Critically ill COVID-19 patients were 10 times more likely than hospitalized patients with less severe coronavirus infections to have cardiac arrest or heart rhythm disorders and die, but these conditions are likely not due to infection with the novel coronavirus, according to a study published yesterday in Heart Rhythm.
Using clinical records, researchers reviewed the characteristics of all 700 COVID-19 patients admitted to the Hospital of the University of Pennsylvania from Mar 6 to May 19.
Mean patient age was 50 years, 45% were men, 71% were black, and 11% were admitted to the intensive care unit (ICU). Among them, there were 9 cardiac arrests, 25 atrial fibrillation (irregular or rapid heartbeat) incidents, 9 clinically significant bradyarrhythmias (slow heartbeat), and 10 nonsustained ventricular tachycardias (rapid heartbeat).
No cardiac arrests in non-ICU patients
After multivariable adjustment, admission to the ICU was linked to atrial fibrillation (odds ratio [OR], 4.68; [95% confidence interval [CI], 1.66 to 13.18]) and nonsustained ventricular tachycardia (OR, 8.92; 95% CI, 1.73 to 46.06), as were age and atrial fibrillation (OR, 1.05; 95% CI, 1.02 to 1.09), heart failure, and bradyarrhythmia (OR, 9.75; 95% CI, 1.95 to 48.65). Only cardiac arrests were associated with in-hospital deaths. None of the 621 less critically ill COVID-19 patients had cardiac arrest.
COVID-19 patients in the ICU were older than patients with less severe disease and had a higher prevalence of cardiovascular disease, high blood pressure, diabetes, obstructive sleep apnea, chronic obstructive pulmonary disease, liver disease, and chronic kidney disease.
On admission, ICU patients also had lower oxygen levels than non-ICU patients and were more likely to have high levels of troponin (indicating heart damage), brain natriuretic peptide (indicating heart failure), D-dimer (indicating blood clots), procalcitonin (indicating tissue damage), and high-sensitivity C-reaction protein (indicating inflammation).
COVID-19 patients in the ICU were also more likely than non-critical patients to be given the malaria drug hydroxychloroquine or the antiviral drug remdesivir. There were no differences in sex or race. Six percent of patients had a history of atrial fibrillation, and 3% had either an implantable cardioverter defibrillator or permanent pacemaker.
Among all 700 hospitalized COVID-19 patients, 30 patients (4%) died, 613 (88%) were released from the hospital, and 57 (8%) were still hospitalized at the end of the study.
Consequence of systemic illnesses
Because cardiac arrest and abnormal heart rhythms were more likely to occur in ICU patients than in their non-critically ill peers, even after controlling for demographic and clinical factors, the authors said that unmeasured factors relating to the severity of disease likely explain the independent link between ICU admission and atrial fibrillation and nonsustained ventricular tachycardia.
"Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection," they wrote.
They noted that their findings support those of a recent University of Alabama at Birmingham study that found higher odds of atrial arrhythmias in ICU versus non-ICU patients and that both atrial fibrillation and COVID-19 are associated with the development of blood clots. "Future studies will need to evaluate the most effective and safest strategies for long-term anticoagulation [clot prevention] and rhythm management in this population," they said.