View source for COVID-19-associated arrhythmia and conduction system disease

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{{Main article|COVID-19}}
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
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{{SK}}[[COVID-19-associated arrhythmia and conduction system disease|COVID-19-associated dysrhythmia]]
==Overview==
An [[arrhythmia]] is a problem with the rate or rhythm of the heartbeat. During an [[arrhythmia]], the heart can beat too quickly, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called [[tachycardia]]. When a heart beats too slowly, the condition is called [[bradycardia]]. [[Cardiac arrhythmia|Cardiac arrhythmia]] is increasingly recognized as one of the earliest clinical manifestations of [[COVID-19]]. There is also anecdotal evidence of [[sudden cardiac death]] among [[COVID-19]] patients. According to a study, 51 of 85 fatal cases of [[COVID-19]] from Wuhan developed an [[Cardiac arrhythmia|arrhythmia]], and 2 patients died of [[Cardiac arrhythmia|malignant arrhythmia]].

[[SARS-CoV-2|Severe acute respiratory syndrome coronavirus 2]] (SARS-CoV-2) utilizes S-spike to bind to [[angiotensin-converting enzyme 2]] (ACE2) receptors to enter the [[Endothelium|endothelial cells]] of the heart. The interaction between [[SARS-CoV-2]] and [[ACER2|ACE2]] can bring about changes in [[ACER2|ACE2]] pathways prompting intense injury to the lung, heart, and [[Endothelium|endothelial cells]]. Hypoxia and electrolyte abnormalities that are common in the acute phase of severe COVID-19 can potentiate [[Cardiac arrhythmia|cardiac arrhythmias]]. COVID-19-associated arrhythmia findings include [[sinus tachycardia]], [[atrial fibrillation]], [[Sick sinus syndrome|tachy-brady syndrome]], [[sinus rhythm]] with a [[First degree AV block|first-degree atrioventricular block]] (AVB) with SITIIIQIII and [[Sinus tachycardia]] with incomplete [[right bundle branch block]]. All patients with [[Torsade de pointes|torsades de pointes]] (TdP) should be determined if they are hemodynamically stable or unstable through immediate evaluation of the symptoms, [[vital signs]], and level of consciousness. Initial treatment with [[Antiarrhythmic agent|antiarrhythmic medications]] is not indicated for hemodynamically unstable or pulseless patients except [[Magnesium|intravenous (IV) magnesium]]. The clinical situation of a patient determines the rate of [[Magnesium|magnesium infusion]]. Infusion occurs over one to two minutes in patients with [[Pulseless electrical activity|pulseless cardiac arrest]]. The infusion should occur over 15 minutes in patients without [[Sudden cardiac death|cardiac arrest]] as a rapid IV bolus of [[magnesium]] can result in [[hypotension]] and [[asystole]]. Some patients are given a continuous bolus of [[Magnesium|IV magnesium]] at a rate of 3 to 20 mg/min until the [[QT interval]] is below 0.50 seconds. The treatment for other [[Cardiac arrhythmia|arrhythmias]] in [[COVID-19]] patients is the same as in patients with [[Cardiac arrhythmia|arrhythmias]] without [[COVID-19|COVID-19 infection]].

To browse the complete chapter of COVID-19, [[COVID-19|click here]].

==Historical Perspective==
* Diseases of [[heart]] and [[lung]] are the most common [[causes]] of [[COVID-19]]-related death.<ref name="pmid32253449">{{cite journal| author=Ruan Q, Yang K, Wang W, Jiang L, Song J| title=Correction to: Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. | journal=Intensive Care Med | year= 2020 | volume= 46 | issue= 6 | pages= 1294-1297 | pmid=32253449 | doi=10.1007/s00134-020-06028-z | pmc=7131986 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253449  }} </ref>
*[[Cardiac arrhythmia|Cardiac rhythm problems]] are increasingly recognized as a clinical manifestation of [[COVID-19]].<ref name="pmid32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570  }} </ref>
* There is anecdotal evidence of [[sudden cardiac death]] among [[COVID-19]] patients.<ref name="pmid32228309">{{cite journal| author=Lakkireddy DR, Chung MK, Gopinathannair R, Patton KK, Gluckman TJ, Turagam M | display-authors=etal| title=Guidance for Cardiac Electrophysiology During the COVID-19 Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. | journal=Circulation | year= 2020 | volume= 141 | issue= 21 | pages= e823-e831 | pmid=32228309 | doi=10.1161/CIRCULATIONAHA.120.047063 | pmc=7243667 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32228309  }} </ref> According to a study, 51 of 85 fatal cases of [[COVID-19|COVID]]-19 from Wuhan developed an [[Cardiac arrhythmia|arrhythmia]],  and 2 patients died of [[Cardiac arrhythmia|malignant arrhythmia]].<ref name="pmid32242738">{{cite journal| author=Du Y, Tu L, Zhu P, Mu M, Wang R, Yang P | display-authors=etal| title=Clinical Features of 85 Fatal Cases of COVID-19 from Wuhan. A Retrospective Observational Study. | journal=Am J Respir Crit Care Med | year= 2020 | volume= 201 | issue= 11 | pages= 1372-1379 | pmid=32242738 | doi=10.1164/rccm.202003-0543OC | pmc=7258652 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32242738  }} </ref>
*In 137 subjects from Hubei province, 10 patients (7.3%) noted [[Palpitation|palpitations]] as one of the initial symptoms.<ref name="pmid32044814">{{cite journal| author=Liu K, Fang YY, Deng Y, Liu W, Wang MF, Ma JP | display-authors=etal| title=Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. | journal=Chin Med J (Engl) | year= 2020 | volume= 133 | issue= 9 | pages= 1025-1031 | pmid=32044814 | doi=10.1097/CM9.0000000000000744 | pmc=7147277 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32044814  }} </ref>
To browse the historical perspective of COVID-19, [[COVID-19 historical perspective|click here]].

==Classification==
* [[Arrhythmia]]  in [[COVID-19]]  may be classified into:
* [[Atrial fibrillation]]
* [[Atrial flutter]]
* [[Supraventricular tachycardia]]
* [[Nonsustained ventricular tachycardia]]
* [[Ventricular tachycardia]]
* [[Ventricular fibrillation]]
* [[Atrioventricular block]]
* Marked [[sinus bradycardia]] ([[heart rate]]<40 [[bpm]]



:*'''[[Cardiac arrhythmia|Acquired arrhythmia]]:'''
::*
::*
::*
:*'''[[Cardiac arrhythmia|Inherited arrhythmia]]:'''
::COVID-19 patients with inherited arrhythmia syndromes are believed to be more liable to pro-arrhythmic consequences of [[COVID-19]] such as [[stress]], [[fever]], use of [[Antiviral drug (patient information)|antiviral medications]] and [[electrolyte disturbance]].<ref name="pmid32253318">{{cite journal| author=Duan K, Liu B, Li C, Zhang H, Yu T, Qu J | display-authors=etal| title=Effectiveness of convalescent plasma therapy in severe COVID-19 patients. | journal=Proc Natl Acad Sci U S A | year= 2020 | volume= 117 | issue= 17 | pages= 9490-9496 | pmid=32253318 | doi=10.1073/pnas.2004168117 | pmc=7196837 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253318  }} </ref> which includes: 
::*[[Long QT syndrome|Long QT syndrome]]
::*[[Short QT syndrome]]
::*[[Brugada syndrome]]
::*[[Catecholaminergic polymorphic ventricular tachycardia]], 

*To browse the [[classification]] of COVID-19, [[COVID-19 classification|click here]].

==Pathophysiology==
* [[Respiratory]] [[disease]] is the chief target of [[COVID-19]].
*[[SARS-CoV-2|Severe acute respiratory syndrome coronavirus 2]] ([[SARS-CoV-2]]) utilizes S-spike to bind to [[angiotensin-converting enzyme 2]] (ACE2) [[receptors]] to enter the [[cells]].
* Type 1 and type 2 [[pneumocytes]] exhibit [[Angiotensin-converting enzyme 2|ACE 2]] receptors in the lung. 
*Studies report that coronary [[endothelial cells]] in the heart and intrarenal [[Endothelium|endothelial cells]] and renal tubular epithelial cells in the kidney exhibit [[Angiotensin-converting enzyme 2|ACE2]]. [[Angiotensin-converting enzyme 2|ACE2]] is an inverse regulator of the [[renin-angiotensin system]].<ref name="XuShi2020">{{cite journal|last1=Xu|first1=Zhe|last2=Shi|first2=Lei|last3=Wang|first3=Yijin|last4=Zhang|first4=Jiyuan|last5=Huang|first5=Lei|last6=Zhang|first6=Chao|last7=Liu|first7=Shuhong|last8=Zhao|first8=Peng|last9=Liu|first9=Hongxia|last10=Zhu|first10=Li|last11=Tai|first11=Yanhong|last12=Bai|first12=Changqing|last13=Gao|first13=Tingting|last14=Song|first14=Jinwen|last15=Xia|first15=Peng|last16=Dong|first16=Jinghui|last17=Zhao|first17=Jingmin|last18=Wang|first18=Fu-Sheng|title=Pathological findings of COVID-19 associated with acute respiratory distress syndrome|journal=The Lancet Respiratory Medicine|volume=8|issue=4|year=2020|pages=420–422|issn=22132600|doi=10.1016/S2213-2600(20)30076-X}}</ref>
* The interaction between [[SARS-CoV-2]] and ACE2 can bring about changes in [[Angiotensin-converting enzyme 2|ACE2]] pathways prompting intense injury to the lung, heart, and [[Endothelium|endothelial cells]].
*[[Hypoxemia|Hypoxia]] and [[Electrolyte disturbance|electrolyte abnormalities]] that are common in the acute phase of severe [[COVID-19]] can potentiate [[Cardiac arrhythmia|cardiac arrhythmias]].
* Binding of [[SARS-CoV-2]] to ACE2 receptors can result in [[hypokalemia]] which causes various types of [[Cardiac arrhythmia|arrhythmia]].
* Elevated levels of [[Cytokine|cytokines]] as a result of the [[Systemic inflammatory response syndrome|systemic inflammatory response]] of the severe [[COVID-19|Coronavirus disease 2019]] (COVID-19) can cause injury to multiple organs, including [[Cardiac muscle|cardiac myocytes]].<ref name="ChenPrendergast2020">{{cite journal|last1=Chen|first1=Mao|last2=Prendergast|first2=Bernard|last3=Redwood|first3=Simon|last4=Xiong|first4=Tian-Yuan|title=Coronaviruses and the cardiovascular system: acute and long-term implications|journal=European Heart Journal|volume=41|issue=19|year=2020|pages=1798–1800|issn=0195-668X|doi=10.1093/eurheartj/ehaa231}}</ref>
*In COVID-19 patients, excessive ranges of circulating [[Cytokine|cytokines]], especially interleukin [[Interleukin 6|(IL)-6]] is related to in-hospital death.<ref name="pmid32201335">{{cite journal| author=Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G | display-authors=etal| title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. | journal=J Am Coll Cardiol | year= 2020 | volume= 75 | issue= 18 | pages= 2352-2371 | pmid=32201335 | doi=10.1016/j.jacc.2020.03.031 | pmc=7198856 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32201335  }} </ref>
* As a result of cytokine storm triggered by Sars-CoV-2 that includes IL-6, tumor necrosis factor (TNF) α, and IL-1, duration of ventricular action potential can be prolonged. 
*Studies suggest that cytokine storm can modulate the function of cardiomyocyte ion channels such as Na+, K+ and Ca+ channels (inflammatory cardiac channelopathies).<ref name="pmid30552387">{{cite journal| author=Lazzerini PE, Laghi-Pasini F, Boutjdir M, Capecchi PL| title=Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies. | journal=Nat Rev Immunol | year= 2019 | volume= 19 | issue= 1 | pages= 63-64 | pmid=30552387 | doi=10.1038/s41577-018-0098-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30552387  }} </ref>
* According to the data based on studies on previous [[Severe acute respiratory syndrome]] ([[Severe acute respiratory syndrome|SARS]]) and the [[Middle East respiratory syndrome coronavirus infection|Middle East respiratory syndrome]] ([[Middle East respiratory syndrome coronavirus infection|MERS]]) epidemic and the ongoing [[COVID-19]] outbreak, multiple mechanisms have been suggested for cardiac damage.<ref name="ClerkinFried2020">{{cite journal|last1=Clerkin|first1=Kevin J.|last2=Fried|first2=Justin A.|last3=Raikhelkar|first3=Jayant|last4=Sayer|first4=Gabriel|last5=Griffin|first5=Jan M.|last6=Masoumi|first6=Amirali|last7=Jain|first7=Sneha S.|last8=Burkhoff|first8=Daniel|last9=Kumaraiah|first9=Deepa|last10=Rabbani|first10=LeRoy|last11=Schwartz|first11=Allan|last12=Uriel|first12=Nir|title=COVID-19 and Cardiovascular Disease|journal=Circulation|volume=141|issue=20|year=2020|pages=1648–1655|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.046941}}</ref>


[[File:COVID-19 arrhythmia1.png|700px|center]]

To browse the pathophysiology of COVID-19, [[COVID-19 pathophysiology|click here]].

==Causes==
SARS-CoV-2 causes COVID-19-associated arrhythmia through different mechanisms, including direct viral attack, cytokine storm, etc.

Common causes of arrhythmia include: 
*Abnormal levels of [[potassium]] or other substances in the body
*[[ST elevation myocardial infarction|Heart attack]], or a damaged heart muscle from a past heart attack
*[[Coronary heart disease prevention|Heart disease]] that is present at birth (congenital)
*Heart failure or an enlarged heart
*[[Hyperthyroidism|Overactive thyroid gland]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>

To browse the causes of COVID-19, [[COVID-19 causes|click here]].

==Differentiating COVID-19-associated arrhythmia from other Diseases==
[[COVID-19]]-associated arrhythmia and conduction system disease must be differentiated from other diseases that cause [[Cardiac arrhythmia|arrhythmia]], such as:
*[[Hyperkalemia]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Hypokalemia]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Congenital heart disease]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Congestive heart failure|Heart failure]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[ST elevation myocardial infarction|Myocardial Infarction]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Hyperthyroidism]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Dehydration]]<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>
*[[Hypoglycemia]]<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>
*[[Hypocalcemia]]<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>
*[[Hypomagnesemia]]<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>
*[[Alcoholism|Alcohol-induced cardiac arrhythmia]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Caffeine|Caffeine-induced arrhythmia]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>
*[[Antihypertensive|Antihypertensive therapy-induced arrhythmia]]<ref name="urlArrhythmias: MedlinePlus Medical Encyclopedia">{{cite web |url=https://medlineplus.gov/ency/article/001101.htm |title=Arrhythmias: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref>

To browse the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].

==Epidemiology and Demographics==
* According to the available data on COVID-19-associated arrhythmia, the prevalence of [[Cardiac arrhythmia|arrhythmias]] and [[conduction system disease]] in patients with [[COVID-19]] varies between populations.
*The incidence of COVID-19-associated arrhythmia and conduction system disease in asymptomatic, mildly ill, critically ill, and recovered patients is not known.<ref name="pmid32228309">{{cite journal| author=Lakkireddy DR, Chung MK, Gopinathannair R, Patton KK, Gluckman TJ, Turagam M | display-authors=etal| title=Guidance for Cardiac Electrophysiology During the COVID-19 Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. | journal=Circulation | year= 2020 | volume= 141 | issue= 21 | pages= e823-e831 | pmid=32228309 | doi=10.1161/CIRCULATIONAHA.120.047063 | pmc=7243667 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32228309  }} </ref>
* According to a cohort of 137 COVID-19 patients from Hubei province, 10 patients were reported to have [[Palpitation|palpitations]] as one of the earliest symptoms.<ref name="pmid32044814">{{cite journal| author=Liu K, Fang YY, Deng Y, Liu W, Wang MF, Ma JP | display-authors=etal| title=Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. | journal=Chin Med J (Engl) | year= 2020 | volume= 133 | issue= 9 | pages= 1025-1031 | pmid=32044814 | doi=10.1097/CM9.0000000000000744 | pmc=7147277 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32044814  }} </ref>
* In a cohort of 138 [[COVID-19]] patients from Wuhan, [[Cardiac arrhythmia|arrhythmias]] were observed in 17% of patients hospitalized because of [[COVID-19|COVID-19-related pneumonia]], and in 44% of patients admitted to an intensive care unit.<ref name="pmid32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570  }} </ref>
* One-third of patients with the severe [[disease]] also reported other [[symptoms]] including [[Cardiac arrhythmia|arrhythmia]]. According to a study done in Wuhan, China, 16.7% of hospitalized and 44.4% of ICU patients with [[COVID-19]] had [[Cardiac arrhythmia|arrhythmias]].<ref name="WangHu2020">{{cite journal|last1=Wang|first1=Dawei|last2=Hu|first2=Bo|last3=Hu|first3=Chang|last4=Zhu|first4=Fangfang|last5=Liu|first5=Xing|last6=Zhang|first6=Jing|last7=Wang|first7=Binbin|last8=Xiang|first8=Hui|last9=Cheng|first9=Zhenshun|last10=Xiong|first10=Yong|last11=Zhao|first11=Yan|last12=Li|first12=Yirong|last13=Wang|first13=Xinghuan|last14=Peng|first14=Zhiyong|title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China|journal=JAMA|volume=323|issue=11|year=2020|pages=1061|issn=0098-7484|doi=10.1001/jama.2020.1585}}</ref>
===Age===
* The prevalence of arrhythmia and Atrial Fibrillation increases with age.<ref name="urlUnderstand Your Risk For Arrhythmia | American Heart Association">{{cite web |url=https://www.heart.org/en/health-topics/arrhythmia/understand-your-risk-for-arrhythmia |title=Understand Your Risk For Arrhythmia &#124; American Heart Association |format= |work= |accessdate=}}</ref>

===Gender===
*There is not much data available to delineate the gender of COVID-19 patients prone to develop arrhythmia.
===Race===
* There is not enough data on a racial predilection for COVID-19-associated arrhythmia.

To browse the epidemiology and demographics of COVID-19, [[COVID-19 epidemiology and demographics|click here]].

==Risk Factors==
*Common risk factors in the development of COVID-19-associated arrhythmia are:
** Patients who present with other cardiovascular complications in the setting of [[COVID-19]] infection, such as [[ST elevation myocardial infarction|myocardial injury]] or [[Coronary heart disease|myocardial ischemia]].<ref name="pmid32201335">{{cite journal| author=Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G | display-authors=etal| title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. | journal=J Am Coll Cardiol | year= 2020 | volume= 75 | issue= 18 | pages= 2352-2371 | pmid=32201335 | doi=10.1016/j.jacc.2020.03.031 | pmc=7198856 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32201335  }} </ref>
** Patients with [[Hypoxia (medical)|hypoxia]], [[shock]] ([[Sepsis|septic]] or [[Cardiogenic shock|cardiogenic]]), or evidence of widespread [[systemic inflammation]].<ref name="pmid32286863">{{cite journal| author=Lazzerini PE, Boutjdir M, Capecchi PL| title=COVID-19, Arrhythmic Risk, and Inflammation: Mind the Gap! | journal=Circulation | year= 2020 | volume= 142 | issue= 1 | pages= 7-9 | pmid=32286863 | doi=10.1161/CIRCULATIONAHA.120.047293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32286863  }} </ref>
** Patients with [[Electrolyte disturbance|electrolyte disturbances]] (eg, [[hypokalemia]]).<ref name="pmid30464746">{{cite journal| author=Skogestad J, Aronsen JM| title=Hypokalemia-Induced Arrhythmias and Heart Failure: New Insights and Implications for Therapy. | journal=Front Physiol | year= 2018 | volume= 9 | issue=  | pages= 1500 | pmid=30464746 | doi=10.3389/fphys.2018.01500 | pmc=6234658 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30464746  }} </ref>
** Patients who are receiving QT-prolonging therapies and who may develop [[polymorphic ventricular tachycardia]] (VT).<ref name="pmid32286863">{{cite journal| author=Lazzerini PE, Boutjdir M, Capecchi PL| title=COVID-19, Arrhythmic Risk, and Inflammation: Mind the Gap! | journal=Circulation | year= 2020 | volume= 142 | issue= 1 | pages= 7-9 | pmid=32286863 | doi=10.1161/CIRCULATIONAHA.120.047293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32286863  }} </ref>
** Patients with fever, which can unmask cases of [[Channelopathies|cardiac channelopathies]] such as [[Brugada syndrome]] and [[long QT syndrome]].<ref name="pmid18551196">{{cite journal| author=Amin AS, Herfst LJ, Delisle BP, Klemens CA, Rook MB, Bezzina CR | display-authors=etal| title=Fever-induced QTc prolongation and ventricular arrhythmias in individuals with type 2 congenital long QT syndrome. | journal=J Clin Invest | year= 2008 | volume= 118 | issue= 7 | pages= 2552-61 | pmid=18551196 | doi=10.1172/JCI35337 | pmc=2423868 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18551196  }} </ref><ref name="pmid32292696">{{cite journal| author=Chang D, Saleh M, Garcia-Bengo Y, Choi E, Epstein L, Willner J| title=COVID-19 Infection Unmasking Brugada Syndrome. | journal=HeartRhythm Case Rep | year= 2020 | volume=  | issue=  | pages=  | pmid=32292696 | doi=10.1016/j.hrcr.2020.03.012 | pmc=7138191 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32292696  }} </ref>

*To browse the risk factors of COVID-19 [[COVID-19 risk factors|click here]].

==Screening==

According to the National Heart, Lung, and Blood Institute, screening for arrhythmia is based on risk factors, such as age or family history.<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

[[Electrocardiogram]]: 
*An [[electrocardiogram]] (EKG or ECG) is the main test for detecting [[Cardiac arrhythmia|arrhythmia]].
*An [[The electrocardiogram|EKG]] records the [[Electrical conduction system of the heart|heart’s electrical activity]]. The doctor may do the test while you are at rest or may do a stress test, which records the heart’s activity when it is working hard.
*The doctor may also give a portable monitor to wear for a day or several days if no [[Cardiac arrhythmia|arrhythmia]] was detected during testing in the clinic. If there is a child who is at risk of [[Cardiac arrhythmia|arrhythmia]] because of a genetic condition, the doctor may recommend regular testing for the child and his or her siblings.

[[Genetics|Genetic Testing]]:
*Genetic testing can help understand the risk when a family member has been diagnosed with a genetic condition. Testing is especially important if the newborn or another close relative died suddenly and had a genetic risk. 
*The doctor may also suggest genetic testing if there is a history of fainting or have survived [[Sudden cardiac death|cardiac arrest]] or [[Drowning|near-drowning]].

[[Cardiovascular magnetic resonance imaging (CMR)|Imaging tests]]:
*Imaging tests, such as [[Cardiac magnetic resonance imaging|cardiac magnetic resonance imaging (MRI)]], can help detect scarring or other problems that can increase the risk of [[Cardiac arrhythmia|arrhythmia]].<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

To browse the screening of COVID-19, [[COVID-19 screening|click here]].

== Natural History, Complications and Prognosis==
'''Natural History:'''
*[[Cardiac arrhythmia]] is considered as one of the earliest manifestations of [[COVID-19]].<ref name="KochiTagliari2020">{{cite journal|last1=Kochi|first1=Adriano Nunes|last2=Tagliari|first2=Ana Paula|last3=Forleo|first3=Giovanni Battista|last4=Fassini|first4=Gaetano Michele|last5=Tondo|first5=Claudio|title=Cardiac and arrhythmic complications in patients with COVID‐19|journal=Journal of Cardiovascular Electrophysiology|volume=31|issue=5|year=2020|pages=1003–1008|issn=1045-3873|doi=10.1111/jce.14479}}</ref>
*[[Cardiac arrhythmia|Arrhythmia]] presents with the history of:
**Slow or irregular heartbeat or pauses between heartbeats
**Skipping a heartbeat
**Heart pounding or racing
**[[Anxiety]]
**[[Blurred vision]]
**[[Chest pain]]
**[[Dyspnea|Difficulty breathing]]
**[[Syncope|Fainting or nearly fainting]]
**Foggy thinking
**[[Fatigue]]
**[[Perspiration|Sweating]]
**[[Weakness (medical)|Weakness]], [[dizziness]], and [[Lightheadedness and vertigo|light-headedness]]<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

===Complications===

[[Cardiac arrhythmia|Arrhythmias]] that are unrecognized or left untreated can cause sometimes life-threatening complications affecting the heart and brain.<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

:*[[Congestive heart failure|Heart failure]]. To browse [[COVID-19-associated heart failure]], [[COVID-19-associated heart failure|click here]].
:*[[Stroke]]. To browse [[COVID-19-associated stroke]], [[COVID-19-associated stroke|Click here]]
:*[[Sudden cardiac death|Sudden cardiac arrest]]. To browse [[COVID-19-associated cardiac arrest]], [[COVID-19-associated cardiac arrest|click here]]
:*[[Cardiac arrhythmia|Worsening arrhythmia]].

===Prognosis===
*In-hospital death among patients with COVID-19-associated arrhythmia and [[conduction system disease]] is 4.3% according to a study by Wang et al<ref name="WangHu2020">{{cite journal|last1=Wang|first1=Dawei|last2=Hu|first2=Bo|last3=Hu|first3=Chang|last4=Zhu|first4=Fangfang|last5=Liu|first5=Xing|last6=Zhang|first6=Jing|last7=Wang|first7=Binbin|last8=Xiang|first8=Hui|last9=Cheng|first9=Zhenshun|last10=Xiong|first10=Yong|last11=Zhao|first11=Yan|last12=Li|first12=Yirong|last13=Wang|first13=Xinghuan|last14=Peng|first14=Zhiyong|title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China|journal=JAMA|volume=323|issue=11|year=2020|pages=1061|issn=0098-7484|doi=10.1001/jama.2020.1585}}</ref>  and 23% among COVID-19 patients who develop Ventricular fibrillation and Ventricular tachycardia according to a study by Guo et al <ref name="GuoFan2020">{{cite journal|last1=Guo|first1=Tao|last2=Fan|first2=Yongzhen|last3=Chen|first3=Ming|last4=Wu|first4=Xiaoyan|last5=Zhang|first5=Lin|last6=He|first6=Tao|last7=Wang|first7=Hairong|last8=Wan|first8=Jing|last9=Wang|first9=Xinghuan|last10=Lu|first10=Zhibing|title=Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)|journal=JAMA Cardiology|year=2020|issn=2380-6583|doi=10.1001/jamacardio.2020.1017}}</ref> .
*According to the data available, the [[Cardiac arrhythmia|Arrhythmia]] rate is more frequent in Intensive care unit (ICU) patients.<ref name="WangHu2020">{{cite journal|last1=Wang|first1=Dawei|last2=Hu|first2=Bo|last3=Hu|first3=Chang|last4=Zhu|first4=Fangfang|last5=Liu|first5=Xing|last6=Zhang|first6=Jing|last7=Wang|first7=Binbin|last8=Xiang|first8=Hui|last9=Cheng|first9=Zhenshun|last10=Xiong|first10=Yong|last11=Zhao|first11=Yan|last12=Li|first12=Yirong|last13=Wang|first13=Xinghuan|last14=Peng|first14=Zhiyong|title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China|journal=JAMA|volume=323|issue=11|year=2020|pages=1061|issn=0098-7484|doi=10.1001/jama.2020.1585}}</ref>

To browse COVID-19 history, complications, and prognosis, [[COVID-19 natural history, complications and prognosis|click here]].

== Diagnosis ==

=== Diagnostic Study of Choice ===
*'''ECG:''' 

::* Most patients with the severe [[COVID-19]], and especially patients who receive [[QT prolongation|QT-prolonging medications]], should have a baseline [[electrocardiogram]] (ECG) performed at the time of admission to the hospital.
::* The best technique to get the [[QT interval]] is with a 12-lead electrocardiogram (ECG). However, to scale back exposure to hospital workers, this could not perpetually be possible. 
::* A single-lead [[ECG]] might underestimate the QT interval, and there ought to be an effort to use a multiple-lead telemetry system to observe the QT interval.<ref name="GandhiSolomon2020">{{cite journal|last1=Gandhi|first1=Rajesh T.|last2=Solomon|first2=Caren G.|last3=Lynch|first3=John B.|last4=del Rio|first4=Carlos|title=Mild or Moderate Covid-19|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMcp2009249}}</ref><ref name="ChangSaleh2020">{{cite journal|last1=Chang|first1=David|last2=Saleh|first2=Moussa|last3=Gabriels|first3=James|last4=Ismail|first4=Haisam|last5=Goldner|first5=Bruce|last6=Willner|first6=Jonathan|last7=Beldner|first7=Stuart|last8=Mitra|first8=Raman|last9=John|first9=Roy|last10=Epstein|first10=Laurence M.|title=Inpatient Use of Ambulatory Telemetry Monitors for COVID-19 Patients Treated With Hydroxychloroquine and/or Azithromycin|journal=Journal of the American College of Cardiology|volume=75|issue=23|year=2020|pages=2992–2993|issn=07351097|doi=10.1016/j.jacc.2020.04.032}}</ref>
*'''Transthoracic echocardiography:''' 

::*[[Transthoracic echocardiography]] is recommended for an inpatient with [[heart failure]], [[arrhythmia]], ECG changes, or newly diagnosed [[cardiomegaly]] on chest [[x-ray]] or [[CT]]-chest.<ref name="InciardiLupi2020">{{cite journal|last1=Inciardi|first1=Riccardo M.|last2=Lupi|first2=Laura|last3=Zaccone|first3=Gregorio|last4=Italia|first4=Leonardo|last5=Raffo|first5=Michela|last6=Tomasoni|first6=Daniela|last7=Cani|first7=Dario S.|last8=Cerini|first8=Manuel|last9=Farina|first9=Davide|last10=Gavazzi|first10=Emanuele|last11=Maroldi|first11=Roberto|last12=Adamo|first12=Marianna|last13=Ammirati|first13=Enrico|last14=Sinagra|first14=Gianfranco|last15=Lombardi|first15=Carlo M.|last16=Metra|first16=Marco|title=Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)|journal=JAMA Cardiology|year=2020|issn=2380-6583|doi=10.1001/jamacardio.2020.1096}}</ref>

To browse the diagnostic study of choice of COVID-19, [[COVID-19 diagnostic study of choice|click here]].

=== History and Symptoms ===
[[Cardiac arrhythmia|Arrhythmia]] or [[conduction system disease]] is the nonspecific clinical presentation of [[COVID-19]]. Patients may be [[Tachycardia|tachycardic]] (with or without [[Palpitation|palpitations]]) in the setting of other COVID-19-related symptoms (eg, fever, shortness of breath, pain, etc).
*According to a study done in Hubei province,[[Palpitation|palpitations]] were reported as a presenting symptom by 7.3 percent of patients.<ref name="pmid32044814">{{cite journal| author=Liu K, Fang YY, Deng Y, Liu W, Wang MF, Ma JP | display-authors=etal| title=Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. | journal=Chin Med J (Engl) | year= 2020 | volume= 133 | issue= 9 | pages= 1025-1031 | pmid=32044814 | doi=10.1097/CM9.0000000000000744 | pmc=7147277 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32044814  }} </ref><ref name="pmid32201335">{{cite journal| author=Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G | display-authors=etal| title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. | journal=J Am Coll Cardiol | year= 2020 | volume= 75 | issue= 18 | pages= 2352-2371 | pmid=32201335 | doi=10.1016/j.jacc.2020.03.031 | pmc=7198856 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32201335  }} </ref>
*[[Sinus tachycardia]]
*[[Atrial fibrillation]]
*[[Tachy-brady syndrome|Tachy-brady syndrome]].
*[[Sinus rhythm]] with a [[first-degree atrioventricular block]] (AVB) with SITIIIQIII; [[Sinus tachycardia]] with incomplete [[right bundle branch block]].<ref name="HeWu2020" /><ref name="McculloughGoyal2020" />

To browse the history and symptoms of COVID-19, [[COVID-19 history and symptoms|click here]].

=== Physical Examination ===
*Patients with COVID-19-associated arrhythmia and [[conduction system disease]] on cardiac auscultation reveal [[tachycardia]] or [[Cardiac arrhythmia|arrhythmias]] (irregular beat).
*[[Sinus tachycardia]], the most common type of [[Cardiac arrhythmia|arrhythmia]] in COVID-19 patients can be due to fever, [[Hypoxemia|hypoxia]], shock due to [[sepsis]], and anxiety. Some pathologic causes of arrhythmias include ventricular [[tachyarrhythmia]], [[atrial fibrillation]] (pulse rate 100 to 175 bpm) and [[atrial flutter]] (pulse rate 150 bpm).<ref name="GuoFan2020">{{cite journal|last1=Guo|first1=Tao|last2=Fan|first2=Yongzhen|last3=Chen|first3=Ming|last4=Wu|first4=Xiaoyan|last5=Zhang|first5=Lin|last6=He|first6=Tao|last7=Wang|first7=Hairong|last8=Wan|first8=Jing|last9=Wang|first9=Xinghuan|last10=Lu|first10=Zhibing|title=Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)|journal=JAMA Cardiology|year=2020|issn=2380-6583|doi=10.1001/jamacardio.2020.1017}}</ref>
*To browse the physical examination of COVID-19, [[COVID-19 physical examination|click here]].

=== Laboratory Findings ===
* There are no specific laboratory findings associated with COVID-19-associated arrhythmia.
* COVID-19 patients with elevated [[troponin T]] experienced higher risk of [[ventricular arrhythmias]] (17.3% in high [[troponin T]] group versus 1.5% in normal [[troponin T]] group, P < 0.001).<ref name="pmid32253318">{{cite journal| author=Duan K, Liu B, Li C, Zhang H, Yu T, Qu J | display-authors=etal| title=Effectiveness of convalescent plasma therapy in severe COVID-19 patients. | journal=Proc Natl Acad Sci U S A | year= 2020 | volume= 117 | issue= 17 | pages= 9490-9496 | pmid=32253318 | doi=10.1073/pnas.2004168117 | pmc=7196837 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32253318  }} </ref>

To browse the laboratory findings of COVID-19, [[COVID-19 laboratory findings|click here]].

===Electrocardiogram===
COVID-19-associated arrhythmia findings include:

*'''Prolong QT Interval:''' 

::* According to a multicenter study done in New York that involved 4250 [[COVID-19]] patients, 260 patients (6.1%) had [[QT interval|corrected QT interval]] (QTc) >500 milliseconds at the time of admittance.
::* However, in another study that involved 84 patients who got [[hydroxychloroquine]] and [[azithromycin]], the baseline QTc interval was 435 milliseconds before receiving these medications.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref><ref name="GiudicessiNoseworthy2020">{{cite journal|last1=Giudicessi|first1=John R.|last2=Noseworthy|first2=Peter A.|last3=Friedman|first3=Paul A.|last4=Ackerman|first4=Michael J.|title=Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19)|journal=Mayo Clinic Proceedings|volume=95|issue=6|year=2020|pages=1213–1221|issn=00256196|doi=10.1016/j.mayocp.2020.03.024}}</ref>

[[File:Prolong QT Interval.png|700px|center]]

*'''Atrial Arrhythmia:''' 

::* According to a study, among 393 patients with COVID-19, [[Cardiac arrhythmia|atrial arrhythmias]] were more common among patients requiring invasive [[mechanical ventilation]] than noninvasive [[mechanical ventilation]] (17.7% versus 1.9%).<ref name="GoyalChoi2020">{{cite journal|last1=Goyal|first1=Parag|last2=Choi|first2=Justin J.|last3=Pinheiro|first3=Laura C.|last4=Schenck|first4=Edward J.|last5=Chen|first5=Ruijun|last6=Jabri|first6=Assem|last7=Satlin|first7=Michael J.|last8=Campion|first8=Thomas R.|last9=Nahid|first9=Musarrat|last10=Ringel|first10=Joanna B.|last11=Hoffman|first11=Katherine L.|last12=Alshak|first12=Mark N.|last13=Li|first13=Han A.|last14=Wehmeyer|first14=Graham T.|last15=Rajan|first15=Mangala|last16=Reshetnyak|first16=Evgeniya|last17=Hupert|first17=Nathaniel|last18=Horn|first18=Evelyn M.|last19=Martinez|first19=Fernando J.|last20=Gulick|first20=Roy M.|last21=Safford|first21=Monika M.|title=Clinical Characteristics of Covid-19 in New York City|journal=New England Journal of Medicine|volume=382|issue=24|year=2020|pages=2372–2374|issn=0028-4793|doi=10.1056/NEJMc2010419}}</ref>

[[File:Atrial Arrhythmia.png|700px|center]]

*'''Ventricular Arrhythmia:''' 

::* According to a study done in Wuhan, China. among 187 hospitalized patients with [[COVID-19]], 11 patients (5.9%) developed [[Ventricular arrhythmias|ventricular tachyarrhythmias]].<ref name="pmid32219356">{{cite journal| author=Guo T, Fan Y, Chen M, Wu X, Zhang L, He T | display-authors=etal| title=Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). | journal=JAMA Cardiol | year= 2020 | volume=  | issue=  | pages=  | pmid=32219356 | doi=10.1001/jamacardio.2020.1017 | pmc=7101506 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32219356  }} </ref>

[[File:Ventricular Arrhythmia.png|700px|center]]

*'''Cardiac Arrest:''' 

::* According to a Lombardia Cardiac Arrest Registry (Lombardia CARe) in the region of Lombardy, Italy.
::** Out of 9806 cases of [[COVID-19]], 362 cases of out-of-hospital [[cardiac arrest]] were reported during the study time frame in 2020.
::** During a similar period in 2019, 229 cases of out-of-hospital [[cardiac arrest]] were reported, which means an increment of 58% was observed in 2020 among [[COVID-19]] patients.  <br />
::* According to the records from a tertiary care hospital in Wuhan. Out of 761 patients with severe [[COVID-19]], 151 patients developed in-hospital [[cardiac arrest]].
::**136 patients received resuscitation. Out of 136 patients, 119 patients had a respiratory cause.
::** 10 patients had a cardiac cause. 7 patients had other causes.
::** [[Ventricular fibrillation]] or [[pulseless ventricular tachycardia]] was observed in 8 patients (5.9%), [[Pulseless electrical activity]] in 6 patients (4.4%), and [[asystole]] in 122 [[COVID-19]] patients (89.7%).<ref name="BaldiSechi2020">{{cite journal|last1=Baldi|first1=Enrico|last2=Sechi|first2=Giuseppe M.|last3=Mare|first3=Claudio|last4=Canevari|first4=Fabrizio|last5=Brancaglione|first5=Antonella|last6=Primi|first6=Roberto|last7=Klersy|first7=Catherine|last8=Palo|first8=Alessandra|last9=Contri|first9=Enrico|last10=Ronchi|first10=Vincenza|last11=Beretta|first11=Giorgio|last12=Reali|first12=Francesca|last13=Parogni|first13=Pierpaolo|last14=Facchin|first14=Fabio|last15=Bua|first15=Davide|last16=Rizzi|first16=Ugo|last17=Bussi|first17=Daniele|last18=Ruggeri|first18=Simone|last19=Oltrona Visconti|first19=Luigi|last20=Savastano|first20=Simone|title=Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMc2010418}}</ref><ref name="ShaoXu2020">{{cite journal|last1=Shao|first1=Fei|last2=Xu|first2=Shuang|last3=Ma|first3=Xuedi|last4=Xu|first4=Zhouming|last5=Lyu|first5=Jiayou|last6=Ng|first6=Michael|last7=Cui|first7=Hao|last8=Yu|first8=Changxiao|last9=Zhang|first9=Qing|last10=Sun|first10=Peng|last11=Tang|first11=Ziren|title=In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China|journal=Resuscitation|volume=151|year=2020|pages=18–23|issn=03009572|doi=10.1016/j.resuscitation.2020.04.005}}</ref>

[[File:Cardiac arrest.png|700px|center]]

* To browse the electrocardiogram findings of COVID-19, [[COVID-19 electrocardiogram|click here]].

===X-Ray===
*To browse the X-ray finding of COVID-19, [[COVID-19 x-ray|click here]].

===Echocardiography/Ultrasound===

*There are no specific [[Echocardiography and ultrasound|echocardiography/ultrasound]] findings associated with coronavirus [[infection]].
*Non specific [[Echocardiography|echocardiographic]] findings can include:<ref name="pmid32219357">{{cite journal |vauthors=Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, Cani DS, Cerini M, Farina D, Gavazzi E, Maroldi R, Adamo M, Ammirati E, Sinagra G, Lombardi CM, Metra M |title=Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19) |journal=JAMA Cardiol |volume= |issue= |pages= |date=March 2020 |pmid=32219357 |doi=10.1001/jamacardio.2020.1096 |url=}}</ref><ref name="pmid26922692">{{cite journal |vauthors=Alhogbani T |title=Acute myocarditis associated with novel Middle east respiratory syndrome coronavirus |journal=Ann Saudi Med |volume=36 |issue=1 |pages=78–80 |date=2016 |pmid=26922692 |pmc=6074274 |doi=10.5144/0256-4947.2016.78 |url=}}</ref>

:*[[Left ventricular systolic dysfunction]]
:*[[Pericardial effusion]]
:*[[Myocardial edema]]
:*Increased wall thickness with diffuse biventricular hypokinesis

===CT Scan===
* To browse the CT-Scan findings of COVID-19, [[COVID-19 CT scan|click here]].

===MRI===
*We ought to consider that myocardial injury may bring about atrial or [[Cardiac fibrosis|ventricular fibrosis]], the substrate for resulting [[Cardiac arrhythmia|cardiovascular arrhythmias]].
*[[COVID-19]] patients with evidence of myocardial injury should undergo cardiac [[Magnetic resonance imaging|magnetic resonance]] to assess the extent of [[Scar tissue|myocardial scar]].<ref name="KochiTagliari2020">{{cite journal|last1=Kochi|first1=Adriano Nunes|last2=Tagliari|first2=Ana Paula|last3=Forleo|first3=Giovanni Battista|last4=Fassini|first4=Gaetano Michele|last5=Tondo|first5=Claudio|title=Cardiac and arrhythmic complications in patients with COVID‐19|journal=Journal of Cardiovascular Electrophysiology|volume=31|issue=5|year=2020|pages=1003–1008|issn=1045-3873|doi=10.1111/jce.14479}}</ref>
*To browse the MRI findings of COVID, [[COVID-19 MRI|click here]].

===Other Imaging Findings===
*There are no other imaging findings associated with COVID-19-associated arrhythmia.
=== Other Diagnostic Studies ===
*[[Cardiac biomarkers|Myocardial biomarkers]] should be assessed in all patients with [[COVID-19|COVID‐19]].<ref name="KochiTagliari2020">{{cite journal|last1=Kochi|first1=Adriano Nunes|last2=Tagliari|first2=Ana Paula|last3=Forleo|first3=Giovanni Battista|last4=Fassini|first4=Gaetano Michele|last5=Tondo|first5=Claudio|title=Cardiac and arrhythmic complications in patients with COVID‐19|journal=Journal of Cardiovascular Electrophysiology|volume=31|issue=5|year=2020|pages=1003–1008|issn=1045-3873|doi=10.1111/jce.14479}}</ref>
*American Heart Association (AHA) recommends the following tests to diagnose arrhythmia:
**[[Holter monitor]]
**[[Transtelephonic monitor]]
**[[Exercise stress testing|Treadmill testing]]
**[[Tilt-table test]]
**[[Electrophysiologic testing (EP study)]]
**[[Esophageal electrophysiologic procedure]]
**[[Echocardiogram]]

== Treatment ==
=== Medical Therapy ===
*'''Polymorphic Ventricular Tachycardia (torsades de pointes):''' 

::All patients with [[torsades de pointes]] (TdP) should be determined if they are hemodynamically stable or unstable through immediate evaluation of the symptoms, vital signs, and level of consciousness.<ref name="PanchalBerg2018">{{cite journal|last1=Panchal|first1=Ashish R.|last2=Berg|first2=Katherine M.|last3=Kudenchuk|first3=Peter J.|last4=Del Rios|first4=Marina|last5=Hirsch|first5=Karen G.|last6=Link|first6=Mark S.|last7=Kurz|first7=Michael C.|last8=Chan|first8=Paul S.|last9=Cabañas|first9=José G.|last10=Morley|first10=Peter T.|last11=Hazinski|first11=Mary Fran|last12=Donnino|first12=Michael W.|title=2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care|journal=Circulation|volume=138|issue=23|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000613}}</ref>
:*'''Unstable patients:''' 
:**Patients with [[COVID-19]] with sustained [[torsades de pointes]] (TdP) usually become hemodynamically unstable, severely symptomatic because of perfusion failure, or pulseless and should be treated according to [[standard resuscitation algorithms]], including [[cardioversion/defibrillation]]. 
:**Initial treatment with antiarrhythmic medications is not indicated for hemodynamically unstable or pulseless patients except intravenous (IV) magnesium.
:*'''Stable patients:''' 
:**In a patient with a single episode of TdP, treatment with IV magnesium along with correction of metabolic/electrolyte disturbances or removal of any inciting medications may be sufficient.
:**The patient should be kept under observation until the [[electrolytes]], and the [[QT interval]] nearly normalizes. 
:**An IV bolus of 2-gram magnesium sulfate is the standard therapy for an adult. This is equivalent to a dose of 8.12 mmol of magnesium. 
:**The clinical situation of a patient determines the rate of magnesium infusion. 
:**Infusion occurs over one to two minutes in patients with pulseless [[cardiac arrest]].
:**The infusion should occur over 15 minutes in patients without [[cardiac arrest]] as a rapid IV bolus of magnesium can result in [[hypotension]] and [[asystole]]. Some patients are given a continuous bolus of IV magnesium at a rate of 3 to 20 mg/min until the QT interval is below 0.50 seconds.<ref name="TzivoniBanai1988">{{cite journal|last1=Tzivoni|first1=D|last2=Banai|first2=S|last3=Schuger|first3=C|last4=Benhorin|first4=J|last5=Keren|first5=A|last6=Gottlieb|first6=S|last7=Stern|first7=S|title=Treatment of torsade de pointes with magnesium sulfate.|journal=Circulation|volume=77|issue=2|year=1988|pages=392–397|issn=0009-7322|doi=10.1161/01.CIR.77.2.392}}</ref><ref name="NeumarOtto2010">{{cite journal|last1=Neumar|first1=R. W.|last2=Otto|first2=C. W.|last3=Link|first3=M. S.|last4=Kronick|first4=S. L.|last5=Shuster|first5=M.|last6=Callaway|first6=C. W.|last7=Kudenchuk|first7=P. J.|last8=Ornato|first8=J. P.|last9=McNally|first9=B.|last10=Silvers|first10=S. M.|last11=Passman|first11=R. S.|last12=White|first12=R. D.|last13=Hess|first13=E. P.|last14=Tang|first14=W.|last15=Davis|first15=D.|last16=Sinz|first16=E.|last17=Morrison|first17=L. J.|title=Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care|journal=Circulation|volume=122|issue=18_suppl_3|year=2010|pages=S729–S767|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.110.970988}}</ref>
*'''Other Cardiac arrhythmia:''' 

::* The treatment for other [[arrhythmias]] in [[COVID-19]] patients is the same as in patients with arrhythmias without COVID-19 infection. To browse the treatment of other arrhythmias, [[Cardiac arrhythmia|click here]].

Some medicines are used in combination with each other or together with a procedure or a pacemaker. If the dose is too high, medicines to treat arrhythmia can cause an irregular rhythm. This happens more often in women.<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

*'''[[Adenosine]]''' to slow a racing heart. Adenosine acts quickly to slow electrical signals. It can cause some chest pain, flushing, and shortness of breath, but any discomfort typically passes soon.
*'''[[Atropine]]''' to treat a slow heart rate. This medicine may cause difficulty swallowing.
*'''[[Beta-blockers]]''' to treat high blood pressure or a fast heart rate or to prevent repeat episodes of arrhythmia. Beta blockers can cause digestive trouble, sleep problems, and sexual dysfunction and can make some conduction disorders worse.
*'''[[Blood thinners]]''' to reduce the risk of blood clots forming. This helps prevent stroke. With blood-thinning medicines, there is a risk of bleeding.
*'''[[Calcium channel blockers]]''' to slow a rapid heart rate or the speed at which signals travel. Typically, they are used to control arrhythmias of the upper chambers. In some cases, calcium channel blockers can trigger ventricular fibrillation. They can also cause digestive trouble, swollen feet, or low blood pressure.
*'''[[Digoxin|Digitalis, or digoxin]]''', to treat a fast heart rate. This medicine can cause nausea and may trigger arrhythmias.
*'''[[Antiarrhythmic|Potassium channel blockers]]''' to slow the heart rate. They work by lengthening the time it takes for heart cells to recover after firing, so that they do not fire and squeeze as often. Potassium channel blockers can cause low blood pressure or other arrhythmias.
*'''[[Antiarrhythmic agent|Sodium channel blockers]]''' to block transmission of electrical signals, lengthen cell recovery periods, and make cells less excitable. However, these drugs can increase risks of sudden cardiac arrest in people who have heart disease.<ref name="urlArrhythmia | NHLBI, NIH">{{cite web |url=https://www.nhlbi.nih.gov/health-topics/arrhythmia |title=Arrhythmia &#124; NHLBI, NIH |format= |work= |accessdate=}}</ref>

*To browse the medical therapy of COVID-19, [[COVID-19 medical therapy|click here]].

=== Surgery ===

*Surgery is usually the treatment recommended only if all other options have failed. In this case, a person is put under [[anesthesia]] and a surgeon removes the tissue causing the [[Cardiac arrhythmia|arrhythmia]].<ref name="urlArrhythmias (for Teens) - Nemours KidsHealth">{{cite web |url=https://kidshealth.org/en/teens/arrhythmias.html |title=Arrhythmias (for Teens) - Nemours KidsHealth |format= |work= |accessdate=}}</ref>

*To have a better insight of treatment for different types of arrhythmia, [[Cardiac arrhythmia|click here]].

===Primary Prevention===

*American Heart Association (AHA) recommends the following change in lifestyle:
**Reduce high [[blood pressure]]
**Control cholesterol levels
**Lose excess weight
**Maintain a heart-healthy diet
**Stop smoking and avoid secondhand smoke.
**Regular physical activity
**Drink alcohol only in moderation

*To browse the primary prevention of COVID-19, [[COVID-19 primary prevention|click here]].

===Secondary Prevention===

* Fever can increase the risk of [[ventricular arrhythmias]] in patients with [[Brugada syndrome]]. Studies have shown significant results with [[acetaminophen]] which lowers [[fever]]. [[Patients]] with prior history of [[syncope]] and who develop [[Brugada Syndrome|type 1 ECG finding of Brugada Syndrome]] should head to the Emergency department if [[acetaminophen]] is unable to normalize the [[fever]].<ref name="pmid32244059">{{cite journal| author=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C | display-authors=etal| title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=32244059 | doi=10.1016/j.hrthm.2020.03.024 | pmc=7156157 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32244059  }} </ref>

*To browse the secondary prevention of COVID-19, [[COVID-19 secondary prevention|click here]].

==References==
{{Reflist|2}}
 
[[Category: Pick One of 28 Approved]]

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