Prognostic value of right ventricular strain pattern on ECG in COVID-19 patients

S1Q3T3 Electrocardiographic Pattern in a Case of Colonic Ileus: A Case Report

The S1Q3T3 electrocardiographic (ECG) pattern is commonly described in patients with acute pulmonary embolism (PE). However, it is a nonspecific, nonsensitive ECG finding associated with right heart strain that can be found in other acute presentations as well. Most of these acute diseases are of cardiac or pulmonary origin and pathophysiology. Acute abdominal pathologies are not well-known etiologies for this characteristic ECG pattern. We present a case of postoperative colonic dilation and ileus that showed up as acute, new atrial fibrillation (AF) associated with the S1Q3T3 pattern and that resolved after the resolution of the ileus symptoms.

Are Pre-Hospitalization ECG Abnormalities Associated With Increased Mortality in COVID-19 Patients? A Quantitative Systematic Literature Review

BACKGROUND

While COVID-19 is predominantly a respiratory disease, cardiovascular complications occur and are associated with worse outcomes. Electrocardiogram (ECG) abnormalities are frequently observed in hospitalized COVID-19 patients, some of which are associated with increased mortality. It is unclear whether ECG abnormalities occurring before hospitalization are associated with increased mortality. This quantitative systematic literature review aims to determine which ECG changes occurring before hospitalization are associated with mortality and discuss whether these findings can aid the assessment of patients and decision-making in the pre-hospital environment.

METHODS

A systematic search of the following digital databases was conducted: CINAL, PUBMED, MEDLINE, and Coronavirus Research Database. Eight cohort studies (primary papers) including COVID-19 patients with ECGs taken in the Emergency Department before hospitalization were selected for quantitative synthesis and results were obtained for the prevalence of ECG changes among survivors compared with non-survivors. Odds and hazard ratios for ECG abnormalities associated with mortality were also collected and compared.

RESULTS

Identification of ECG abnormalities on pre-hospitalization ECG is associated with increased mortality in COVID-19 patients. These ECG abnormalities include non-sinus rhythm, QTc prolongation, left bundle branch block, axis deviation, atrial fibrillation, atrial flutter, right ventricular strain patterns, ST segment changes, T wave abnormalities, and evidence of left ventricular hypertrophy.

CONCLUSION

Electrocardiogram assessment in the pre-hospital environment may be beneficial when assessing COVID-19 patients and could help identify patients at increased risk of mortality.

Screening for RV Dysfunction Using Smartphone ECG Analysis App: Validation Study with Acute Pulmonary Embolism Patients

Background: Acute pulmonary embolism (PE) is a critical condition where the timely and accurate assessment of right ventricular (RV) dysfunction is important for patient management. Given the limited availability of echocardiography in emergency departments (EDs), an artificial intelligence (AI) application that can identify RV dysfunction from electrocardiograms (ECGs) could improve the treatment of acute PE. Methods: This retrospective study analyzed adult acute PE patients in an ED from January 2021 to December 2023. We evaluated a smartphone application which analyzes printed ECGs to generate digital biomarkers for various conditions, including RV dysfunction (QCG-RVDys). The biomarker's performance was compared with that of cardiologists and emergency physicians. Results: Among 116 included patients, 35 (30.2%) were diagnosed with RV dysfunction. The QCG-RVDys score demonstrated significant effectiveness in identifying RV dysfunction, with a receiver operating characteristic-area under the curve (AUC) of 0.895 (95% CI, 0.829-0.960), surpassing traditional biomarkers such as Troponin I (AUC: 0.692, 95% CI: 0.536-0.847) and ProBNP (AUC: 0.655, 95% CI: 0.532-0.778). Binarized based on the Youden Index, QCG-RVDys achieved an AUC of 0.845 (95% CI: 0.778-0.911), with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.2% (95% CI: 82.4-100%), 77.8% (95% CI: 69.1-86.4%), 63.3% (95% CI: 54.4-73.9%), and 95.5% (95% CI: 90.8-100%), respectively, significantly outperforming all the expert clinicians, with their AUCs ranging from 0.628 to 0.683. Conclusions: The application demonstrates promise in rapidly assessing RV dysfunction in acute PE patients. Its high NPV could streamline patient management, potentially reducing the reliance on echocardiography in emergency settings.

A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74 years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.

Chronic thromboembolic pulmonary hypertension is an uncommon complication of COVID-19: UK national surveillance and observational screening cohort studies

BACKGROUND

Pulmonary embolism (PE) is a well-recognised complication of coronavirus disease 2019 (COVID-19) infection, and chronic thromboembolic pulmonary disease with and without pulmonary hypertension (CTEPD/CTEPH) are potential life-limiting consequences. At present the burden of CTEPD/CTEPH is unclear and optimal and cost-effective screening strategies yet to be established.

METHODS

We evaluated the CTEPD/CTEPH referral rate to the UK national multidisciplinary team (MDT) during the 2017-2022 period to establish the national incidence of CTEPD/CTEPH potentially attributable to COVID-19-associated PE with historical comparator years. All individual cases of suspected CTEPH were reviewed by the MDT for evidence of associated COVID-19. In a separate multicentre cohort, the risk of developing CTEPH following hospitalisation with COVID-19 was calculated using simple clinical parameters at a median of 5 months post-hospital discharge according to existing risk scores using symptoms, ECG and N-terminal pro-brain natriuretic peptide.

RESULTS

By the second year of the pandemic, CTEPH diagnoses had returned to the pre-pandemic baseline (23.1 versus 27.8 cases per month; p=0.252). Of 334 confirmed CTEPD/CTEPH cases, four (1.2%) patients were identified to have CTEPH potentially associated with COVID-19 PE, and a further three (0.9%) CTEPD without PH. Of 1094 patients (mean age 58 years, 60.4% male) hospitalised with COVID-19 screened across the UK, 11 (1.0%) were at high risk of CTEPH at follow-up, none of whom had a diagnosis of CTEPH made at the national MDT.

CONCLUSION

A priori risk of developing CTEPH following COVID-19-related hospitalisation is low. Simple risk scoring is a potentially effective way of screening patients for further investigation.

Coronavirus disease 2019 death prediction by electrocardiographic abnormalities and elevated D-dimer levels

Background

Electrocardiography (ECG) plays a very important role in various cardiovascular diseases and elevated D-dimer in serum associated with thrombosis. In patients with coronavirus disease 2019 (COVID-19), immense pieces of evidence showed that ECG abnormalities or elevated D-dimer in serum occurred frequently. However, it remains unclear whether ECG abnormalities combined with elevated D-dimer could be a new risk predictor in patients with COVID-19.

Methods and results

This retrospective cohort study enrolled 416 patients with COVID-19 at Wuhan Tongji Hospital from 1 February to 20 March 2020. ECG manifestations, D-dimer levels, and in-hospital deaths were recorded for all patients. Logistic regression analysis was performed to examine the association between ECG manifestations and in-hospital mortality in patients with elevated D-dimer levels. In patients hospitalized for COVID-19, ST-T abnormalities (34.3%) were the most frequent ECG manifestations, whereas sinus tachycardia (ST) (13.3%) and atrial arrhythmias with rapid rhythms (8.5%) were the two most common cardiac arrhythmias. Compared to severely ill patients with COVID-19, ST-T abnormalities, ST and atrial arrhythmias (p<0.001) with rapid rhythms, D-dimer levels, and in-hospital deaths were significantly more frequent in critically ill patients with COVID-19. Moreover, elevated D-dimer levels were observed in all the patients who died. In the subgroup of 303 patients with elevated serum D-dimer levels, the patient's age, the incidence of ST-T abnormalities, ST, atrial fibrillation (AF), and atrial premature beat were significantly higher than those in the non-elevated D-dimer subgroup. Multivariate logistic regression analysis further revealed that ST and AF were risk factors for in-hospital mortality in COVID-19 patients with elevated D-dimer levels.

Conclusions

ECG abnormalities and elevated D-dimer levels were associated with a higher risk of critical illness and death in patients hospitalized for COVID-19. ECG abnormalities, including ST and AF, combined with elevated D-dimer levels, can be used to predict death in COVID-19.

Continuous Heart Rate Dynamics Preceding In-Hospital Pulseless Electrical Activity or Asystolic Cardiac Arrest of Respiratory Etiology

INTRODUCTION

Respiratory failure is a common cause of pulseless electrical activity (PEA) and asystolic cardiac arrest, but the changes in heart rate (HR) pre-arrest is not well described. We describe HR dynamics prior to in-hospital cardiac arrest (IHCA) among PEA/asystole arrest patients with respiratory etiology.

METHODS

In this retrospective study, we evaluated 139 patients with 3-24 hours of continuous electrocardiogram data recorded preceding PEA/asystole IHCA from 2010-2017. We identified respiratory failure cases by chart review and evaluated electrocardiogram data to identify patterns of HR changes, sinus bradycardia or sinus arrest, escape rhythms, and development right ventricular strain prior to IHCA.

RESULTS

A higher proportion of respiratory cases (58/73, 79%) fit a model of HR response characterized by tachycardia followed by rapid HR decrease prior to arrest, compared to non-respiratory cases (30/66, 45%, p<0.001). Among the 58 respiratory cases fitting this model, 36 (62%) had abrupt increase in HR occurring 64 (IQR 23-191) minutes prior to arrest, while 22 (38%) had stable tachycardia until time of HR decrease. Mean peak HR was 123±21 bpm. HR decrease occurred 3.0 (IQR 2.0-7.0) minutes prior to arrest. Sinus arrest occurred during the bradycardic phase in 42/58 of cases; escape rhythms were present in all but 2/42 (5%) cases. Right ventricular strain ECG pattern, when present, occurred at a median of 2.2 (IQR -0.05-17) minutes prior to onset of HR decrease.

CONCLUSION

IHCAs of respiratory etiology follow a model of HR increase from physiologic compensation to hypoxia, followed by rapid HR decrease prior to arrest.

The role of admission electrocardiogram in predicting outcome in patients hospitalized for COVID-19

BACKGROUND

Abnormal electrocardiogram (ECG) has been associated with poor outcome in patients hospitalized for COVID-19. However, the independent association between admission ECG and the risk of a poor outcome remains to be established. Our aim was to determine if abnormal admission ECG predicts treatment at intensive care unit or in-hospital death within 30 days in patients hospitalized for COVID-19.

METHODS

We analyzed the propensity weighted association between abnormal admission ECG and outcome in patients hospitalized for COVID-19 (March to May 2020). All adult patients hospitalized for COVID-19 at the three centers of Sahlgrenska University Hospital (Gothenburg, Sweden) were eligible for inclusion (N = 439). Patients with available admission ECG within six hours from admission were included.

RESULTS

238 patients (age 62 ± 16 years, 74% male) were included. 103 patients had normal ECG and 135 patients had abnormal ECG. 99 patients were admitted to intensive care unit or died in-hospital within 30 days. Abnormal ECG was associated with increased risk of the outcome (odds ratio 2.11 [95% confidence interval 1.21-3.66]).

CONCLUSIONS

Abnormal admission ECG was associated with increased risk of treatment at intensive care unit or in-hospital death within 30 days; and could be considered a high-risk criterion in patients hospitalized for COVID-19.