COVID-19-associated cardiac arrest
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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.
Historical Perspective
- In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.[1]
- On February 20, 2020, the first case of COVID-19 was documented in Lodi Province of Italy.[2]
- In April 2020, An increase in out of hospital cardiac arrest was reported during the COVID-19 pandemic.
- In January 2020, the first COVID-19 case was documented in the United States.[3]
Classification
There is no established system for the classification of COVID-19-associated cardiac arrest.
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
Causes
- COVID-19 associated cardiac arrest may occur due to the following causes:
- Acute respiratory distress syndrome
- Myocardial injury
- Ventricular arrhythmias
- Shock
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.
- According to a study done in China, about 12% of patients with COVID-19 without a history of heart problems experience cardiac arrest during their hospitalization.[4]
Mortality
- There is a significant increase in the mortality rate of the OHCA patients.[5]
Age
- Mean age 69.7 years is observed among patients who experienced Out of hospital Sudden cardiac arrest (OHCA) .[5] .
Gender
- Studies show that males have a slightly higher incidence of Out of hospital Sudden cardiac arrest (OHCA) as compared to the females.[5]
Race
A higher incidence is seen among African-Americans as compared to the Caucasians.[6]
Risk Factors
- The most common identified risk factors for cardiac arrest in patients with COVID-19 infection are:
- To view the risk factors of COVID-19, click here.
Screening
- To view screening for COVID-19, click here.
Natural History, Complications, and Prognosis
- Early clinical features before developing anosmia related to COVID-19 include cough, fever, and arthralgias.
- To view natural history, complications, and prognosis of COVID-19, click here.
Diagnosis
Diagnostic Study of Choice
- To view the study of choice for diagnosis of COVID-19, click here.
History and Symptoms
- To view the history and symptoms of COVID-19, click here.
Physical Examination
- To view the complete physical examination in COVID-19, click here.
Laboratory Findings
- Laboratory testing and self-isolation should be made in patients who present with anosmia, even if this is found as an isolated symptom.[7]
- To view the laboratory findings on COVID-19, click here.
Electrocardiogram
- 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.[8]
- Pulseless electrical activity.[8]
- Other abnormal ECG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms..
- Asystole.[8] [9]
X-ray
- There are no typical x-ray findings for cardiac arrest due to COVID-19.
- To view the x-ray finidings on COVID-19, click here.
Echocardiography or Ultrasound
- There are no typical echocardiographic findings for cardiac arrest due to COVID-19.
- To view the echocardiographic findings on COVID-19, click here.
CT scan
- There are no typical CT scan findings for cardiac arrest due to COVID-19.
- To view the CT scan findings on COVID-19, click here.
MRI
- There are no typical MRI findings for cardiac arrest due to COVID-19.
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
- There are no other imaging findings for cardiac arrest due to COVID-19.
- To view other imaging findings on COVID-19, click here.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
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.[8]
References
- ↑ Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.
- ↑ Baldi, Enrico; Sechi, Giuseppe M.; Mare, Claudio; Canevari, Fabrizio; Brancaglione, Antonella; Primi, Roberto; Klersy, Catherine; Palo, Alessandra; Contri, Enrico; Ronchi, Vincenza; Beretta, Giorgio; Reali, Francesca; Parogni, Pierpaolo; Facchin, Fabio; Bua, Davide; Rizzi, Ugo; Bussi, Daniele; Ruggeri, Simone; Oltrona Visconti, Luigi; Savastano, Simone (2020). "Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy". New England Journal of Medicine. doi:10.1056/NEJMc2010418. ISSN 0028-4793.
- ↑ Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.
- ↑ Zheng, Ying-Ying; Ma, Yi-Tong; Zhang, Jin-Ying; Xie, Xiang (2020). "COVID-19 and the cardiovascular system". Nature Reviews Cardiology. 17 (5): 259–260. doi:10.1038/s41569-020-0360-5. ISSN 1759-5002.
- ↑ 5.0 5.1 5.2 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). - ↑
- ↑ 8.0 8.1 8.2 8.3 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).
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