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Revision as of 13:58, 2 July 2020

For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS [2]

Overview

Out-of-hospital cardiac arrest and Sudden Cardiac Death

The sudden cardiac death is defined as the death that occurs within one hour of onset of symptoms in witnessed cases and within 24 hours of last being seen alive when it is unwitnessed. Out-of-hospital cardiac arrest means cessation of cardiac mechanical activity that occurs outside of the hospital setting and is confirmed by the absence of signs of circulation.

Pathophysiology

Drug induced

Since the COVID-19 pandemic, several pharmacological therapies have been proposed, one of them is of two anti-malarial and antirheumatic drugs called Chloroquine or Hydroxychloroquine.
Due to their cost-effectiveness and easy availability, there is a surge in the use of Chloroquine and Hydroxychloroquine, with or without Azithromycin. The clinical trials in order to estimate their efficacy are still in the preliminary stage, however, a notable concern is of their cardiac adverse effects.
This includes QT prolongation and Torsade de pointes (TdP) leading to sudden cardiac death.
The risk is there when these drugs are prescribed separately, however it increases several folds when these drugs are administered together, especially in patients with underlying hepatic disease or renal failure.

Genetic susceptibility:

Epidemiological studies have shown that African Americans have higher COVID-19 associated morbidity and mortality as compared to people from other ethnic groups.
Recent studies show that this ethnic predilection is due to the genetic factors which contribute to a common ion channel variant p.Ser1103Tyr-SCN5A which confer an increased risk of drug-induced long QT syndrome (DI-LQTS) and drug-induced sudden cardiac death (DI-SCD).
p.Ser1103Tyr-SCN5A generates late or persistent sodium current which is further aggravated by hypoxia or respiratory acidosis secondary to lungs involvement in COVID-19.
This has and has been linked to an increased risk of ventricular arrhythmia (VA) such as torsade de pointes and sudden cardiac death (SCD) in African Americans.

Cytokine storm and heart damage:

Pre-existing heart disease

Epidemiology and Demographics

Incidence

There is a two-times rise in the incidence of Out of hospital Sudden cardiac arrest (OHCA) during the COVID-19 pandemic as compared to the non-pandemic time period.

Mortality

There is a significant increase in the mortality rate of the OHCA patients.^[1]

Age

Mean age 69.7 years is observed among patients who experienced Out of hospital Sudden cardiac arrest (OHCA) .^[1] .

Gender

Studies show that males have a slightly higher incidence of Out of hospital Sudden cardiac arrest (OHCA) as compared to the females.^[1]

Race

A higher incidence is seen among African-Americans as compared to the Caucasians.^[2]

Diagnosis

EKG
- A patient experiencing sudden cardiac death can have ventricular fibrillation associated ECG changes such as ventricular tachycardia with irregular rhythm and indiscernible P waves or QRS complexes.
- Heart block.^[3]
- Pulseless electrical activity.^[3]
- Other abnormal ECG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms..
- Asystole.^[3] ^[4]

Treatment

Cardiopulmonary resuscitation

Immediate basic life support or advanced cardiac life support with an automatic external defibrillator is essential to safe the life of the patient. If the COVID-19 infection was confirmed, the EMS personnel is instructed to wear personal protective equipment (PPE) before performing cardiopulmonary resuscitation.

Implantable Cardioverter Defibrillator (ICD)

An Implantable cardioverter defibrillator (ICD) is the preferred therapeutic modality in most survivors of sudden cardiac death. This device does not prevent the recurrence of arrhythmia, instead, it terminates them in case if they do recur.

Pharmacologic therapy in survivors of sudden cardiac arrest

Antiarrhythmic drugs: Amiodarone is the most effective for preventing recurrent ventricular tachyarrhythmias. It is recommended to immediately give Amiodarone following an event of sudden cardiac arrest in patients with recurrent ventricular tachyarrhythmias as well as for those who have refused Implantable Cardioverter Defibrillator (ICD).
Beta blocker:It is recommended that almost all patients who survive an episode of sudden cardiac arrest should receive a beta-blocker as part of their therapy in combination with an antiarrhythmic drug, particularly in those patients who have survived sudden cardiac death due to ventricular tachycardia or ventricular fibrillation. Beta-blockers has shown to reduce the future incidence of sudden cardiac death.

Prevention

Identification and treatment of acute reversible causes of sudden cardiac death.
Evaluation and management of structural heart disease and arrhythmia.^[3]

↑ ^1.0 ^1.1 ^1.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check |pmc= value (help). PMID 32473113 PMID: 32473113 Check |pmid= value (help).
↑ Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ (2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 PMID: 32380288 Check |pmid= value (help).
↑ ^3.0 ^3.1 ^3.2 ^3.3 Srinivasan NT, Schilling RJ (2018). "Sudden Cardiac Death and Arrhythmias". Arrhythm Electrophysiol Rev. 7 (2): 111–117. doi:10.15420/aer.2018:15:2. PMC 6020177. PMID 29967683 PMID: 29967683 Check |pmid= value (help).
↑ Parish DC, Goyal H, Dane FC (2018). "Mechanism of death: there's more to it than sudden cardiac arrest". J Thorac Dis. 10 (5): 3081–3087. doi:10.21037/jtd.2018.04.113. PMC 6006107. PMID 29997977 PMID: 29997977 Check |pmid= value (help).

[pmidPMID:_32473113-1] 1.0 ^1.1 ^1.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check |pmc= value (help). PMID 32473113 PMID: 32473113 Check |pmid= value (help).

[pmidPMID:_32380288-2] Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ (2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 PMID: 32380288 Check |pmid= value (help).

[pmidPMID:_29967683-3] 3.0 ^3.1 ^3.2 ^3.3 Srinivasan NT, Schilling RJ (2018). "Sudden Cardiac Death and Arrhythmias". Arrhythm Electrophysiol Rev. 7 (2): 111–117. doi:10.15420/aer.2018:15:2. PMC 6020177. PMID 29967683 PMID: 29967683 Check |pmid= value (help).

[pmidPMID:_29997977-4] Parish DC, Goyal H, Dane FC (2018). "Mechanism of death: there's more to it than sudden cardiac arrest". J Thorac Dis. 10 (5): 3081–3087. doi:10.21037/jtd.2018.04.113. PMC 6006107. PMID 29997977 PMID: 29997977 Check |pmid= value (help).

[1]

[2]

[3]

[4]

@@ Line 9: / Line 9: @@
 ===Out-of-hospital cardiac arrest and Sudden Cardiac Death===
-The [[sudden cardiac death]] is [[defined]] as the [[death]] that occurs within one hour of [[onset]] of [[symptoms]] in [[witnessed]] [[cases]] and within 24 hours of last being seen alive when it is [[unwitnessed]].<ref name="pmidPMID: 20142817">{{cite journal| author=Adabag AS, Luepker RV, Roger VL, Gersh BJ| title=Sudden cardiac death: epidemiology and risk factors. | journal=Nat Rev Cardiol | year= 2010 | volume= 7 | issue= 4 | pages= 216-25 | pmid=PMID: 20142817 | doi=10.1038/nrcardio.2010.3 | pmc=5014372 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20142817  }} </ref> [[Out-of-hospital]] [[cardiac arrest]] means [[cessation]] of [[cardiac]] [[mechanical]] [[activity]] that occurs outside of the [[hospital]] setting and is confirmed by the absence of [[signs]] of [[circulation]].
+The [[sudden cardiac death]] is [[defined]] as the [[death]] that occurs within one hour of [[onset]] of [[symptoms]] in [[witnessed]] [[cases]] and within 24 hours of last being seen alive when it is [[unwitnessed]]. [[Out-of-hospital]] [[cardiac arrest]] means [[cessation]] of [[cardiac]] [[mechanical]] [[activity]] that occurs outside of the [[hospital]] setting and is confirmed by the absence of [[signs]] of [[circulation]].
-====Pathophysiology====
+==Pathophysiology==
-*'''Drug induced:'''
+'''Drug induced'''
-Since the [[COVID-19]] [[pandemic]], several [[pharmacological]] [[therapies]] have been proposed, one of them is of two [[anti-malarial]] and [[antirheumatic]] drugs called [[Chloroquine]] or [[Hydroxychloroquine]]. Due to their cost-effectiveness and easy availability, there is a surge in the use of [[Chloroquine]] and [[Hydroxychloroquine]], with or without [[Azithromycin]]. The [[clinical trials]] in order to estimate their [[efficacy]] are still in the preliminary stage, however, a notable concern is of their [[cardiac]] [[adverse effects]]. This includes [[QT prolongation]] and [[Torsade de pointes]] (TdP) leading to [[sudden cardiac death]]. The risk is there when these drugs are prescribed separately, however it increases several folds when these drugs are administered together, especially in patients with underlying [[hepatic]] [[disease]] or [[renal failure]].<ref name="pmidPMID: 32409150">{{cite journal| author=Vouri SM, Thai TN, Winterstein AG| title=An evaluation of co-use of chloroquine or hydroxychloroquine plus azithromycin on cardiac outcomes: A pharmacoepidemiological study to inform use during the COVID19 pandemic. | journal=Res Social Adm Pharm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32409150 | doi=10.1016/j.sapharm.2020.04.031 | pmc=7190482 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32409150  }} </ref>
-*'''Genetic susceptibility:'''
-[[Epidemiological]] studies have shown that [[African Americans]] have higher [[COVID-19]] associated [[morbidity]] and [[mortality]] as compared to people from other [[ethnic]] groups. Recent [[studies]] show that this [[ethnic]] [[predilection]] is due to the [[genetic]] [[factors]] which contribute to a common [[ion channel]] [[variant]] [[p.Ser1103Tyr-SCN5A]] which confer an increased [[risk]] of [[drug-induced]] [[long QT syndrome]] ([[DI-LQTS]]) and [[drug-induced]] [[sudden cardiac death]] (DI-SCD). p.Ser1103Tyr-SCN5A generates late or persistent sodium current which is further aggravated by [[hypoxia]] or [[respiratory acidosis]] secondary to [[lungs]] involvement in [[COVID-19]]. This has and has been linked to an increased [[risk]] of [[ventricular arrhythmia]] (VA) such as [[torsade de pointes]] and [[sudden cardiac death]] ([[SCD]]) in [[African Americans]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>
-*'''Cytokine storm and heart damage:'''
-*'''Pre-existing heart disease'''
-====Epidemiology====
+* Since the [[COVID-19]] [[pandemic]], several [[pharmacological]] [[therapies]] have been proposed, one of them is of two [[anti-malarial]] and [[antirheumatic]] drugs called [[Chloroquine]] or [[Hydroxychloroquine]].
+* Due to their cost-effectiveness and easy availability, there is a surge in the use of [[Chloroquine]] and [[Hydroxychloroquine]], with or without [[Azithromycin]]. The [[clinical trials]] in order to estimate their [[efficacy]] are still in the preliminary stage, however, a notable concern is of their [[cardiac]] [[adverse effects]].
+* This includes [[QT prolongation]] and [[Torsade de pointes]] (TdP) leading to [[sudden cardiac death]].
+* The risk is there when these drugs are prescribed separately, however it increases several folds when these drugs are administered together, especially in patients with underlying [[hepatic]] [[disease]] or [[renal failure]].
-*'''Incidence'''
+'''Genetic susceptibility:'''
-There is a two-times rise in the [[incidence]] of Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) during the [[COVID-19]] [[pandemic]] as compared to the non-pandemic time period.<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
+* [[Epidemiological]] studies have shown that [[African Americans]] have higher [[COVID-19]] associated [[morbidity]] and [[mortality]] as compared to people from other [[ethnic]] groups.
+* Recent [[studies]] show that this [[ethnic]] [[predilection]] is due to the [[genetic]] [[factors]] which contribute to a common [[ion channel]] [[variant]] [[p.Ser1103Tyr-SCN5A]] which confer an increased [[risk]] of [[drug-induced]] [[long QT syndrome]] ([[DI-LQTS]]) and [[drug-induced]] [[sudden cardiac death]] (DI-SCD).
+* p.Ser1103Tyr-SCN5A generates late or persistent sodium current which is further aggravated by [[hypoxia]] or [[respiratory acidosis]] secondary to [[lungs]] involvement in [[COVID-19]].
+* This has and has been linked to an increased [[risk]] of [[ventricular arrhythmia]] (VA) such as [[torsade de pointes]] and [[sudden cardiac death]] ([[SCD]]) in [[African Americans]].
+'''Cytokine storm and heart damage:'''
+'''Pre-existing heart disease'''
+==Epidemiology and Demographics==
+'''Incidence'''
+There is a two-times rise in the [[incidence]] of Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) during the [[COVID-19]] [[pandemic]] as compared to the non-pandemic time period.
+'''Mortality'''
-*'''Mortality'''
 There is a significant increase in the [[mortality rate]] of the OHCA [[patients]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
-*'''Age'''
+'''Age'''
 Mean [[age]] 69.7 years is observed among [[patients]] who experienced Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) .<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref> .
-*'''Gender'''
+'''Gender'''
 Studies show that [[males]] have a slightly higher [[incidence]] of Out of hospital Sudden cardiac arrest (OHCA) as compared to the [[females]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
-*'''Race'''
-A higher [[incidence]] is seen among [[African-Americans]] as compared to the [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref><ref name="pmidPMID: 32558876">{{cite journal| author=Lai PH, Lancet EA, Weiden MD, Webber MP, Zeig-Owens R, Hall CB | display-authors=etal| title=Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City. | journal=JAMA Cardiol | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32558876 | doi=10.1001/jamacardio.2020.2488 | pmc=7305567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32558876  }} </ref>
-====Diagnosis====
+'''Race'''
+A higher [[incidence]] is seen among [[African-Americans]] as compared to the [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>
+==Diagnosis==
 *'''EKG'''
-** A [[patient]] experiencing [[sudden cardiac death]] can have [[ventricular fibrillation]] associated [[ECG]] changes such as [[ventricular tachycardia]] with [[irregular rhythm]] and indiscernible [[P waves]] or [[QRS complexes]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
+** A [[patient]] experiencing [[sudden cardiac death]] can have [[ventricular fibrillation]] associated [[ECG]] changes such as [[ventricular tachycardia]] with [[irregular rhythm]] and indiscernible [[P waves]] or [[QRS complexes]].
 **[[Heart block]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
-**[[Pulseless electrical activity]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref> <ref name="pmidPMID: 29997977">{{cite journal| author=Parish DC, Goyal H, Dane FC| title=Mechanism of death: there's more to it than sudden cardiac arrest. | journal=J Thorac Dis | year= 2018 | volume= 10 | issue= 5 | pages= 3081-3087 | pmid=PMID: 29997977 | doi=10.21037/jtd.2018.04.113 | pmc=6006107 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29997977  }} </ref>
+**[[Pulseless electrical activity]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
-**Other abnormal [[ECG]] findings include [[QT prolongation]]. [[ECG]] shows [[corrected QT interval]] ([[QTc]]) more than 500 ms.<ref name="pmidPMID: 32488217">{{cite journal| author=Chorin E, Dai M, Shulman E, Wadhwani L, Bar-Cohen R, Barbhaiya C | display-authors=etal| title=The QT interval in patients with COVID-19 treated with hydroxychloroquine and azithromycin. | journal=Nat Med | year= 2020 | volume= 26 | issue= 6 | pages= 808-809 | pmid=PMID: 32488217 | doi=10.1038/s41591-020-0888-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32488217  }} </ref>.
+**Other abnormal [[ECG]] findings include [[QT prolongation]]. [[ECG]] shows [[corrected QT interval]] ([[QTc]]) more than 500 ms..
 **[[Asystole]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref> <ref name="pmidPMID: 29997977">{{cite journal| author=Parish DC, Goyal H, Dane FC| title=Mechanism of death: there's more to it than sudden cardiac arrest. | journal=J Thorac Dis | year= 2018 | volume= 10 | issue= 5 | pages= 3081-3087 | pmid=PMID: 29997977 | doi=10.21037/jtd.2018.04.113 | pmc=6006107 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29997977  }} </ref>
-====Treatment====
+==Treatment==
 *'''Cardiopulmonary resuscitation'''
-:*Immediate [[basic life support]] or [[advanced cardiac life support]] with an automatic [[external defibrillator]] is essential to safe the life of the [[patient]]. If the [[COVID-19]] [[infection]] was confirmed, the [[EMS]] personnel is instructed to wear [[personal protective equipment]] ([[PPE]]) before performing [[cardiopulmonary resuscitation]].<ref name="pmidPMID: 32325096">{{cite journal| author=Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R | display-authors=etal| title=COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. | journal=Resuscitation | year= 2020 | volume= 151 | issue=  | pages= 59-66 | pmid=PMID: 32325096 | doi=10.1016/j.resuscitation.2020.04.022 | pmc=7169929 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32325096  }} </ref>
+:*Immediate [[basic life support]] or [[advanced cardiac life support]] with an automatic [[external defibrillator]] is essential to safe the life of the [[patient]]. If the [[COVID-19]] [[infection]] was confirmed, the [[EMS]] personnel is instructed to wear [[personal protective equipment]] ([[PPE]]) before performing [[cardiopulmonary resuscitation]].
 *'''Implantable Cardioverter Defibrillator (ICD)'''
-:*An [[Implantable cardioverter defibrillator]] ([[ICD]]) is the preferred [[therapeutic]] modality in most [[survivors]] of [[sudden cardiac death]].<ref name="pmidPMID: 30015993">{{cite journal| author=Gupta A, Pasupula DK, Bhonsale A, Kancharla K, Wang NC, Adelstein E | display-authors=etal| title=Implantable cardioverter-defibrillator therapy in device recipients who survived a cardiac arrest associated with a reversible cause. | journal=J Cardiovasc Electrophysiol | year= 2018 | volume= 29 | issue= 10 | pages= 1413-1417 | pmid=PMID: 30015993 | doi=10.1111/jce.13696 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30015993  }} </ref> This [[device]] does not prevent the [[recurrence]] of [[arrhythmia]], instead, it [[terminates]] them in case if they do recur.<ref name="pmidPMID: 27617090">{{cite journal| author=Abboud J, R Ehrlich J| title=Antiarrhythmic Drug Therapy to Avoid Implantable Cardioverter Defibrillator Shocks. | journal=Arrhythm Electrophysiol Rev | year= 2016 | volume= 5 | issue= 2 | pages= 117-21 | pmid=PMID: 27617090 | doi=10.15420/AER.2016.10.2 | pmc=5016598 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27617090  }} </ref>
+:*An [[Implantable cardioverter defibrillator]] ([[ICD]]) is the preferred [[therapeutic]] modality in most [[survivors]] of [[sudden cardiac death]]. This [[device]] does not prevent the [[recurrence]] of [[arrhythmia]], instead, it [[terminates]] them in case if they do recur.
 *'''Pharmacologic therapy in survivors of sudden cardiac arrest'''
-:*'''Antiarrhythmic drugs:''' [[Amiodarone]] is the most effective for [[preventing]] recurrent [[ventricular tachyarrhythmias]]. It is recommended to immediately give [[Amiodarone]] following an event of [[sudden cardiac arrest]] in patients with [[recurrent ventricular tachyarrhythmias]] as well as for those who have refused [[Implantable]] [[Cardioverter Defibrillator]] ([[ICD]]).<ref name="pmidPMID: 20730062">{{cite journal| author=Van Herendael H, Dorian P| title=Amiodarone for the treatment and prevention of ventricular fibrillation and ventricular tachycardia. | journal=Vasc Health Risk Manag | year= 2010 | volume= 6 | issue=  | pages= 465-72 | pmid=PMID: 20730062 | doi=10.2147/vhrm.s6611 | pmc=2922307 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20730062  }} </ref>
-:*'''Beta blocker:'''It is recommended that almost all [[patients]] who survive an episode of [[sudden cardiac arrest]] should receive a [[beta-blocker]] as part of their [[therapy]] in combination with an [[antiarrhythmic drug]], particularly in those [[patients]] who have survived [[sudden cardiac death]] due to [[ventricular tachycardia]] or [[ventricular fibrillation]]. [[Beta-blockers]] has shown to [[reduce]] the future [[incidence]] of [[sudden cardiac death]].<ref name="pmidPMID: 26044246">{{cite journal| author=Hayashi M, Shimizu W, Albert CM| title=The spectrum of epidemiology underlying sudden cardiac death. | journal=Circ Res | year= 2015 | volume= 116 | issue= 12 | pages= 1887-906 | pmid=PMID: 26044246 | doi=10.1161/CIRCRESAHA.116.304521 | pmc=4929621 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26044246  }} </ref>
-=====Prevention=====
+:*'''Antiarrhythmic drugs:''' [[Amiodarone]] is the most effective for [[preventing]] recurrent [[ventricular tachyarrhythmias]]. It is recommended to immediately give [[Amiodarone]] following an event of [[sudden cardiac arrest]] in patients with [[recurrent ventricular tachyarrhythmias]] as well as for those who have refused [[Implantable]] [[Cardioverter Defibrillator]] ([[ICD]]).
-*[[Identification]] and [[treatment]] of [[acute]] [[reversible]] causes of [[sudden cardiac death]].<ref name="pmidPMID: 19252119">{{cite journal| author=Koplan BA, Stevenson WG| title=Ventricular tachycardia and sudden cardiac death. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 3 | pages= 289-97 | pmid=PMID: 19252119 | doi=10.1016/S0025-6196(11)61149-X | pmc=2664600 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19252119  }} </ref>
+:*'''Beta blocker:'''It is recommended that almost all [[patients]] who survive an episode of [[sudden cardiac arrest]] should receive a [[beta-blocker]] as part of their [[therapy]] in combination with an [[antiarrhythmic drug]], particularly in those [[patients]] who have survived [[sudden cardiac death]] due to [[ventricular tachycardia]] or [[ventricular fibrillation]]. [[Beta-blockers]] has shown to [[reduce]] the future [[incidence]] of [[sudden cardiac death]].
+==Prevention==
+*[[Identification]] and [[treatment]] of [[acute]] [[reversible]] causes of [[sudden cardiac death]].
 *Evaluation and management of [[structural]] [[heart disease]] and [[arrhythmia]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
+<references />