Behavior of the PR interval with increasing heart rate in patients with COVID-19

Abstract

BACKGROUND Myriad manifestations of cardiovascular involvement have been described in patients with coronavirus disease 2019 (COVID-19), but there have been no reports of COVID-19 affecting the cardiac conduction system. The PR interval on the electrocardiogram (ECG) normally shortens with increasing heart rate (HR). The case of a patient with COVID-19 manifesting Mobitz type 1 atrioventricular (AV) block that normalized as the patient's condition improved prompted us to investigate PR interval behavior in patients with COVID-19.OBJECTIVE The purpose of this study was to characterize PR interval behavior in hospitalized patients with COVID-19 and to correlate that behavior with clinical outcomes.METHODS This study was a cross-sectional cohort analysis of confirmed COVID-19 cases (March 26, 2020, to April 25, 2020. We reviewed pre-COVID-19 and COVID-19 ECGs to characterize AV conduction by calculating the PR interval to HR (PR:HR) slope. Clinical endpoints were death or need for endotracheal intubation.RESULTS ECGs from 75 patients (246 pre-COVID-19 ECGs and 246 COVID-19 ECGs) were analyzed for PR:HR slope. Of these patients, 38 (50.7%) showed the expected PR interval shortening with increasing HR (negative PR:HR slope), whereas 37 (49.3%) showed either no change (8 with PR:HR slope 5 0) or paradoxical PR interval prolongation (29 with positive PR:HR slope) with increasing HR. Patients without PR interval shortening were more likely to die (11/37 [29.7%] vs 3/38 [7.9%]; P 5 .019) or require endotracheal intubation (16/37 [43.2%] vs 8/38 [21.1%]; P 5 .05) compared to patients with PR interval shortening.CONCLUSION Half of patients with COVID-19 showed abnormal PR interval behavior (paradoxical prolongation or lack of shortening) with increasing HR. This finding was associated with increased risk of death and need for endotracheal intubation.

Electrocardiographic Changes in Children with Multisystem Inflammation Associated with COVID-19

“…Pavri et al have recently shown around 50% of adult patients with COVID-19 had an abnormal PR:HR slope, which correlated with the worst clinical outcomes. 17 This finding occurred in 25% of our cohort, however, our data showed no correlation with either ICU admission or inotropic support.…”

“… 16 In patients with a ≥5 bpm difference in heart rate in ≥2 ECGs, a positive slope, with paradoxical lengthening of PR interval at increasing heart rates, was defined as abnormal PR:HR slope. 17 QRS prolongation is the QRS duration over 98th percentile for age and sex. 16 Prolonged corrected QT interval is the QTc over 98th percentile for age and sex.…”

A case of complete heart block in a COVID-19 infected patient

“…Cardiac involvement has been reported with varying incidence as one of the manifestations that confer a worse prognosis [2]. It has been reported that there was a correlation between paradoxical prolongation or lack of shortening of the PR interval with increasing heart rate and higher mortality and intubation rate in COVID-19 patients, suggesting a worse prognosis when conduction abnormalities are present [3]. Cardiac arrhythmias have been reported in association with cardiac injury [2,4,5].…”

COVID-19 infection and cardiac arrhythmias

“…Another study analyzing the ECGs of 75 COVID-19 patients showed that abnormal PR interval behavior (paradoxical prolongation or lack of shortening) with increasing heart rate was associated with increased risk of death (29.7% vs 7.9%, p =0.019) and need for endotracheal intubation (43.2% vs. 21.1%, p =0.05) compared to patients with PR interval shortening [20] .…”