Remdesivir-Induced Bradycardia

Impact of Remdesivir on Heart Rate and Bradycardia Incidence Among Hospitalized Adults With COVID-19

BACKGROUND

Bradycardia is not currently described as an adverse effect in prescribing information for remdesivir but has been reported postapproval. Therefore, effects on heart rate (HR) and bradycardia incidence after remdesivir initiation may be underrecognized by clinicians.

OBJECTIVE

To evaluate HR and bradycardia incidence after remdesivir initiation among patients with COVID-19.

METHODS

This was a single-center, retrospective cohort study between May 1, 2020 and December 1, 2021. Hospitalized patients eligible for inclusion were ≥18 years and received > 1 dose of remdesivir. Patients were excluded if they were pregnant, incarcerated, or received new medications associated with bradycardia. The primary outcome was to evaluate differences in median HR among patients preremdesivir (up to 24 hours prior to remdesivir) and postremdesivir (first dose through the treatment duration). Secondary outcomes included bradycardia episodes postremdesivir, nadir HR postremdesivir, and interventions for bradycardia management. Variables to assess postremdesivir bradycardia were considered in multivariate logistic regression if they had a P < 0.1 on univariate analysis.

RESULTS

Among 514 patients, 328 were included. Most were male (53.4%), had severe COVID-19 (59.8%), and median (interquartile range [IQR]) age was 62 (23.7) years. Median (IQR) remdesivir duration was 4.9 (1.5) days. Median (IQR) HR was significantly lower postremdesivir than preremdesivir (74 (15) vs 87 (19), P < 0.001). There were significantly more bradycardia episodes postremdesivir than before (48.8% [160/328] vs (2.4% [8/328]), P < 0.001). Among 48.8% (160/328) of patients with bradycardia postremdesivir, median (IQR) nadir HR was 53 (6.8). Remdesivir was discontinued early in 1 patient (0.6%). In multivariate logistic regression, remdesivir duration (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.04 to 1.54, P = 0.019) and median preremdesivir HR (OR = 0.96, 95% CI = 0.94 to 0.97, P < 0.001) were identified as significant predictors for bradycardia.

CONCLUSION AND RELEVANCE

Remdesivir was associated with a significantly lower HR and higher incidence of bradycardia among hospitalized patients with COVID-19. These data may help improve recognition and management of these remdesivir-associated effects during COVID-19 treatment.

Electrophysiological and sick sinus syndrome effects of Remdesivir challenge in guinea-pig hearts

Remdesivir (RDV) is the first drug approved by the FDA for clinical treatment of hospitalized patients infected with COVID-19 because it has been shown to have good antiviral activity against a variety of viruses, including Arenaviridae and Coronaviridae viral families. However, it has been reported that its clinical treatment leads to the symptoms of sick sinus syndrome such as sinus bradycardia, conduction block, and sinus arrest, but the electrophysiological mechanism of its specific cardiac adverse events is still unclear. We report complementary, experimental, studies of its electrophysiological effects. In wireless cardiac telemetry experiments in vivo and electrocardiographic studies in ex vivo cardiac preparations, RDV significantly caused sinus bradycardia, sinus atrial block, and prolongation of the QT interval in guinea pigs. Dose-dependent effects of RDV on the electrical activities of sinoatrial node (SA node) preparations of guinea pigs were characterised by multielectrode, optical RH237 voltage mapping. These revealed reversibly reduced sinoatrial conduction time (SACT), increased AP durations (APDs), and decreased the pacemaking rate of the SA node. Patch-clamp experiments showed that RDV significantly inhibited the If current of HCN4 channels, resulting in a significant decrease in the spontaneous firing rate of SA node cells, which may underlie the development of sick sinus node syndrome. In addition, RDV significantly inhibits IKr currents in hERG channels, leading to prolongation of the QT interval and playing a role in bradycardia. Therefore, these findings provide insights into the understanding the bradycardia effect of RDV, which may be used as basic theoretical guidance for the intervention of its adverse events, and prompt safety investigations of RDV's cardiac safety in the future.

Remdesivir-Related Cardiac Adverse Effects in COVID-19 Patients: A Case-Control Study

BACKGROUND

There have been reports of serious side effects of Remdesivir, including cardiovascular complications. The present study aimed to determine the adverse cardiovascular effects of Remdesivir and the factors affecting them in COVID-19 patients.

METHODS

The patients were classified into two groups: those receiving Remdesivir without cardiac complications and those receiving Remdesivir with cardiovascular complications. After reviewing the patient's medical records, the relationship of some factors with the incidence of adverse cardiovascular effects was measured.

RESULTS

Chi-square test showed that the distribution of complications in men was significantly higher than in women (P=0.001). The independent t-test revealed that the mean age in the group with complications was significantly higher than the group without complications (P=0.013). Fisher's exact test demonstrated a significant relationship between smoking and cardiovascular complications (P=0.05). According to the Mann-Whitney test, a significant difference was found in the mean changes of Bilirubin (P=0.02) and ALKP (P=0.01) before and after treatment in the groups with and without heart complications.

CONCLUSION

Our findings indicated that most of the COVID-19 patients suffered from sinus bradycardia, and the distribution of complications was more pronounced in men than in women. The mean age in the group with complications was higher than the group without complications. Smoking was found to be associated with the occurrence of cardiovascular complications and the mean changes of Bilirubin and ALKP before and after treatment were significantly different in the groups with and without cardiovascular complications.

Remdesivir-Induced Bradycardia and Mortality in SARS-CoV-2 Infection, Potential Risk Factors Assessment: A Systematic Review and Meta-Analysis

Background: The efficacy of remdesivir in reducing disease severity among COVID-19-infected patients has been established, but concerns have emerged regarding the potential side effects of bradycardia. The aim of this study was to investigate the association between remdesivir-induced bradycardia and mortality, while also identifying the related risk factors. Materials and methods: The PubMed/Medline, Cochrane Central and ClinicalTrials.gov databases were searched. Randomized controlled trials and prospective or retrospective cohort studies were included (through 14 July 2023). The random-effects model was implemented using Comprehensive Meta-Analysis software version 3.0 to examine the outcomes. Results: A total of 12 prospective or retrospective studies involving 7674 patients were analyzed. The primary outcomes revealed a significant association between remdesivir administration and bradycardia development (Odds ratio = 2.556, 95% CI = 2.049-3.188, p < 0.001). However, no statistically significant increase in the mortality rate was observed among patients with bradycardia during remdesivir treatment (Odds ratio = 0.872, 95% CI = 0.483-1.576, p = 0.651). The secondary outcome demonstrated a significant association between chronic kidney disease (CKD) and remdesivir-induced bradycardia (OR: 1.251, 95% CI: 1.003-1.561, p = 0.047). Moreover, patients with obesity (OR = 1.347, 95% CI = 1.098-1.652, p = 0.004) were more likely to experience remdesivir-induced bradycardia. Conclusions: Although a higher risk of bradycardia occurred during remdesivir treatment, the occurrence of remdesivir-induced bradycardia did not lead to higher mortality. Our study also identified patients with obesity and CKD as high-risk subgroups for experiencing bradycardia during remdesivir treatment.

Precipitating factors of bradycardia after remdesivir administration: ICU admission and cutoff value for declining heart rate

BACKGROUND

Despite increasing concerns about the association between remdesivir and bradycardia in severe coronavirus disease 2019 (COVID-19) patients receiving remdesivir, information on its clinical course and precipitating factors is limited. Our aim was to investigate possible triggers of bradycardia after remdesivir administration.

METHODS

We retrieved the medical records of hospitalized severe and critical COVID-19 patients who received remdesivir from May 1, 2021 to June 30, 2021. Bradycardia was defined as two episodes of a heart rate (HR) < 60 bpm in 24 h. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the discriminability of heart rate pattern on the occurrence of bradycardia. The precipitating factors of bradycardia were examined by a logistic regression model.

RESULTS

Regardless of bradycardia status, the median heart rate dropped during remdesivir treatment (from 85 to 72 bpm, p < 0.001), with the heart rate dropping considerably within the first two days of remdesivir treatment. Among various heart rate descriptors, HR ratiomin (d2-d1) had the best discrimination (AUC = 0.7336), and a reduction in HR ratiomin (d2-d1) by 14.65% was associated with bradycardia. Intensive care unit (ICU) admission was associated with an increased risk of bradycardia (odds ratio: 3.41; 95% CI: 1.12-10.41).

CONCLUSIONS

In severe COVID-19 patients receiving remdesivir, the risks of bradycardia were influenced by a substantial reduction in heart rate during the first two days of remdesivir treatment and ICU admission. These findings suggest that clinical practitioners should intensively monitor heart rates during remdesivir treatment.