Prognostic value of initial electrocardiography in predicting long-term all-cause mortality in COVID-19.

BACKGROUND: The electrocardiography (ECG) has short-term prognostic value in coronavirus disease 2019 (COVID-19), yet its ability to predict long-term mortality is unknown. This study aimed to elucidate the predictive role of initial ECG on long-term all-cause mortality in patients diagnosed with COVID-19. METHODS: In this prospective cohort study, adults with COVID-19 who underwent ECG testing within a 17-hospital health system in Northeast Ohio and Florida between 03/2020-06/2020 were identified. An expert ECG reader analyzed all studies blinded to patient status. The associations of ECG characteristics with long-term all-cause mortality and intensive care unit (ICU) admission were assessed using Cox proportional hazards regression model and multivariable logistic regression models, respectively. Status of long-term mortality was adjudicated on 01/07/2022. RESULTS: Of 837 patients (median age 65 years, 51% female, 44% Black), 683 (81.6%) were hospitalized, 281 (33.6%) required ICU admission, 67 (8.0%) died in-hospital, and 206 (24.6%) died at final follow-up after a median (IQR) of 21 (9-103) days after ECG. Overall, 179 (20.7%) patients presented with sinus tachycardia, 12 (1.4%) with atrial flutter, and 45 (5.4%) with atrial fibrillation (AF). After multivariable adjustment, sinus tachycardia (E-value for HR=3.09, lower CI=2.2) and AF (E-value for HR=3.13, lower CI=2.03) each independently predicted all-cause mortality. At final follow-up, patients with AF had 64.5% probability of death compared with 20.5% for those with normal sinus rhythm (P<.0001). CONCLUSIONS: Sinus tachycardia and AF on initial ECG strongly predict long-term all-cause mortality in COVID-19. The ECG can serve as a powerful long-term prognostic tool in COVID-19.

Prognostic value of initial electrocardiography in predicting long-term all-cause mortality in COVID-19

Background The electrocardiography (ECG) has short-term prognostic value in coronavirus disease 2019 (COVID-19), yet its ability to predict long-term mortality is unknown. This study aimed to elucidate the predictive role of initial ECG on long-term all-cause mortality in patients diagnosed with COVID-19. Methods In this prospective cohort study, adults with COVID-19 who underwent ECG testing within a 17-hospital health system in Northeast Ohio and Florida between 03/2020-06/2020 were identified. An expert ECG reader analyzed all studies blinded to patient status. The associations of ECG characteristics with long-term all-cause mortality and intensive care unit (ICU) admission were assessed using Cox proportional hazards regression model and multivariable logistic regression models, respectively. Status of long-term mortality was adjudicated on 01/07/2022. Results Of 837 patients (median age 65 years, 51% female, 44% Black), 683 (81.6%) were hospitalized, 281 (33.6%) required ICU admission, 67 (8.0%) died in-hospital, and 206 (24.6%) died at final follow-up after a median (IQR) of 21 (9-103) days after ECG. Overall, 179 (20.7%) patients presented with sinus tachycardia, 12 (1.4%) with atrial flutter, and 45 (5.4%) with atrial fibrillation (AF). After multivariable adjustment, sinus tachycardia (E-value for HR=3.09, lower CI=2.2) and AF (E-value for HR=3.13, lower CI=2.03) each independently predicted all-cause mortality. At final follow-up, patients with AF had 64.5% probability of death compared with 20.5% for those with normal sinus rhythm (P<.0001). Conclusions Sinus tachycardia and AF on initial ECG strongly predict long-term all-cause mortality in COVID-19. The ECG can serve as a powerful long-term prognostic tool in COVID-19.

A Case of COVID-19 ARDS with Unusual Refractory Hypoxia

Aim and background: Since the beginning of COVID-19 pandemic, we have come across a large number of ARDS patients with different presentations and clinical manifestations. The usual management is using a lung-protective ventilatory strategy followed by proning to improve oxygenation. Here, we present a case where the usual management failed to improve oxygenation which led us to think of co-existing alternative diagnosis. Case description: A 59-year-old male with a history of cardiovascular disease, presented with cough and breathing difficulty for 10 days and COVID RT PCR was positive. He was started on remdesivir, steroids, anti-coagulants, and other supportive measures but worsened and had to be intubated and mechanically ventilated. Lung-protective ventilation was initiated but the patient remained hypoxic even at 100% fiO2. Chest X-ray and HRCT did not show much severity and the measured lung compliance was also good. A transesophageal ECHO showed good LV function and no significant diastolic dysfunction. 2 sessions of proning were done and yet the oxygenation did not improve. Repeat HRCT + CTPA was done to look for pulmonary embolism but it instead revealed a pulmonary AV malformation. Coiling of the AV malformation was done. Oxygenation then substantially improved. Further sessions of proning were done and patient was gradually weaned off. Conclusion: There may be several co-existing causes of ventilation-perfusion mismatch which needs to be looked for. Pulmonary AV malformation, though rare, can cause shunting and hence persistent hypoxia.

Outcomes of COVID-19 ARDS on VV ECMO in a Tertiary Care Hospital in Kerala: A Case Series

Introduction: Acute respiratory distress syndrome (ARDS) is associated with high mortality despite the use of low-volume, low-pressure ventilation strategies that are aimed at reducing ventilator-induced lung injury. Initiation of ECMO for adult ARDS should be considered when conventional therapy cannot maintain adequate oxygenation. ECMO can stabilize gas exchange and haemodynamic compromise, consequently preventing further hypoxic organ damage. Here, we present a case series of COVID-19 ARDS who were put on VV ECMO in a tertiary care hospital in Kerala and their primary and secondary outcomes. Aims and objectives: The primary outcome is to determine the 28-day mortality from all causes in all COVID-positive patients put on VV ECMO till date. The secondary outcome is the incidence of ventilator-associated pneumonia (VAP) and acute kidney injury (AKI) in all COVID-positive patients put on VV ECMO. Materials and methods: Retrospective continuous case series. Retrospective data were collected from all COVID-positive patients who were put on VV ECMO till date in the hospital and the primary and secondary outcome was analyzed. Results: The mean duration from onset of dyspnea to initiation of ECMO was 11 days. The mean duration of ECMO for a patient was 7 days 19 hours. Out of 14 patients, 9 patients expired within 28 days of initiating ECMO (64.2%). Out of these, 2 patients were weaned off ECMO but died later. 2 patients died due to intracranial haemorrhage while on ECMO. Of all the patients put on ECMO, 6 patients had VAP complicating the course of ECMO (42.8%). Of the organisms isolated, 2 patients had MDR Acinetobacter, 2 patients had MDR Klebsiella, 1 patient had had MDR Acinetobacter, MDR Pseudomonas and MDR Klebsiella, and one patient has Aspergillus sp. Of the total patients, 7 had AKI during the course of ECMO as defined by KDIGO criteria (50%). Of these, 4 had to undergo at least one session of dialysis while the others were managed conservatively. Conclusion: The 28-day mortality was higher than an international multi-centric trial done by De Troy et al. probably because of late referrals to our hospital after many days of NIV and high oxygen requirement. VAP complicated the course of ECMO in many patients which emphasizes strict infection control practices in patients on ECMO. AKI was found in half of the patients and was usually secondary to sepsis.

Validating and implementing cardiac telemetry for continuous QTc monitoring: A novel approach to increase healthcare personnel safety during the COVID-19 pandemic.

BACKGROUND: Minimizing direct patient contact among healthcare personnel is crucial for mitigating infectious risk during the coronavirus disease 2019 (COVID-19) pandemic. The use of remote cardiac telemetry as an alternative to 12­lead electrocardiography (ECG) for continuous QTc monitoring may facilitate this strategy, but its application has not yet been validated or implemented. METHODS: In the validation component of this two-part prospective cohort study, a total of 65 hospitalized patients with simultaneous ECG and telemetry were identified. QTc obtained via remote telemetry as measured by 3 independent, blinded operators were compared with ECG as assessed by 2 board-certified electrophysiologists as the gold-standard. Pearson correlation coefficients were calculated to measure the strength of linear correlation between the two methods. In a separate cohort comprised of 68 COVID-19 patients treated with combined hydroxychloroquine and azithromycin, telemetry-based QTc values were compared at serial time points after medication administration using Friedman rank-sum test of repeated measures. RESULTS: Telemetry-based QTc measurements highly correlated with QTc values derived from ECG, with correlation coefficients of 0.74, 0.79, 0.85 (individual operators), and 0.84 (mean of all operators). Among the COVID-19 cohort, treatment led to a median QTc increase of 15 milliseconds between baseline and following the 9th dose (p = 0.002), with 8 (12%) patients exhibiting an increase in QTc ≥ 60 milliseconds and 4 (6%) developing QTc ≥ 500 milliseconds. CONCLUSIONS: Cardiac telemetry is a validated clinical tool for QTc monitoring that may serve an expanding role during the COVID-19 pandemic strengthened by its remote and continuous monitoring capability and ubiquitous presence throughout hospitals.

Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people's lives. It is not known whether the stress of the pandemic is associated with an increase in the incidence of stress cardiomyopathy. Objective: To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic. Design, Setting, and Participants: This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020. Exposures: Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic. Main Outcomes and Measures: Incidence of stress cardiomyopathy. Results: Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median [interquartile range] age, 67 [59-74]; 1094 [66.1%] men) presented during the pre-COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median [interquartile range] age, 67 [57-75]; 175 [67.8%] men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P < .001). All patients during the COVID-19 pandemic had negative reverse transcription-polymerase chain reaction test results for COVID-19. Patients with stress cardiomyopathy during the COVID-19 pandemic had a longer median (interquartile range) hospital length of stay compared with those hospitalized in the prepandemic period (COVID-19 period: 8 [6-9] days; March-April 2018: 4 [3-4] days; January-February 2019: 5 [3-6] days; March-April 2019: 4 [4-8] days; January-February: 5 [4-5] days; P = .006). There were no significant differences between the COVID-19 period and the overall pre-COVID-19 period in mortality (1 patient [5.0%] vs 1 patient [3.6%], respectively; P = .81) or 30-day rehospitalization (4 patients [22.2%] vs 6 patients [21.4%], respectively; P = .90). Conclusions and Relevance: This study found that there was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 pandemic when compared with prepandemic periods.