Cardiac arrhythmias among hospitalized Coronavirus 2019 (COVID-19) patients: prevalence, characterization, and clinical algorithm to classify arrhythmic risk

Abstract

Objectives: A significant proportion of COVID-19 patients may have cardiac involvement including arrhythmias. Although arrhythmia characterization and possible predictors were previously reported, there are conflicting data regarding the exact prevalence of arrhythmias. Clinically applicable algorithms to classify COVID patients' arrhythmic risk are still lacking, and are the aim of our study. Methods: We describe a single center cohort of hospitalized patients with a positive nasopharyngeal swab for COVID-19 during the initial Israeli outbreak between 1/2/2020-30/5/2020. The study's outcome was any documented arrhythmia during hospitalization, based on daily physical examination, routine ECG's, periodic 24-hour Holter, and continuous monitoring. Multivariate analysis was used to find predictors for new arrhythmias and create classification trees for discriminating patients with high and low arrhythmic risk. Results: Out of 390 COVID-19 patients included, 28 (7.2%) had documented arrhythmias during hospitalization, including: 23 atrial tachyarrhythmias, combined atrial fibrillation (AF) and ventricular fibrillation, ventricular tachycardia storm, and 3 bradyarrhythmias. Only 7/28 patients had previous arrhythmias. Our study showed significant correlation between disease severity and arrhythmia prevalence (p<0.001) with a low arrhythmic prevalence among mild disease patients (2%). Multivariate analysis revealed background heart failure (CHF) and disease severity are independently associated with overall arrhythmia while age, CHF, disease severity, and arrhythmic symptoms are associated with tachyarrhythmias. A novel decision tree using age, disease severity, CHF, and troponin levels was created to stratify patients into high and low risk for developing arrhythmia. Conclusions: Dominant arrhythmia among COVID-19 patients is AF. Arrhythmia prevalence is dependent on age, disease severity, CHF, and troponin levels. A novel simple Classification tree, based on these parameters, can discriminate between high and low arrhythmic risk patients. WHAT'S KNOWN? • A significant proportion of COVID-19 patients may have cardiac involvement including arrhythmias. • There is a correlation between disease severity in general and cardiac involvement specifically to occurrence of cardiac arrhythmias. • Arrhythmia characterization and possible predictors. WHAT'S NEW? • Using a 24-hour Holter monitoring among hospitalized COVID-19 patients, for better arrythmias detection. • Among of all hospitalized COVID-19 patients, 7.2% had new arrhythmias during hospitalization. • Classification tree which discriminate between high and low arrhythmic risk patients

Prevalence of Atrial Fibrillation and Associated Mortality Among Hospitalized Patients With COVID-19: A Systematic Review and Meta-Analysis

“…There was a strong association between new-onset AF and all-cause mortality among hospitalized patients with COVID-19 (crude OR: 2.32, 95% CI: 1.60 to 3.37, I 2 = 54%) (Figure 5A). Consistently, the pooled multivariate analysis (15,28) showed similar results (adjusted OR: 2.01, 95% CI: 1.12 to 3.62, P = 0.02, I 2 = 82%) (Figure 5B).…”

“…Among the included studies, the diagnosis of AF was based on electrocardiograms. Three reports were from Asia, ( 16 , 24 , 25 ) 1 from Africa, ( 20 ) 7 from Europe, ( 17 – 19 , 23 , 26 , 27 , 29 ) and 8 from America ( 14 , 15 , 21 , 22 , 28 , 30 – 32 ). Apart from 4 prospective cohort studies, ( 20 , 22 , 26 , 27 ) the remaining 15 articles were designed as retrospective cohort studies ( 14 – 19 , 21 , 23 – 25 , 28 – 32 ).…”

“…Based on the Joanna Briggs Institute Critical Appraisal Checklist, all 19 studies ( 14 – 32 ) that reported the prevalence of AF met a minimum of six of the nine criteria, which meant that these articles applied rigorous methodology ( Supplemental Table 2 ). In accordance with the NOS, all 8 studies ( 15 , 16 , 19 , 21 , 25 , 26 , 28 , 29 ) that involved the association between AF and outcomes of patients with COVID-19 were viewed as moderate to high quality, with a score range of 6–8 ( Supplemental Table 3 ).…”

“…Furthermore, the prevalence of AF in patients with severe COVID-19 was 6-fold higher than in patients with nonsevere COVID-19 (ES: 19 vs. 3%, P for subgroup difference < 0.001) ( Figure 3C ). Ten articles ( 15 , 16 , 19 , 22 , 25 – 28 , 30 , 31 ) provided data on the prevalence of new-onset AF (ES: 10%, 95% CI: 7% to 13%, I 2 = 92.9%) ( Figure 3D ). There was no significant difference in the study design ( P = 0.92), sample size ( P = 0.74), or cases of AF ( P = 0.20) ( Table 2 ).…”

“…More recently, numerous epidemiological studies have shown an increased risk of AF and new-onset AF among patients with COVID-19 but have yielded inconsistent results (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). Moreover, accumulating literature has demonstrated that AF or new-onset AF might be significantly associated with the worst outcomes (e.g., mortality) in patients with COVID-19 (21,25,29).…”