ABSTRACT
Background: The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias. Purpose: To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality. Methods: A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables. Results: The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016). When adjusted for confounding variables, prone was the most significant predictor (OR 2.800;95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484;95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440;95% CI 0.950-6.310;p 0.065). Conclusions: COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias. (Figure Presented).
ABSTRACT
Background: The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality. Purpose: Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality. Methods: A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR). Results: A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p <0.001) and had more hypertension (p 0.034), heart failure (HF) (p <0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA). Patients with HF had the highest risk of tachyarrhythmia (OR 3.539;95% CI 2.666-4.698;p <0.001), followed by severe VHD (OR 1.990;95% CI 1.192-3.365;p 0.009) and CAD (OR 1.575;95% CI 1.040-2.386;p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819;95% CI 1.272-2.602;p 0.001) Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820;95% CI 2.151-3.695;p <0.001). Conclusions: Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed. Odds-ratio of tachyarrhythmias (Figure Presented).
ABSTRACT
Background: COVID-19 was first considered a pandemic on the 11th of March of 2020 by the World Health Organization. Its impact comprised not only the direct consequences of the disease but a decrease in the follow-up and interventions of patients with cardiovascular (CV) disease. In Portugal and the World, the consequences of this complex paradigm shift on emergent pacemaker implantation rates during and after this pandemic is largely unknown. Purpose: We sought to analyse the impact of COVID-19 pandemic on emergent pacemaker implantation rate and patient profile in a tertiary hospital during the first Portuguese lockdown and subsequent post-lockdown period. Methods: We retrospectively reviewed the clinical profile of patients who had pacemakers implanted in our hospital in an urgent/emergent setting from March 18, 2020 to May 17, 2020 (lockdown) and May 19 to July 17, 2020 (post-lockdown). This data was then directly compared to the homologous periods from the year before (H1 and H2, respectively). Results: A total of 180 patients submitted to emergent pacemaker implantation were included. The cohort was comprised of 29 patients who had a pacemaker implanted during lockdown, 60 post-lockdown, 38 in H1 (+31% vs lockdown) and 53 in H2. Average age and gender proportion were similar for all groups. When comparing lockdown and post-lockdown periods, the number of cases significantly increased in the second period (+106.9%) and there was a tendency for a higher number of temporary pacemaker use (3.4% vs 16.7%;p=0.076). Patients admitted during lockdown were 7.57 times more likely to present with hypotension/shock (odds ratio (OR) 7.57;p=0.013). Regarding lockdown and its homologous 2019 period, there was a decrease in the number of patients admitted (-23.7%). Again, there was a higher tendency for hypotension on presentation during lockdown (p=0.054). In comparison to its homologous 2019 period, post-lockdown saw a slight increase in the number of patients (+13.2%) and more patients presented with bradycardia (16.7% vs 3.8%;p=0.026). Also of note, no patients were admitted to the emergency department during lockdown for anomalies detected on ambulatory tests (Holter, electrocardiogram or implanted loop recorder). Conclusion: During lockdown, clinical presentation was generally more severe, with a greater number of patients presenting with hypotension/ shock. In addition, there appears to be a lockdown effect on emergent bradyarrhtmias admissions in the post-lockdown period with a profound impact: higher admission rates and more severe presentations including a higher need of temporary pacemaker. Patients with symptoms suggestive of bradyarrhythmias should be advised to present promptly regardless of the pandemic. (Figure Presented).