Electrocardiographic features of 431 consecutive, critically ill COVID-19 patients: an insight into the mechanisms of cardiac involvement

Abstract

Aims Our aim was to describe the electrocardiographic features of critical COVID-19 patients. Methods and results We carried out a multicentric, cross-sectional, retrospective analysis of 431 consecutive COVID-19 patients hospitalized between 10 March and 14 April 2020 who died or were treated with invasive mechanical ventilation. This project is registered on ClinicalTrials.gov (identifier: NCT04367129). Standard ECG was recorded at hospital admission. ECG was abnormal in 93% of the patients. Atrial fibrillation/flutter was detected in 22% of the patients. ECG signs suggesting acute right ventricular pressure overload (RVPO) were detected in 30% of the patients. In particular, 43 (10%) patients had the S1Q3T3 pattern, 38 (9%) had incomplete right bundle branch block (RBBB), and 49 (11%) had complete RBBB. ECG signs of acute RVPO were not statistically different between patients with (n = 104) or without (n=327) invasive mechanical ventilation during ECG recording (36% vs. 28%, P = 0.10). Non-specific repolarization abnormalities and low QRS voltage in peripheral leads were present in 176 (41%) and 23 (5%), respectively. In four patients showing ST-segment elevation, acute myocardial infarction was confirmed with coronary angiography. No ST-T abnormalities suggestive of acute myocarditis were detected. In the subgroup of 110 patients where high-sensitivity troponin I was available, ECG features were not statistically different when stratified for above or below the 5 times upper reference limit value. Conclusions The ECG is abnormal in almost all critically ill COVID-19 patients and shows a large spectrum of abnormalities, with signs of acute RVPO in 30% of the patients. Rapid and simple identification of these cases with ECG at hospital admission can facilitate classification of the patients and provide pathophysiological insights.

Electrocardiographic manifestations of COVID-19

“…COVID-19 may also result in cytokine storm, sepsis, disseminated intravascular coagulation, and ultimately multiorgan dysfunction and death. Myocardial abnormalities with ECG changes in COVID-19 may be due to this cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, and microthrombi, as well as direct endothelial or myocardial injury [ [3] , [4] , [5] , [6] , [7] , [8] , 11 , 32 ].…”

“…Interestingly, the interpretation of the ECG, with either dysrhythmia recognition or identification of a concerning morphologic issue, is unchanged from the non-COVID-19 patient; in contrast, the context of the patient presentation and thus the clinical impact of the ECG findings has significantly changed. ECG abnormalities are common, present in 93% of hospitalized critically ill patients in one study [ 32 ]. Palpitations, likely reflective of dysrhythmia, may be the initial presenting symptom in approximately 7% of patients, and one study suggests 17% of patients in the general cohort and 44% of patients in the intensive care unit (ICU) setting experience dysrhythmias [ 3 , 4 , 19 , 20 , 33 ].…”

“…One study conducted in New York hospitals found atrial fibrillation/flutter was present in 14.3% of patients at admission and occurred in 10.1% of patients during hospitalization [ 39 ]. Another study found atrial fibrillation/flutter to be present in 22% of critically ill patients requiring mechanical ventilation [ 32 ]. Atrial fibrillation is more common in patients following an inflammatory insult such as cardiomyopathy from COVID-19 and occurs in up to half of the patients admitted to an ICU [ [41] , [42] , [43] , [44] , [45] , [46] ].…”

“…QT interval prolongation is associated with more critical illness requiring ICU admission, as well as cardiac injury and mortality [ 61 , 69 ]. Left and right bundle branch blocks may occur in up to 12% of patients at the time of admission or during hospitalization [ 32 , 39 ]. Significant QT interval prolongation may lead to torsade des pointes.…”

“…One study found ST segment and T wave changes to be the most common abnormality in patients requiring ICU admission, occurring in 40% of patients [ 70 ]. Another investigation noted that nonspecific repolarization changes including ST segment and T wave abnormalities were encountered in 41% of patients; reportedly, these findings resulted from myocardial injury and are associated with poor outcomes, including increased need for ICU admission, more frequent mechanical ventilatory support, and increased mortality [ 32 , 40 ]. A case series included 18 patients with COVID-19 infection and ST segment elevation, 10 of which had ST segment elevation at the time of presentation and 8 developed ST segment elevation during hospitalization [ 71 ].…”