Background Despite a lack of clinical evidence, hydroxychloroquine and azithromycin are being administered widely to patients with verified or suspected coronavirus disease 2019 ( COVID ‐19). Both drugs may increase risk of lethal arrhythmias associated with QT interval prolongation. Methods and Results We analyzed a case series of COVID ‐19–positive/suspected patients admitted between February 1, 2020, and April 4, 2020, who were treated with azithromycin, hydroxychloroquine, or a combination of both drugs. We evaluated baseline and postmedication QT interval (corrected QT interval [QTc]; Bazett) using 12‐lead ECG s. Critical QT c prolongation was defined as follows: (1) maximum QT c ≥500 ms (if QRS <120 ms) or QT c ≥550 ms (if QRS ≥120 ms) and (2) QT c increase of ≥60 ms. Tisdale score and Elixhauser comorbidity index were calculated. Of 490 COVID ‐19–positive/suspected patients, 314 (64%) received either/both drugs and 98 (73 COVID ‐19 positive and 25 suspected) met study criteria (age, 62±17 years; 61% men). Azithromycin was prescribed in 28%, hydroxychloroquine in 10%, and both in 62%. Baseline mean QT c was 448±29 ms and increased to 459±36 ms ( P =0.005) with medications. Significant prolongation was observed only in men (18±43 ms versus −0.2±28 ms in women; P =0.02). A total of 12% of patients reached critical QT c prolongation. Changes in QT c were highest with the combination compared with either drug, with much greater prolongation with combination versus azithromycin (17±39 ms versus 0.5±40 ms; P =0.07). No patients manifested torsades de pointes. Conclusions Overall, 12% of patients manifested critical QT c prolongation, and the combination caused greater prolongation than either drug alone. The balance between uncertain benefit and potential risk when treating COVID ‐19 patients should be carefully assessed.

Objectives To evaluate the potential impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) response and outcomes in two US communities with relatively low infection rates. Background Studies in areas with high COVID-19 infection rates indicate that the pandemic has had direct and indirect effects on community response to OHCA and negative impacts on survival. Data from areas with lower infection rates are lacking. Methods In Multnomah County, OR and Ventura County, CA, we evaluated OHCA with attempted resuscitation by EMS from March 1 – May 31, 2020 and March 1 – May 31, 2019. Results Comparing 231 OHCA in 2019 to 278 in 2020, the proportion receiving bystander CPR was lower in 2020 (61% to 51%, p=0.02) and bystander use of automated external defibrillators (AEDs) declined (5% to 1%, p=0.02). EMS response time increased (6.6 ± 2.0 to 7.6 ± 3.0 minutes, p<0.001), and fewer OHCA survived to hospital discharge (14.7% to 7.9%, p=0.02). Incidences rates did not change significantly (p>0.07), and coronavirus infection rates were low (Multnomah 143/100,000, Ventura 127/100,000 as of May 31), compared to rates of ∼1600-3000/100,000 in the New York City region at that time. Conclusions The community response to OHCA was altered from March to May 2020, with less bystander CPR, delays in EMS response time, and reduced survival from OHCA. These results highlight the pandemic’s indirect negative impact on OHCA even in communities with relatively low incidence of COVID-19 and point to potential opportunities for countering the impact.

Background-The prevalence rates and influencing factors for deployment of primary prevention implantable cardioverter defibrillators (ICDs) among subjects who eventually experience sudden cardiac arrest in the general population have not been evaluated. Methods and Results-Cases of adult sudden cardiac arrest with echocardiographic evaluation before the event were identified from the ongoing Oregon Sudden Unexpected Death Study (population approximately 1 million). Eligibility for primary ICD implantation was determined from medical records based on established guidelines. The frequency of prior primary ICD implantation in eligible subjects was evaluated, and ICD nonrecipients were characterized. Of 2093 cases (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012), 448 had appropriate pre-sudden cardiac arrest left ventricular ejection fraction information available. Of these, 92 (20.5%) were eligible for primary ICD implantation, 304 (67.9%) were ineligible because of left ventricular ejection fraction >35%, and the remainder (52, 11.6%) had left ventricular ejection fraction ≤35% but were ineligible on the basis of clinical guideline criteria. Among eligible subjects, only 12 (13.0%; 95% confidence interval, 6.1%-19.9%) received a primary ICD. Compared with recipients, primary ICD nonrecipients were older (age at ejection fraction assessment, 67.1±13.6 versus 58.5±14.8 years, P=0.05), with 20% aged ≥80 years (versus 0% among recipients, P=0.11). Additionally, a subgroup (26%) had either a clinical history of dementia or were undergoing chronic dialysis. Conclusions-Only one fifth of the sudden cardiac arrest cases in the community were eligible for a primary prevention ICD before the event, but among these, a small proportion (13%) were actually implanted. Although older age and comorbidity may explain nondeployment in a subgroup of these cases, other determinants such as socioeconomic factors, health insurance, patient preference, and clinical practice patterns warrant further detailed investigation. Key Words: death, sudden ◼ epidemiology ◼ heart arrest ◼ implantable defibrillators ◼ population ◼ utilization © 2013 American Heart Association, Inc.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.113.002539Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz. Received March 11, 2013; accepted August 21, 2013. From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (K.N., K.R., A.U.-E., C.T., H.C., E.M., S.S.C.); and Departments of Pathology (K.G.) and Emergency Medicine (J.J.), Oregon Health and Science University, Portland, OR.Correspondence to Sumeet S. Chugh, MD, Cedars-Sinai Medical Center, The Heart Institute, AHSP Suite A3100, 127 S. San Vicente Blvd., Los Angeles, CA 90048, Los Angeles, CA 90048. E-mail sumeet.chugh@cshs.org be significantly underused in the community for both primary and secondary prevention. [13][14][15] However, the extent of deployment of the primary ICD amon...