COVID-19-associated cardiac arrest
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
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 the cardiac arrest. Prodromes signs and symptoms of deterioration of cardiovascular status may occur weeks or months before an event. Sudden onset of chest pain, dyspnea or palpitations and other symptoms of arrhythmia may precede the onset of cardiac arrest. During the outbreak of COVID-19 there was the surge in the number of out of hospital cardiac arrest in Italy.[1] Prognosis of inhospital cardiac arrest was generally poor. Factors related to medical services restriction and also side effects of drugs and complication related to COVID-19, increased the number of cardiac arrest during COVID-19 pandemic.
Historical Perspective
- In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.[2]
- On February 20, 2020, the first case of COVID-19 was documented in Lodi Province of Italy.[1]
- 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
Causes
The causes of ventricular tachyarrhythmia and sudden cardiac death in covid-19 are caracterized by:[4]
1.Environmental risk factors include:
- COVID-19 directed QTc prolongation drugs( hydroxychloroquine ± 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)
Pathophysiology
- The pathogenesis of cardiac arrest associated COVID-19 is characterized by cytokine storm, especially elevation of IL-6.[5]
- IL-6 directely blocks hERG/Kv11.1 potassium channels and causes action potential depolarization(APD) prolongation and ventricular repolarization.
- IL-6 induces hyperactivity of cardiac sympathetic nerve[6]
- IL-6 inhibits cytochrome P450 enzyme involved in matobolism of some QTc prolongation drugs.[7]
- Hydroxychloroquine and lopinavir/ritonavir inhibit HERG-K+ channel and increase both ventriculat repolarization and the level of other QTc prolongation drugs.[7]Hydroxychloroquine inhibits CYP2D6 (cytochrome P450 2D6) ,then the level of antipsychotics,antidepressants and antihistamins increase.[7]
- Ritonavir inhibits CYP3A4 (cytochrome P450 3A4), then the level of azols antifungals, macrolides (particulary azithromycin),antidepressants,antihistamines,fluoroquinolones increase.[7]
- Intrinsic genetic susceptibility (Ser1103Tyr-SCN5A) in african americans COVID-19 patients has been associated with increased risk of torsade points arrhythmia.[8]
Differentiating inherited cardiac arrest from other causes of cardiac arrest
- For more information on the COVID-19-associated cardiac arrest differential diagnosis click here.
- To view the differential diagnosis of COVID-19 click here.
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.[9]
- 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.[10]
Mortality
- There is a significant increase in the mortality rate of the OHCA patients.[11]
Age
- Mean age 69.7 years is observed among patients who experienced Out of hospital Sudden cardiac arrest (OHCA) .[11] .
Gender
- Studies show that males have a slightly higher incidence of Out of hospital Sudden cardiac arrest (OHCA) as compared to the females.[11]
Race
A higher incidence is seen among African-Americans as compared to the Caucasians.[12]
Risk Factors
- Common risk factors in the development of arrhythmia and cardiac arrest in COVID-19 are :[13]
- 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.[14]
- Common causes of OHCA durig covid-19 pandemic include:
- .Acute cardiac events ( coronary syndrome, heart failure,arrhythmia)
- Thromboembolic events related to COVID-19 (pulmonary embolism, acute coronary syndrome)[15]
- Acute respiratory distress and hypoxia related to COVID-19
- Letal arrhythmia by using azithromycin and hydroxychloroquine [16]
- Myocardial injury and myocarditis
- late presentation of acute STEMI in hospital due to fear of being infected in hospital
- Overwhelming of medical service
- Avoidance of bystander CPR in public due to concern of trasmission of disease.[17]
3.Prognosis of patients with severe COVID-19 pneumonia with in hospital cardiac arrest (IHCA) was poor in wohan .[18]
4.Mortality rate of patients with COVID-19 is approximately 1-2%[19]
Diagnosis
Diagnostic Criteria
- 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 collapse, loss of effective circulation, loss of consciousness
- Biologic death: failure of resuscitation or failure of electerical, mechanical or CNS function after initial resuscitation
Symptoms
- Symptoms before cardiac arrest in covid19 may include the following:
- Chest pain
- Palpitation
- Dyspnea
- Lightheadness
Physical Examination
There is no specific finding associated physical examination with cardiac arrest in COVID-19.
Laboratory Findings
- An elevated concentration of serum cardiac troponinI was detected in severe COVID-19 patients with cardiac complications. [20]
Imaging Findings
- There are no imaging study findings associated with cardiac arrest in COVID-19.
Electrocardiogram
- Findings on EKG during inhospital cardiac arrest(IHCA) in covid19 include:asystole(89.7%),pulseless electrical activity(4.4%) shockable rhythm(5.9%)[18]
- Other abnormal EKG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms..
Treatment
- The mainstay of therapy for cardiac arrest in COVID-19 is cardiopulmonary rescucitation. [21]
- 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.
- limit personnles in room or on the scene
- Using high-efficacy particulate air filter for ventilator
- intubate with cuffed tube
- stop chest compression to intubate
- Using bag mask device before intubation
- Using nonrebreathing face mask instead of bag mask for short term oxygenation
Prevention
1.Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in the setting of: 1. long QT syndrome or 2.aquired LQTS or 3.heart rate<50/min or 4. recieving azithromycin,redmisivir, lopinavir, ritonavir, include EKG and QTc measurement.[13]
- 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.
- Treatment of hypokalemia due to diarrhea associated COVID-19 ,which prolonges QTinterval.
2.Effective measures for the primary prevention of ventricular arrhythmia in brugada syndrome is starting acetaminophen or parastamol immediately if there is sign of fever and also self isolation.
References
- ↑ 1.0 1.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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) - ↑ 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) - ↑ 7.0 7.1 7.2 7.3 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). - ↑ 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.
- ↑ 11.0 11.1 11.2 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). - ↑ 13.0 13.1 Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde A (March 2020). "SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes". Heart Rhythm. doi:10.1016/j.hrthm.2020.03.024. PMC 7156157 Check
|pmc=value (help). PMID 32244059 Check|pmid=value (help). Vancouver style error: initials (help) - ↑ Pfefferbaum, Betty; North, Carol S. (2020). "Mental Health and the Covid-19 Pandemic". New England Journal of Medicine. doi:10.1056/NEJMp2008017. ISSN 0028-4793.
- ↑ Klok, F.A.; Kruip, M.J.H.A.; van der Meer, N.J.M.; Arbous, M.S.; Gommers, D.A.M.P.J.; Kant, K.M.; Kaptein, F.H.J.; van Paassen, J.; Stals, M.A.M.; Huisman, M.V.; Endeman, H. (2020). "Incidence of thrombotic complications in critically ill ICU patients with COVID-19". Thrombosis Research. 191: 145–147. doi:10.1016/j.thromres.2020.04.013. ISSN 0049-3848.
- ↑ Mehra, Mandeep R; Desai, Sapan S; Ruschitzka, Frank; Patel, Amit N (2020). "RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis". The Lancet. doi:10.1016/S0140-6736(20)31180-6. ISSN 0140-6736.
- ↑ Scquizzato, Tommaso; Olasveengen, Theresa Mariero; Ristagno, Giuseppe; Semeraro, Federico (2020). "The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation". Resuscitation. 150: 92–93. doi:10.1016/j.resuscitation.2020.03.019. ISSN 0300-9572.
- ↑ 18.0 18.1 Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z (June 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. PMC 7151543 Check
|pmc=value (help). PMID 32283117 Check|pmid=value (help). - ↑ Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui D, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS (April 2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N. Engl. J. Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check
|pmc=value (help). PMID 32109013 Check|pmid=value (help). Vancouver style error: initials (help) - ↑ Paul P (May 2020). "Cardiac Troponin-I may be a predictor of complications and mortality in COVID-19 patients". Curr Med Res Pract. doi:10.1016/j.cmrp.2020.05.001. PMC 7204698 Check
|pmc=value (help). PMID 32382587 Check|pmid=value (help). - ↑ Edelson, Dana P.; Sasson, Comilla; Chan, Paul S.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bradley, Steven M.; Brooks, Steven C.; Cheng, Adam; Escobedo, Marilyn; Flores, Gustavo E.; Girotra, Saket; Hsu, Antony; Kamath-Rayne, Beena D.; Lee, Henry C.; Lehotsky, Rebecca E.; Mancini, Mary E.; Merchant, Raina M.; Nadkarni, Vinay M.; Panchal, Ashish R.; Peberdy, Mary Ann R.; Raymond, Tia T.; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis A.; Starks, Monique Anderson; Bobrow, Bentley J.; Chan, Melissa; Berg, Katherine; Duff, Jonathan P.; Joyner, Benny L.; Lasa, Javier J.; Levy, Arielle; Mahgoub, Melissa; O’Connor, Michael F.; Hoover, Amber V.; Rodriguez, Amber J.; Meckler, Garth; Roberts, Kathryn; Mohr, Nicholas M.; Nassar, Boulos; Rubinson, Lewis; Sutton, Robert M.; Schexnayder, Stephen M.; Kleinman, Monica; de Caen, Allan; Morgan, Ryan; Bhanji, Farhan; Fuchs, Susan; Terry, Mark; McBride, Mary; Levy, Michael; Cabanas, Jose G.; Tan, David K.; Moitra, Vivek K.; Szokol, Joseph W. (2020). "Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19". Circulation. 141 (25). doi:10.1161/CIRCULATIONAHA.120.047463. ISSN 0009-7322.