key: cord-1054012-w5awkeoz
authors: Matos Bela, Margarida; Parente, Dalila; Soares, Sofia Garcês; Silva, Bárbara; Vilaça, Helena; Nogueira, Luís
title: COVID-19 and risk of arrhythmia?
date: 2020-12-10
journal: Porto Biomed J
DOI: 10.1097/j.pbj.0000000000000110
sha: 05fd76494ed7d6ecc2ec6493d052e43224192bff
doc_id: 1054012
cord_uid: w5awkeoz

nan

Coronavirus disease-2019 (COVID-19) is an infectious disease caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) with a wide range of clinical manifestations, mainly dominated by respiratory symptoms. 1 With the growing number of infected patients, major cardiac complications have been reported 2,3 with higher risk of in-hospital mortality. 4 An 85-year-old male with a history of hypertension, type 2 diabetes and junctional rhythm (Fig. 1A) presented to the ED due to progressive dyspnea and dry cough in the previous week and paroxysmal nocturnal dyspnea on the previous day. The physical examination revealed a blood pressure of 118/45 mm Hg, heart rate of 36 bpm, O2 saturation of 90% on room air and an axillary temperature of 37.7°C. The patient had bilateral crackles on lung auscultation. Arterial blood gas analysis showed type 1 respiratory failure. A 12-lead electrocardiogram (EKG) showed junctional rhythm with left bundle branch block (Fig. 1B ). Bloodwork revealed an elevated C-reactive protein (83.8 mg/dL; normal 7.5 mg/L), D-dimer (2095 ng/mL; normal <243 ng/ mL), N-terminal pro-brain natriuretic peptide (5360 pg/mL; normal 133 pg/mL), creatinine phosphokinase (760 UI/L; normal 10-72 UI/L) and high sensitivity troponin (139 pg/mL; normal <19.8 pg/mL). The chest x-ray showed an enlarged cardiothoracic ratio. The patient's nasopharyngeal swab was positive for SARS-CoV-2 PCR. The patient had a favorable chronotropic response to inhaled salbutamol and was admitted to the COVID ward under cardiac telemetry monitoring. On the first day of admission, a new episode of bradycardia was observed. The EKG showed a complete left bundle branch block and a permanent pacemaker was placed. The remainder of his hospital stay was uneventful with resolution of heart failure symptoms, respiratory failure and progressive decrease of the inflammatory markers and troponin levels.

Although the pathophysiology underlying COVID-19 remains poorly understood, SARS-CoV-2 may directly injure the heart leading to higher risk of in-hospital mortality. 4 Some theories have been postulated to explain the myocardial injury and the damage to the conduction system. 2 One explanation suggests that patients with chronic cardiovascular diseases may become unstable due to the imbalance between metabolic demand and reduced cardiac reserve, intensified by the inflammatory response and disturbance of autonomic tone. 2 This injurious effect could be perpetuated by the prompt and severe downregulation of myocardial and pulmonary ACE2 pathways. 2 Another matter of debate has been the use of drugs that have been tested in patients with COVID-19 that predispose to arrythmias, such as hydroxychloroquine and azithromycin. 5 This was not the case since this patient was treated with supportive care alone without any antiviral or immunomodulatory therapies.

In conclusion, we present the case of an elderly man with a predisposition to arrhythmia in whom SARS-CoV-2 infection was diagnosed when he presented to the ED with severe bradycardia. Could the conduction abnormality described in this patient (who already had a predisposition to arrhythmia) be interpreted as a result of the disfunction of the electrical conduction system induced by SARS-CoV-2? Or could it merely reflect the impact of a systemic illness like many others? 6 Our knowledge regarding the cardiovascular involvement of SARS-CoV-2 infection is still limited. In these patients, one should remain on high alert for cardiovascular complications.

COVID-19 diagnosis and management: a comprehensive review

Cardiac and arrhythmic complications in patients with COVID-19

COVID-19 and the cardiovascular system

Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China

COVID-19 management and arrhythmia: risks and challenges for clinicians treating patients affected by SARS-CoV-2

COVID-19 and cardiac arrhythmias

We acknowledge Mari Mesquita MD MSc and Mariana Meireles MD MSc for their helpful comments regarding this patient's case.

MMB, DP, SG, BS, HV and LN declares no conflicts of interest, real or perceived, financial or nonfinancial