Sinus Node Dysfunction in a Young Patient With COVID-19

Infection with COVID-19 Complicated by Sinus Arrest

As a respiratory tract-transmitted disease, coronavirus disease 2019 (COVID-19) exerts a profound immune injury effect, leading not only to pulmonary impairment but also to cardiac complications. We present a case of a 79-year-old woman, who had previously contracted COVID-19 and subsequently developed sinus arrest (SA) following her second infection. The longest asystole time detected by Holter monitoring was 7.2 seconds. Although the patient met criteria for permanent pacemaker implantation, her family declined this intervention and conservative management was pursued instead. However, after a period of observation, the patient's SA resolved. The present case study describes a patient who experienced SA upon reinfection with COVID-19, which was not present during the initial infection. It emphasizes the impact of COVID-19 on cardiac health, particularly its potential to induce arrhythmias. In addition, it is worth noting that the arrhythmia induced by a COVID-19 infection may show reversibility, suggesting that a permanent pacemaker might not be the priority option if further pacing therapy is being considered.

Repeated Syncope Following COVID-19 Infection

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Pacemaker implantation for persistent sinus node dysfunction in a patient with COVID-19

A 46-year-old woman was admitted with coronavirus disease-2019 infection. Symptomatic sinus bradycardia occurred, followed by congestive heart failure. Therapeutics such as isoproterenol, theophylline, and cilostazol could not safely improve her symptoms. She underwent pacemaker implantation 53 days after admission. Atrial pacing remained was at 60% after 6 months.

Assessment of Adult Patients with Long COVID Manifestations Suspected as Cardiovascular: A Single-Center Experience

Background: Persistent symptoms affect a subset of coronavirus disease 2019 (COVID-19) survivors. Some of these may be cardiovascular (CV)-related. Objective: To assess the burden of objective CV morbidity among, and to explore the short-term course experienced by, COVID-19 patients with post-infectious symptomatology suspected as CV. Methods: This was a single-center, retrospective analysis of consecutive adult patients with new-onset symptoms believed to be CV following recovery from COVID-19, who had been assessed at a dedicated ‘Cardio’-COVID clinic between June 2020 and June 2021. All participants were followed for 1 year for symptomatic course and the occurrence of new CV diagnoses and major adverse cardiovascular events (MACE). Results: A total of 96 patients (median age 54 (IQR, 44–64) years, 52 (54%) females) were included in the final analysis. Initial visits occurred within a median of 142 days after the diagnosis of acute COVID. Nearly all (99%) patients experienced a symptomatic acute illness, which was graded as severe in 26 (27%) cases according to the National Institutes of Health (NIH) criteria. Long-COVID symptoms included mainly dyspnea and fatigue. While the initial work-up was mostly normal, 45% of the 11 cardiac magnetic resonance studies performed revealed pathologies. New CV diagnoses were made in nine (9%) patients and mainly included myocarditis that later resolved. An abnormal spirometry was the only variable associated with these. No MACE were recorded. Fifty-two (54%) participants felt that their symptoms improved. No association was found between CV morbidity and symptomatic course. Conclusions: In our experience, long-COVID symptoms of presumed CV origin signified actual CV disease in a minority of patients who, irrespective of the final diagnosis, faced a fair 1-year prognosis.

Arrhythmia occurring as the sole presenting feature in Covid-19

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) infection is observed to be associated with several cardiac complications. Cardiac arrhythmias are frequently observed in critically ill patients and are usually associated with myocarditis. We report two patients with Covid-19, in whom serious arrhythmias were the sole presenting feature, in the absence of any of the known manifestations of the disease. Further research is required into this yet unknown mechanism of the effect of Covid-19 on the conduction system. Thus, managing patients with acute-onset arrhythmias of unexplained aetiology, even when they present without known clinical features of Covid-19, should be done with care.

Asystole in a COVID-19 patient without systemic illness: a case report

There is growing evidence that patients with severe systemic illness from coronavirus disease 2019 (COVID-19) are at risk for developing a variety of cardiac arrhythmias. Less is known about patients with milder symptoms. Here, we report on the case of a 62-year-old male, admitted to the hospital following an episode of syncope, who experienced multiple episodes of cardiac arrest due to asystole lasting up to 30 seconds. History revealed a recent asymptomatic COVID-19 infection, and recurrent episodes of prolonged asystole necessitated permanent pacemaker placement. To our knowledge, this is the first report of an asymptomatic COVID-19 patient experiencing prolonged asystole. Cardiac arrhythmias in asymptomatic or oligosymptomatic COVID-19 patients may be underestimated.

COVID-19 and Bradyarrhythmias: A Case Report With Literature Review

We report a case of a 51-year-old male with no past medical history who was admitted for acute hypoxic respiratory failure secondary to COVID-19. During his hospitalization, the patient developed sinus bradycardia and frequent sinus pauses were observed on telemetry. No other cause of his bradyarrhythmia was identified except for his COVID-19 infection. There has been numerous case reports and case series describing different arrhythmias seen in patients infected with COVID-19. We present a case of sinus arrest in a patient with COVID-19 and a review of other case reports describing bradyarrhythmia in COVID-19 patients.

Paroxysmal Atrioventricular Block in a Relatively Young Patient with COVID-19

Cardiac involvement has been reported in patients with coronavirus disease 2019 (COVID-19). We herein report a 41-year-old man who presented with recurrent paroxysmal atrioventricular block without showing significant cardiac injuries or comorbidities. The patient was diagnosed with COVID-19 and admitted to our hospital, where he was noted to have paroxysmal atrioventricular block. Cardiac biomarkers, echocardiography, and cardiac magnetic resonance imaging findings were fairly normal. An endomyocardial biopsy performed before the implantation of a permanent pacemaker revealed mild myocardial fibrosis without inflammatory infiltrates. The unusual myocardial involvement of the novel coronavirus was suspected.

Bradyarrhythmias in patients with SARS-CoV-2 infection: A narrative review and a clinical report

Several cardiovascular diseases and arrhythmic disorders have been described in COVID‐19 era as likely related to SARS‐CoV‐2 infection. The prognostic relevance of bradyarrhythmias during the infection has not been yet described and no data are available about long‐term heart conduction disorders. A review of literature concerning the association between hypokinetic arrhythmias and COVID‐19 from January 2020 to February 2021 was performed. The key‐words used for the research were: “sinus node disfunction,” “sick sinus syndrome (SSS),” “sino‐atrial block,” “atrio‐ventricular block (AVB),” “bradyarrhythmias,” and “COVID‐19″ or ”SARS‐CoV‐2.″ Excluding “relative bradycardia,” a total of 38 cases of bradyarrhythmia related to SARS‐CoV‐2 infection have been described, even in very young people, requiring in many cases a definitive pacemaker implantation. Furthermore, we report a case of non‐hospitalized 47‐years old man with a SSS developed as a consequence of mild SARS‐CoV‐2 infection. While in all described cases heart conduction disorders were found at presentation of the infection or during hospitalization for COVID‐19, in our case the diagnosis of SSS was made after the resolution of the infection. Although rarely, heart conduction disorders may occur during COVID‐19 and the present case highlights that a cardiological follow up may be desirable even after the resolution of infection, especially in the presence of symptoms suggesting a possible heart involvement.

Asystole in COVID-19 Infection: A Case Report

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has been associated with a broad spectrum of cardiac manifestations ranging from myocardial injury and heart failure to cardiac arrhythmias. In this report, we present a rare case of sinus node dysfunction/asystole in a young patient without any known history of coronary artery disease or cardiac arrhythmias, which necessitated pacemaker placement.

Regulation of sinus node pacemaking and atrioventricular node conduction by HCN channels in health and disease

The funny current, I_f, was first recorded in the heart 40 or more years ago by Dario DiFrancesco and others. Since then, we have learnt that I_f plays an important role in pacemaking in the sinus node, the innate pacemaker of the heart, and more recently evidence has accumulated to show that I_f may play an important role in action potential conduction through the atrioventricular (AV) node. Evidence has also accumulated to show that regulation of the transcription and translation of the underlying Hcn genes plays an important role in the regulation of sinus node pacemaking and AV node conduction under normal physiological conditions - in athletes, during the circadian rhythm, in pregnancy, and during postnatal development - as well as pathological states - ageing, heart failure, pulmonary hypertension, diabetes and atrial fibrillation. There may be yet more pathological conditions involving changes in the expression of the Hcn genes. Here, we review the role of I_f and the underlying HCN channels in physiological and pathological changes of the sinus and AV nodes and we begin to explore the signalling pathways (microRNAs, transcription factors, GIRK4, the autonomic nervous system and inflammation) involved in this regulation. This review is dedicated to Dario DiFrancesco on his retirement.

Prehospital Sinus Node Dysfunction and Asystole in a Previously Healthy Patient with COVID-19

We report a case of a previously healthy 47-year-old female with syncope due to multiple episodes of nodal dysfunction and asystole. During these brief episodes, she was hypoxic in the mid-80's as a result of COVID-19 pneumonia. The patient was admitted and treated for viral pneumonia and found to have normal electrocardiograms (ECG's), normal troponin levels and a normal echocardiogram during her hospital stay. As she recovered from COVID-19, no further episodes of bradycardia or bradyarrhythmia were noted. This case highlights a growing body of evidence that arrhythmias, specifically bradycardia, should be anticipated by prehospital providers as a potential cardiac complication of SARS-CoV-2 infection.

Sinus bradycardia in a toddler with multisystem inflammatory syndrome in children (MIS-C) related to COVID-19

This report documents a case of sinus bradycardia in a hospitalised 27-month-old girl with a history of moderate persistent asthma, recent suspected viral respiratory infection and suspicion for multisystem inflammatory syndrome in children (MIS-C). This patient developed profound sinus bradycardia during her hospitalisation despite an overall well clinical appearance and good outcome. Reports of bradycardia related to COVID-19 infection are few but growing in number. In this article, we discuss what has been observed in the literature about bradycardia in relation to COVID-19 and MIS-C. We also propose sinus bradycardia as a potential sign of MIS-C with recent respiratory symptoms, which would warrant close follow-up of such patients.

Getting to the Heart of the Matter: Myocardial Injury, Coagulopathy, and Other Potential Cardiovascular Implications of COVID-19

COVID-19 was primarily identified as a respiratory illness, but reports of patients presenting initially with cardiovascular complaints are rapidly emerging. Many patients also develop cardiovascular complications during and after COVID-19 infection. Underlying cardiovascular disease increases the severity of COVID-19 infection; however, it is unclear if COVID-19 increases the risk of or causes cardiovascular complications in patients without preexisting cardiovascular disease. The review is aimed at informing the primary care physicians of the potential cardiovascular complications, especially in patients without underlying cardiovascular disease. A comprehensive literature review was performed on cardiac and vascular complications of COVID-19. The primary cardiac and vascular complications include myocarditis, acute coronary syndrome, myocardial injury, arrhythmia, heart failure, shock, multisystem inflammatory syndrome, venous and arterial thrombotic events, stroke, and coagulopathy. A detailed analysis of the pathogenesis revealed six possible mechanisms: direct cardiac damage, hypoxia-induced injury, inflammation, a dysfunctional endothelial response, coagulopathy, and the catecholamine stress response. Autopsy reports from studies show cardiomegaly, hypertrophy, ventricular dilation, infarction, and fibrosis. A wide range of cardiac and vascular complications should be considered when treating patients with confirmed or suspected COVID-19 infection. Elevated troponin and natriuretic peptides indicate an early cardiac involvement in COVID-19. Continuous monitoring of coagulation by measuring serum D-dimer can potentially prevent vascular complications. A long-term screening protocol to follow-up the patients in the primary care settings is needed to follow-up with the patients who recovered from COVID cardiovascular complications.

Multiple Sinus Pauses in a Patient With COVID-19

Cardiovascular complications in coronavirus disease 2019 (COVID-19) patients have been associated with poor prognosis. Myocarditis, acute coronary syndrome, heart failure, and arrhythmia have been reported. 

We present a case of a 55-year-old female patient with no significant past medical history who was admitted due to COVID-19 induced acute hypoxemic respiratory failure. She developed multiple asymptomatic episodes of long sinus pauses as her oxygen requirements increased. These resolved without atropine and pacing as her respiratory status improved.

Hypoxemia, cytokine storm, dysautonomia, direct viral infiltration, and surrounding myocardial inflammation are thought to be responsible for bradyarrhythmias associated with COVID-19. Both symptomatic and asymptomatic cases have been reported. Hospitalized COVID-19 patients should be monitored closely on telemetry in order to promptly recognize any arrhythmia; hence preventing an unexplained rapid decline in cardiopulmonary status by intensifying care and managing the arrhythmia in a timely manner. Follow-up studies would be needed to determine the long-term outcomes of COVID-19 patients who developed bradyarrhythmias.

Syncope Associated with Sinus Nodal Dysfunction in a COVID-19 Patient: A Case Report and Review of the Literature

COVID-19 caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is associated with significant cardiovascular dysfunction in patients with, and without, pre-existing cardiovascular disease [1]. There are now well-documented cardiac complications of COVID-19 infection which include myocarditis, heart failure, and acute coronary syndrome [2]. There is growing evidence showing that arrhythmias are also one of the major complications of COVID-19. We report a patient with no known cardiac conduction disease who presented with syncope, positive SARS-CoV-2 PCR, who was persistently bradycardic and subsequently developed sinus node dysfunction (SND). To date, there are a limited number of reports of sinus node dysfunction (SND) associated with COVID-19. We describe the clinical characteristics, potential pathophysiologic mechanisms and management of COVID-19 patients who experienced de novo SND.

New-onset Postural Orthostatic Tachycardia Syndrome Following Coronavirus Disease 2019 Infection

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. We report a case of new-onset postural orthostatic tachycardia syndrome in an otherwise healthy female patient following COVID-19 infection. The patient presented with fatigue, orthostatic palpitations, dizziness, and presyncope. She underwent head-up tilt-table testing and the findings were suggestive of postural orthostatic tachycardia syndrome.