Fragmented QRS on surface electrocardiography as a predictor of cardiac mortality in patients with SARS-CoV-2 infection

Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients

BACKGROUND

QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography.

METHODS

A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation.

RESULTS

Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria.

CONCLUSION

Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.

Myocarditis and COVID-19 related issues

The recent COVID-19 (Coronavirus Disease 2019) pandemic by SARS-CoV2 infection has caused millions of deaths and hospitalizations across the globe. In the early pandemic phases, the infection had been initially considered a primary pulmonary disease. However, increasing evidence has demonstrated a wide range of possible cardiac involvement. Most of systemic and cardiac damage is likely sustained by a complex interplay between inflammatory, immune-related and thrombotic mechanisms. Biventricular failure and myocardial damage with elevation of cardiac biomarkers have been reported in COVID-19 patients, although histological demonstration of acute myocarditis has been rarely documented. Indeed while cardiac magnetic resonance findings include different patterns of myocardial involvement in terms of late gadolinium enhancement, histological data from necropsy and endomyocardial biopsy showed peculiar inflammatory patterns, mostly composed by macrophages. On the other hand COVID-19 vaccines based on mRN technology have been also associated with increased risk of myocarditis. COVID-19 and mRNA vaccine-related myocarditis present different clinical and imaging presentations and recent data suggest the presence of distinctive immunological mechanisms involved.

Serial Assessment of Myocardial Injury Markers in Mechanically Ventilated Patients With SARS-CoV-2 (from the Prospective MaastrICCht Cohort)

Myocardial injury in COVID-19 is associated with in-hospital mortality. However, the development of myocardial injury over time and whether myocardial injury in patients with COVID-19 at the intensive care unit is associated with outcome is unclear. This study prospectively investigates myocardial injury with serial measurements over the full course of intensive care unit admission in mechanically ventilated patients with COVID-19. As part of the prospective Maastricht Intensive Care COVID cohort, predefined myocardial injury markers, including high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and electrocardiographic characteristics were serially collected in mechanically ventilated patients with COVID-19. Linear mixed-effects regression was used to compare survivors with nonsurvivors, adjusting for gender, age, APACHE-II score, daily creatinine concentration, hypertension, diabetes mellitus, and obesity. In 90 patients, 57 (63%) were survivors and 33 (37%) nonsurvivors, and a total of 628 serial electrocardiograms, 1,565 hs-cTnT, and 1,559 NT-proBNP concentrations were assessed. Log-hs-cTnT was lower in survivors compared with nonsurvivors at day 1 (β -0.93 [-1.37; -0.49], p <0.001) and did not change over time. Log-NT-proBNP did not differ at day 1 between both groups but decreased over time in the survivor group (β -0.08 [-0.11; -0.04] p <0.001) compared with nonsurvivors. Many electrocardiographic abnormalities were present in the whole population, without significant differences between both groups. In conclusion, baseline hs-cTnT and change in NT-proBNP were strongly associated with mortality. Two-thirds of patients with COVID-19 showed electrocardiographic abnormalities. Our serial assessment suggests that myocardial injury is common in mechanically ventilated patients with COVID-19 and is associated with outcome.

Repolarization abnormalities on admission predict 1-year outcome in COVID-19 patients

Background

ECG abnormalities in COVID-19 have been widely reported, however data after discharge is limited. The aim was to describe ECG abnormalities on admission and following recovery of COVID-19, and their associated mortality.

Methods

All patients hospitalized in a tertiary care hospital between March 7th and July 1st 2020 with COVID-19 were included in a retrospective registry. The first ECG on admission was collected, together with an ECG after hospital discharge in the absence of acute pathology. Automated measures and clinical ECG interpretations were collected. Multivariate Cox regression analysis was performed to predict 1-year all-cause mortality.

Results

In total 420 patients were included, of which 83 patients (19.8%) died during the 1-year follow-up period. Repolarization abnormalities were present in 189 patients (45.0%). The extent of repolarization abnormalities was an independent predictor of 1-year all-cause mortality (HR per region 1.30, 95%CI 1.04–1.64) together with age (/year HR 1.06, 95%CI 1.04–1.08), heart rate (/bpm HR 1.02, 95%CI 1.01–1.03), neurological disorders (HR 2.41, 95%CI 1.47–3.93), active cancer (HR 2.75, 95%CI 1.57–4.82), CRP (per 10 mg/L HR 1.05, 95%CI 1.02–1.08) and eGFR (per 10 mg/L HR 0.90, 95%CI 0.83–0.98).

In 245 patients (68.1%) an ECG post discharge was available. New repolarization abnormalities were more frequent in patients who died after discharge (4.7% versus 41.7%, p < 0.001) and 8 (3.3%) had new ventricular conduction defects, none of whom died during follow-up.

Conclusions

The presence and extent of repolarization abnormalities predicted outcome in patients with COVID-19. New repolarization abnormalities after discharge were associated with post-discharge mortality.

Fragmented QRS is a marker of mortality in patients with severe COVID-19: A retrospective observational study

OBJECTIVE

In this study, we aimed to investigate the association of fragmented QRS (f-QRS) with in-hospital death in patients with severe novel coronavirus disease 2019 (COVID-19).

METHODS

This was a retrospective and observational study. A total of 201 consecutive patients with severe COVID-19 were enrolled. Demographic data, laboratory parameters, medications, electrocardiographic (ECG) findings, and clinical outcomes were recorded. Patients with and without f-QRS were compared, and predictors of all-cause in-hospital mortality were analyzed.

RESULTS

A total of 135 patients without f-QRS (mean age of 64 years, 43% women) and 66 patients with f-QRS (mean age of 66 years, 39% women) were included. C-reactive protein (CRP), D-dimer, troponin I, ferritin levels, and CRP to albumin ratio were significantly higher in patients with f-QRS. The need for invasive mechanical ventilation (63.6% vs. 41.5%, p=0.003) and all-cause in-hospital mortality [54.5% vs. 28.9%, log rank p=0.001, relative risk 1.88, 95% confidence interval (CI) 1.16-4.78] were significantly higher in patients with f-QRS. A number value of f-QRS leads ≥2 yields sensitivity and specificity (85.3% and 86.7%, respectively) for predicting in-hospital all-cause mortality. Multivariable analysis showed that f-QRS (odds ratio: 1.041, 95% Cl: 1.021-1.192, p=0.040) were independently associated with in-hospital death.

CONCLUSION

This study revealed that the presence of f-QRS in ECG is associated with higher in-hospital all-cause mortality in patients with severe COVID-19. f-QRS is an easily applicable simple indicator to predict the risk of death in these patients.