Death, discharge and arrhythmias among patients with COVID-19 and cardiac injury

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Cardiac arrhythmia and immune response in COVID-19 patients

The coronavirus disease 2019 (COVID-19) pandemic has presented substantial challenges for providing health care due to the numerous complications on the respiratory and cardiovascular systems of people. Cardiac arrhythmia is one of the cardiac complications, and it was observed in COVID-19 patients. Moreover, arrhythmia and cardiac arrest are common in COVID-19 patients in the intensive care unit. The occurrence of cardiac arrhythmia in COVID-19 patients is associated with hypoxia, cytokine storm, myocardial ischemia and inflammatory disease such as congestive heart failure. It is necessary to know the occurrence and mechanisms of tachyarrhythmia and bradyarrhythmia in patients with COVID-19 infection for their proper management. This review provides an overview of the association between COVID-19 and arrhythmias by detailing possible pathophysiological mechanisms.

Acute and Post-Acute COVID-19 Cardiovascular Complications: A Comprehensive Review

PURPOSE OF REVIEW

The risk of cardiovascular complications due to SARS-CoV-2 are significantly increased within the first 6 months of the infection. Patients with COVID-19 have an increased risk of death, and there is evidence that many may experience a wide range of post-acute cardiovascular complications. Our work aims to provide an update on current clinical aspects of diagnosis and treatment of cardiovascular manifestations during acute and long-term COVID-19.

RECENT FINDINGS

SARS-CoV-2 has been shown to be associated with increased incidence of cardiovascular complications such as myocardial injury, heart failure, and dysrhythmias, as well as coagulation abnormalities not only during the acute phase but also beyond the first 30 days of the infection, associated with high mortality and poor outcomes. Cardiovascular complications during long-COVID-19 were found regardless of comorbidities such as age, hypertension, and diabetes; nevertheless, these populations remain at high risk for the worst outcomes during post-acute COVID-19. Emphasis should be given to the management of these patients. Treatment with low-dose oral propranolol, a beta blocker, for heart rate management may be considered, since it was found to significantly attenuate tachycardia and improve symptoms in postural tachycardia syndrome, while for patients on ACE inhibitors or angiotensin-receptor blockers (ARBs), under no circumstances should these medications be withdrawn. In addition, in patients at high risk after hospitalization due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. In this work we provide a comprehensive review on acute and post-acute COVID-19 cardiovascular complications, symptomatology, and pathophysiology mechanisms. We also discuss therapeutic strategies for these patients during acute and long-term care and highlight populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease have worse outcomes during acute SARS-CoV-2 infection and are more likely to develop cardiovascular complications during long-COVID-19.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Administration of macrolide antibiotics increases cardiovascular risk

Background

The increased risk of cardiovascular events in patients prescribed macrolides has been subject to debate for decades.

Methods

Medline, EMBASE databases and ClinicalTrials.gov were searched from inception until August 31, 2022 for studies investigating the link between macrolides and cardiovascular risk. A meta-analysis was performed using a random-effects model.

Results

A total of 80 studies involving 39,374,874 patients were included. No association was found between macrolides and all-cause death. However, compared with the non-macrolide group, macrolides were associated with a significantly increased risk of ventricular arrhythmia or sudden cardiac death (VA or SCD) (azithromycin, relative ratio [RR]: 1.53; 95% confidence interval [CI]: 1.19 to 1.97; clarithromycin, RR: 1.52; 95% CI: 1.07 to 2.16). Besides, administration of macrolides was associated with a higher risk of cardiovascular disease (CVD) death (azithromycin, RR: 1.63; 95% CI: 1.17 to 2.27) and a slightly increased risk of myocardial infarction (MI) (azithromycin, RR: 1.08; 95% CI: 1.02 to 1.15). Interestingly, no association was observed between roxithromycin and adverse cardiac outcomes. Increased risk of VA or SCD was observed for recent or current use of macrolides, MI for former use, and CVD death for current use.

Conclusion

Administration of macrolide antibiotics and timing of macrolide use are associated with increased risk for SCD or VTA and cardiovascular death, but not all-cause death.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation

Cardiovascular complications and predictors of mortality in hospitalized patients with COVID-19: a cross-sectional study from the Indian subcontinent

Background

COVID-19 has spread rapidly across the world, producing significant morbidity and mortality. We investigated the cardiovascular complications and association of laboratory parameters with severity and mortality predictors in COVID-19 hospitalized patients.

Methods

Between May 2020 and June 2021, 730 COVID-19 patients were included in this retrospective observational study in the Coastal Karnataka region of South India. Acute coronary syndrome (ACS), myocarditis, arrhythmias, and all-cause mortality were reported as cardiovascular consequences. Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), serum creatinine, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide (NT-ProBNP), serum ferritin, and serum lactate dehydrogenase (LDH) were among the laboratory parameters measured.

Results

Most common electrocardiogram (ECG) changes were prolonged QTc interval (45.6%) followed by ST-T changes (40.7%) and sinus tachycardia (24.2%). 9.2% patients presented with ACS, with 38.8% having ST-elevation myocardial infarction (STEMI) and 61.2% having non-ST elevation myocardial infarction (NSTEMI). In non-survivors, NLR (p < 0.001) and PLR (p = 0.001) were significantly higher. Multivariable regression analysis showed that age (OR:1.019, 95% CI 1.003–1.034; p = 0.017), acute kidney injury (OR:3.562, 95% CI 1.737–7.301; p = 0.001), white blood cell count (WBC) (OR = 1.100, 95% CI 1.035–1.169; p = 0.002), platelet count (OR = 0.994, 95% CI 0.990–0.997; p = 0.001), PLR (OR = 1.002, 95% CI 1.000–1.004; p = 0.023) and severe COVID-19 (OR = 9.012, 95% CI 3.844–21.129; p = 0.001) were independent predictors of mortality in COVID-19 patients.

Conclusions

Age, WBC count, neutrophil%, NLR, PLR, creatinine, D-dimer, ferritin, LDH, tachycardia, and lymphocytes% strongly correlated with the severity of the disease. Age, acute kidney injury, elevated WBC count, a greater PLR, low platelet count, and COVID-19 severity were independent predictors of mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-022-00449-w.

Coronavirus disease 2019 and the cardiologist

PURPOSE OF REVIEW

There continues to be extensive clinical and epidemiological data to suggest that coronavirus disease 2019 (COVID-19) infection is associated with numerous different types of cardiac involvement.

RECENT FINDINGS

Myocardial injury has been reported in over 25% of patients hospitalized due to COVID-19 infection and is not only associated with a worse prognosis but with higher mortality, approaching 40%. Currently proposed mechanisms of myocardial injury include direct viral infection, cytokine storm, endothelial inflammation, demand ischemia, interferon-mediated response and stress cardiomyopathy. COVID-19 infection is associated with new-onset arrhythmias and heart failure regardless of history of previous cardiovascular disease. Echocardiographic findings can be useful to predict mortality in COVID-19 patients and cardiac MRI is an effective tool to both assess COVID-19 induced myocarditis and to follow-up on cardiac complications of COVID-19 long-term. Although there is an association between COVID-19 vaccination and myocarditis, pericarditis or arrhythmias, the risk appears lower when compared to risk attributable to the natural infection.

SUMMARY

Patients with cardiovascular disease are not only more likely to suffer from severe COVID-19 infection but are at increased risk for further complications and higher mortality. Further data compilation on current and emerging treatments of COVID-19 will have additional impact on cardiovascular morbidity and mortality of COVID-19 infection.

Cardiac Implications of COVID-19 in Deceased and Recovered Patients: A Systematic Review

Background

Patients infected with coronavirus disease 2019 (COVID-19) present with various clinical presentations with majority of them developing pulmonary complications. This study focuses on cardiac implications of COVID-19 which are less discussed and thus will help to address cardiac implications of COVID-19.

Methods

PubMed, PubMed Central, and Google Scholar were screened for articles which mentioned cardiac implications of COVID-19. NHLBI Study Quality Assessment Tools for the observational cohort and cross-sectional studies was used for assessing the risk of bias of our studies.

Results

All 14 studies selected were good and had score of ≥9 by NHLBI Study Quality Assessment Tools. Cardiac complications of COVID-19 are common. They are associated with significant mortality. Also, people infected with COVID-19 with premorbid conditions such as cardiovascular diseases and diabetes mellitus have poor prognosis as compared to those without premorbid conditions. Cardiac biomarkers such as highly sensitive troponin I, creatinine, and creatinine kinase-MB on admission are good prognostic markers.

Conclusions

Cardiac complications such as heart failure, myocardial injury, and arrhythmias are common among patients infected with COVID-19. Elevated cardiac markers and patients with cardiac complications require utmost care and continuous cardiac monitoring.

Cardiac Registries During the COVID-19 Pandemic: Lessons Learned

Purpose of this Review

We discuss the role of observational studies and cardiac registries during the COVID-19 pandemic. We focus on published cardiac registries and highlight contributions to the field that have had clinical implications.

Recent Findings

We included observational studies of COVID-19 patients published in peer-reviewed medical journals with defined inclusion and exclusion criteria, defined study design, and primary outcomes. A PubMed and MEDLINE literature review results in 437 articles, of which 52 include patients with COVID-19 with cardiac endpoints. From July 2020 to December 2021, the average time from last data collected to publication was 8.9 ± 4.1 months, with an increasing trend over time (R = 0.9444, p < 0.0001). Of the 52 articles that met our inclusion criteria, we summarize main findings of 4 manuscripts on stroke, 14 on acute coronary syndrome, 4 on cardiac arrest, 7 on heart failure, 7 on venous thromboembolism, 5 on dysrhythmia, and 11 on different populations at risk for cardiovascular.

Summary

Registries are cost effective, not disruptive to essential health services, and can be rapidly disseminated with short intervals between last data point collected and publication. In less than 2 years, cardiac registries have filled important gaps in knowledge and informed the care of COVID-19 patients with cardiovascular conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11886-022-01686-5.

The Potential Impact of COVID-19 Virus on the Heart and the Circulatory System

Heart attacks, arrhythmias, and cardiomyopathy are all linked to the 2019 coronavirus disease (COVID-19), which has been identified as a risk factor for cardiovascular disease. Nothing can be held accountable in the current state of affairs. Undiagnosed chronic systolic heart failure (CSHF) develops when the heart’s second half of the cardiac cycle does not function properly. As a result, the heart’s blood pumping function is interrupted. Stress-induced cardiomyopathy may be caused by a variety of factors inside the body (SICM). Cytokine storm and microvascular dysfunction are among the issues. There is inflammation in the heart muscle, which may lead to stress-induced cardiomyopathy. A major part of our study is going to be devoted to understanding the effects of coronavirus on the cardiovascular system and blood vessels. A lot of time and effort has been put into figuring out the health effects of radiation exposure. The heart and circulatory system are shown to be affected by the coronavirus in this research. COVID-19 is shown to influence persons with heart disease, heart failure, arrhythmias, microvascular angiopathy, and cardiac damage in this study.

Cardiac biomarkers alterations in patients with SARS-CoV-2 infection

Reliable biomarkers are necessary for the risk stratification of patients infected with SARS-CoV-2. This novel coronavirus is now established to affect several organs in addition to the lungs, most prominently the heart. This is achieved through direct damage to the myocardium and indirect immune-associated effects during the cytokine storm. We performed a literature review aiming to identify the prognostic value of alterations of cardiac biomarkers in SARS-CoV-2 infection. Cardiac biomarkers are significantly elevated in patients with severe COVID-19 and are independent predictors of mortality. High-sensitivity troponin I and T are correlated with multiple inflammatory indexes and poor outcomes. Although cut-off values have been established for most of cardiac biomarkers, lower limits for troponins may have better prognostic values and longitudinal monitoring of cardiac biomarkers can help the clinician assess the patient's course. Additional measurements of NT-proBNP, can detect the subgroup of patients with poor prognosis.

Electrocardiographic Features of Patients with COVID-19: An Updated Review

Numerous systemic manifestations, including cardiac involvement in the form of myocardial infarction, myocarditis, and electrocardiographic changes, have been associated with COVID-19..In this review, the authors describe the electrocardiographic features that have been reported to date in patients affected by this disease and their possible underlying mechanisms.

Age-Related Risk Factors and Complications of Patients With COVID-19: A Population-Based Retrospective Study

Objective: To study the differences in clinical characteristics, risk factors, and complications across age-groups among the inpatients with the coronavirus disease 2019 (COVID-19). Methods: In this population-based retrospective study, we included all the positive hospitalized patients with COVID-19 at Wuhan City from December 29, 2019 to April 15, 2020, during the first pandemic wave. Multivariate logistic regression analyses were used to explore the risk factors for death from COVID-19. Canonical correlation analysis (CCA) was performed to study the associations between comorbidities and complications. Results: There are 36,358 patients in the final cohort, of whom 2,492 (6.85%) died. Greater age (odds ration [OR] = 1.061 [95% CI 1.057-1.065], p < 0.001), male gender (OR = 1.726 [95% CI 1.582-1.885], p < 0.001), alcohol consumption (OR = 1.558 [95% CI 1.355-1.786], p < 0.001), smoking (OR = 1.326 [95% CI 1.055-1.652], p = 0.014), hypertension (OR = 1.175 [95% CI 1.067-1.293], p = 0.001), diabetes (OR = 1.258 [95% CI 1.118-1.413], p < 0.001), cancer (OR = 1.86 [95% CI 1.507-2.279], p < 0.001), chronic kidney disease (CKD) (OR = 1.745 [95% CI 1.427-2.12], p < 0.001), and intracerebral hemorrhage (ICH) (OR = 1.96 [95% CI 1.323-2.846], p = 0.001) were independent risk factors for death from COVID-19. Patients aged 40-80 years make up the majority of the whole patients, and them had similar risk factors with the whole patients. For patients aged <40 years, only cancer (OR = 17.112 [95% CI 6.264-39.73], p < 0.001) and ICH (OR = 31.538 [95% CI 5.213-158.787], p < 0.001) were significantly associated with higher odds of death. For patients aged >80 years, only age (OR = 1.033 [95% CI 1.008-1.059], p = 0.01) and male gender (OR = 1.585 [95% CI 1.301-1.933], p < 0.001) were associated with higher odds of death. The incidence of most complications increases with age, but arrhythmias, gastrointestinal bleeding, and sepsis were more common in younger deceased patients with COVID-19, with only arrhythmia reaching statistical difference (p = 0.039). We found a relatively poor correlation between preexisting risk factors and complications. Conclusions: Coronavirus disease 2019 are disproportionally affected by age for its clinical manifestations, risk factors, complications, and outcomes. Prior complications have little effect on the incidence of extrapulmonary complications.

Prognostic Accuracy of Cardiovascular Disease Biomarkers in Patients with COVID-19: A Diagnostic Test Accuracy Meta-Analysis

Background: Several reports have determined that cardiovascular diseases (CVDs) are common complications in patients with coronavirus disease 2019 (COVID-19) and lead them to poor outcomes. CVD biomarkers have, thus, great potential to be used as prognostic biomarkers. We aimed to determine the accuracy of CVD biomarkers for the prognosis of the COVID-19 patient’s outcome via a diagnostic test accuracy (DTA) meta-analysis.

Methods: Until September 30, 2020, we searched Web of Sciences, Scopus, and MEDLINE/PubMed databases to obtain related papers. The summary points and lines were calculated using bivariate/HSROC model. As outcomes, we considered critical conditions and mortality.

Results: A total of 17 659 patients from 33 studies were included. Five biomarkers, namely increased levels of lactate dehydrogenase (LDH), cardiac troponin I (cTnI), creatine kinase (CK), D-dimer, and thrombocytopenia, met the inclusion criteria. Our results indicated that LDH and cTnI had good accuracy for the prognosis of critical condition (AUC_HSROC=0.83 and 0.80, respectively), while LDH, cTnI, and D-dimer had acceptable accuracy (AUC_HSROC=0.74, 0.71, and 0.72, respectively) for the prognosis of mortality. LDH and D-dimer had high sensitivity, whereas cTnI had high specificity. The other biomarkers did not have acceptable accuracy. Significant publication bias was found for D-dimer (P=0.053).

Conclusion: Among CVD biomarkers, LDH and cTnI had good accuracy for the prognosis of critical outcomes and acceptable accuracy for the prognosis of mortality, without publication bias. Given their different sensitivities and specificities, we recommend the use of these 2 biomarkers concomitantly.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Prevalence and Associated Death of Ventricular Arrhythmia and Sudden Cardiac Death in Hospitalized Patients With COVID-19: A Systematic Review and Meta-Analysis

Background

Arrhythmia is a very common complication of coronavirus disease 2019 (COVID-19); however, the prevalence of ventricular arrhythmia and associated outcomes are not well-explored. Here, we conducted a systematic review and meta-analysis to determine the prevalence and associated death of ventricular arrhythmia and sudden cardiac death (SCD) in patients with COVID-19.

Methods

Databases of PubMed, Cochrane Library, Embase, and MdeRxiv were searched. Studies that could calculate the prevalence of ventricular arrhythmia/SCD during hospital admission or associated death in patients with COVID-19 were included. The study was registered with the PROSPERO (CRD42021271328).

Results

A total of 21 studies with 13,790 patients were included. The pooled prevalence of ventricular arrhythmia was 5% (95% CI: 4–6%), with a relatively high-SCD prevalence (1.8% in hospitalized COVID-19 and 10% in deceased cases of COVID-19). Subgroup analysis showed that ventricular arrhythmia was more common in patients with elevated cardiac troponin T [ES (effect size): 10%, 95% CI: −0.2 to 22%] and in European (ES: 20%, 95% CI: 11–29%) populations. Besides, ventricular arrhythmia was independently associated with an increased risk of death in patients with COVID-19 [odds ratio (OR) = 2.83; 95% CI: 1.78–4.51].

Conclusion

Ventricular arrhythmia and SCD resulted as a common occurrence with a high prevalence in patients with COVID-19 admitted to the hospital. Furthermore, ventricular arrhythmia significantly contributed to an increased risk of death in hospitalized patients with COVID-19. Clinicians might be vigilant of ventricular arrhythmias for patients with COVID-19, especially for severe cases.

Systematic Review Registration

www.york.ac.uk/inst/crd, identifier: CRD42021271328.

Emergency activations for chest pain and ventricular arrhythmias related to regional COVID-19 across the US

Evidence that patients may avoid healthcare facilities for fear of COVID-19 infection has heightened the concern that true rates of myocardial infarctions have been under-ascertained and left untreated. We analyzed data from the National Emergency Medical Services Information System (NEMSIS) and incident COVID-19 infections across the United States (US) between January 1, 2020 and April 30, 2020. Grouping events by US Census Division, multivariable adjusted negative binomial regression models were utilized to estimate the relationship between COVID-19 and EMS cardiovascular activations. After multivariable adjustment, increasing COVID-19 rates were associated with less activations for chest pain and non-ST-elevation myocardial infarctions. Simultaneously, increasing COVID-19 rates were associated with more activations for cardiac arrests, ventricular fibrillation, and ventricular tachycardia. Although direct effects of COVID-19 infections may explain these discordant observations, these findings may also arise from patients delaying or avoiding care for myocardial infarction, leading to potentially lethal consequences.

Risk of drug-induced cardiac arrhythmia during COVID-19 therapeutic treatment

Therapeutic treatment of severe COVID-19 infection involves the administration of multiple pharmacologic agents to reduce the risk of serious complications; this may result in drug interactions and possible adverse reactions and induced cardiotoxicity. The risk-benefit ratio associated with the use of medications to treat COVID-19 should be carefully monitored. In addition, the severe COVID-19 patient may experience cardiac damage, and alteration of normal cardiac electrophysiology function. Severe COVID-19 with cardiac involvement and the risk of drug-induced adverse reactions may cause cardiac arrhythmias, including long qt syndrome, which in some cases may lead to sudden death. In this short review we briefly review the pharmacological agents used to treat severe COVID-19 with increased risk of causing long qt forms.

COVID-19 and the Incidence of Acute Myocardial Injury

Cardiovascular manifestations are frequent in COVID-19 infection and are predictive of adverse outcomes. Elevated cardiac biomarkers are common findings in patients with cardiovascular comorbidities and severe COVID-19 infection. Troponin, inflammatory and thrombotic markers may also improve risk prediction in COVID-19. In our comprehensive review, we provide an overview of the incidence, potential mechanisms and outcome of acute cardiac injury in COVID-19. Thereby, we discuss coagulation abnormalities in sepsis and altered immune response as contributing factors favoring myocardial injury. We further highlight the role of endothelial damage in the pathophysiological concepts. Finally, observational studies addressing the incidence of myocardial infarction during COVID-19 pandemic are discussed.

COVID-19 and Cardiac Arrhythmias

Since the coronavirus disease (COVID-19) pandemic spread unrelentingly all over the world, millions of cases have been reported. Despite a high number of asymptomatic cases, the course of the disease can be serious or even fatal. The affection of the myocardium, called myocardial injury, is caused by multiple triggers. The occurrence of cardiac arrhythmias in COVID-19 patients with myocardial involvement and a critical course is common. In this review, potential mechanisms, incidence, and treatment options for cardiac arrhythmias in COVID-19 patients will be provided by performing a literature research in MESH database and the National Library of Medicine. Common cardiac arrhythmias in COVID-19 patients were sinus tachycardia, atrial fibrillation (AF), ventricular tachycardia (VT), ventricular fibrillation (VF), atrioventricular block, sinusoidal block or QTc prolongation. AF was the most common heart rhythm disorder. About 10% of COVID-19 patients develop new-onset AF and 23 to 33% showed recurrence of AF in patients with known AF. One retrospective trial revealed the incidence of VT or VF to be 5.9% in hospitalized patients. Both AF and VT are clearly associated with worse outcome. Several mechanisms such as hypoxia, myocarditis, myocardial ischemia, or abnormal host immune response, which induce cardiac arrhythmias, have been described. The effect of QT-prolonging drugs in inducing cardiac arrhythmias has become mitigated as these medications are no longer recommended. Acute management of cardiac arrhythmias in COVID-19 patients is affected by the reduction of exposure of health care personnel. More prospective data are desirable to better understand pathophysiology and consecutively adapt management.

Direct cardiovascular complications and indirect collateral damage during the COVID-19 pandemic : A review

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), puts a heavy strain on healthcare systems around the globe with high numbers of infected patients. Pre-existing cardiovascular disease is a major risk factor for a severe clinical course of COVID-19 and is associated with adverse outcome. COVID-19 may directly exacerbate underlying heart disease and is frequently aggravated by cardiovascular complications, including arterial and venous thromboembolic events, malignant arrhythmia and myocardial injury. In addition to these direct cardiac manifestations of COVID-19, patients with cardiovascular disease face further indirect consequences of the pandemic, as the respective resources in the healthcare systems need to be redirected to cope with the high numbers of infected patients. Consecutively, a substantial decrease in cardiac procedures was reported during the pandemic with lower numbers of coronary angiographies and device implantations worldwide. As a consequence an increased number of out-of-hospital cardiac arrests, late-comers with subacute myocardial infarction and of patients presenting in cardiogenic shock or preshock were observed. Maintenance of high-quality cardiac care by avoiding a reduction of cardiac services is of utmost importance, especially in times of a pandemic.

High-value laboratory testing for hospitalized COVID-19 patients: a review

We present here an evidence-based review of the utility, timing, and indications for laboratory test use in the domains of inflammation, cardiology, hematology, nephrology and co-infection for clinicians managing the care of hospitalized COVID-19 patients. Levels of IL-6, CRP, absolute lymphocyte count, neutrophils and neutrophil-to-lymphocyte ratio obtained upon admission may help predict the severity of COVID-19. Elevated LDH, ferritin, AST, and d-dimer are associated with severe illness and mortality. Elevated cardiac troponin at hospital admission can alert clinicians to patients at risk for cardiac complications. Elevated proBNP may help distinguish a cardiac complication from noncardiac etiologies. Evaluation for co-infection is typically unnecessary in nonsevere cases but is essential in severe COVID-19, intensive care unit patients, and immunocompromised patients.

Doctors managing the complex care of individuals with COVID-19 need timely evidence to guide which lab tests to send to predict outcomes and prevent and treat COVID-19 complications involving the heart, blood clots, the kidney, and other infections that occur during the hospital course. Several lab tests such as IL-6, CRP and white blood cell subset counts may help predict the severity of COVID-19 during the patient’s hospital course if obtained when the patient first presents to the hospital. Other tests such as LDH, ferritin and AST are also associated with severe illness and mortality but have less evidence for their utility beyond IL-6, CRP and other tests. A test related to blood coagulation, d-dimer, is also associated with COVID-19 severity, and it may be used if the patient is suspected of having a blood clot. Two heart biomarkers – cardiac troponin and proBNP – may help doctors diagnose and manage heart-related complications of COVID-19. Patients in the hospital with COVID-19 may be susceptible to other infections, but testing for these is most useful in patients with severe disease, such as those in the intensive care unit. Specific recommendations for testing for viral, bacterial and fungal infections are presented here. The judicious use of laboratory testing can help identify patients at high risk for severe or critical COVID-19 and aid in prevention, diagnosis and treatment of common COVID-19 complications.

Electrocardiographic manifestations of COVID-19: Effect on cardiac activation and repolarization

BACKGROUND

Prolonged QT intervals are reported in patients with COVID-19. Additionally, virus particles in heart tissue and abnormal troponin levels have been reported. Consequently, we hypothesize that cardiac electrophysiologic abnormalities may be associated with COVID-19.

METHODS

This is a retrospective study between March 15^th, 2020 and May 30^th, 2020 of 828 patients with COVID-19 and baseline ECG. Corrected QT (QTc) and QRS intervals were measured from ECGs performed prior to intervention or administration of QT prolonging drugs. QTc and QRS intervals were evaluated as a function of disease severity (patients admitted versus discharged; inpatients admitted to medical unit vs ICU) and cardiac involvement (troponin elevation >0.03 ng/ml, elevated B-natriuretic peptide (BNP) or NT pro-BNP >500 pg/ml). Multivariable analysis was used to test for significance. Odds ratios for predictors of disease severity and mortality were generated.

FINDINGS

Baseline QTc of inpatients was prolonged compared to patients discharged (450.1±30.2 versus 423.4±21.7  msec, p<0.0001) and relative to a control group of patients with influenza (p=0.006). Inpatients with abnormal cardiac biomarkers had prolonged QTc and QRS compared to those with normal levels (troponin - QTc: 460.9±34.6 versus 445.3±26.6  msec, p<0.0001, QRS: 98.7±24.6 vs 90.5±16.9  msec, p<0.0001; BNP - QTc: 465.9±33.0 versus 446.0±26.2  msec, p<0.0001, QRS: 103.6±25.3 versus 90.6±17.6 msec, p<0.0001). Findings were confirmed with multivariable analysis (all p<0.05). QTc prolongation independently predicted mortality (8.3% increase in mortality for every 10  msec increase in QTc; OR 1.083, CI [1.002, 1.171], p=0.04).

INTERPRETATION

QRS and QTc intervals are early markers for COVID-19 disease progression and mortality. ECG, a readily accessible tool, identifies cardiac involvement and may be used to predict disease course.

FUNDING

St. Francis Foundation.

Genetic and Molecular Aspects of Drug-Induced QT Interval Prolongation

Long QT syndromes can be either acquired or congenital. Drugs are one of the many etiologies that may induce acquired long QT syndrome. In fact, many drugs frequently used in the clinical setting are a known risk factor for a prolonged QT interval, thus increasing the chances of developing torsade de pointes. The molecular mechanisms involved in the prolongation of the QT interval are common to most medications. However, there is considerable inter-individual variability in drug response, thus making the application of personalized medicine a relevant aspect in long QT syndrome, in order to evaluate the risk of every individual from a pharmacogenetic standpoint.

Corrected QT interval in hospitalized patients with coronavirus disease 2019: Focus on drugs therapy

Corrected QT (QTc) interval prolongation has been associated with poor patient prognosis. In this study, we assessed the effects of different drugs and cardiac injury on QTc interval prolongation in patients with coronavirus disease 2019 (COVID-19).The study cohort consisted of 395 confirmed COVID-19 cases from the Wuhan Union Hospital West Campus. All hospitalized patients were treated with chloroquine/hydroxychloroquine (CQ/HCQ), lopinavir/ritonavir (LPV/r), quinolones, interferon, Arbidol, or Qingfei Paidu decoction (QPD) and received at least 1 electrocardiogram after drug administration.Fifty one (12.9%) patients exhibited QTc prolongation (QTc ≥ 470 ms). QTc interval prolongation was associated with COVID-19 severity and mortality (both P < .001). Administration of CQ/HCQ (odds ratio [OR], 2.759; 95% confidence interval [CI], 1.318-5.775; P = .007), LPV/r (OR, 2.342; 95% CI, 1.152-4.760; P = .019), and quinolones (OR, 2.268; 95% CI, 1.171-4.392; P = .015) increased the risk of QTc prolongation. In contrast, the administration of Arbidol, interferon, or QPD did not increase the risk of QTc prolongation. Notably, patients treated with QPD had a shorter QTc duration than those without QPD treatment (412.10 [384.39-433.77] vs 420.86 [388.19-459.58]; P = .042). The QTc interval was positively correlated with the levels of cardiac biomarkers (creatine kinase-MB fraction [rho = 0.14, P = .016], high-sensitivity troponin I [rho = .22, P < .001], and B-type natriuretic peptide [rho = 0.27, P < .001]).In conclusion, QTc prolongation was associated with COVID-19 severity and mortality. The risk of QTc prolongation was higher in patients receiving CQ/HCQ, LPV/r, and quinolones. QPD had less significant effects on QTc prolongation than other antiviral agents.

Ambulatory External Electrocardiography Monitoring: Holter, Extended Holter, Mobile Cardiac Telemetry Monitoring

Ambulatory external electrocardiography (AECG) monitoring is effective as an evidence-based diagnostic tool when suspicion for cardiac arrhythmia is high. Multiple modalities of AECG monitoring exist, with unique advantages and limitations that predict effectiveness in a variety of clinical settings. Knowledge of these characteristics allows appropriate use of AECG, maximizing patient adherence, diagnostic yield, and cost-effectiveness. In addition, new technology has allowed the development of a modern generation of devices that offer increased efficacy and functionality compared with Holter monitors.

Cardiovascular RNA markers and artificial intelligence may improve COVID-19 outcome: a position paper from the EU-CardioRNA COST Action CA17129

The coronavirus disease 2019 (COVID-19) pandemic has been as unprecedented as unexpected, affecting more than 105 million people worldwide as of 8 February 2020 and causing more than 2.3 million deaths according to the World Health Organization (WHO). Not only affecting the lungs but also provoking acute respiratory distress, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is able to infect multiple cell types including cardiac and vascular cells. Hence a significant proportion of infected patients develop cardiac events, such as arrhythmias and heart failure. Patients with cardiovascular comorbidities are at highest risk of cardiac death. To face the pandemic and limit its burden, health authorities have launched several fast-track calls for research projects aiming to develop rapid strategies to combat the disease, as well as longer-term projects to prepare for the future. Biomarkers have the possibility to aid in clinical decision-making and tailoring healthcare in order to improve patient quality of life. The biomarker potential of circulating RNAs has been recognized in several disease conditions, including cardiovascular disease. RNA biomarkers may be useful in the current COVID-19 situation. The discovery, validation, and marketing of novel biomarkers, including RNA biomarkers, require multi-centre studies by large and interdisciplinary collaborative networks, involving both the academia and the industry. Here, members of the EU-CardioRNA COST Action CA17129 summarize the current knowledge about the strain that COVID-19 places on the cardiovascular system and discuss how RNA biomarkers can aid to limit this burden. They present the benefits and challenges of the discovery of novel RNA biomarkers, the need for networking efforts, and the added value of artificial intelligence to achieve reliable advances.

ECG changes in hospitalised patients with COVID-19 infection

The coronavirus disease 2019 (COVID-19) commonly involves the respiratory system but increasingly cardiovascular involvement is recognised. We assessed electrocardiogram (ECG) abnormalities in patients with COVID-19. We performed retrospective analysis of the hospital's COVID-19 database from April to May 2020. Any ECG abnormality was defined as: 1) new sinus bradycardia; 2) new/worsening bundle-branch block; 3) new/worsening heart block; 4) new ventricular or atrial bigeminy/trigeminy; 5) new-onset atrial fibrillation (AF)/atrial flutter or ventricular tachycardia (VT); and 6) new-onset ischaemic changes. Patients with and without any ECG change were compared. There were 455 patients included of whom 59 patients (12.8%) met criteria for any ECG abnormality. Patients were older (any ECG abnormality 77.8 ± 12 years vs. no ECG abnormality 67.4 ± 18.2 years, p<0.001) and more likely to die in-hospital (any ECG abnormality 44.1% vs. no ECG abnormality 27.8%, p=0.011). Coxproportional hazard analysis demonstrated any ECG abnormality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.12 to 3.47, p=0.019), age (HR 1.03, 95%CI 1.01 to 1.05, p=0.0009), raised high sensitivity troponin I (HR 2.22, 95%CI 1.27 to 3.90, p=0.006) and low estimated glomerular filtration rate (eGFR) (HR 1.73, 95%CI 1.04 to 2.88, p=0.036) were independent predictors of in-hospital mortality. In conclusion, any new ECG abnormality is a significant predictor of in-hospital mortality.

Arrhythmias and electrocardiographic findings in Coronavirus disease 2019: A systematic review and meta-analysis

Background

Coronavirus disease 2019 (COVID‐19) primarily causes lung infection, but recent studies have shown that cardiac involvement is associated with a worse prognosis.

Objectives

We conducted a systematic review and meta‐analysis to examine the prevalence of cardiac arrhythmias detected by the electrocardiogram and their relationships with adverse outcomes in patients with COVID‐19.

Methods

PubMed and Google were searched for studies that reported on cardiac arrhythmias and/or examined the relationship between arrhythmias and adverse outcomes.

Results

Thirty studies with 12,713 participants were included in the systematic review, and 28 studies (n = 12,499) in the meta‐analysis. The mean age was 61.3 ± 16.8 years; 39.3% were female. In 25 studies with 7578 patients, the overall prevalence of cardiac arrhythmias was 10.3% (95% confidence interval [CI]: 8.4%–12.3%). The most common arrhythmias documented during hospitalization were supraventricular arrhythmias (6.2%, 95% CI: 4.4%–8.1%) followed by ventricular arrhythmias (2.5%, 95% CI: 1.8%–3.1%). The incidence of cardiac arrhythmias was higher among critically ill patients (relative risk [RR]: 12.1, 95% CI: 8.5–17.3) and among non‐survivors (RR: 3.8, 95%, CI: 1.7–8.7). Eight studies reported changes in the QT interval. The prevalence of QTc > 500 ms was 12.3% (95% CI: 6.9%–17.8%). ST‐segment deviation was reported in eight studies, with a pooled estimate of 8.7% (95% CI: 7.3% to 10.0%).

Conclusion

Our meta‐analysis showed that QTc prolongation, ST‐segment deviation, and various other cardiac arrhythmias were observed in patients hospitalized with COVID‐19. The presence of cardiac arrhythmias was associated with a worse prognosis.

Exercise Training and Cardiac Rehabilitation in COVID-19 Patients with Cardiovascular Complications: State of Art

Recent scientific literature has investigated the cardiovascular implications of COVID-19. The mechanisms of cardiovascular damage seem to involve the protein angiotensin-converting enzyme 2 (ACE2), to which severe acute respiratory syndrome (SARS) coronavirus-2 (CoV-2) binds to penetrate cells and other mechanisms, most of which are still under study. Cardiovascular sequelae of COVID-19 include heart failure, cardiomyopathy, acute coronary syndrome, arrhythmias, and venous thromboembolism. This article aims to collect scientific evidence by exploiting PubMed, Scopus, and Pedro databases to highlight the cardiovascular complications of COVID-19 and to define the physiotherapy treatment recommended for these patients. Exercise training (ET), an important part of cardiac rehabilitation, is a powerful tool in physiotherapy, capable of inducing significant changes in the cardiovascular system and functional in the recovery of endothelial dysfunction and for the containment of thromboembolic complications. In conclusion, due to the wide variety of possible exercise programs that can be obtained by combining intensity, duration, and speed in various ways, and by adjusting the program based on continuous patient monitoring, exercise training is well suited to the treatment of post-COVID patients with an impaired cardiovascular system of various degrees.

Clinical Evidences and Pathophysiology of Cardiac Arrhythmia in the Era of Coronavirus Disease-2019

The coronavirus disease-2019 (COVID-19) is primarily caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has been a challenge to the clinician. Epidemiological studies unveiled the involvement of the cardiovascular system during the course of SARS-CoV-2 infection. The cardiac complications in patients with COVID-19 include myocarditis, heart failure, acute coronary syndrome, and cardiac arrhythmia. The pathophysiological states of the disease and multiple concurrent medications (unfamiliar to the clinicians) lead to a significant threat to arrhythmia. This review article hopes to elucidate the mechanisms of arrhythmias in COVID-19.

COVID-19 infection and cardiac arrhythmias

As the coronavirus 2019 (COVID-19) pandemic marches unrelentingly, more patients with cardiac arrhythmias are emerging due to the effects of the virus on the respiratory and cardiovascular (CV) systems and the systemic inflammation that it incurs, and also as a result of the proarrhythmic effects of COVID-19 pharmacotherapies and other drug interactions and the associated autonomic imbalance that enhance arrhythmogenicity. The most worrisome of all arrhythmogenic mechanisms is the QT prolonging effect of various anti-COVID pharmacotherapies that can lead to polymorphic ventricular tachycardia in the form of torsade des pointes and sudden cardiac death. It is therefore imperative to monitor the QT interval during treatment; however, conventional approaches to such monitoring increase the transmission risk for the staff and strain the health system. Hence, there is dire need for contactless monitoring and telemetry for inpatients, especially those admitted to the intensive care unit, as well as for outpatients needing continued management. In this context, recent technological advances have ushered in a new era in implementing digital health monitoring tools that circumvent these obstacles. All these issues are herein discussed and a large body of recent relevant data are reviewed.

COVID-19 and cardiac injury: clinical manifestations, biomarkers, mechanisms, diagnosis, treatment, and follow up

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has the characteristics of high transmission, diverse clinical manifestations, and a long incubation period. In addition to infecting the respiratory system, COVID-19 also has adverse effects on the cardiovascular system. COVID-19 causes acute myocardial injuries, as well as chronic damage to the cardiovascular system.

AREAS COVERED

The present review is aimed at providing current information on COVID-19 and the cardiovascular system. PubMed, Scopus, Science direct, and Google Scholar were searched.

EXPERT OPINION

It is suggested that heart injury caused by COVID-19 infection might be an important cause of severe clinical phenotypes or adverse events in affected patients. Myocardial damage is closely related to the severity of the disease and even the prognosis in patients with COVID-19. In addition to disorders that are caused by COVID-19 on the cardiovascular system, more protection should be employed for patients with preexisting cardiovascular disease (CVD). Hence, it is very important that once relevant symptoms appear, patients with COVID-19 be rapidly treated to reduce mortality. Thus, early measurements of cardiac damage via biomarkers following hospitalization for COVID-19 infections in a patient with preexisting CVD are recommended, together with careful monitoring of any myocardial injury that might be caused by the infection.Abbreviations: ICU: An intensive care unit; 2019-nCoV: 2019 novel coronavirus; ACEI: ACE inhibitor; ACS: Acute coronary syndrome; ARDS: Acute respiratory distress syndrome; AT₁R: Ang II type 1 receptor; ATP: Adenosine triphosphate; ACC: American College of Cardiology; ACE: Angiotensin converting enzyme; Ang II: Angiotensin II; ARB: Angiotensin II receptor blocker; AV block: Atrioventricular block; CAD: Coronary artery disease; CVD: Cardiovascular disease; CT: Computerized tomography; CHF: Congestive heart failure; CHD: Coronary heart disease; CK-MB: Creatine kinase isoenzyme-MB; CRP: C-reactive protein; cTnI: Cardiac troponin I; EAT: Epicardial adipose tissue; ECMO: Extracorporeal membrane oxygenation; FDA: Food and Drug Administration; G-CSF: Granulocyte colony-stimulating factor; HFrEF: HF with a reduced ejection fraction; synhACE2: Human isoform of ACE2; IL: Interleukin; IABP: Intra-aortic balloon counterpulsation; IP10: Interferon γ-induced protein 10 kDa; LPC: Lysophosphatidylcholine; Mas: Mitochondrial assembly receptor; MCP1: Monocyte chemoattractant protein-1; MERS: Middle East respiratory syndrome; MIP1a: macrophage inflammatory protein 1a: MOF: Multiple organ failure; MI: Myocardial infarction; MRI: Magnetic resonance imaging; MYO: Myohe-moglobin; NT-proBNP: N-terminal pro-brain natriuretic peptide; PCPS: Percutaneous cardiopulmonary assistance; rhACE2: Recombinant human ACE2; SARS: Severe acute respiratory syndrome; Th: T helper; RAS: Renin-angiotensin system; TNF-α: Tumor necrosis factor-α; WHO: World Health Organization.

D-dimer surge and coagulation disorders in COVID-19 related pneumonia patients with cardiac injury: A case series

BACKGROUND

Cardiac injury and coagulation disorders have been two increasing concerns in the management of patients with severe coronavirus disease (COVID-19). Coagulation disorders in COVID-19 patients with cardiac injury have not been characterized.

METHODS

We analyzed the data of five COVID-19 patients with cardiac injury who had D-dimer surge (defined as a rapid increase in the D-dimer level in 72 h, from <5-21 μg/mL) during hospitalization, which were extracted from a registered retrospective study (ChiCTR2000031301). Clinical data and data on changes in coagulation parameters were collected, verified, and characterized.

RESULTS

Among these five patients, four had pre-existing cardiovascular or cerebrovascular diseases. D-dimer surge was accompanied with prolonged prothrombin time (PT) and reduced platelet count (PLT) and fibrinogen level. Three patients had an ISTH DIC score of 5 and met the criteria for overt DIC. All five patients needed invasive ventilation support and were incubated 0 to 6 days after the first D-dimer upper reference limit (URL) was reached. All five patients died within 10 days after the first D-dimer URL was reached. All five patients had observed D-dimer URL results 1 to 3 days before death.

CONCLUSION

D-dimer surge in COVID-19 patients with cardiac injury surely leads to worse in-hospital outcome. D-dimer surge and concomitant DIC can be the leading causes of in-hospital death. Pre-existing cardiovascular or cerebrovascular diseases might pose a higher risk for developing these coagulation disorders. These findings can serve as hypothesis generating and need further clinical trials to confirm.