When COVID Meets Arrhythmia

So far there is no evidence suggesting an increased incidence of cardiac arrhythmia specifically associated with Covid-19 infection. However, in patients with either Covid-19-related fulminant myocarditis or ARDS, both ventricular and atrial arrhythmias have been reported. Most likely this was a consequence of acute myocardial injury, severe hypoxemia, and cytokine storm. Other factors that contribute to arrhythmias in Covid-19 patients include psychological factors, pre-existing cardiovascular disease, and side effect of therapeutic drugs.

Sinus tachycardia is the most common arrhythmia in Covid-19 patients. At the acute stage, sinus tachycardia may reflect systemic hyper-sympathetic tone. Of note, sinus tachycardia can be sustained even months after patients become stable and free from hypoxemia, anemia, etc. It is unknown whether the sinus tachycardia during the recovery phase following Covid-19 infections is a long-term physiological response to Covid-19 infection itself or is a manifestation of autonomic dysfunction caused by the virus.

Several medications have been recommended for compassionate use in patients with severe Covid-19 infection without thorough safety evaluation. Specifically, the combination of hydroxychloroquine or chloroquine with azithromycin should be used with caution. Both drugs are classified as QT-prolonging medications. Simultaneous administration of these two drugs could put patients at very high risk of QT prolongation and Tdp.

In rare situations, patients not infected with Covid-19 who developed life-threatening arrhythmias such as VT/VF storm or complete heart block will need emergency invasive procedures during the pandemic. Limited experience has shown that both catheter ablation and device implantation can be performed safely with proper personal protection equipment. A more widespread impact of Covid-19 on arrhythmia patients may be the delay in provision of care for elective procedures. While it is very likely that ablation for conditions such as SVT and AF may be safely deferred for many months, delay in performing other procedures (e.g. implantation of primary prevention ICDs) may confer some risks to patients.

Written by Professor Changsheng Ma, Professor Yumei Xue and Dr. David Spragg