COVID-19-associated arrhythmia and conduction system disease: Difference between revisions

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{{SI}}
{{Main article|COVID-19}}
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>                                                            
{{COVID-19}}                                                                  
{{CMG}} {{AE}} {{Sara.Zand}} {{TAM}}
{{CMG}} {{AE}} {{TAM}}


{{SK}}[[COVID-19-associated arrhythmia and conduction system disease|COVID-19-associated dysrhythmia]]
{{SK}}[[COVID-19-associated arrhythmia and conduction system disease|COVID-19-associated dysrhythmia]]
==Overview==
==Overview==
An [[arrhythmia]] is a problem with the rate or rhythm of the heartbeat. During an [[arrhythmia]], the heart can beat too fast, 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]].
[[Sever acute respiratory syndrome coronavirus-2]] ([[SARS-COV-2]]) is the [[virus]] that causes [[coronavirus disease 2019]] may affect every [[organ]] system including the [[heart]]. [[Arrhythmia]] is a disorder of [[conduction]] system including [[atrial arrhythmia]], [[ventricular arrhythmia]], [[bradyarrhythmia]] , resulting from  direct effect of [[virus]]  by attaching viral [[spike protein]] to [[ACE2]] receptors on [[myocardium]] and inducing [[myocardial injury]] and conduction damage system or indirect effect of [[covid-19]] such as coexisting [[hypoxia]], [[electrolytes]] disarray, and the administration of [[arrhythmogenic]] [[medications]] ([[hydroxychloroquine]], [[azithromycin]]). Reported case about new onset [[atrial fibrillation]] in [[covid-19]] [[infection]] may indicate the [[atrial arrhythmogenicity]] of [[covid-19]] [[infection]]. In the presence of [[covid-19]], approperiate approach to life threatening [[arrhythmia]] and considering [[fulminant myocarditis]] are warranted. High number of out-of hospital [[cardiac arrest]] in Italy during the 40 first days of initiation of pandemic, raised the concerns about the risk of [[arrhythmia]] in [[covid-19]]. [[Incidence]] of [[arrhythmia]] in [[ICU]] admitted [[covid-19]] [[patients]] increased to 10 folds. [[Cardiac ]] [[arrhythmia]] was associated with increased  [[mortality]] and [[morbidity]] in [[hospitalized]] [[covid-19]] [[patients]].
 
==Historical Perspective==
==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>
* 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>
*[[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 also 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>
* 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]].
To browse the historical perspective of COVID-19, [[COVID-19 historical perspective|click here]].


==Classification==
==Classification==
* COVID-19-associated arrhythmia may be classified into two subtypes/groups based on the clinical presentation:
* [[Arrhythmia]] related to [[COVID-19]]  may be classified into [[atrial arrhythmia]] (81.8%), [[ventricular arrhythmia]] (21%), [[bradyarrhythmia]] (22.6%) as follows:
 
* [[Atrial fibrillation]]
:*'''[[Cardiac arrhythmia|Acquired arrhythmia]]:'''
* [[Atrial flutter]]
::*
* [[Supraventricular tachycardia]]
::*
*  Nonsustained [[ventricular tachycardia]]
::*
* [[Ventricular tachycardia]]
:*'''[[Cardiac arrhythmia|Inherited arrhythmia]]:'''
* [[Ventricular fibrillation]]
::COVID-19 patients with inherited arrhythmia syndromes are believed to be more liable to pro-arrhythmic consequences of [[SARS-CoV-2]] 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:
* [[Atrioventricular block]]
::*[[Long QT syndrome|Long QT syndrome]]
* Marked [[sinus bradycardia]] ([[heart rate]]<40 [[bpm]])
::*[[Short QT syndrome]]
::*[[Brugada syndrome]]
::*[[Catecholaminergic polymorphic ventricular tachycardia]],
 
*To browse the [[classification]] of COVID-19, [[COVID-19 classification|Click here]].


==Pathophysiology==
==Pathophysiology==
* [[Respiratory]] [[disease]] is the chief target of [[COVID-19|Coronavirus disease 2019]] (COVID-19).  
* [[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]].
*[[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>
* Type 1 and type 2 [[pneumocytes]] exhibit [[Angiotensin-converting enzyme 2|ACE 2]] receptors in the lung.  
* 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]].
*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>
* Binding of [[SARS-CoV-2]] to ACE2 receptors can result in [[hypokalemia]] which causes various types of [[Cardiac arrhythmia|arrhythmia]].
* 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]].
* 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>
*[[Hypoxemia|Hypoxia]] and [[Electrolyte disturbance|electrolyte abnormalities]] that are common in the acute phase of severe [[COVID-19]] can potentiate [[Cardiac arrhythmia|cardiac arrhythmias]].
* 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>
* Binding of [[SARS-CoV-2]] to [[ACE2]] receptors can result in [[hypokalemia]] which causes various types of [[Cardiac arrhythmia|arrhythmia]].
* 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>
* 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>
* Use of [[hydroxychloroquine]] and [[azithromycin]] was associated with  [[QT prolongation]] and [[ventricular arrhythmia]] due to [[action potential]] prolongation, inhibition of hERG-K channels, and [[early afterdepolarization]].
* It is thought that abnormal host immune response is due to over activation of the [[cardiac]] [[sympathetic]] system, [[immune cell-mediated injury]] and inhibition of [[CYP450]] by [[IL6]].
* Inhibition of [[CYP450]] by [[IL6]] may lead to increased bioavailability of [[QT prolongation]] drugs and [[ventricular arrhythmia]].
* [[immune cell-mediated injury]] may cause [[inflammatory myocardial scarring]] and [[ventricular arrhythmia]] by the mechanisms of [[electrical imbalance ]] and [[reentry]]
* Overactivity of the [[cardiac]] [[sympathetic system]] is the precursor of [[myocardial ischemia]] and [[cardiac arrhythmia]].
[[File:COVID-19 arrhythmia1.png|700px|center]]
* [[Acute renal injury]] and [[diarrhea]] may lead to intravascular volume imbalance , [[electrolytes imblance]] resulting [[arrhythmia]].
*  [[Pulmonary hypertension ]] and [[pulmonary embolism]] may cause [[increased]] right sided pressures and [[myocardial injury]] and [[arrhythmia]].


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


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


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


==Causes==
*Potential causes of [[arrhythmia]] in [[covid-19]] include: (doi:10.1016/j.jacep.2020.08.002)
SARS-CoV-2 causes COVID-19-associated arrhythmia through different mechanisms, including direct viral attack, cytokine storm, etc.
*[[Hypoxia]]
*[[Myocarditis]]
*[[Abnormal host immune response]]
*[[Myocardial ischemia]]
*[[Myocardial strain]]
*[[Electrolytes]] derangement
*[[Intravascular]] volume imbalance
*[[ Drug]] side effects


Common causes of arrhythmia include:  
*Common causes of [[bradyarrhythmia]] in [[covid-19]] [[patients]] include:
*Abnormal levels of [[potassium]] or other substances in the body
*: Use of [[remdesivir]]
*[[ST elevation myocardial infarction|Heart attack]], or a damaged heart muscle from a past heart attack
*: [[Hypoxia]]
*[[Coronary heart disease prevention|Heart disease]] that is present at birth (congenital)
*: [[Viral]] [[myocarditis]]
*Heart failure or an enlarged heart
*: Damage to [[pacemaker cells]] due to [[inflammatory]] [[cytokines]]
*[[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>


==Differentiating COVID-19-associated arrhythmia from other Diseases==
==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:
*Differentiation diagnosis of [[arrhythmia]] and conduction disorder related to [[COVID-19]] include the following:
*[[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>
* [[Atrial fibrillation]]
*[[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>
* [[Atrial flutter]]
*[[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>
* [[Supraventricular tachycardia]]
*[[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>
* Nonsustained [[ventricular tachycardia]]
*[[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>
* [[Ventricular tachycardia]]
*[[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>
* [[Ventricular fibrillation]]
*[[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>
* [[Atrioventricular block]]
*[[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>
To browse the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].
*[[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|Antihyperetnsive 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>


==Epidemiology and Demographics==
==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 from population to population. 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>
===Incidence===
* 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>
* The [[incidence]] of [[cardiac arrhythmia]] including [[AF]], [[atrial flutter]], [[SVT]], nonsustained [[VT]], [[VT]], [[VF]], marked [[sinus bradycardia]], [[atrioventricular block]], or pauses> 3 seconds was estimated to be 12900 per 100,000 [[covid-19]] [[patients]].  
* In a cohort of 138 [[COVID-19]] patients from Wuhan, [[Cardiac arrhythmia|arrhythmias]] were observed in 17 percent of hospitalized patients because of [[COVID-19|COVID-19-related pneumonia]], and in 44 percent 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===
===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>
The mean age of [[covid-19]] [[patients]] who developed [[arrhythmia]] was 71± 14 years.


===Gender===
===Gender===
*There is not much data available to delineate the gender of COVID-19 patients prone to develop arrhythmia.
[[Arrhythmia]] in [[covid-19]] [[patients]] was more common in [[men]].
 
===Race===
===Race===
* There is not enough data on a racial predilection for COVID-19-associated arrhythmia.
*[[Asian]] individuals  with [[COVID-19]] are less likely to develop [[atrial arrhythmia]] compared with other continents (34% versus 81%). However, the [[incidence]] of [[bradyarrhythmia]] and [[atrioventricular block]] were higher in [[asian]] than other continents.
*Distribution of [[ventricular arrhythmia]]  was similar to other continents.<ref name="pmid33554620">{{cite journal |vauthors=Coromilas EJ, Kochav S, Goldenthal I, Biviano A, Garan H, Goldbarg S, Kim JH, Yeo I, Tracy C, Ayanian S, Akar J, Singh A, Jain S, Zimerman L, Pimentel M, Osswald S, Twerenbold R, Schaerli N, Crotti L, Fabbri D, Parati G, Li Y, Atienza F, Zatarain E, Tse G, Leung KSK, Guevara-Valdivia ME, Rivera-Santiago CA, Soejima K, De Filippo P, Ferrari P, Malanchini G, Kanagaratnam P, Khawaja S, Mikhail GW, Scanavacca M, Abrahão Hajjar L, Rizerio B, Sacilotto L, Mollazadeh R, Eslami M, Laleh Far V, Mattioli AV, Boriani G, Migliore F, Cipriani A, Donato F, Compagnucci P, Casella M, Dello Russo A, Coromilas J, Aboyme A, O'Brien CG, Rodriguez F, Wang PJ, Naniwadekar A, Moey M, Kow CS, Cheah WK, Auricchio A, Conte G, Hwang J, Han S, Lazzerini PE, Franchi F, Santoro A, Capecchi PL, Joglar JA, Rosenblatt AG, Zardini M, Bricoli S, Bonura R, Echarte-Morales J, Benito-González T, Minguito-Carazo C, Fernández-Vázquez F, Wan EY |title=Worldwide Survey of COVID-19-Associated Arrhythmias |journal=Circ Arrhythm Electrophysiol |volume=14 |issue=3 |pages=e009458 |date=March 2021 |pmid=33554620 |pmc=7982128 |doi=10.1161/CIRCEP.120.009458 |url=}}</ref>


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


==Risk Factors==
==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|clicking here]].
*Concomitant [[comorbidities]] among [[covid-19]] [[patients]] with [[arrhythmia]] include:<ref name="pmid33554620">{{cite journal |vauthors=Coromilas EJ, Kochav S, Goldenthal I, Biviano A, Garan H, Goldbarg S, Kim JH, Yeo I, Tracy C, Ayanian S, Akar J, Singh A, Jain S, Zimerman L, Pimentel M, Osswald S, Twerenbold R, Schaerli N, Crotti L, Fabbri D, Parati G, Li Y, Atienza F, Zatarain E, Tse G, Leung KSK, Guevara-Valdivia ME, Rivera-Santiago CA, Soejima K, De Filippo P, Ferrari P, Malanchini G, Kanagaratnam P, Khawaja S, Mikhail GW, Scanavacca M, Abrahão Hajjar L, Rizerio B, Sacilotto L, Mollazadeh R, Eslami M, Laleh Far V, Mattioli AV, Boriani G, Migliore F, Cipriani A, Donato F, Compagnucci P, Casella M, Dello Russo A, Coromilas J, Aboyme A, O'Brien CG, Rodriguez F, Wang PJ, Naniwadekar A, Moey M, Kow CS, Cheah WK, Auricchio A, Conte G, Hwang J, Han S, Lazzerini PE, Franchi F, Santoro A, Capecchi PL, Joglar JA, Rosenblatt AG, Zardini M, Bricoli S, Bonura R, Echarte-Morales J, Benito-González T, Minguito-Carazo C, Fernández-Vázquez F, Wan EY |title=Worldwide Survey of COVID-19-Associated Arrhythmias |journal=Circ Arrhythm Electrophysiol |volume=14 |issue=3 |pages=e009458 |date=March 2021 |pmid=33554620 |pmc=7982128 |doi=10.1161/CIRCEP.120.009458 |url=}}</ref>
*:[[Hypertension]] (69%)
*: [[Diabetes mellitus]] (42%)
*: [[Congestive heart failure]] (30%)
*:[[Coronary artery disease]] (24%)
*Independent predictors of [[QTc prolongation]]≥ 500 ms in [[covid-19]] [[patients]] include:<ref name="pmid33478708">{{cite journal |vauthors=O'Connell TF, Bradley CJ, Abbas AE, Williamson BD, Rusia A, Tawney AM, Gaines R, Schott J, Dmitrienko A, Haines DE |title=Hydroxychloroquine/Azithromycin Therapy and QT Prolongation in Hospitalized Patients With COVID-19 |journal=JACC Clin Electrophysiol |volume=7 |issue=1 |pages=16–25 |date=January 2021 |pmid=33478708 |pmc=7406234 |doi=10.1016/j.jacep.2020.07.016 |url=}}</ref>
* [[Older]] age
* Lower [[body mass index]]
* Higher [[creatinine]] level
* Higher peak of [[troponin]]
* [[Congestive heart failure]]
* Use of [[hydroxychloroquine]], [[azithromycin]]
 
==Screening==
==Screening==
*There is no established screening method for detecting [[arrhythmia]] related to [[covid-19]]. However, [[QT interval]] measurement is recommended in [[covid-19]] [[patients]] before initiation of treatment with  [[hydroxychloroquine]], [[azithromycin]], [[remdesivir]], [[lopinavir]]/[[ritonavir]].<ref name="pmid33478708">{{cite journal |vauthors=O'Connell TF, Bradley CJ, Abbas AE, Williamson BD, Rusia A, Tawney AM, Gaines R, Schott J, Dmitrienko A, Haines DE |title=Hydroxychloroquine/Azithromycin Therapy and QT Prolongation in Hospitalized Patients With COVID-19 |journal=JACC Clin Electrophysiol |volume=7 |issue=1 |pages=16–25 |date=January 2021 |pmid=33478708 |pmc=7406234 |doi=10.1016/j.jacep.2020.07.016 |url=}}</ref>


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>
== Natural History, Complications and Prognosis==


[[Electrocardiogram]]:
* The majority  of [[patients]] with [[covid-19]] who developed [[arrhythmia]]s were intubated.<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>
*An [[electrocardiogram]] (EKG or ECG) is the main test for detecting [[Cardiac arrhythmia|arrhythmia]].
* [[Atrial fibrillation]] is the most common arrhythmia in [[covid-19]] [[patients]] and is associated with severe [[disease]] and poor [[outcome]].  
*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.
* Reported case about new onset [[atrial fibrillation ]] in [[covid-19]] [[patients]] may indicate the [[arrhythmogenicity]] of [[covid-19]] [[infection]]. <ref name="pmid7218462">{{cite journal |vauthors=Kelalis PP, Malek RS |title=Infundibulopelvic stenosis |journal=J Urol |volume=125 |issue=4 |pages=568–71 |date=April 1981 |pmid=7218462 |doi=10.1016/s0022-5347(17)55107-1 |url=}}</ref>
*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.
* Early clinical features include deterioration of underlying [[covid-19]] disease, [[ACS]], [[decompensated heart failure]], pre-[[syncope]], [[syncope]].
* If left untreated, [[patients]] with [[arrhythmia]] may progress to developed decompensated [[heart failure]], [[myocardial ischemia]], [[cardiac arrest]], [[intubation]], [[death]].
*Common complications of [[arrhythmia]] are [[congestive heart failure]], [[ACS]], [[stroke]], [[sudden cardiac death]].
* Prognosis is related to the type of [[arrhythmia]] and underlying mechanism of [[arrhythmia]], and survival rate to hospital discharge of [[covid-19]] [[patients]] with [[arrhythmia]] is approximately 51%.  
* Among [[covid-19]] [[patients]] with [[ventricular arrhythmia]], [[mortality]] rate (1.4×)  and risk of developing to [[ mechanical ventilation]] (1.3×) were higher than other [[arrhythmia]]s, and [[survival rate]] to discharge was approximately 38%.<ref name="pmid33554620">{{cite journal |vauthors=Coromilas EJ, Kochav S, Goldenthal I, Biviano A, Garan H, Goldbarg S, Kim JH, Yeo I, Tracy C, Ayanian S, Akar J, Singh A, Jain S, Zimerman L, Pimentel M, Osswald S, Twerenbold R, Schaerli N, Crotti L, Fabbri D, Parati G, Li Y, Atienza F, Zatarain E, Tse G, Leung KSK, Guevara-Valdivia ME, Rivera-Santiago CA, Soejima K, De Filippo P, Ferrari P, Malanchini G, Kanagaratnam P, Khawaja S, Mikhail GW, Scanavacca M, Abrahão Hajjar L, Rizerio B, Sacilotto L, Mollazadeh R, Eslami M, Laleh Far V, Mattioli AV, Boriani G, Migliore F, Cipriani A, Donato F, Compagnucci P, Casella M, Dello Russo A, Coromilas J, Aboyme A, O'Brien CG, Rodriguez F, Wang PJ, Naniwadekar A, Moey M, Kow CS, Cheah WK, Auricchio A, Conte G, Hwang J, Han S, Lazzerini PE, Franchi F, Santoro A, Capecchi PL, Joglar JA, Rosenblatt AG, Zardini M, Bricoli S, Bonura R, Echarte-Morales J, Benito-González T, Minguito-Carazo C, Fernández-Vázquez F, Wan EY |title=Worldwide Survey of COVID-19-Associated Arrhythmias |journal=Circ Arrhythm Electrophysiol |volume=14 |issue=3 |pages=e009458 |date=March 2021 |pmid=33554620 |pmc=7982128 |doi=10.1161/CIRCEP.120.009458 |url=}}</ref>
* Presence of [[atrial arrhythmia]] in [[covid-19]] [[patients]] was associated with  severe [[disease]] and poor [[outcome]].<ref name="pmid33470951">{{cite journal |vauthors=Mulia EPB, Maghfirah I, Rachmi DA, Julario R |title=Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis |journal=Diagnosis (Berl) |volume= |issue= |pages= |date=January 2021 |pmid=33470951 |doi=10.1515/dx-2020-0155 |url=}}</ref>
* Use of [[remdesivir]] was associated with [[bradycardia]] and [[complete heart block]], especially in [[patients]] with preexisting [[conduction disorder]], older [[patients]] or concomitant use of [[betablocker]].<ref name="pmid34222786">{{cite journal |vauthors=Selvaraj V, Bavishi C, Patel S, Dapaah-Afriyie K |title=Complete heart block associated with Remdesivir in COVID-19: a case report |journal=Eur Heart J Case Rep |volume=5 |issue=7 |pages=ytab200 |date=July 2021 |pmid=34222786 |pmc=8247739 |doi=10.1093/ehjcr/ytab200 |url=}}</ref>
* Use of [[hydroxychloroquine]], [[azithromycin]] were associated with [[QTc prolongation]]. However, the likelihood of [[torsades de pointes]] and [[mortality]] were low.<ref name="pmid33478708">{{cite journal |vauthors=O'Connell TF, Bradley CJ, Abbas AE, Williamson BD, Rusia A, Tawney AM, Gaines R, Schott J, Dmitrienko A, Haines DE |title=Hydroxychloroquine/Azithromycin Therapy and QT Prolongation in Hospitalized Patients With COVID-19 |journal=JACC Clin Electrophysiol |volume=7 |issue=1 |pages=16–25 |date=January 2021 |pmid=33478708 |pmc=7406234 |doi=10.1016/j.jacep.2020.07.016 |url=}}</ref>
* Before prescription of [[hydroxychloroquine]] and [[azithromycin]], potential risk factors of [[QT prolongation]] and [[ECG]] monitoring strategy should be noticed.
* In the presence of [[QTc prolongation]]≥ 500 ms, [[hydroxychloroquine]] and [[azithromycin]] should be withdrawn.
* Reported cases of life-threatening [[arrhythmia]] such as [[high grade atrioventricular block]], [[polymorphic ventricular tachycardia]], [[accelerated ideoventricular rhythm]] and [[atrial fibrillation ]] in [[covid-19]] [[patients]] without severe [[lung]] involvement, showed the need for appropriate [[rhythm]] monitoring, particularly if [[fulminant myocarditis]] is suspected.<ref name="pmid32434385">{{cite journal |vauthors=Kochav SM, Coromilas E, Nalbandian A, Ranard LS, Gupta A, Chung MK, Gopinathannair R, Biviano AB, Garan H, Wan EY |title=Cardiac Arrhythmias in COVID-19 Infection |journal=Circ Arrhythm Electrophysiol |volume=13 |issue=6 |pages=e008719 |date=June 2020 |pmid=32434385 |pmc=7299099 |doi=10.1161/CIRCEP.120.008719 |url=}}</ref>


[[Genetics|Genetic Testing]]:
*Reported [[ECG]] changes prompting [[arrhythmia]] complication associated medications in [[covid-19]] include:
*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.  
*[[Remdesivir]]:
*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]].
*:: [[QT prolongation]]<ref name="pmid33240723">{{cite journal |vauthors=Gupta AK, Parker BM, Priyadarshi V, Parker J |title=Cardiac Adverse Events With Remdesivir in COVID-19 Infection |journal=Cureus |volume=12 |issue=10 |pages=e11132 |date=October 2020 |pmid=33240723 |pmc=7682945 |doi=10.7759/cureus.11132 |url=}}</ref>
*:: [[Non specific T waves change]]
*:: [[Cardiac arrest]] (1.1%)
*:: [[Severe bradycardia]]<ref name="pmid33163977">{{cite journal |vauthors=Gubitosa JC, Kakar P, Gerula C, Nossa H, Finkel D, Wong K, Khatri M, Ali H |title=Marked Sinus Bradycardia Associated With Remdesivir in COVID-19: A Case and Literature Review |journal=JACC Case Rep |volume=2 |issue=14 |pages=2260–2264 |date=November 2020 |pmid=33163977 |pmc=7598346 |doi=10.1016/j.jaccas.2020.08.025 |url=}}</ref><ref name="pmid33903133">{{cite journal |vauthors=Day LB, Abdel-Qadir H, Fralick M |title=Bradycardia associated with remdesivir therapy for COVID-19 in a 59-year-old man |journal=CMAJ |volume=193 |issue=17 |pages=E612–E615 |date=April 2021 |pmid=33903133 |pmc=8101980 |doi=10.1503/cmaj.210300 |url=}}</ref>
*:: Transient [[complete heart block]]<ref name="pmid34222786">{{cite journal |vauthors=Selvaraj V, Bavishi C, Patel S, Dapaah-Afriyie K |title=Complete heart block associated with Remdesivir in COVID-19: a case report |journal=Eur Heart J Case Rep |volume=5 |issue=7 |pages=ytab200 |date=July 2021 |pmid=34222786 |pmc=8247739 |doi=10.1093/ehjcr/ytab200 |url=}}</ref>
*:: [[Atrial fibrillation]] (4%)
* [[Azithromycin]]
*::[[Bradycardia]], prolonged [[PR interval]], [[QTc prolongation]] with very low risk of [[torsades de pointes]]
*:: Severe interaction with [[amiodarione]], [[disopyramide]], [[dofetilide]], [[flecainide]], [[sotalol]], [[propafenone]]
*:: Moderate interaction with [[betablocker]], [[digoxin]]
*[[Hydroxychloroquine]]
*::[[Bradycardia]], prolonged [[PR interval]], [[QTc prolongation]] with very low risk of [[torsades de pointes]]<ref name="pmid32434385">{{cite journal |vauthors=Kochav SM, Coromilas E, Nalbandian A, Ranard LS, Gupta A, Chung MK, Gopinathannair R, Biviano AB, Garan H, Wan EY |title=Cardiac Arrhythmias in COVID-19 Infection |journal=Circ Arrhythm Electrophysiol |volume=13 |issue=6 |pages=e008719 |date=June 2020 |pmid=32434385 |pmc=7299099 |doi=10.1161/CIRCEP.120.008719 |url=}}</ref>
*:: Severe interaction with [[amiodarone]], [[flecainide]], [[mexiletine]], [[sotalol]], [[dofetilide]]
*::Moderate interaction with [[disopyramide]], [[propafenone]], [[quinidine]], [[digoxin]]
*::Mild interaction with [[metoprolol]], [[nebivolol]], [[propranolol]], [[timolol]], [[verapamil]]
*[[Lopinavir]]/ [[ritonavir]]
*::Prolonged [[PR interval]], [[QTc prolongation]] with very low risk of [[torsades de pointes]]
*:: Severe interaction with [[amiodarone]], [[drondarone]], [[disopyramide]], [[dofetilide]], [[flecainide]], [[sotalol]]
*::Moderate interaction with [[lidocaine]], [[mexiletine]], [[propafenone]], [[quinidine]], [[digoxin]], [[batablocker]], [[calcium channel blocker]]<ref name="pmid32972561">{{cite journal |vauthors=Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U |title=Arrhythmias and COVID-19: A Review |journal=JACC Clin Electrophysiol |volume=6 |issue=9 |pages=1193–1204 |date=September 2020 |pmid=32972561 |pmc=7417167 |doi=10.1016/j.jacep.2020.08.002 |url=}}</ref>


[[Cardiovascular magnetic resonance imaging (CMR)|Imaging tests]]:
== Diagnosis ==
*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>


== Natural History, Complications and Prognosis==
=== Diagnostic Study of Choice ===
'''Natural History:'''
*'''ECG:'''  
*[[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>
 
::* 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).
*[[Cardiac arrhythmia|Arrhythmia]] presents with the history of:
*[[Cardiac arrhythmia|Arrhythmia]] presents with the history of:
**Slow or irregular heartbeat or pauses between heartbeats
**Slow or irregular [[heartbeat]] or pauses between [[heartbeats]]
**Skipping a heartbeat
**Skipping a [[heartbeat]]
**Heart pounding or racing
**[[Heart]] pounding or racing
**[[Anxiety]]
**[[Anxiety]]
**[[Blurred vision]]
**[[Blurred vision]]
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**[[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>
**[[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===
=== 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 arrhythmia]], [[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]].


[[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>
*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 ===
=== Laboratory Findings ===
* There are no specific laboratory findings associated with COVID-19-associated arrhythmia.
* 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>
* 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===
===Electrocardiogram===
COVID-19-associated arrhythmia findings include:
COVID-19-associated arrhythmia findings include:
*[[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" />


*'''Prolong QT Interval:'''  
*'''Prolong QT Interval:'''  


::According to a multicenter study done in New York that involved 4250 [[COVID-19]] patients, 260 patients (6.1 percent) 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>
::* 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]]
[[File:Prolong QT Interval.png|700px|center]]
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*'''Atrial Arrhythmia:'''  
*'''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 percent).<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>
::* 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]]
[[File:Atrial Arrhythmia.png|700px|center]]
Line 190: Line 215:
*'''Ventricular Arrhythmia:'''  
*'''Ventricular Arrhythmia:'''  


::According to a study done in Wuhan, China. among 187 hospitalized patients with [[COVID-19]], 11 patients (5.9 percent) 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>
::* 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]]
[[File:Ventricular Arrhythmia.png|700px|center]]
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*'''Cardiac Arrest:'''  
*'''Cardiac Arrest:'''  


::According to a Lombardia Cardiac Arrest Registry (Lombardia CARe) of the region Lombardia in 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. 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>
::* 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]]
[[File:Cardiac arrest.png|700px|center]]


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


===X-Ray===
===X-Ray===
*To browse the X-ray finding of COVID-19, [[COVID-19 x-ray|Click here]].
*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===
===CT Scan===
* To browse the CT-Scan findings of COVID-19, [[COVID-19 CT scan|Click here]].
* To browse the CT-Scan findings of COVID-19, [[COVID-19 CT scan|click here]].
 
===MRI===
===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]].
*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>
*[[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===
===Other Imaging Findings===
*There are no other imaging findings associated with COVID-19-associated arrhythmia.
*There are no other imaging findings associated with [[COVID-19]]-associated [[arrhythmia]].
 
=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===
*[[Cardiac biomarkers|Myocardial biomarkers]] ought to 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>
*[[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:
*American Heart Association (AHA) recommends the following tests to diagnose arrhythmia:
**[[Holter monitor]]
**[[Holter monitor]]
Line 224: Line 268:


== Treatment ==
== Treatment ==
=== Medical Therapy ===
=== Medical Therapy based on 2020 ESC Guidline for management of arrhythmia in [[covid-19]] [[patients]] ===
*'''Polymorphic Ventricular Tachycardia (torsades de pointes):'''
*The mainstay of therapy of [[arrhythmia]] in [[patients]] with [[covid-19]] is  limiting exposure and minimizing drug-drug interactions.<ref name="pmid32972561">{{cite journal |vauthors=Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U |title=Arrhythmias and COVID-19: A Review |journal=JACC Clin Electrophysiol |volume=6 |issue=9 |pages=1193–1204 |date=September 2020 |pmid=32972561 |pmc=7417167 |doi=10.1016/j.jacep.2020.08.002 |url=}}</ref>
 
*Treatment of [[tachyarrhythmia]] and [[bradyarrhythmia]] in [[patients]] with [[covid-19]] is similar to any patients with [[arrhythmia]] due to [[infection]] and transient [[metabolic disturbance]].
::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>
* In [[patients]] who use [[QTc prolongation]] drugs, or have a history of inherited [[arrhythmia]], specific consideration should be given.
:*'''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|<u>Click here</u>]].
 
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]].
===[[Bradyarrhythmia]]===
*Causes of [[bradycardia]] ([[sinus node block]] or [[AV block]]) in [[covid-19]] [[patients]]:<ref name="pmid32972561">{{cite journal |vauthors=Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U |title=Arrhythmias and COVID-19: A Review |journal=JACC Clin Electrophysiol |volume=6 |issue=9 |pages=1193–1204 |date=September 2020 |pmid=32972561 |pmc=7417167 |doi=10.1016/j.jacep.2020.08.002 |url=}}</ref>
*:Side effects of drugs such as [[hydroxychloroquine]], [[lopinavir]]/[[ritonavir]], [[azithromycin]]
*: [[Myocarditis]]: if conduction system involved
*: Transient [[bradycardia]] during suction of [[secretion]] in [[intubated]] [[patients]] or [[proning position]] leading to increased [[vagal tone]]
# In [[patients]] with persistent [[bradycardia]], before insertion of [[ temporary pacemaker]], [[atropine]] or [[isoprenaline]] are considered.
# [[Temporary pacemaker]] is the first option before making decision for [[permanent pacemaker]] because of the transient nature of [[bradyarrhythmia]], [[critical illness]], risk of [[bacterial superinfection]], risk of device [[infection]].
# After recovery of [[covid-19]] , reevaluation about  [[permanent pacemaker implantation ]] should be considered.<ref name="pmid32350745">{{cite journal |vauthors=Saenz LC, Miranda A, Speranza R, Texeira RA, Rojel U, Enriquez A, Figuereido M |title=Recommendations for the organization of electrophysiology and cardiac pacing services during the COVID-19 pandemic : Latin American Heart Rhythm Society (LAHRS) in collaboration with: Colombian College Of Electrophysiology, Argentinian Society of Cardiac Electrophysiology (SADEC), Brazilian Society Of Cardiac Arrhythmias (SOBRAC), Mexican Society Of Cardiac Electrophysiology (SOMEEC) |journal=J Interv Card Electrophysiol |volume=59 |issue=2 |pages=307–313 |date=November 2020 |pmid=32350745 |pmc=7189002 |doi=10.1007/s10840-020-00747-5 |url=}}</ref>
* If the use of [[remdesivir]] is associated with [[severe bradycardia]], [[remdesivir]] should be discontinued, and [[ECG]] monitoring is recommended.<ref name="pmid33903133">{{cite journal |vauthors=Day LB, Abdel-Qadir H, Fralick M |title=Bradycardia associated with remdesivir therapy for COVID-19 in a 59-year-old man |journal=CMAJ |volume=193 |issue=17 |pages=E612–E615 |date=April 2021 |pmid=33903133 |pmc=8101980 |doi=10.1503/cmaj.210300 |url=}}</ref>


=== Surgery ===
===[[Atrial tachyarrhythmia]] ([[supraventricular tachycardia]], [[atrial fibrillation]], [[atrial flutter]])===
*Treatment of underlying causes including [[hypoxia]], [[metabolic imbalance]], [[electrolytes imbalance]], [[proarrhythmic effect of drugs]], [[myocardial ischemia]]
*In the presence of [[supraventricular tachycardia]]: administration of [[adenosine]], [[low threshold shock]] in refractory cases with [[hemodynamic instability]], administration of  [[betablocker]] or [[calcium channel blocker]] with concerns about interaction with [[antiviral]] drug  or the risk of [[bradycardia]] and  [[QTc prolongation]] should be noticed.
*In [[patients]] with [[atrial fibrillation]] or [[atrial flutter]], [[betablockers]] and [[calcium channel blockers]] are preferred to rating control and  discontinuation of [[antiarrhythmic]] drug such as [[sotalol]], [[flecainide]], [[amiodarone]] and [[propafenone]] is recommended because of serious drug-drug interaction with [[antiviral]] [[drugs]].
*[[Rhythm]] control strategy should be reserved only for [[patients]] with [[ unstable hemodynamic]] and [[congestive heart failure]].
* [[Anticoagulant]] therapy should be considered in [[covid-19]] [[patients]] with [[atrial fibrillation]] due to [[hypercoagulability]] state in such [[condition]].
*[[Immunosupressant]] therapy is considered for [[patients]] with [[myocarditis]].


*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>
===[[Ventricular arrhythmia]]===
*Treatment of underlying causes of [[ventricular arrhythmia]] such as [[hypoxia]], [[electrolytes imbalance]], [[proarrhythmic]] effect of [[drug]]s are recommended.
* [[Amiodarone]] , [[lidocaine]] are first choice of [[VT]] storm therapy, especially in the setting of [[myocardial ischemia]].
* [[Esmolol]], [[sedation]], [[intubation]] are further choices for treatnig [[ventricular arrhythmia]] storm.
*[[Lidocaine]] and [[mexiletine]] are useful in the context of [[prolonged QT]] interval and [[torsades de pointes]] due to slightly shortening of [[QT interval]].
* In the presence of [[polymorphic ventricular tachycardia]] due to [[QT prolongation]] by [[antiviral therapy]], discontinuation the [[antiviral therapy]] and [[infusion]] of [[magnesium]] and correction of [[hypokalemia]] and infusion of [[isoprenaline]] are recommended.
*In case of recurrent [[torsades de pointes]] and [[bradycardia]], [[arrhythmia]] can be suppressed by overdrive pacing of [[temporary pacemaker]] [[implantation]].
* [[Echocardiogtaphy]] is needed if there is new onset of malignant [[ventricular arrhythmia]] unrelated to [[prolonged QTc]].


*To have a better insight of treatment for different types of arrhythmia, [[Cardiac arrhythmia|Click here]].
===[[QT prolongation]] in [[covid-19]] therapy===
* [[QT prolongation ]] has been found in 12% of [[patients]] recieving [[hydroxychloroquine]], [[azithromycin]], or both. However, there was no [[torsades de pointes]].<ref name="pmid32463348">{{cite journal |vauthors=Ramireddy A, Chugh H, Reinier K, Ebinger J, Park E, Thompson M, Cingolani E, Cheng S, Marban E, Albert CM, Chugh SS |title=Experience With Hydroxychloroquine and Azithromycin in the Coronavirus Disease 2019 Pandemic: Implications for QT Interval Monitoring |journal=J Am Heart Assoc |volume=9 |issue=12 |pages=e017144 |date=June 2020 |pmid=32463348 |pmc=7429030 |doi=10.1161/JAHA.120.017144 |url=}}</ref>
* High dose of [[chloroquine]] (600 mg BD for 10 days compared with 450 mg BD for one day then 450mg daily for 4 days) was associated with increased adverse effects.<ref name="pmid32330277">{{cite journal |vauthors=Borba MGS, Val FFA, Sampaio VS, Alexandre MAA, Melo GC, Brito M, Mourão MPG, Brito-Sousa JD, Baía-da-Silva D, Guerra MVF, Hajjar LA, Pinto RC, Balieiro AAS, Pacheco AGF, Santos JDO, Naveca FG, Xavier MS, Siqueira AM, Schwarzbold A, Croda J, Nogueira ML, Romero GAS, Bassat Q, Fontes CJ, Albuquerque BC, Daniel-Ribeiro CT, Monteiro WM, Lacerda MVG |title=Effect of High vs Low Doses of Chloroquine Diphosphate as Adjunctive Therapy for Patients Hospitalized With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection: A Randomized Clinical Trial |journal=JAMA Netw Open |volume=3 |issue=4 |pages=e208857 |date=April 2020 |pmid=32330277 |doi=10.1001/jamanetworkopen.2020.8857 |url=}}</ref>
*High risk [[patients]] for [[QT prolongation]] include:<ref name="pmid33521580">{{cite journal |vauthors=Castagna A, Ruotolo G, Manzo C |title=Hydroxychloroquine and QT Prolongation in Older Patients with Rheumatic Diseases: Who is afraid of the Boogeyman? We are not! |journal=Mediterr J Rheumatol |volume=31 |issue=4 |pages=433–435 |date=December 2020 |pmid=33521580 |pmc=7841093 |doi=10.31138/mjr.31.4.433 |url=}}</ref>
*:Age> 68 years
*:[[Female]] sex
*:Use of [[loop diuretic]]
*:Serum [[potassium]] level ≤3.5 mEq/l
*: Baseline QTc≥ 450 ms
*:Acute [[myocardial infarction]]
*:Use of numbers [[QT prolongation]] [[medications]]
*:[[Sepsis]]
*: [[Heart failure]]
* In the presence of baseline  QTc≥ 500 ms, or increased greater than 60 ms after 2-3 hours of administration of [[hydroxychloroquine]] or other [[QT prolongation]] [[drugs]], risk of [[torsades de pointes]] should be considered.<ref name="pmid32703574">{{cite journal |vauthors=Cheung CC, Davies B, Gibbs K, Laksman ZW, Krahn AD |title=Multilead QT Screening Is Necessary for QT Measurement: Implications for Management of Patients in the COVID-19 Era |journal=JACC Clin Electrophysiol |volume=6 |issue=7 |pages=878–880 |date=July 2020 |pmid=32703574 |pmc=7141442 |doi=10.1016/j.jacep.2020.04.001 |url=}}</ref>


===Primary Prevention===
===[[Cardiac ]] medications interaction with [[covid-19]] therapy===
*The level of drug that are metabolized by CP450 isoenzyme such as  [[amiodarone]], [[propafenon]], [[flecainide]], [[quinidine]], [[apixaban]], [[rivaroxaban]] can be increased by administration of [[lopinavir]]/[[ritonavir]].


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


*To browse the primary prevention of COVID-19, [[COVID-19 primary prevention|Click here]].
[[Electrophysiology]] study in an [[elective procedure]] and should be planned for  management of specific [[arrhythmia]]s  after recovery of [[covid-19]] [[infection]].


===Secondary Prevention===
==Primary 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>
* Effective measurement  for [[primary prevention]] of [[ventricular arrhythmia]] in [[covid-19]] [[patients]] who recieve [[hydroxychloroquine]] and [[azithromycin]] or other [[QTc prolongation]] [[drugs]] is determination baseline [[QTc]] on [[ECG]].
* If baseline QTc is > 500ms for [[QRS]]< 120 ms, or if QTc is >550 ms for [[QRS]]> 120ms, or QTc prolonged by 60 ms, these medications should be withheld.<ref name="pmid32434385">{{cite journal |vauthors=Kochav SM, Coromilas E, Nalbandian A, Ranard LS, Gupta A, Chung MK, Gopinathannair R, Biviano AB, Garan H, Wan EY |title=Cardiac Arrhythmias in COVID-19 Infection |journal=Circ Arrhythm Electrophysiol |volume=13 |issue=6 |pages=e008719 |date=June 2020 |pmid=32434385 |pmc=7299099 |doi=10.1161/CIRCEP.120.008719 |url=}}</ref>
* [[Primary prevention]] strategy in [[covid-19]] [[patients]] with [[brugada]] pattern type 1 is controlling [[fever]] by [[acetaminophen]] for reducing the risk of [[ventricular arrhythmia]] and [[self isolation]].<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]].
==Secondary Prevention==
[[Secondary prevention ]] for [[covid-19]] associated with [[arrhythmia]]  is implantation of [[ICD]] after recovery of [[covid-19]] in case of [[ventricular arrhythmia]] and low [[LVEF]] based on the guideline.


==References==
==References==

Latest revision as of 05:51, 21 October 2021

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Main article: COVID-19

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: Sara Zand, M.D.[2] Tayyaba Ali, M.D.[3]

Synonyms and keywords:COVID-19-associated dysrhythmia

Overview

Sever acute respiratory syndrome coronavirus-2 (SARS-COV-2) is the virus that causes coronavirus disease 2019 may affect every organ system including the heart. Arrhythmia is a disorder of conduction system including atrial arrhythmia, ventricular arrhythmia, bradyarrhythmia , resulting from direct effect of virus by attaching viral spike protein to ACE2 receptors on myocardium and inducing myocardial injury and conduction damage system or indirect effect of covid-19 such as coexisting hypoxia, electrolytes disarray, and the administration of arrhythmogenic medications (hydroxychloroquine, azithromycin). Reported case about new onset atrial fibrillation in covid-19 infection may indicate the atrial arrhythmogenicity of covid-19 infection. In the presence of covid-19, approperiate approach to life threatening arrhythmia and considering fulminant myocarditis are warranted. High number of out-of hospital cardiac arrest in Italy during the 40 first days of initiation of pandemic, raised the concerns about the risk of arrhythmia in covid-19. Incidence of arrhythmia in ICU admitted covid-19 patients increased to 10 folds. Cardiac arrhythmia was associated with increased mortality and morbidity in hospitalized covid-19 patients.

Historical Perspective

To browse the historical perspective of COVID-19, click here.

Classification

Pathophysiology


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

Causes

Differentiating COVID-19-associated arrhythmia from other Diseases


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

Epidemiology and Demographics

Incidence

Age

The mean age of covid-19 patients who developed arrhythmia was 71± 14 years.

Gender

Arrhythmia in covid-19 patients was more common in men.

Race


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

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

  • ECG:
  • Most patients with the severe COVID-19, and especially patients who receive 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.[22][23]
  • Transthoracic echocardiography:

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

History and Symptoms

Arrhythmia or conduction system disease is the nonspecific clinical presentation of COVID-19. Patients may be tachycardic (with or without palpitations) in the setting of other COVID-19-related symptoms (eg, fever, shortness of breath, pain, etc).

Physical Examination

Laboratory Findings

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 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.[28][29]
  • Atrial Arrhythmia:
  • Ventricular Arrhythmia:
  • 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.
  • 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.
  • To browse the electrocardiogram findings of COVID-19, click here.

X-Ray

  • To browse the X-ray finding of COVID-19, click here.

Echocardiography/Ultrasound

CT Scan

  • To browse the CT-Scan findings of COVID-19, click here.

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy based on 2020 ESC Guidline for management of arrhythmia in covid-19 patients

Bradyarrhythmia

  1. In patients with persistent bradycardia, before insertion of temporary pacemaker, atropine or isoprenaline are considered.
  2. Temporary pacemaker is the first option before making decision for permanent pacemaker because of the transient nature of bradyarrhythmia, critical illness, risk of bacterial superinfection, risk of device infection.
  3. After recovery of covid-19 , reevaluation about permanent pacemaker implantation should be considered.[37]

Atrial tachyarrhythmia (supraventricular tachycardia, atrial fibrillation, atrial flutter)

Ventricular arrhythmia

QT prolongation in covid-19 therapy

Cardiac medications interaction with covid-19 therapy

Surgery

Electrophysiology study in an elective procedure and should be planned for management of specific arrhythmias after recovery of covid-19 infection.

Primary Prevention

Secondary Prevention

Secondary prevention for covid-19 associated with arrhythmia is implantation of ICD after recovery of covid-19 in case of ventricular arrhythmia and low LVEF based on the guideline.

References

  1. ↑ Ruan Q, Yang K, Wang W, Jiang L, Song J (2020). "Correction to: Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China". Intensive Care Med. 46 (6): 1294–1297. doi:10.1007/s00134-020-06028-z. PMC 7131986 Check |pmc= value (help). PMID 32253449 Check |pmid= value (help).
  2. ↑ Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J; et al. (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". JAMA. doi:10.1001/jama.2020.1585. PMC 7042881 Check |pmc= value (help). PMID 32031570 Check |pmid= value (help).
  3. ↑ Lakkireddy DR, Chung MK, Gopinathannair R, Patton KK, Gluckman TJ, Turagam M; et al. (2020). "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". Circulation. 141 (21): e823–e831. doi:10.1161/CIRCULATIONAHA.120.047063. PMC 7243667 Check |pmc= value (help). PMID 32228309 Check |pmid= value (help).
  4. ↑ Du Y, Tu L, Zhu P, Mu M, Wang R, Yang P; et al. (2020). "Clinical Features of 85 Fatal Cases of COVID-19 from Wuhan. A Retrospective Observational Study". Am J Respir Crit Care Med. 201 (11): 1372–1379. doi:10.1164/rccm.202003-0543OC. PMC 7258652 Check |pmc= value (help). PMID 32242738 Check |pmid= value (help).
  5. ↑ Liu K, Fang YY, Deng Y, Liu W, Wang MF, Ma JP; et al. (2020). "Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province". Chin Med J (Engl). 133 (9): 1025–1031. doi:10.1097/CM9.0000000000000744. PMC 7147277 Check |pmc= value (help). PMID 32044814 Check |pmid= value (help).
  6. ↑ Xu, Zhe; Shi, Lei; Wang, Yijin; Zhang, Jiyuan; Huang, Lei; Zhang, Chao; Liu, Shuhong; Zhao, Peng; Liu, Hongxia; Zhu, Li; Tai, Yanhong; Bai, Changqing; Gao, Tingting; Song, Jinwen; Xia, Peng; Dong, Jinghui; Zhao, Jingmin; Wang, Fu-Sheng (2020). "Pathological findings of COVID-19 associated with acute respiratory distress syndrome". The Lancet Respiratory Medicine. 8 (4): 420–422. doi:10.1016/S2213-2600(20)30076-X. ISSN 2213-2600.
  7. ↑ Chen, Mao; Prendergast, Bernard; Redwood, Simon; Xiong, Tian-Yuan (2020). "Coronaviruses and the cardiovascular system: acute and long-term implications". European Heart Journal. 41 (19): 1798–1800. doi:10.1093/eurheartj/ehaa231. ISSN 0195-668X.
  8. ↑ Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G; et al. (2020). "Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic". J Am Coll Cardiol. 75 (18): 2352–2371. doi:10.1016/j.jacc.2020.03.031. PMC 7198856 Check |pmc= value (help). PMID 32201335 Check |pmid= value (help).
  9. ↑ Lazzerini PE, Laghi-Pasini F, Boutjdir M, Capecchi PL (2019). "Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies". Nat Rev Immunol. 19 (1): 63–64. doi:10.1038/s41577-018-0098-z. PMID 30552387.
  10. ↑ Clerkin, Kevin J.; Fried, Justin A.; Raikhelkar, Jayant; Sayer, Gabriel; Griffin, Jan M.; Masoumi, Amirali; Jain, Sneha S.; Burkhoff, Daniel; Kumaraiah, Deepa; Rabbani, LeRoy; Schwartz, Allan; Uriel, Nir (2020). "COVID-19 and Cardiovascular Disease". Circulation. 141 (20): 1648–1655. doi:10.1161/CIRCULATIONAHA.120.046941. ISSN 0009-7322.
  11. ↑ 11.0 11.1 11.2 Coromilas EJ, Kochav S, Goldenthal I, Biviano A, Garan H, Goldbarg S, Kim JH, Yeo I, Tracy C, Ayanian S, Akar J, Singh A, Jain S, Zimerman L, Pimentel M, Osswald S, Twerenbold R, Schaerli N, Crotti L, Fabbri D, Parati G, Li Y, Atienza F, Zatarain E, Tse G, Leung K, Guevara-Valdivia ME, Rivera-Santiago CA, Soejima K, De Filippo P, Ferrari P, Malanchini G, Kanagaratnam P, Khawaja S, Mikhail GW, Scanavacca M, Abrahão Hajjar L, Rizerio B, Sacilotto L, Mollazadeh R, Eslami M, Laleh Far V, Mattioli AV, Boriani G, Migliore F, Cipriani A, Donato F, Compagnucci P, Casella M, Dello Russo A, Coromilas J, Aboyme A, O'Brien CG, Rodriguez F, Wang PJ, Naniwadekar A, Moey M, Kow CS, Cheah WK, Auricchio A, Conte G, Hwang J, Han S, Lazzerini PE, Franchi F, Santoro A, Capecchi PL, Joglar JA, Rosenblatt AG, Zardini M, Bricoli S, Bonura R, Echarte-Morales J, Benito-González T, Minguito-Carazo C, Fernández-Vázquez F, Wan EY (March 2021). "Worldwide Survey of COVID-19-Associated Arrhythmias". Circ Arrhythm Electrophysiol. 14 (3): e009458. doi:10.1161/CIRCEP.120.009458. PMC 7982128 Check |pmc= value (help). PMID 33554620 Check |pmid= value (help). Vancouver style error: initials (help)
  12. ↑ 12.0 12.1 12.2 O'Connell TF, Bradley CJ, Abbas AE, Williamson BD, Rusia A, Tawney AM, Gaines R, Schott J, Dmitrienko A, Haines DE (January 2021). "Hydroxychloroquine/Azithromycin Therapy and QT Prolongation in Hospitalized Patients With COVID-19". JACC Clin Electrophysiol. 7 (1): 16–25. doi:10.1016/j.jacep.2020.07.016. PMC 7406234 Check |pmc= value (help). PMID 33478708 Check |pmid= value (help).
  13. ↑ Wang, Dawei; Hu, Bo; Hu, Chang; Zhu, Fangfang; Liu, Xing; Zhang, Jing; Wang, Binbin; Xiang, Hui; Cheng, Zhenshun; Xiong, Yong; Zhao, Yan; Li, Yirong; Wang, Xinghuan; Peng, Zhiyong (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China". JAMA. 323 (11): 1061. doi:10.1001/jama.2020.1585. ISSN 0098-7484.
  14. ↑ Kelalis PP, Malek RS (April 1981). "Infundibulopelvic stenosis". J Urol. 125 (4): 568–71. doi:10.1016/s0022-5347(17)55107-1. PMID 7218462.
  15. ↑ Mulia E, Maghfirah I, Rachmi DA, Julario R (January 2021). "Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis". Diagnosis (Berl). doi:10.1515/dx-2020-0155. PMID 33470951 Check |pmid= value (help). Vancouver style error: initials (help)
  16. ↑ 16.0 16.1 Selvaraj V, Bavishi C, Patel S, Dapaah-Afriyie K (July 2021). "Complete heart block associated with Remdesivir in COVID-19: a case report". Eur Heart J Case Rep. 5 (7): ytab200. doi:10.1093/ehjcr/ytab200. PMC 8247739 Check |pmc= value (help). PMID 34222786 Check |pmid= value (help).
  17. ↑ 17.0 17.1 17.2 Kochav SM, Coromilas E, Nalbandian A, Ranard LS, Gupta A, Chung MK, Gopinathannair R, Biviano AB, Garan H, Wan EY (June 2020). "Cardiac Arrhythmias in COVID-19 Infection". Circ Arrhythm Electrophysiol. 13 (6): e008719. doi:10.1161/CIRCEP.120.008719. PMC 7299099 Check |pmc= value (help). PMID 32434385 Check |pmid= value (help).
  18. ↑ Gupta AK, Parker BM, Priyadarshi V, Parker J (October 2020). "Cardiac Adverse Events With Remdesivir in COVID-19 Infection". Cureus. 12 (10): e11132. doi:10.7759/cureus.11132. PMC 7682945 Check |pmc= value (help). PMID 33240723 Check |pmid= value (help).
  19. ↑ Gubitosa JC, Kakar P, Gerula C, Nossa H, Finkel D, Wong K, Khatri M, Ali H (November 2020). "Marked Sinus Bradycardia Associated With Remdesivir in COVID-19: A Case and Literature Review". JACC Case Rep. 2 (14): 2260–2264. doi:10.1016/j.jaccas.2020.08.025. PMC 7598346 Check |pmc= value (help). PMID 33163977 Check |pmid= value (help).
  20. ↑ 20.0 20.1 Day LB, Abdel-Qadir H, Fralick M (April 2021). "Bradycardia associated with remdesivir therapy for COVID-19 in a 59-year-old man". CMAJ. 193 (17): E612–E615. doi:10.1503/cmaj.210300. PMC 8101980 Check |pmc= value (help). PMID 33903133 Check |pmid= value (help).
  21. ↑ 21.0 21.1 21.2 Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U (September 2020). "Arrhythmias and COVID-19: A Review". JACC Clin Electrophysiol. 6 (9): 1193–1204. doi:10.1016/j.jacep.2020.08.002. PMC 7417167 Check |pmc= value (help). PMID 32972561 Check |pmid= value (help).
  22. ↑ Gandhi, Rajesh T.; Solomon, Caren G.; Lynch, John B.; del Rio, Carlos (2020). "Mild or Moderate Covid-19". New England Journal of Medicine. doi:10.1056/NEJMcp2009249. ISSN 0028-4793.
  23. ↑ Chang, David; Saleh, Moussa; Gabriels, James; Ismail, Haisam; Goldner, Bruce; Willner, Jonathan; Beldner, Stuart; Mitra, Raman; John, Roy; Epstein, Laurence M. (2020). "Inpatient Use of Ambulatory Telemetry Monitors for COVID-19 Patients Treated With Hydroxychloroquine and/or Azithromycin". Journal of the American College of Cardiology. 75 (23): 2992–2993. doi:10.1016/j.jacc.2020.04.032. ISSN 0735-1097.
  24. ↑ Inciardi, Riccardo M.; Lupi, Laura; Zaccone, Gregorio; Italia, Leonardo; Raffo, Michela; Tomasoni, Daniela; Cani, Dario S.; Cerini, Manuel; Farina, Davide; Gavazzi, Emanuele; Maroldi, Roberto; Adamo, Marianna; Ammirati, Enrico; Sinagra, Gianfranco; Lombardi, Carlo M.; Metra, Marco (2020). "Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiology. doi:10.1001/jamacardio.2020.1096. ISSN 2380-6583.
  25. ↑ "Arrhythmia | NHLBI, NIH".
  26. ↑ Guo, Tao; Fan, Yongzhen; Chen, Ming; Wu, Xiaoyan; Zhang, Lin; He, Tao; Wang, Hairong; Wan, Jing; Wang, Xinghuan; Lu, Zhibing (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiology. doi:10.1001/jamacardio.2020.1017. ISSN 2380-6583.
  27. ↑ Duan K, Liu B, Li C, Zhang H, Yu T, Qu J; et al. (2020). "Effectiveness of convalescent plasma therapy in severe COVID-19 patients". Proc Natl Acad Sci U S A. 117 (17): 9490–9496. doi:10.1073/pnas.2004168117. PMC 7196837 Check |pmc= value (help). PMID 32253318 Check |pmid= value (help).
  28. ↑ Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check |pmc= value (help). PMID 32320003 Check |pmid= value (help).
  29. ↑ Giudicessi, John R.; Noseworthy, Peter A.; Friedman, Paul A.; Ackerman, Michael J. (2020). "Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19)". Mayo Clinic Proceedings. 95 (6): 1213–1221. doi:10.1016/j.mayocp.2020.03.024. ISSN 0025-6196.
  30. ↑ Goyal, Parag; Choi, Justin J.; Pinheiro, Laura C.; Schenck, Edward J.; Chen, Ruijun; Jabri, Assem; Satlin, Michael J.; Campion, Thomas R.; Nahid, Musarrat; Ringel, Joanna B.; Hoffman, Katherine L.; Alshak, Mark N.; Li, Han A.; Wehmeyer, Graham T.; Rajan, Mangala; Reshetnyak, Evgeniya; Hupert, Nathaniel; Horn, Evelyn M.; Martinez, Fernando J.; Gulick, Roy M.; Safford, Monika M. (2020). "Clinical Characteristics of Covid-19 in New York City". New England Journal of Medicine. 382 (24): 2372–2374. doi:10.1056/NEJMc2010419. ISSN 0028-4793.
  31. ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check |pmc= value (help). PMID 32219356 Check |pmid= value (help).
  32. ↑ 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.
  33. ↑ 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.
  34. ↑ 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 (March 2020). "Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1096. PMID 32219357 Check |pmid= value (help).
  35. ↑ Alhogbani T (2016). "Acute myocarditis associated with novel Middle east respiratory syndrome coronavirus". Ann Saudi Med. 36 (1): 78–80. doi:10.5144/0256-4947.2016.78. PMC 6074274. PMID 26922692.
  36. ↑ 36.0 36.1 Kochi, Adriano Nunes; Tagliari, Ana Paula; Forleo, Giovanni Battista; Fassini, Gaetano Michele; Tondo, Claudio (2020). "Cardiac and arrhythmic complications in patients with COVID‐19". Journal of Cardiovascular Electrophysiology. 31 (5): 1003–1008. doi:10.1111/jce.14479. ISSN 1045-3873.
  37. ↑ Saenz LC, Miranda A, Speranza R, Texeira RA, Rojel U, Enriquez A, Figuereido M (November 2020). "Recommendations for the organization of electrophysiology and cardiac pacing services during the COVID-19 pandemic : Latin American Heart Rhythm Society (LAHRS) in collaboration with: Colombian College Of Electrophysiology, Argentinian Society of Cardiac Electrophysiology (SADEC), Brazilian Society Of Cardiac Arrhythmias (SOBRAC), Mexican Society Of Cardiac Electrophysiology (SOMEEC)". J Interv Card Electrophysiol. 59 (2): 307–313. doi:10.1007/s10840-020-00747-5. PMC 7189002 Check |pmc= value (help). PMID 32350745 Check |pmid= value (help).
  38. ↑ Ramireddy A, Chugh H, Reinier K, Ebinger J, Park E, Thompson M, Cingolani E, Cheng S, Marban E, Albert CM, Chugh SS (June 2020). "Experience With Hydroxychloroquine and Azithromycin in the Coronavirus Disease 2019 Pandemic: Implications for QT Interval Monitoring". J Am Heart Assoc. 9 (12): e017144. doi:10.1161/JAHA.120.017144. PMC 7429030 Check |pmc= value (help). PMID 32463348 Check |pmid= value (help).
  39. ↑ Borba M, Val F, Sampaio VS, Alexandre M, Melo GC, Brito M, Mourão M, Brito-Sousa JD, Baía-da-Silva D, Guerra M, Hajjar LA, Pinto RC, Balieiro A, Pacheco A, Santos J, Naveca FG, Xavier MS, Siqueira AM, Schwarzbold A, Croda J, Nogueira ML, Romero G, Bassat Q, Fontes CJ, Albuquerque BC, Daniel-Ribeiro CT, Monteiro WM, Lacerda M (April 2020). "Effect of High vs Low Doses of Chloroquine Diphosphate as Adjunctive Therapy for Patients Hospitalized With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection: A Randomized Clinical Trial". JAMA Netw Open. 3 (4): e208857. doi:10.1001/jamanetworkopen.2020.8857. PMID 32330277 Check |pmid= value (help). Vancouver style error: initials (help)
  40. ↑ Castagna A, Ruotolo G, Manzo C (December 2020). "Hydroxychloroquine and QT Prolongation in Older Patients with Rheumatic Diseases: Who is afraid of the Boogeyman? We are not!". Mediterr J Rheumatol. 31 (4): 433–435. doi:10.31138/mjr.31.4.433. PMC 7841093 Check |pmc= value (help). PMID 33521580 Check |pmid= value (help).
  41. ↑ Cheung CC, Davies B, Gibbs K, Laksman ZW, Krahn AD (July 2020). "Multilead QT Screening Is Necessary for QT Measurement: Implications for Management of Patients in the COVID-19 Era". JACC Clin Electrophysiol. 6 (7): 878–880. doi:10.1016/j.jacep.2020.04.001. PMC 7141442 Check |pmc= value (help). PMID 32703574 Check |pmid= value (help).
  42. ↑ Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C; et al. (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).

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