Cardiac and arrhythmic complications in patients with COVID‐19

Abstract

In December 2019, the world started to face a new pandemic situation, the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). Although coronavirus disease (COVID-19) clinical manifestations are mainly respiratory, major cardiac complications are being reported. Cardiac manifestations etiology seems to be multifactorial, comprising direct viral myocardial damage, hypoxia, hypotension, enhanced inflammatory status, ACE2-receptors downregulation, drug toxicity, endogenous catecholamine adrenergic status, among others. Studies evaluating patients with COVID-19 presenting cardiac injury markers show that it is associated with poorer outcomes, and arrhythmic events are not uncommon. Besides, drugs currently used to treat the COVID-19 are known to prolong the QT interval and can have a proarrhythmic propensity. This review focus on COVID-19 cardiac and arrhythmic manifestations and, in parallel, makes an appraisal of other virus epidemics as SARS-CoV, Middle East respiratory syndrome coronavirus, and H1N1 influenza. K E Y W O R D S arrhythmia, COVID-19, myocardial damage, myocarditis, SARS-CoV-2 | KOCHI ET AL.

Anticoagulant and antiarrhythmic effects of heparin in the treatment of COVID‐19 patients

“…[2] in this journal reported that heparin treatment reduced mortality of COVID-19 patients with elevated D-dimer; similar preliminary results have been reported elsewhere [3]. A mounting body of evidence shows that SARS-CoV-2 causes a "cytokine storm" [1,4] that activates the coagulation cascade, leading to thrombosis. Similar to the findings in severe sepsis, generalized deposition of intravascular thrombi compromises the blood supply of several organs, leading to organ failure [5].…”

“…Disseminated intravascular coagulation (DIC) secondary to severe infection is classically associated with gram-positive and gram-negative bacteria, malaria and other hemorrhagic fevers, such as hemorrhagic dengue, though SARS-CoV and MERS-CoV have also been shown to trigger DIC. Similar results in COVID-19 [2][3][4] now suggest that widespread coagulation events significantly contribute to worse outcomes and patient mortality, which might be attenuated by anticoagulant treatment.…”

“…We would also like to add that, while a direct anticoagulant effect is likely crucial to the therapeutic effect of heparin, it also has antiarrhythmic properties [6,7] that could show promise in the treatment of COVID-19, in which cardiac arrhythmias are the immediate cause of several patient deaths [4]. Heparin oligosaccharides have a marked antiarrhythmic effect in an animal model of heart ischemia-reperfusion, as well as in isolated rat atria, reducing both ventricular arrhythmias and atrioventricular block, likely by increasing Na + -Ca 2+ exchanger activity [6].…”

“…About 16% of COVID-19 patients show cardiac arrhythmias and 7.2% had acute cardiac lesions [4]. Increased cardiac lesion markers, such as interleukin-6, high-sensitivity troponin I (TnI) and lactate dehydrogenase are correlated with poorer patient outcomes [4]. COVID-19 increases TnI and these higher levels correlate with more frequent complications, including malignant ventricular arrhythmias [4].…”

“…Increased cardiac lesion markers, such as interleukin-6, high-sensitivity troponin I (TnI) and lactate dehydrogenase are correlated with poorer patient outcomes [4]. COVID-19 increases TnI and these higher levels correlate with more frequent complications, including malignant ventricular arrhythmias [4]. There are many reports of fulminant myocarditis with cardiogenic shock, associated with atrial and ventricular arrhythmias [1,4].…”