The Prognostic Value of Electrocardiogram at Presentation to Emergency Department in Patients With COVID-19

Abstract

Objective: To study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication. Methods: This study analyzed 1258 adults with coronavirus disease 2019 who were seen at three hospitals in New York in March and April 2020. Electrocardiograms at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs. Results: At 48 hours, 73 of 1258 patients (5.8%) had died and 174 of 1258 (13.8%) were alive but receiving mechanical ventilation with 277 of 1258 (22.0%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (odds ratio [OR], 2.5; 95% CI, 1.1 to 6.2), right ventricular strain (OR, 2.7; 95% CI, 1.3 to 6.1), and ST segment abnormalities (OR, 2.4; 95% CI, 1.5 to 3.8) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 breaths/min and saturation >95%), only 5 (4.6%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31.5%) having both ECG and respiratory vital sign abnormalities. Conclusion: The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with coronavirus disease 2019 and may assist with patient triage.

Electrocardiographic manifestations of COVID-19

“…There are a variety of arrhythmias and ECG abnormalities that may occur in COVID-19 [ 3 , 4 , 19 , 20 ]. 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 ]. Another study reported a 9.6% rate of dysrhythmias [ 34 ].…”

“…Arrhythmias and ECG abnormalities are more common in critically ill patients [ 33 , 35 ], which may occur in 33–93% of these cases [ 36 , 37 ], and they are also associated with increased risk of in-hospital mortality (odds ratio [OR]1.95) and need for mechanical ventilation [ 38 ]. A study of 1258 patients found atrial fibrillation/flutter (OR 2.5), right ventricular (RV) strain (OR 2.7), and ST segment abnormalities (OR 2.4) to be associated with increased risk of mechanical ventilation and death [ 19 ]. Emergency clinicians should note that RV strain electrocardiographically presents with ST segment depression and T wave inversion in the right to mid-precordial (leads V1-V4) and the inferior leads (leads II, III, and aVF).…”

“…Myocardial involvement in COVID-19 has been associated with poor outcomes, especially in myocardial injury which occurs in 22–44% of critical or severe cases [ [4] , [5] , [6] , [7] , [8] ]. Therefore, it is crucial that the emergency clinician to recognize the electrocardiographic (ECG) manifestations of COVID-19 [ 19 , 20 ]. This narrative review provides a discussion of the various electrocardiographic presentations encountered in the COVID-19-infected patient.…”

Meta-Analysis of Atrial Fibrillation in Patients With COVID-19

“…Nine hundred and sixteen potentially relevant studies were screened according to the inclusion and exclusion criteria. Finally, 23 studies with 108,745 COVID-19 patients 1 , 2 , 3 , 4 , 5 , 6 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 were eligibly included in the present quantitative meta-analysis. The study characteristics are summarized in Table 1 .…”