Safety of Adenosine for the Treatment of Supraventricular Tachycardia in Hospitalized Patients with COVID-19 Pneumonia.

Coronavirus disease 2019 (COVID-19) is associated with pulmonary involvement and cardiac arrhythmias, including supraventricular tachycardia (SVT). Adenosine is commonly used to treat SVT and is generally safe, but is rarely associated with bronchospasm. There are no data regarding the safety of adenosine use in patients with COVID-19 pneumonia and physicians may hesitate to use it in such patients. We surveyed resident physicians and cardiology attendings regarding their level of comfort in administering adenosine to hospitalized COVID-19 patients. We compared a study group of 42 COVID-19 hospitalized patients who received adenosine for SVT to a matched (for age, sex, and co-morbidities) control group of 42 non-COVID-19 hospitalized patients during the same period, all of whom received IV adenosine for SVT. Escalation of care following intravenous adenosine administration was defined as increased/new pressor requirement, need for higher O2 flow rates, need for endotracheal intubation, new nebulizer therapy, or transfer to intensive care unit within 2 h of adenosine administration. Survey results showed that 82% (59/72) of residents and 62% (16/26) of cardiologists expressed hesitation/significant concerns regarding administering adenosine in hospitalized COVID-19 patients. Adenosine use was associated with escalation of care in 47.6% (20/42) COVID-19 as compared to 50% (21/42) non-COVID-19 patients (odds ratio 0.95, 95% CI 0.45-2.01, p = NS). Escalation of care was more likely in patients who were on higher FiO2, on prior nebulizer therapy, required supplemental oxygen, or were already on a ventilator. In conclusion, we identified significant hesitation among physicians regarding the use of adenosine for SVT in hospitalized COVID-19 patients. In this study, there was no evidence of increased harm from administering adenosine to patients with SVT and COVID-19. This finding needs to be confirmed in larger studies. Based on the current evidence, adenosine for treatment of SVT in this setting should not be avoided. Key Points: Question: Given the known bronchospastic effects of adenosine, is the use of adenosine safe for treatment of supraventricular tachycardia in hospitalized patients with COVID-19? Findings: A survey of residents and cardiology attending identified that a majority expressed some level of apprehension in using adenosine for SVT in COVID-19 patients. In our matched cohort study, we found adenosine use to be comparably safe in COVID-19 and non-COVID-19 hospitalized patients. Meaning: Based on current evidence, adenosine for treatment of SVT in this setting should not be avoided.

Implantation of cardiac electronic devices in active COVID-19 patients: Results from an international survey.

BACKGROUND: Cardiac implantable electronic device (CIED) implantation rates as well as the clinical and procedural characteristics and outcomes in patients with known active coronavirus disease 2019 (COVID-19) are unknown. OBJECTIVE: The purpose of this study was to gather information regarding CIED procedures during active COVID-19, performed with personal protective equipment, based on an international survey. METHODS: Fifty-three centers from 13 countries across 4 continents provided information on 166 patients with known active COVID-19 who underwent a CIED procedure. RESULTS: The CIED procedure rate in 133,655 hospitalized COVID-19 patients ranged from 0 to 16.2 per 1000 patients (P <.001). Most devices were implanted due to high-degree/complete atrioventricular block (112 [67.5%]) or sick sinus syndrome (31 [18.7%]). Of the 166 patients in the study survey, the 30-day complication rate was 13.9% and the 180-day mortality rate was 9.6%. One patient had a fatal outcome as a direct result of the procedure. Differences in patient and procedural characteristics and outcomes were found between Europe and North America. An older population (76.6 vs 66 years; P <.001) with a nonsignificant higher complication rate (16.5% vs 7.7%; P = .2) was observed in Europe vs North America, whereas higher rates of critically ill patients (33.3% vs 3.3%; P <.001) and mortality (26.9% vs 5%; P = .002) were observed in North America vs Europe. CONCLUSION: CIED procedure rates during known active COVID-19 disease varied greatly, from 0 to 16.2 per 1000 hospitalized COVID-19 patients worldwide. Patients with active COVID-19 infection who underwent CIED implantation had high complication and mortality rates. Operators should take these risks into consideration before proceeding with CIED implantation in active COVID-19 patients.

Describing heart rate variability in patients with chronic atrial fibrillation during hospitalization for COVID-19.

INTRODUCTION: Myriad cardiovascular manifestations have been reported with COVID-19. We previously reported that failure of PR interval shortening with increasing heart rate (HR) in patients with COVID-19 is associated with adverse outcomes. Here, we report on heart rate variability (HRV) and clinical outcomes in patients with chronic atrial fibrillation (cAF) hospitalized for COVID-19. METHODS: A retrospective review of admitted COVID-19 patients with cAF between 1 March 2020 to 30 June 2020 was performed. HRV in cAF was compared during pre-COVID-19 and COVID-19 admissions; we selected pre-COVID-19 ECGs with HRs that were within 10 beats per minute of the COVID-19 ECGs. Mean HR and each RR interval were recorded. Time-domain measurements of HR variability were then calculated (SDSD, RMSSD, pNN50). Clinical outcomes during COVID-19 were correlated to indices of HRV. RESULTS: A total of 184 ECGs (95 pre-COVID-19, 89 COVID-19) from 38 cAF in-patients were included. Mean age 78.6 ± 11.4 years, male 44.7%. The mean number of ECGs analyzed per patient pre-COVID-19 was 2.50 and during COVID-19 was 2.34. Comparing pre-COVID-19 versus COVID-19 ECGs showed: mean HR (95.9 ± 24.3 vs. 101.6 ± 22.8 BPM; P = .10), SDSD (109.0 ± 50.6 vs. 90.3 ± 37.2 ms; P < .01), RMSSD (184.1 ± 80.4 vs. 147.3 ± 59.8 ms; P < .01), pNN50 (73.8 ± 16.3 vs. 65.6 ± 16.6%; P < .01). Patients who had a smaller pNN50 during a COVID-19 admission had increased mortality (50.0% vs. 14.3%; log-rank test P = .02). CONCLUSION: In patients with cAF, the HRV was reduced during COVID-19 compared with prior illnesses at similar average heart rates. Patients with the most depressed HRV as measured by pNN50 had an associated increase in mortality compared with patients whose HRV was preserved.

Behavior of the PR interval with increasing heart rate in patients with COVID-19.

BACKGROUND: Myriad manifestations of cardiovascular involvement have been described in patients with coronavirus disease 2019 (COVID-19), but there have been no reports of COVID-19 affecting the cardiac conduction system. The PR interval on the electrocardiogram (ECG) normally shortens with increasing heart rate (HR). The case of a patient with COVID-19 manifesting Mobitz type 1 atrioventricular (AV) block that normalized as the patient's condition improved prompted us to investigate PR interval behavior in patients with COVID-19. OBJECTIVE: The purpose of this study was to characterize PR interval behavior in hospitalized patients with COVID-19 and to correlate that behavior with clinical outcomes. METHODS: This study was a cross-sectional cohort analysis of confirmed COVID-19 cases (March 26, 2020, to April 25, 2020). We reviewed pre-COVID-19 and COVID-19 ECGs to characterize AV conduction by calculating the PR interval to HR (PR:HR) slope. Clinical endpoints were death or need for endotracheal intubation. RESULTS: ECGs from 75 patients (246 pre-COVID-19 ECGs and 246 COVID-19 ECGs) were analyzed for PR:HR slope. Of these patients, 38 (50.7%) showed the expected PR interval shortening with increasing HR (negative PR:HR slope), whereas 37 (49.3%) showed either no change (8 with PR:HR slope = 0) or paradoxical PR interval prolongation (29 with positive PR:HR slope) with increasing HR. Patients without PR interval shortening were more likely to die (11/37 [29.7%] vs 3/38 [7.9%]; P = .019) or require endotracheal intubation (16/37 [43.2%] vs 8/38 [21.1%]; P = .05) compared to patients with PR interval shortening. CONCLUSION: Half of patients with COVID-19 showed abnormal PR interval behavior (paradoxical prolongation or lack of shortening) with increasing HR. This finding was associated with increased risk of death and need for endotracheal intubation.