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
The sudden cardiac death is defined as the natural death from cardiac causes developed by abrupt loss of consciousness within one hour of onset of acute change in cardiovascular status. Preexisting heart disease may or may not present at the time of cardiac arrest. Prodromes signs and symptoms of deterioration of cardiovascular status may occur weeks or months before an events. Sudden onset of chest pain, dyspnea or palpitations and other symptoms of arrhythmia may precede the onset of cardiac arrest. If cardiopulmonary resuscitation fails to rescue the circulation, biologic death may occur within minutes to weeks.
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
Cardiac arrest associated covid19 may be classified into three subtypes:
1.Pulseless electerical activity
2. bradyarrhythmia and asystolic arrest
3.letal tachyarrhythmia
Pathophysiology
- The pathogenesis of cardiac arrest associated covid-19 is characterized by cytokine storm, especially elevation of IL-6.[4]
doi: 10.1038/s41577-018-0098-z
- IL-6 directely blocks hERG/Kv11.1 potassium channels and causes APD prolongation and ventricular repolarization.
- IL-6 induces hyperactivity of cardiac sympathetic nerve[5]
.doi: 10.1093/eurheartj/ehw208MedlineGoogle Sch
- IL-6 inhibits cytochrome P450 enzyme involved in matobolism of some QTc prolongation drugs.[6]
doi: 10.1016/j.jacc.2020.03.031
- Hydroxychloroquine and lopinavir/ritonavir inhibit hERG-K+ channel and induce both ventriculat repolarization and the level of other QT prolongation drugs[6]
- 10.1016/j.jacc.2020.03.031
- Hydroxychloroquine inhibit CYP2D6 (cytochrome P450 2D6) ,then the level of antipsychotics,antidepressants and antihistamins increase[6]
.doi: 10.1016/j.jacc.2020.03.031
- Ritonavir inhibits CYP3A4 (cytochrome P450 3A4), then the level of azols antifungals, macrolides (particulary azithromycin),antidepressants,antihistamines,fluoroquinolones increase.[6]
- 10.1016/j.jacc.2020.03.031
- intrinsic genetic susceptibility (ie, p.Ser1103Tyr-SCN5A) in african americans covid-19 patients has been associated with increased risk of torsade points arrhythmia [7]PMID: 32359771
Causes
he causes of ventricular tachyarrhythmia and sudden cardiac death in covid-19 are caracterized by:[8]PMID: 32380288
1.Environmental risk factors include:
- covid-19 directed QTc prolongation drugs( hydroxychloroquin ± azithromycin and lupinavir/ritonavir)
- Concurrent use of QT prolongation drug (anti -emetics,floroquinolones,SSRIs)
- Electrolitise abnormalities(hypokelemia and hypomagnesemia)
2. Internistics risk factors includes:
- High risk comorbidity condition(CHF,CKD,DM,COPD)
- Ages≥65,male gender
- inherited arrhythmia syndromes
3. Other mechanisms include:
- hypoxia causes ventricular arrhythmia and sudden cardiac death by myocardial injuries and increased in late I /NA
- exaggerated immune response ( IL-6 increased the proportion of action potential duration/ QTc)
- increased sympathetic activity
- inhition of CYP450
- direct myocardial injury(SARS-COV-2 myocarditis
Differentiating [disease name] from other Diseases[edit | edit source]
- differentiation diagnosis of inherited cardiac arrest in covid19 patients include:
| Inherited causes of cardiac arrest and malignant arrhythmia associated covid-19 | long QT syndrome | BRUGADA syndrome | short QT syndrome | cathecolaminergic polymorphic ventricular tachaycardia |
|---|---|---|---|---|
| mechanism of arrhythmia | mutation in KCNQ1, KCNH2, and SCN5A)
block potassium current and prolongation of ventricular repolarization induces EAD and [9]PMID: 16412861 |
PMID: [10]27423412
loss of function in SCN5A in %30 of patients |
mutation in potassium channel genes KCNH2, KCNQ1, and KCNJ2 and SLC4A3 | mutation in RYR2
[11]PMID: 23390049 |
| EKG finding | QTc>450ms in men
QTc>470ms in women [12]: 20642543 |
coved-type ST-segment elevation
and T-wave inversion in lead V1 and/or V2) |
QTc<360 msec | |
| risk factors related to covid-19 | 1.using hydroxychloquine and chloroquine 2. using CYP3a4 inhibitore that increases
hydroxychloroquine level include;lupinavir,ritonavir . azithromycin 3. hydroxychloquine does not resultPMID: 17646028 significant prolonged QT in cases without LQTS [13] 3. fever:PMID: 18551196 causes QT prolongation and cardiac arrest in Long QTS type2 in the setting of septic shock in covid-19.[14]
|
1.fever may increased PR interval, QRS width, and the maximum J point in patients with BrSPMID: 18678856
2. fever increases the risk of cardiac arrest in BrS 3. Risk of life threatening arrythmia in BrS related to fever was (65%)higher in young patients less than 5 year old (%65)PMID: 29649615 and %25 in patients older than 70 year old |
1.There is no risk of arrhythmia when patients affected by covid19. |
2.fever is not the risk factor of arrhythmia |
| symptoms | torsade de pointes and fatal ventricular arrhythmia | ventricular fibrilation and sudden cardiac death | syncope,ventricular fibrillation, sudden cardiac death | ventricular arrhythmia during exercise and stress related to covid-19 |
| management | do not use ≥ one drugs inducing prolongation of QT interval in the setting of LQTc and covid-19 | 1.controlling the fever with parastamol
2.ECG monitoring untill resolving type1 brugada pattern 3. self isolation |
2. hydroxychloroquine may prolonge QTinterval and useful in treatment of SQTS type 1 (KCNH2-related) and type 3 (KCNJ2 related PMID: 30441573 | 1.do not use epinephrine in the setting of ventricular arrhythmia
2. flecainide is treatment of choice without any interaction with lopinavir, ritonavir and chloroquine. |
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.[15]
- In a study done among 761 Chinese patients with severe COVID-19, about 20% patients developed in-hospital cardiac arrest within 40 days of their hospitalization course.[16]
Mortality
- There is a significant increase in the mortality rate of the OHCA patients.[17]
Age
- Mean age 69.7 years is observed among patients who experienced Out of hospital Sudden cardiac arrest (OHCA) .[17] .
Gender
- Studies show that males have a slightly higher incidence of Out of hospital Sudden cardiac arrest (OHCA) as compared to the females.[17]
Race
A higher incidence is seen among African-Americans as compared to the Caucasians.[18]
Risk Factors
- Common risk factors in the development of arrhythmia and cardiac arrest in covid-19 are :PMID: 32244059
- fever
- stress
- electrolytis disrturbances
- use of viral drugs
Screening
- To view screening for COVID-19, click here.
Natural History, Complications, and Prognosis
- The proportion of patients developed out of hospital cardiac arrest (OHCA) increased during covid-19 pandemic.DOI: 10.1056/NEJMp2008017
- common causes of OHCA durig covid-19 pandemic include:acu 1.acute cardiac events ( coronary syndrome, heart failure,arrhythmia,) 2.http://dx.doi.org/10.1016/j.thromres.2020.04.013 thromboembolic events related to covid19 (pulmonary embolism, acute coronary syndrome)3.acute respiratory distress and hypoxia related to covid19 4. late presentation for example acute MI in hospital due to lockdown and movement restriction 4. overwelming of medical service 5. myocarditis
5. letal arrhythmia by using azithromycin and https://doi.org/10.1016/S0140-6736(20)31180-6 6.myocardial injury and myocarditis
- Prognosis of patients with severe covid 19 pneumonia with in hospital cardiac arrest (IHCA) was poor in wohan .PMID: 32283117
- mortality rate of patients with COVID-19 is approximately 1-2%PMID: 32109013
- Prognosis of patients with severe covid 19 pneumonia with in hospital cardiac arrest (IHCA) was poor in wohan .PMID: 32283117
Diagnosis
Diagnostic Criteria[edit | edit source]
- The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:
- Prodromes phase occuring weeks or months before an event includes: new or worsening cardiovascular symptoms(chest pain, dyspnea, palpitations, fatigability)
- Onset of terminal event occuring one hour before cardiac arrest includes:abrupt change in clinical status( arrhythmia, hypotension, chest pain, dyspnea,lightheadness)
- cardiac arrest includes: sudden collaps loss of effective circulation, loss of consciousness
- Biologic death: failure of resuscitation or failure of electerical, mechanical or CNS function after initial resuscitation
Symptoms[edit | edit source]
- Symptoms before cardiac arrest in covid19 may include the following:
- chest pain
- palpitation
- dyspnea
- lightheadness
Physical Examination[edit | edit source
- Physical examination may be remarkable for:
- [finding 1]
- [finding 2]
- [finding 3]
- [finding 4]
- [finding 5]
- [finding 6]
Laboratory Findings[edit | edit source]
- An elevated concentration of serum cardiac troponinI was detected in severe covid19 patients with cardiac complication. PMID: 32382587
Imaging Findings[edit | edit source]
- There are no imaging studyfindings associated with cardiac arrest in covid19
Electrocardiogram
- Findings on EKG during inhospital cardiac arrest(IHCA) in covid19 include:asystole(89.7%),pulseless electrical activity(4.4%) shockable rhythm(5.9%)PMID: 32283117
- Other abnormal ECG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms..
Treatment
- The mainstay of therapy for cardiac arrest in covid19 is cardiopulmonary rescucitation https://doi.org/10.1161/CIRCULATIONAHA.120.047463
- 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.
Prevention
- .Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in long QT syndrome or aquired LQTS or heart rate<50/min or recieving azithromycin,redmisivir, lopinavir, ritonavir include EKG and QTc measurement.PMID: 32244059
- If QTc ≥500 ms, consult with cardiologist.
- If QTc<500ms, start hydroxychloroquine and repeat EKG after 1-3 days.
- After starting first dose of hydroxychloroquine, If QTc≥500mse, increased QTc>60ms, or ventricular ectopy were observed , repeat EKG after 4 hours.
- avoidance of hypokalemia and treatment of diarrhea 2.Effective measures for the primary prevention of ventricular arrhythmia in brugada syndrom is startind acetaminophen or parastamol immediately if there is sign of fever and self isolation
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.
- ↑ Lazzerini, Pietro Enea; Laghi-Pasini, Franco; Boutjdir, Mohamed; Capecchi, Pier Leopoldo (2018). "Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies". Nature Reviews Immunology. 19 (1): 63–64. doi:10.1038/s41577-018-0098-z. ISSN 1474-1733.
- ↑ . doi:10.1093/eurheartj/ehw208MedlineGoogle Sch Check
|doi=value (help). Missing or empty|title=(help) - ↑ 6.0 6.1 6.2 6.3 Driggin, Elissa; Madhavan, Mahesh V.; Bikdeli, Behnood; Chuich, Taylor; Laracy, Justin; Biondi-Zoccai, Giuseppe; Brown, Tyler S.; Der Nigoghossian, Caroline; Zidar, David A.; Haythe, Jennifer; Brodie, Daniel; Beckman, Joshua A.; Kirtane, Ajay J.; Stone, Gregg W.; Krumholz, Harlan M.; Parikh, Sahil A. (2020). "Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic". Journal of the American College of Cardiology. 75 (18): 2352–2371. doi:10.1016/j.jacc.2020.03.031. ISSN 0735-1097.
- ↑ Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ (June 2020). "Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19)". Mayo Clin. Proc. 95 (6): 1213–1221. doi:10.1016/j.mayocp.2020.03.024. PMC 7141471 Check
|pmc=value (help). PMID 32359771 Check|pmid=value (help). - ↑ Giudicessi JR, Roden DM, Wilde A, Ackerman MJ (May 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 Check|pmid=value (help). Vancouver style error: initials (help) - ↑ Straus SM, Kors JA, De Bruin ML, van der Hooft CS, Hofman A, Heeringa J, Deckers JW, Kingma JH, Sturkenboom MC, Stricker BH, Witteman JC (January 2006). "Prolonged QTc interval and risk of sudden cardiac death in a population of older adults". J. Am. Coll. Cardiol. 47 (2): 362–7. doi:10.1016/j.jacc.2005.08.067. PMID 16412861.
- ↑ Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AA (October 2016). "J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge". Heart Rhythm. 13 (10): e295–324. doi:10.1016/j.hrthm.2016.05.024. PMC 5035208. PMID 27423412.
- ↑ van der Werf C, Wilde AA (April 2013). "Catecholaminergic polymorphic ventricular tachycardia: from bench to bedside". Heart. 99 (7): 497–504. doi:10.1136/heartjnl-2012-302033. PMID 23390049.
- ↑ van Noord C, Eijgelsheim M, Stricker BH (July 2010). "Drug- and non-drug-associated QT interval prolongation". Br J Clin Pharmacol. 70 (1): 16–23. doi:10.1111/j.1365-2125.2010.03660.x. PMC 2909803. PMID 20642543.
- ↑ White NJ (August 2007). "Cardiotoxicity of antimalarial drugs". Lancet Infect Dis. 7 (8): 549–58. doi:10.1016/S1473-3099(07)70187-1. PMID 17646028.
- ↑ Amin AS, Herfst LJ, Delisle BP, Klemens CA, Rook MB, Bezzina CR, Underkofler HA, Holzem KM, Ruijter JM, Tan HL, January CT, Wilde AA (July 2008). "Fever-induced QTc prolongation and ventricular arrhythmias in individuals with type 2 congenital long QT syndrome". J. Clin. Invest. 118 (7): 2552–61. doi:10.1172/JCI35337. PMC 2423868. PMID 18551196.
- ↑ 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.
- ↑ Shao, Fei; Xu, Shuang; Ma, Xuedi; Xu, Zhouming; Lyu, Jiayou; Ng, Michael; Cui, Hao; Yu, Changxiao; Zhang, Qing; Sun, Peng; Tang, Ziren (2020). "In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China". Resuscitation. 151: 18–23. doi:10.1016/j.resuscitation.2020.04.005. ISSN 0300-9572.
- ↑ 17.0 17.1 17.2 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).
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