful predictors of further outcomes.

It has been demonstrated that ECG ST-T segment alterations are the most commonly reported ECG anomaly in patients with COVID-19 23, 24 and are more frequent among patients with severe COVID-19. 13, 40, 41 Barman et al showed that ST-T changes on admission ECG were closely associated with the severity of COVID-19 infection. 13 The present study found ST changes on the first ECGs in 4.1% of patients who suffered CV events and on CV event-triggered ECGs in 9.3%. However, there was no significant correlation with either first or peak troponin.

Sinus tachycardia was reported to be the most common arrhythmia in patients with COVID-19 13, 14, 17, 33 and was more frequent in non-survivors. This study found that heart rate on the final ECG was significantly correlated with ICU LOS. This could indicate higher levels of stress due to sepsis, hypovolemia, pulmonary embolism, anxiety, or mechanical ventilation.

Research on ECG alterations and hospital LOS is limited. Abrams et al compared the characteristics of patients with COVID-19 who died of arrhythmias to those who died of other causes and there was no statistically significant difference in LOS between the two groups (median 5 vs. 4 days; P = .76). 42 In addition to ECG findings, cardiac involvement can be detected by multiple laboratory markers, including troponin and BNP. Higher BNP values have been associated with abnormal ECG 14 and higher in-hospital mortality. 17 Troponin levels were higher in non-survivors than survivors 33 , as well as in patients with severe illness compared to those with non-severe COVID-19. 40 For the entire patient cohort (patients with and without CV events), the present study found that the first troponin, peak troponin, and BNP were all significantly associated with mortality and ICU LOS. First troponin and BNP were also significantly associated with hospital LOS. However, we did not find any significant correlations between first troponin, peak troponin, or BNP and mortality, ICU LOS, or hospital LOS among patients with CV events.

These results were surprising yet explicable. If cardiac injury has been ongoing, additional troponin and BNP values could not help to further predict clinical outcomes. Another explanation could be patients who suffered CV events shared common risk factors that are more dominant to determine the clinical outcomes. It could also be possible that SARS-CoV-2 virus induces myocardial injury through a different mechanism which is not dependent on the level of cardiac biomarkers. This might imply that clinicians should reconsider ordering additional troponin and BNP tests as they did not effectively predict outcomes in COVID-19 CV event patients.

There are limitations to our study. The results of this retrospective study may not be generalizable to all persons with COVID-19, as they may have significantly different characteristics to patients hospitalized with COVID-19; hence, the external validity of our study is limited to hospitalized patients. Studies with retrospective design may bias the true incidence and influence of ECG abnormalities as well as their prognostic value as predictors of clinical outcomes. To reduce these confounders and risk of bias in future research, large-scale prospective studies are needed to determine whether ECG abnormalities play an important role in predicting adverse clinical COVID-19 outcomes.

The simplicity and availability of the 12-lead ECG makes it a potentially valuable predictive tool in the risk stratification and management of COVID -19 patients. Our study sheds light on the importance of ECG findings in hospitalized patients who suffered CV events; we found ECGs at various stages of COVID-19 hospitalization showed significantly different features with dissimilar clinical outcome correlations. 

United States COVID-19 Cases, Deaths, and Laboratory Testing (NAATs) by State, Territory, and Jurisdiction

SARS-CoV-2 and cardiovascular complications: From molecular mechanisms to pharmaceutical management

Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection

Potential Effects of Coronaviruses on the Cardiovascular System: A Review

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

The association between cardiac injury and outcomes in hospitalized patients with COVID-19

Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance

Special Article -Acute myocardial injury in patients hospitalized with COVID-19 infection: A review

Changes of Laboratory Cardiac Markers and Mechanisms of Cardiac Injury in Coronavirus Disease

Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis

The effect of the severity COVID-19 infection on electrocardiography

The value of ECG changes in risk stratification of COVID-19 patients

Characterization of Myocardial Injury in Patients With COVID-19

Electrocardiographic Findings in Coronavirus Disease-19: Insights on Mortality and Underlying Myocardial Processes

Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30-Day Mortality in COVID-19

Outcomes and Risk Factors for Cardiovascular Events in Hospitalized COVID-19 Patients

Healthcare Workers Hospitalized with COVID-19: Outcomes from the Burden of COVID-19 study at the University of Louisville Center of Excellence for Research in Infectious Diseases (CERID)

Implementation of the Louisville COVID-19 Surveillance Protocol: Experiences from the University of Louisville Center of Excellence for Research in Infectious Diseases (CERID)

Chou's Electrocardiography in Clinical Practice: Adult and Pediatric. 6 th ed

Role of B-type natriuretic peptide (BNP) and NT-proBNP in clinical routine

Practical statistics for medical research

Applied Longitudinal Analysis

Arrhythmias and electrocardiographic findings in Coronavirus disease 2019: A systematic review and meta-analysis

A systematic review of ECG findings in patients with COVID-19

Clinical and electrocardiographic characteristics at admission of COVID-19/SARS-CoV2 pneumonia infection

Wide QRS Complex and Lateral ST-T Segment Abnormality Are Associated With Worse Clinical Outcomes in COVID-19 Patients

Wide QRS Complex and Left Ventricular Lateral Repolarization Abnormality: The Importance of ECG Markers on Outcome Prediction in Patients with COVID-19

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

Cardiovascular complications and its impact on outcomes in COVID-19

Electrocardiographic markers of increased risk of sudden cardiac death in patients with COVID-19 pneumonia

Corrected QT interval in hospitalized patients with coronavirus disease 2019: Focus on drugs therapy

Assessment of QT Intervals in a Case Series of Patients With Coronavirus Disease 2019 (COVID-19) Infection Treated With Hydroxychloroquine Alone or in Combination With Azithromycin in an Intensive Care Unit

Prolonged QT Interval in SARS-CoV-2 Infection: Prevalence and Prognosis

Risk of QT Interval Prolongation Associated With Use of Hydroxychloroquine With or Without Concomitant Azithromycin Among Hospitalized Patients Testing Positive for Coronavirus Disease 2019 (COVID-19)

QT prolongation, torsades de pointes, and sudden death with short courses of chloroquine or hydroxychloroquine as used in COVID-19: A systematic review

Suspected myocardial injury in patients with COVID-19: Evidence from front-line clinical observation in Wuhan, China

Association between electrocardiographic features and mortality in COVID-19 patients

Clinical and cardiac characteristics of COVID-19 mortalities in a diverse New York City Cohort

The authors acknowledge the excellent efforts of University of Louisville CERID group and Kornhauser Health Sciences Library to assist with this project. Alex Glynn, Jessica Petrey: literature review, study design, manuscript preparation.