Cardiac arrhythmias and Covid-19

ABSTRACT: Cardiovascular manifestations of COVID-19 include cardiac rhythm disturbances, whose mechanisms, incidence, and most common types are not well established in this population. Intense inflammatory response and metabolic activity contribute to recurrence of pre-existing arrhythmias, and other arrhythmias can occur due to myocardial injury, acute coronary insufficiency, and electrolyte disturbances. Brady- and tachyarrhythmias, as well as conduction disorders have been described. QT interval prolongation and fatal ventricular arrhythmias (Torsades de Pointes) may result from the pathological process or adverse effect of drugs (antiarrhythmics, chloroquine / hydroxychloroquine, azithromycin and antivirals). Patients with congenital heart disease and hemodynamic repercussions, patients with signs of heart failure, pulmonary hypertension, cyanosis, hypoxemia, and those who underwent heart transplantation and immunosuppression are at greater risk. In patients with implantable cardioverter defibrillators (ICDs), the risk depends on the presence of structural heart disease. In the course of COVID-19, in-person assessment of these patients should be limited to high-risk situations, including syncope, worsening of heart failure and shock delivery by ICDs. Likewise, cardiac implantable electronic device implantation or replacement surgery should be limited to emergency and urgent cases, including symptomatic high-degree atrioventricular block, ICD for secondary prevention and pulse generator replacement due to battery drain.

Eventos arrítmicos no lúpus eritematoso sistêmico: [revisão] / Arrhythmias in systemic lupus erythematosus: [review]

Mais da metade dos pacientes com lúpus eritematoso sistêmico (LES) apresentam envolvimento cardíaco. Porém, não existem estudos de prevalência de eventos arrítmicos (EA) nesta doença, nem de correlações laboratoriais preditoras de sua ocorrência. É possível que o clássico segundo pico de mortalidade da doença esteja relacionado com a ocorrência da EA, sobretudo pela natureza súbita dos óbitos relatados. Processo autoimune, complicações ateroscleróticas e, até mesmo, efeito adverso do tratamento (cardiotoxicidade pela cloroquina) parecem ser os mecanismos fisiopatológicos mais prováveis para estes distúrbios. A participação direta de autoanticorpos, como o anti-Ro/SSA e o anti-RNP ainda é controversa.Todos os tipos de bloqueios atrioventriculares (BAV), distúrbios da condução intraventricular e a doença do nó sinusal já foram descritos na doença. As taquicardias mais identificadas são a taquicardia sinusal, a fibrilação atrial e as extrassístoles atriais. O prolongamento do intervalo QT e a presença de potenciais tardios ao eletrocardiograma de alta resolução também já foram documentados em pacientes com LES e podem estar associados a maiores taxas de mortalidade. A toxicidade cardíaca secundária ao uso de cloroquina poderia determinar diversos tipos de EA. Entretanto, existem poucos relatos de bloqueio fascicular que poderiam evoluir para BAVT com o uso desta droga. Uma vez que estes efeitos adversos são raramente descritos, os benefícios das propriedades anti-inflamatórias e imunes reforçam o uso dos antimaláricos nesta doença. Uma avaliação cardiológica completa deve incluir exames do sistema excito-condutor e deve ser realizada em todos os pacientes com LES no sentido de identificar EA, prevenindo sintomas e até mesmo a morte súbita.

Cardiac involvement is present in more than half of the patients with Systemic Lupus Erythematosus (SLE). However, studies on the prevalence of arrhythmias in this disease and laboratorial correlations predictive of their development do not exist. It seems possible that the classic second mortality peak is related to arrhythmias, mainly due to the sudden nature of those deaths. Autoimmune process, atherosclerotic complications, and even adverse effects secondary to the treatment of this disorder (chloroquine cardiotoxicity) seem to be the main pathophysiological mechanisms of those disturbances. The direct participation of autoantibodies, such as anti-Ro/SSA and anti-RNP, is still controversial. All types of AV blocks (AVB), intraventricular conduction disturbances, and sick sinus syndrome have already been described in this disease. Tachycardias identified more often include sinus tachycardia, atrial fibrillation, and atrial ectopies. Long QT syndrome and the presence of late potentials in signal-averaged ECG have also been described in SLE patients and they can be associated with increased mortality rates. Cardiac toxicity secondary to chloroquine could be responsible for several types of arrhythmias. However, few cases of fascicular block evolving to complete AV block have been described. Since these adverse effects are rarely reported, the beneficial anti-inflammatory and immune properties support the use of antimalarials in this disease. A complete cardiologic evaluation should include the conduction system and must be carried out in all SLE patients to identify arrhythmias, therefore preventing symptoms and also sudden cardiac death.

Eventos arrítmicos em pacientes com lúpus eritematoso sistêmico: correlações eletrocardiográficas e laboratoriais / Arrhythmic events in patients with systemic lupus erythematosus: electrocardiographic and laboratory correlations

INTRODUÇÃO: O Lúpus Eritematoso Sistêmico (LES) é uma doença inflamatória crônica que pode acometer qualquer órgão ou sistema. O acometimento do coração pode ocorrer em até 50% dos casos e não existem estudos de prevalência de eventos arrítmicos (EA) em pacientes com LES, nem de correlações laboratoriais preditoras de sua ocorrência. OBJETIVOS: Estabelecer a taxa de ocorrência de EA e identificar variáveis laboratoriais preditoras de sua ocorrência em pacientes com LES em seguimento em ambulatório de hospital terciário; estabelecer a associação entre o uso de cloroquina com a ocorrência de EA e óbitos (tipo, número e tempo de seguimento). MÉTODOS: Foi realizado um estudo clínico descritivo, observacional e aberto com pacientes em seguimento ambulatorial no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo que foram submetidos a avaliação clínica, exames laboratoriais, ECG de repouso e Holter de 24h. A associação entre as variáveis e os EA foi avaliada por meio dos testes qui-quadrado, razão de verossimilhança, teste exato de Fisher, teste t-Student, teste não-paramétrico de Mann-Whitney, regressão logística múltipla e curva ROC. RESULTADOS: Entre agosto/2005 e agosto/2006 foram estudados 325 pacientes consecutivos, sendo 8 excluídos. A idade média foi de 40,25 anos, 91% mulheres. O tempo médio do diagnóstico de LES foi de 11,36 anos e apenas 6 pacientes apresentaram critérios para atividade do LES (escore SLEDAI). Duzentos e vinte e um pacientes estavam em uso de cloroquina. Alterações ao ECG ocorreram em 66 pacientes (20,82%): 5 bloqueios atrioventriculares de 1º grau; 4 bradicardias sinusais; 4 taquicardias sinusais e 1 supraventricular; 6 bloqueios do ramo direito (BRD); 2 bloqueios do ramo esquerdo (BRE); 45 QT prolongados. Ao Holter foram identificados 4 pacientes com pausas > 2,0 segundos; 45 com FC mínima < 50bpm; 90 com extrassístoles supraventriculares (ESV); 26 com taquiarritmias supraventriculares (FA/TA); 65 com...

INTRODUCTION: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory illness that can affect any organ and system. Up to 50% of patients have their heart affected and there are no prevalence studies of arrhythmic events (AE) in SLE patients and laboratory predictors are also unknown. OBJECTIVES: To establish the rate of occurrence of AE and to identify laboratory predictors in outpatients with SLE; to establish the association between chloroquine use and the occurrence of AE and death (type, number and time of follow-up). METHODS: A descriptive, observational and opened clinical study was carried out with SLE oupatients selected from the Rheumatology clinic of São Paulo University Medical School, Brazil. They were submitted to clinical evaluation, laboratory exams, resting-ECG and 24-hour Holter monitoring. Statistics: The association between the variables and the occurrence of AE was assessed by chi-square, likelihood ratio, Fishers test, t-Student, Mann-Whitney, ROC curve and logistic regressions. RESULTS: Between august/05-august/06, 325 consecutive patients were studied. Resting-ECG abnormalities were found in 66 patients, rate of 20.82%. The average age was 40.25yo, 91% female. The average time of SLE diagnosis was of 11.36y and only 6 presented criteria for diseases activity (SLEDAI score). There were 221 patients using chloroquine. ECG disturbances found: 5 1st degree AV-block; 4 sinus bradycardia; 4 sinus tachycardia and 1 supraventricular tachycardia; 6 RBBB; 2 LBBB; 45 long QT. At Holter monitoring: 4 pauses>2.0s; 45 HR<50bpm; 90 atrial ectopies; 26 atrial tachyarrhythmia; 65 ventricular ectopies. Seven death were registered (2.47%). Age above 40yo was predictor of AE (p=0.002; OR=2.5; 95%IC=1.4-5.6). Presence of anticardiolipine antibody was predictor of QRS>120ms occurrence (p = 0.005; OR 3.989; IC 95% = 1.615-9.852). C3 level bellow 105mg% was predictor of non-occurrence of...

Cardiac damage from chronic use of chloroquine: a case report and review of the literature

Chloroquine has been widely used in rheumatological treatment, but potential severe side effects require careful follow-up. Cardiac damage is not a common consequence, but its clinical relevance has not yet been described. We report the case of a 58-year-old woman with rheumatoid arthritis, in whom chronic chloroquine use resulted in major irreversible cardiac damage. She presented with syncopal episodes due to complete atrioventricular block confirmed by electrophysiological study whose changes were concluded to be irreversible and a permanent pacemaker was indicated. Endomyocardial biopsy was also performed to search for histopathological and ultrastructural cardiac damage. We also reviewed the 22 cases of chloroquine-induced cardiopathy described to date as well as its pathophysiology