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Clinical Trials
Ongoing Trials on COVID-19-associated cardiac arrest at Clinical Trials.gov Trial results on COVID-19-associated cardiac arrest Clinical Trials on COVID-19-associated cardiac arrest at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on COVID-19-associated cardiac arrest NICE Guidance on COVID-19-associated cardiac arrest NHS PRODIGY Guidance FDA on COVID-19-associated cardiac arrest CDC on COVID-19-associated cardiac arrest
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COVID-19-associated cardiac arrest in the news Be alerted to news on COVID-19-associated cardiac arrest News trends on COVID-19-associated cardiac arrest
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Blogs on COVID-19-associated cardiac arrest
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Revision as of 19:55, 24 July 2020

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. Ayesha Javid, MBBS [2]

Overview

Sudden cardiac death is defined as natural death from cardiac causes developed by abrupt loss of consciousness within one hour of onset of acute change in cardiovascular status. Preexisting heart disease may or may not be present at the time of the cardiac arrest. Sudden onset of chest pain, dyspnea or palpitations and other symptoms of arrhythmia may precede the onset of cardiac arrest. During the outbreak of COVID-19, the number of out-of-hospital cardiac arrests in Italy increased and prognosis of in-hospital cardiac arrest was generally poor. Factors related to medical services restriction, as well as the side effects of drugs and thrombotic complications related to COVID-19, increased the number of cardiac arrest during COVID-19 pandemic.

Historical Perspective

In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.^[1]
In January 2020, the first COVID-19 case was documented in the United States.^[2]
On February 20, 2020, the first case of COVID-19 was documented in the Province of Lodi in Italy.^[3]
In April 2020, an increase in out-of-hospital cardiac arrest was reported during the COVID-19 pandemic.

Classification

Cardiac arrest associated with COVID-19 may be classified into three subtypes:

Causes

The potential causes of ventricular tachyarrhythmia and sudden cardiac death in COVID-19 include:^[4]

Hypercytokinemia
Administration of drugs causing QT interval prolongation such as hydroxychloroquine ± azithromycin, lopinavir, and ritonavir^[5]

Concurrent use of drugs causing QT interval prolongation, such as antiemetics,floroquinolones,SSRIs
Electrolyte abnormalities such as hypokalemia and hypomagnesemia
High-risk comorbidity condition such as Congestive heart failure, chronic kidney disease, diabetes mellitus, and chronic obstructive pulmonary disease
Age ≥65
Male gender
Inherited arrhythmia syndromes
Increased sympathetic activity
Inhibition of CYP450
Direct myocardial injury or SARS-COV-2 myocarditis
Acute cardiac events (acute coronary syndrome, decompensated heart failure, arrhythmia)
Thromboembolic events related to COVID-19 (pulmonary embolism, acute coronary syndrome)^[6]
Hypoxia

Pathophysiology

The pathogenesis of cardiac arrest associated with COVID-19 is characterized by cytokine storm, especially elevation of IL-6.^[7]
IL-6 directly blocks hERG/K_v11.1 potassium channels and causes action potential depolarization(APD) prolongation and ventricular repolarization.
IL-6 induces hyperactivity of cardiac sympathetic nerve.
Hypoxia causes myocardial injury and ventricular repolarization.
IL-6 inhibits cytochrome P450 enzyme involved in metabolism of some QTc prolongation drugs.^[8]
Hydroxychloroquine and lopinavir/ritonavir inhibit HERG-K⁺ channel and increase both ventriculat repolarization and the level of other QTc prolongation drugs.^[8]Hydroxychloroquine inhibits CYP2D6 (cytochrome P450 2D6) ,then the level of antipsychotics,antidepressants and antihistamins increase.^[8]
Ritonavir inhibits CYP3A4 (cytochrome P450 3A4), then the level of azols antifungals, macrolides (particulary azithromycin),antidepressants,antihistamines,fluoroquinolones increase.^[8]
Intrinsic genetic susceptibility (Ser1103Tyr-SCN5A) in African-Americans COVID-19 patients has been associated with increased risk of Torsade points arrhythmia.^[9]

Differentiating inherited cardiac arrest from other causes of cardiac arrest.

To view the differential diagnosis of COVID-19 click here.

Inherited cardiac arrest associated COVID19 must be differentiated from other causes of cardiac arrest based on these characteristics:^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]

Inherited causes of cardiac arrest and malignant arrhythmia associated covid-19	long QT syndrome	Brugada syndrome	Short QT syndrome	Cathecolaminergic polymorphic ventricular tachaycardia
Gene mutation	KCNQ1(LQT1), KCNH2(LQT2), SCN5A(LQT3)	loss of function in SCN5A in %30 of patients	KCNH2(SQT1), KCNQ1(SQT2) KCNJ2(SQT3)	RYR2(CPVT1) CASQ2(CPVT2) KCNJ2(CPVT3)
EKG finding	QTc>450ms in men QTc>470ms in women T waves alternance	Coved-type ST-segment elevation T-wave inversion in lead V₁ and/or V₂	QTc<330 msec	Normal EKG Bradycardia mild u waves
Specific considerations in COVID19 patients	causion in administration of QT prolongation drugs(hydroxychloroquine, azithromycin lupinavir/ritonavir) Controlling the fever for prevention of QT prolongation Avoidance of using≥ one drugs inducing QT prolongation	Controlling the fever as the main cause of cardiac arrest in brugada syndrome, especially in children less than 5 year old	Safety of hydroxychloquine due to prolongation of QT interval in short QT syndrom type 1 (KCNH2 related) and type3(KCNJ2)	Avoidance of administration of epinephrine, isoproterenol, and dobutamine, all α and/or B1 receptor agonists inducing ventricular arrhythmia Controlling the sress related to COVID-19 Safety of flecainide without any interaction with lopinavir, ritonavir and chloroquine.
fatal arrhythmia	Torsade de pointes Ventricular fibrillation	Ventricular fibrillation, Polymorphic Ventricular tachycardia	Ventricular fibrillation	Bidirectional Ventricular tachycardia

Corrected QT(QTc)=1000(QT/1000+0.154(1-RR)

QT, QTc are measured in milliseconds.

RR is measured in seconds and is the interval from the onset of one QRS complex to the onset of the next QRS complex.

Epidemiology and Demographics

Incidence

During the COVID-19 pandemic, the incidence of out-of-hospital Sudden cardiac arrests (OHCA) has been 2 times greater compared to the non-pandemic time period.
According to a study done in China, about 12% of patients with COVID-19 without a history of heart problems experience cardiac arrest during their hospitalization.^[19]
In a study done among 761 Chinese patients with severe COVID-19, about 20% patients developed in-hospital cardiac arrest within 40 days of their hospitalization course.^[20]

Mortality

There is a significant increase in the mortality rate of the OHCA in patients.^[21]

Age

The mean age observed among patients who experienced out-of-hospital Sudden cardiac arrest (OHCA) is 69.7 years.^[21] .

Gender

Studies showed that males have a slightly higher incidence of out-of-hospital sudden cardiac arrest (OHCA) as compared to the females.^[21]

Race

A higher incidence has been seen among African-Americans as compared to Caucasians.^[22]

Risk Factors

Common risk factors in the development of arrhythmia and cardiac arrest in COVID-19 are:^[23]
- Fever
- Stress
- Electrolytes disturbances
- Use of some medications

Screening

To view screening for COVID-19, click here.

Natural History, Complications, and Prognosis

The proportion of patients who developed out-of-hospital cardiac arrest (OHCA) increased during the COVID-19 pandemic and was affected by aggravation of underlying comorbidities, late presentation of acute STEMI(ST elevation myocardial infarction) due to fear of being infected in hospital, and avoidance of bystander cardiopulmonary resuscitation in public due to fear of infection.^[24]^[25]

Prognosis of patients with severe COVID-19 pneumonia with in hospital cardiac arrest (IHCA) was poor in Wuhan, China.^[26]

Mortality rate of patients with COVID-19 is approximately 1-2%^[27]

Diagnosis

Diagnostic Criteria

The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:

Prodromes phase occurring weeks or months before an event includes: new or worsening cardiovascular symptoms(chest pain, dyspnea, palpitations, fatigability)
Onset of terminal event occurring one hour before cardiac arrest includes: abrupt change in clinical status(arrhythmia, hypotension, chest pain, dyspnea, lightheadness)
Cardiac arrest includes: sudden collapse, loss of effective circulation, loss of consciousness
Biologic death: failure of resuscitatio n or failure of electrical, mechanical, or CNS function after initial resuscitation

Symptoms

Symptoms before cardiac arrest in COVID-19 may include the following:

Physical Examination

There is no specific finding associated with physical examination with cardiac arrest in COVID-19.

Laboratory Findings

An elevated concentration of serum cardiac troponinI was detected in severe COVID-19 patients with cardiac complications. ^[28]

Imaging Findings

There are no imaging study findings associated with cardiac arrest in COVID-19.

Electrocardiogram

Findings on EKG during in-hospital cardiac arrest (IHCA) with COVID-19 infection include:^[26]
- Asystole (89.7%)
- Pulseless electrical activity (4.4%)
- Shockable rhythm (5.9%)

Other abnormal EKG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms.

Treatment

The mainstay of therapy for COVID-19-related cardiac arrest is cardiopulmonary resuscitation with attention to the following points:^[29]
- Wearing personal protective equipment (PPE) before entering the room or on the scene.
- Limiting the personnel in the room or on the scene
- Using high-efficacy particulate air filter for ventilator
- Intubating with a cuffed tube
- Stopping chest compression for intubation
- Using bag-mask device before intubation
- Using non-rebreathing face mask instead of bag-mask for short term oxygenation

Prevention

Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in the setting of long QT syndrome or aquired LQTS or heart rate <50/min or receiving azithromycin, redmisivir, lopinavir, ritonavir, include EKG and QTc measurement.^[23]

If QTc ≥500 ms, consult with cardiologist.
If QTc<500ms, start hydroxychloroquine and repeat EKG after 1-3 days.
After starting the first dose of hydroxychloroquine, If any of the following factors were present repeat EKG after 4 hours:
- QTc≥500mse
- Increased QTc>60ms
- Ventricular ectopy
Treatment of hypokalemia due to diarrhea associated COVID-19 ,which prolonges QT interval is another measurement to be considered.
Effective measures for the primary prevention of ventricular arrhythmia in brugada syndrome is starting acetaminophen or parastamol immediately if there is sign of fever and also self-isolation.

References

↑ Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.
↑ Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.
↑ 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.
↑ Giudicessi JR, Roden DM, Wilde A, Ackerman MJ (May 2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 Check |pmid= value (help). Vancouver style error: initials (help)
↑ Mehra, Mandeep R; Desai, Sapan S; Ruschitzka, Frank; Patel, Amit N (2020). "RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis". The Lancet. doi:10.1016/S0140-6736(20)31180-6. ISSN 0140-6736.
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↑ Michowitz Y, Milman A, Sarquella-Brugada G, Andorin A, Champagne J, Postema PG, Casado-Arroyo R, Leshem E, Juang J, Giustetto C, Tfelt-Hansen J, Wijeyeratne YD, Veltmann C, Corrado D, Kim SH, Delise P, Maeda S, Gourraud JB, Sacher F, Mabo P, Takahashi Y, Kamakura T, Aiba T, Conte G, Hochstadt A, Mizusawa Y, Rahkovich M, Arbelo E, Huang Z, Denjoy I, Napolitano C, Brugada R, Calo L, Priori SG, Takagi M, Behr ER, Gaita F, Yan GX, Brugada J, Leenhardt A, Wilde A, Brugada P, Kusano KF, Hirao K, Nam GB, Probst V, Belhassen B (September 2018). "Fever-related arrhythmic events in the multicenter Survey on Arrhythmic Events in Brugada Syndrome". Heart Rhythm. 15 (9): 1394–1401. doi:10.1016/j.hrthm.2018.04.007. PMID 29649615. Vancouver style error: initials (help)
↑ Luo C, Wang K, Liu T, Zhang H (July 2018). "Computational Analysis of the Action of Chloroquine on Short QT Syndrome Variant 1 and Variant 3 in Human Ventricles". Conf Proc IEEE Eng Med Biol Soc. 2018: 5462–5465. doi:10.1109/EMBC.2018.8513572. PMID 30441573.
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↑ 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.
↑ ^21.0 ^21.1 ^21.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check |pmc= value (help). PMID 32473113 PMID: 32473113 Check |pmid= value (help).
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↑ Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui D, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS (April 2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N. Engl. J. Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help). Vancouver style error: initials (help)
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↑ Edelson, Dana P.; Sasson, Comilla; Chan, Paul S.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bradley, Steven M.; Brooks, Steven C.; Cheng, Adam; Escobedo, Marilyn; Flores, Gustavo E.; Girotra, Saket; Hsu, Antony; Kamath-Rayne, Beena D.; Lee, Henry C.; Lehotsky, Rebecca E.; Mancini, Mary E.; Merchant, Raina M.; Nadkarni, Vinay M.; Panchal, Ashish R.; Peberdy, Mary Ann R.; Raymond, Tia T.; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis A.; Starks, Monique Anderson; Bobrow, Bentley J.; Chan, Melissa; Berg, Katherine; Duff, Jonathan P.; Joyner, Benny L.; Lasa, Javier J.; Levy, Arielle; Mahgoub, Melissa; O’Connor, Michael F.; Hoover, Amber V.; Rodriguez, Amber J.; Meckler, Garth; Roberts, Kathryn; Mohr, Nicholas M.; Nassar, Boulos; Rubinson, Lewis; Sutton, Robert M.; Schexnayder, Stephen M.; Kleinman, Monica; de Caen, Allan; Morgan, Ryan; Bhanji, Farhan; Fuchs, Susan; Terry, Mark; McBride, Mary; Levy, Michael; Cabanas, Jose G.; Tan, David K.; Moitra, Vivek K.; Szokol, Joseph W. (2020). "Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19". Circulation. 141 (25). doi:10.1161/CIRCULATIONAHA.120.047463. ISSN 0009-7322.

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[LiuKuo2020-1] Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.

[SayreBarnard2020-2] Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.

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@@ Line 9: / Line 9: @@
 ==Overview==
-The [[sudden cardiac death]] is [[defined]] as the natural [[death]] from [[cardiac]] [[causes]] developed by abrupt loss of consciousness within one hour of onset of acute change in [[cardiovascular]] status. Preexisting [[heart]] [[disease]] may or may not be present at the time of the [[cardiac arrest]]. Sudden onset of [[chest pain]], [[dyspnea]] or [[palpitations]]  and other [[symptoms]] of [[arrhythmia]] may precede the onset of [[cardiac arrest]]. During the  outbreak of [[COVID-19]], the number of out of hospital [[cardiac arrest]] in Italy  increased. [[Prognosis]] of in-hospital [[cardiac arrest]] was generally poor. Factors related to medical services restriction and also side effects of  drugs and [[thrombotic]] [[complications]] related to [[COVID-19]], increased the number of [[cardiac arrest]] during [[COVID-19]] pandemic.
+[[Sudden cardiac death]] is [[defined]] as natural [[death]] from [[cardiac]] [[causes]] developed by abrupt loss of consciousness within one hour of onset of acute change in [[cardiovascular]] status. Preexisting [[heart]] [[disease]] may or may not be present at the time of the [[cardiac arrest]]. Sudden onset of [[chest pain]], [[dyspnea]] or [[palpitations]]  and other [[symptoms]] of [[arrhythmia]] may precede the onset of [[cardiac arrest]]. During the outbreak of [[COVID-19]], the number of out-of-hospital [[cardiac arrest|cardiac arrests]] in Italy  increased and [[prognosis]] of in-hospital [[cardiac arrest]] was generally poor. Factors related to medical services restriction, as well as the side effects of drugs and [[thrombotic]] [[complications]] related to [[COVID-19]], increased the number of [[cardiac arrest]] during [[COVID-19]] pandemic.
 ==Historical Perspective==
 * In December 2019, the [[COVID-19]] outbreak first appeared in China, Wuhan.<ref name="LiuKuo2020">{{cite journal|last1=Liu|first1=Yen-Chin|last2=Kuo|first2=Rei-Lin|last3=Shih|first3=Shin-Ru|title=COVID-19: The first documented coronavirus pandemic in history|journal=Biomedical Journal|year=2020|issn=23194170|doi=10.1016/j.bj.2020.04.007}}</ref>
-* On February 20, 2020, the first case of [[COVID-19]] was documented in Lodi Province of Italy.<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>
-* In April 2020, An increase in out of hospital cardiac arrest was reported during the [[COVID-19]] pandemic.
 *In January 2020, the first [[COVID-19]] case was documented in the United States.<ref name="SayreBarnard2020">{{cite journal|last1=Sayre|first1=Michael R.|last2=Barnard|first2=Leslie M.|last3=Counts|first3=Catherine R.|last4=Drucker|first4=Christopher J.|last5=Kudenchuk|first5=Peter J.|last6=Rea|first6=Thomas D.|last7=Eisenberg|first7=Mickey S.|title=Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR|journal=Circulation|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.048951}}</ref>
+* On February 20, 2020, the first case of [[COVID-19]] was documented in the Province of Lodi in Italy.<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>
+* In April 2020, an increase in out-of-hospital cardiac arrest was reported during the [[COVID-19]] pandemic.
 ==Classification==
-[[Cardiac arrest]] associated with [[COVID19]] may be classified into three subtypes:
+[[Cardiac arrest]] associated with [[COVID-19]] may be classified into three subtypes:
 *[[Pulseless electrical activity]]
 *[[Bradyarrhythmia]] and [[asystolic]] arrest
 *Fatal [[tachyarrhythmia]]
 ==Causes==
-*The potential [[causes]] of  [[ventricular tachyarrhythmia]] and [[sudden cardiac death]] in [[COVID-19]]  are:<ref name="pmid32380288">{{cite journal |vauthors=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ |title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans |journal=Heart Rhythm |volume= |issue= |pages= |date=May 2020 |pmid=32380288 |pmc=7198426 |doi=10.1016/j.hrthm.2020.04.045 |url=}}</ref>
+The potential [[causes]] of [[ventricular tachyarrhythmia]] and [[sudden cardiac death]] in [[COVID-19]] include:<ref name="pmid32380288">{{cite journal |vauthors=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ |title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans |journal=Heart Rhythm |volume= |issue= |pages= |date=May 2020 |pmid=32380288 |pmc=7198426 |doi=10.1016/j.hrthm.2020.04.045 |url=}}</ref>
 * Hypercytokinemia
@@ Line 42: / Line 43: @@
 ==Pathophysiology==
 * The [[pathogenesis]] of [[cardiac arrest]] associated with [[COVID-19]] is characterized by cytokine storm, especially elevation of [[IL-6]].<ref name="LazzeriniLaghi-Pasini2018">{{cite journal|last1=Lazzerini|first1=Pietro Enea|last2=Laghi-Pasini|first2=Franco|last3=Boutjdir|first3=Mohamed|last4=Capecchi|first4=Pier Leopoldo|title=Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies|journal=Nature Reviews Immunology|volume=19|issue=1|year=2018|pages=63–64|issn=1474-1733|doi=10.1038/s41577-018-0098-z}}</ref>
-* [[IL-6]]  directely  blocks  hERG/K<sub>v</sub>11.1 [[potassium channels]] and causes [[APD prolongation|action potential depolarization(APD) prolongation]] and [[ventricular repolarization]].
+* [[IL-6]] directly blocks hERG/K<sub>v</sub>11.1 [[potassium channels]] and causes [[APD prolongation|action potential depolarization(APD) prolongation]] and [[ventricular repolarization]].
-* [[IL-6]]  induces hyperactivity of [[cardiac]] sympathetic nerve.
+* [[IL-6]] induces hyperactivity of [[cardiac]] sympathetic nerve.
 *[[Hypoxia]] causes myocardial injury and ventricular repolarization.
-*[[IL-6]] inhibits cytochrome P450 enzyme involved in matobolism of some [[QTc]] prolongation drugs.<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>
+*[[IL-6]] inhibits cytochrome P450 enzyme involved in metabolism of some [[QTc]] prolongation drugs.<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>
 * <nowiki/><nowiki/><nowiki/>[[Hydroxychloroquine]] and [[lopinavir/ritonavir]]  inhibit [[HERG-K+ channe|HERG-K<sup>+</sup> channe]]<nowiki/>l and increase  both ventriculat repolarization and  the level of other QTc prolongation drugs.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>'''[[Hydroxychloroquine]] inhibits [[CYP2D6]] ([[cytochrome P450]] 2D6) ,then the level of [[antipsychotics]],[[antidepressants]] and [[antihistamins]] increase.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>'''
 *<nowiki/>[[Ritonavir]] inhibits [[CYP3A4]] ([[cytochrome P450 3A4]]), then the level of<nowiki/> [[azols antifungals]], [[macrolides]] (particulary [[azithromycin]]),[[antidepressants]],[[antihistamines]],[[fluoroquinolones]] increase.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>'''
-* Intrinsic genetic susceptibility ([[Ser1103Tyr-SCN5A]]) in african americans  [[COVID-19]] patients has been associated  with increased risk of  [[torsade points arrhythmia]].<ref name="pmid32359771">{{cite journal |vauthors=Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ |title=Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19) |journal=Mayo Clin. Proc. |volume=95 |issue=6 |pages=1213–1221 |date=June 2020 |pmid=32359771 |pmc=7141471 |doi=10.1016/j.mayocp.2020.03.024 |url=}}</ref>
+* Intrinsic genetic susceptibility ([[Ser1103Tyr-SCN5A]]) in African-Americans [[COVID-19]] patients has been associated with increased risk of [[Torsade points arrhythmia]].<ref name="pmid32359771">{{cite journal |vauthors=Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ |title=Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19) |journal=Mayo Clin. Proc. |volume=95 |issue=6 |pages=1213–1221 |date=June 2020 |pmid=32359771 |pmc=7141471 |doi=10.1016/j.mayocp.2020.03.024 |url=}}</ref>
 == Differentiating inherited cardiac arrest from other causes of cardiac arrest. ==
 * To view the differential diagnosis of [[COVID-19]] [[COVID-19 differential diagnosis|click here]].
-* Inherited cardiac arrest associated [[COVID19]]  must be differentiated from other causes of cardiac arrest based on these characteristics:<ref name="pmid27423412">{{cite journal |vauthors=Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AA |title=J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge |journal=Heart Rhythm |volume=13 |issue=10 |pages=e295–324 |date=October 2016 |pmid=27423412 |pmc=5035208 |doi=10.1016/j.hrthm.2016.05.024 |url=}}</ref><ref name="pmid23390049">{{cite journal |vauthors=van der Werf C, Wilde AA |title=Catecholaminergic polymorphic ventricular tachycardia: from bench to bedside |journal=Heart |volume=99 |issue=7 |pages=497–504 |date=April 2013 |pmid=23390049 |doi=10.1136/heartjnl-2012-302033 |url=}}</ref><ref name="pmid20642543">{{cite journal |vauthors=van Noord C, Eijgelsheim M, Stricker BH |title=Drug- and non-drug-associated QT interval prolongation |journal=Br J Clin Pharmacol |volume=70 |issue=1 |pages=16–23 |date=July 2010 |pmid=20642543 |pmc=2909803 |doi=10.1111/j.1365-2125.2010.03660.x |url=}}</ref><ref name="PrioriWilde2013">{{cite journal|last1=Priori|first1=Silvia G.|last2=Wilde|first2=Arthur A.|last3=Horie|first3=Minoru|last4=Cho|first4=Yongkeun|last5=Behr|first5=Elijah R.|last6=Berul|first6=Charles|last7=Blom|first7=Nico|last8=Brugada|first8=Josep|last9=Chiang|first9=Chern-En|last10=Huikuri|first10=Heikki|last11=Kannankeril|first11=Prince|last12=Krahn|first12=Andrew|last13=Leenhardt|first13=Antoine|last14=Moss|first14=Arthur|last15=Schwartz|first15=Peter J.|last16=Shimizu|first16=Wataru|last17=Tomaselli|first17=Gordon|last18=Tracy|first18=Cynthia|title=HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes|journal=Heart Rhythm|volume=10|issue=12|year=2013|pages=1932–1963|issn=15475271|doi=10.1016/j.hrthm.2013.05.014}}</ref><ref name="pmid17646028">{{cite journal |vauthors=White NJ |title=Cardiotoxicity of antimalarial drugs |journal=Lancet Infect Dis |volume=7 |issue=8 |pages=549–58 |date=August 2007 |pmid=17646028 |doi=10.1016/S1473-3099(07)70187-1 |url=}}</ref><ref name="pmid18551196">{{cite journal |vauthors=Amin AS, Herfst LJ, Delisle BP, Klemens CA, Rook MB, Bezzina CR, Underkofler HA, Holzem KM, Ruijter JM, Tan HL, January CT, Wilde AA |title=Fever-induced QTc prolongation and ventricular arrhythmias in individuals with type 2 congenital long QT syndrome |journal=J. Clin. Invest. |volume=118 |issue=7 |pages=2552–61 |date=July 2008 |pmid=18551196 |pmc=2423868 |doi=10.1172/JCI35337 |url=}}</ref><ref name="pmid18678856">{{cite journal |vauthors=Amin AS, Meregalli PG, Bardai A, Wilde AA, Tan HL |title=Fever increases the risk for cardiac arrest in the Brugada syndrome |journal=Ann. Intern. Med. |volume=149 |issue=3 |pages=216–8 |date=August 2008 |pmid=18678856 |doi=10.7326/0003-4819-149-3-200808050-00020 |url=}}</ref><ref name="pmid29649615">{{cite journal |vauthors=Michowitz Y, Milman A, Sarquella-Brugada G, Andorin A, Champagne J, Postema PG, Casado-Arroyo R, Leshem E, Juang JJM, Giustetto C, Tfelt-Hansen J, Wijeyeratne YD, Veltmann C, Corrado D, Kim SH, Delise P, Maeda S, Gourraud JB, Sacher F, Mabo P, Takahashi Y, Kamakura T, Aiba T, Conte G, Hochstadt A, Mizusawa Y, Rahkovich M, Arbelo E, Huang Z, Denjoy I, Napolitano C, Brugada R, Calo L, Priori SG, Takagi M, Behr ER, Gaita F, Yan GX, Brugada J, Leenhardt A, Wilde AAM, Brugada P, Kusano KF, Hirao K, Nam GB, Probst V, Belhassen B |title=Fever-related arrhythmic events in the multicenter Survey on Arrhythmic Events in Brugada Syndrome |journal=Heart Rhythm |volume=15 |issue=9 |pages=1394–1401 |date=September 2018 |pmid=29649615 |doi=10.1016/j.hrthm.2018.04.007 |url=}}</ref><ref name="pmid30441573">{{cite journal |vauthors=Luo C, Wang K, Liu T, Zhang H |title=Computational Analysis of the Action of Chloroquine on Short QT Syndrome Variant 1 and Variant 3 in Human Ventricles |journal=Conf Proc IEEE Eng Med Biol Soc |volume=2018 |issue= |pages=5462–5465 |date=July 2018 |pmid=30441573 |doi=10.1109/EMBC.2018.8513572 |url=}}</ref>
+* Inherited cardiac arrest associated [[COVID19]] must be differentiated from other causes of cardiac arrest based on these characteristics:<ref name="pmid27423412">{{cite journal |vauthors=Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AA |title=J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge |journal=Heart Rhythm |volume=13 |issue=10 |pages=e295–324 |date=October 2016 |pmid=27423412 |pmc=5035208 |doi=10.1016/j.hrthm.2016.05.024 |url=}}</ref><ref name="pmid23390049">{{cite journal |vauthors=van der Werf C, Wilde AA |title=Catecholaminergic polymorphic ventricular tachycardia: from bench to bedside |journal=Heart |volume=99 |issue=7 |pages=497–504 |date=April 2013 |pmid=23390049 |doi=10.1136/heartjnl-2012-302033 |url=}}</ref><ref name="pmid20642543">{{cite journal |vauthors=van Noord C, Eijgelsheim M, Stricker BH |title=Drug- and non-drug-associated QT interval prolongation |journal=Br J Clin Pharmacol |volume=70 |issue=1 |pages=16–23 |date=July 2010 |pmid=20642543 |pmc=2909803 |doi=10.1111/j.1365-2125.2010.03660.x |url=}}</ref><ref name="PrioriWilde2013">{{cite journal|last1=Priori|first1=Silvia G.|last2=Wilde|first2=Arthur A.|last3=Horie|first3=Minoru|last4=Cho|first4=Yongkeun|last5=Behr|first5=Elijah R.|last6=Berul|first6=Charles|last7=Blom|first7=Nico|last8=Brugada|first8=Josep|last9=Chiang|first9=Chern-En|last10=Huikuri|first10=Heikki|last11=Kannankeril|first11=Prince|last12=Krahn|first12=Andrew|last13=Leenhardt|first13=Antoine|last14=Moss|first14=Arthur|last15=Schwartz|first15=Peter J.|last16=Shimizu|first16=Wataru|last17=Tomaselli|first17=Gordon|last18=Tracy|first18=Cynthia|title=HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes|journal=Heart Rhythm|volume=10|issue=12|year=2013|pages=1932–1963|issn=15475271|doi=10.1016/j.hrthm.2013.05.014}}</ref><ref name="pmid17646028">{{cite journal |vauthors=White NJ |title=Cardiotoxicity of antimalarial drugs |journal=Lancet Infect Dis |volume=7 |issue=8 |pages=549–58 |date=August 2007 |pmid=17646028 |doi=10.1016/S1473-3099(07)70187-1 |url=}}</ref><ref name="pmid18551196">{{cite journal |vauthors=Amin AS, Herfst LJ, Delisle BP, Klemens CA, Rook MB, Bezzina CR, Underkofler HA, Holzem KM, Ruijter JM, Tan HL, January CT, Wilde AA |title=Fever-induced QTc prolongation and ventricular arrhythmias in individuals with type 2 congenital long QT syndrome |journal=J. Clin. Invest. |volume=118 |issue=7 |pages=2552–61 |date=July 2008 |pmid=18551196 |pmc=2423868 |doi=10.1172/JCI35337 |url=}}</ref><ref name="pmid18678856">{{cite journal |vauthors=Amin AS, Meregalli PG, Bardai A, Wilde AA, Tan HL |title=Fever increases the risk for cardiac arrest in the Brugada syndrome |journal=Ann. Intern. Med. |volume=149 |issue=3 |pages=216–8 |date=August 2008 |pmid=18678856 |doi=10.7326/0003-4819-149-3-200808050-00020 |url=}}</ref><ref name="pmid29649615">{{cite journal |vauthors=Michowitz Y, Milman A, Sarquella-Brugada G, Andorin A, Champagne J, Postema PG, Casado-Arroyo R, Leshem E, Juang JJM, Giustetto C, Tfelt-Hansen J, Wijeyeratne YD, Veltmann C, Corrado D, Kim SH, Delise P, Maeda S, Gourraud JB, Sacher F, Mabo P, Takahashi Y, Kamakura T, Aiba T, Conte G, Hochstadt A, Mizusawa Y, Rahkovich M, Arbelo E, Huang Z, Denjoy I, Napolitano C, Brugada R, Calo L, Priori SG, Takagi M, Behr ER, Gaita F, Yan GX, Brugada J, Leenhardt A, Wilde AAM, Brugada P, Kusano KF, Hirao K, Nam GB, Probst V, Belhassen B |title=Fever-related arrhythmic events in the multicenter Survey on Arrhythmic Events in Brugada Syndrome |journal=Heart Rhythm |volume=15 |issue=9 |pages=1394–1401 |date=September 2018 |pmid=29649615 |doi=10.1016/j.hrthm.2018.04.007 |url=}}</ref><ref name="pmid30441573">{{cite journal |vauthors=Luo C, Wang K, Liu T, Zhang H |title=Computational Analysis of the Action of Chloroquine on Short QT Syndrome Variant 1 and Variant 3 in Human Ventricles |journal=Conf Proc IEEE Eng Med Biol Soc |volume=2018 |issue= |pages=5462–5465 |date=July 2018 |pmid=30441573 |doi=10.1109/EMBC.2018.8513572 |url=}}</ref>
@@ Line 146: / Line 147: @@
 ==Epidemiology and Demographics==
 ===Incidence===
-*There is a two-times rise in the [[incidence]] of Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) during the [[COVID-19]] [[pandemic]] as compared to the non-pandemic time period.
+*During the [[COVID-19]] pandemic, the [[incidence]] of out-of-[[hospital]] [[Sudden cardiac arrest|Sudden cardiac arrests]] (OHCA) has been 2 times greater compared to the non-pandemic time period.
 *According to a study done in China, about 12% of patients with [[COVID-19]] without a history of heart problems experience [[cardiac arrest]] during their hospitalization.<ref name="ZhengMa2020">{{cite journal|last1=Zheng|first1=Ying-Ying|last2=Ma|first2=Yi-Tong|last3=Zhang|first3=Jin-Ying|last4=Xie|first4=Xiang|title=COVID-19 and the cardiovascular system|journal=Nature Reviews Cardiology|volume=17|issue=5|year=2020|pages=259–260|issn=1759-5002|doi=10.1038/s41569-020-0360-5}}</ref>
 *In a study done among 761 Chinese patients with severe [[COVID-19]], about 20% patients developed in-hospital cardiac arrest within 40 days of their hospitalization course.<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>
@@ Line 152: / Line 153: @@
 *There is a significant increase in the [[mortality rate]] of the OHCA in [[patients]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
 ===Age===
-*Mean [[age]] 69.7 years is observed among [[patients]] who experienced Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) .<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref> .
+*The mean [[age]] observed among [[patients]] who experienced out-of-[[hospital]] [[Sudden cardiac arrest]] (OHCA) is 69.7 years.<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref> .
 ===Gender===
-*Studies showed that [[male]] gender have a slightly higher [[incidence]] of out of hospital [[sudden cardiac arrest]] (OHCA) as compared to the [[females]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
+*Studies showed that [[male|males]] have a slightly higher [[incidence]] of out-of-hospital [[sudden cardiac arrest]] (OHCA) as compared to the [[females]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
 ===Race===
-A higher [[incidence]] has been seen among [[African-Americans]] as compared to the [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>
+* A higher [[incidence]] has been seen among [[African-Americans]] as compared to [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>
 ==Risk Factors==
 * Common [[risk factors]] in the development of arrhythmia and [[cardiac arrest]] in [[COVID-19]] are:<ref name="pmid32244059">{{cite journal |vauthors=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM |title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes |journal=Heart Rhythm |volume= |issue= |pages= |date=March 2020 |pmid=32244059 |pmc=7156157 |doi=10.1016/j.hrthm.2020.03.024 |url=}}</ref>
@@ Line 167: / Line 169: @@
 ==Natural History, Complications, and Prognosis==
-* The proportion of [[patients]] developed  [[out of hospital cardiac arrest]] (OHCA) increased during [[covid-19]] pandemic.<ref name="PfefferbaumNorth2020">{{cite journal|last1=Pfefferbaum|first1=Betty|last2=North|first2=Carol S.|title=Mental Health and the Covid-19 Pandemic|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMp2008017}}</ref>and was affected by aggravation of underlying comorbidities, late presentation of acute [[STEMI]](ST elevation myocardial infarction) due to fear of being infected in hospital and avoidance of bystander [[cardiopulmonary rescucitation|cardiopulmonary resuscitation]] in public due to fear of infection.<ref name="TamCheung2020">{{cite journal|last1=Tam|first1=Chor-Cheung Frankie|last2=Cheung|first2=Kent-Shek|last3=Lam|first3=Simon|last4=Wong|first4=Anthony|last5=Yung|first5=Arthur|last6=Sze|first6=Michael|last7=Lam|first7=Yui-Ming|last8=Chan|first8=Carmen|last9=Tsang|first9=Tat-Chi|last10=Tsui|first10=Matthew|last11=Tse|first11=Hung-Fat|last12=Siu|first12=Chung-Wah|title=Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006631}}</ref><ref name="ScquizzatoOlasveengen2020">{{cite journal|last1=Scquizzato|first1=Tommaso|last2=Olasveengen|first2=Theresa Mariero|last3=Ristagno|first3=Giuseppe|last4=Semeraro|first4=Federico|title=The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation|journal=Resuscitation|volume=150|year=2020|pages=92–93|issn=03009572|doi=10.1016/j.resuscitation.2020.03.019}}</ref>
+* The proportion of [[patients]] who developed [[out of hospital cardiac arrest|out-of-hospital cardiac arrest]] (OHCA) increased during the [[covid-19|COVID-19]] pandemic and was affected by aggravation of underlying comorbidities, late presentation of acute [[STEMI]](ST elevation myocardial infarction) due to fear of being infected in hospital, and avoidance of bystander [[cardiopulmonary rescucitation|cardiopulmonary resuscitation]] in public due to fear of infection.<ref name="TamCheung2020">{{cite journal|last1=Tam|first1=Chor-Cheung Frankie|last2=Cheung|first2=Kent-Shek|last3=Lam|first3=Simon|last4=Wong|first4=Anthony|last5=Yung|first5=Arthur|last6=Sze|first6=Michael|last7=Lam|first7=Yui-Ming|last8=Chan|first8=Carmen|last9=Tsang|first9=Tat-Chi|last10=Tsui|first10=Matthew|last11=Tse|first11=Hung-Fat|last12=Siu|first12=Chung-Wah|title=Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006631}}</ref><ref name="ScquizzatoOlasveengen2020">{{cite journal|last1=Scquizzato|first1=Tommaso|last2=Olasveengen|first2=Theresa Mariero|last3=Ristagno|first3=Giuseppe|last4=Semeraro|first4=Federico|title=The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation|journal=Resuscitation|volume=150|year=2020|pages=92–93|issn=03009572|doi=10.1016/j.resuscitation.2020.03.019}}</ref>
-* Prognosis of patients with severe [[COVID-19]] pneumonia  with  [[in hospital cardiac arrest]] (IHCA) was poor in wohan '''.<ref name="pmid32283117">{{cite journal |vauthors=Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z |title=In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China |journal=Resuscitation |volume=151 |issue= |pages=18–23 |date=June 2020 |pmid=32283117 |pmc=7151543 |doi=10.1016/j.resuscitation.2020.04.005 |url=}}</ref>'''
+* Prognosis of patients with severe [[COVID-19]] pneumonia with [[in hospital cardiac arrest]] (IHCA) was poor in Wuhan, China'''.<ref name="pmid32283117">{{cite journal |vauthors=Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z |title=In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China |journal=Resuscitation |volume=151 |issue= |pages=18–23 |date=June 2020 |pmid=32283117 |pmc=7151543 |doi=10.1016/j.resuscitation.2020.04.005 |url=}}</ref>'''
-* Mortality rate of patients with [[COVID-19]]  is approximately 1-2%'''<ref name="pmid32109013">{{cite journal |vauthors=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS |title=Clinical Characteristics of Coronavirus Disease 2019 in China |journal=N. Engl. J. Med. |volume=382 |issue=18 |pages=1708–1720 |date=April 2020 |pmid=32109013 |pmc=7092819 |doi=10.1056/NEJMoa2002032 |url=}}</ref>'''
+* Mortality rate of patients with [[COVID-19]] is approximately 1-2%'''<ref name="pmid32109013">{{cite journal |vauthors=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS |title=Clinical Characteristics of Coronavirus Disease 2019 in China |journal=N. Engl. J. Med. |volume=382 |issue=18 |pages=1708–1720 |date=April 2020 |pmid=32109013 |pmc=7092819 |doi=10.1056/NEJMoa2002032 |url=}}</ref>'''
 ==Diagnosis==
 ===Diagnostic Criteria===
-* The diagnosis of  sudden cardiac death is made when the following diagnostic criteria are met:
+* The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:
-:* Prodromes phase occuring weeks or months before an event includes: new or worsening cardiovascular symptoms([[chest pain]], [[dyspnea]], [[palpitations]], fatigability)
-:* Onset of terminal event occuring one hour before cardiac arrest includes:abrupt change in clinical status( [[arrhythmia]], hypotension, [[chest pain]], [[dyspnea]],lightheadness)
+:* Prodromes phase occurring weeks or months before an event includes: new or worsening cardiovascular symptoms([[chest pain]], [[dyspnea]], [[palpitations]], fatigability)
+:* Onset of terminal event occurring one hour before cardiac arrest includes: abrupt change in clinical status([[arrhythmia]], hypotension, [[chest pain]], [[dyspnea]], lightheadness)
 :* Cardiac arrest includes: sudden collapse, loss of effective [[circulation]], loss of consciousness
-:*[[Biologic death]]: failure of [[resuscitatio]]<nowiki/>n or failure of electerical, mechanical or CNS function after initial [[resuscitation]]
+:*[[Biologic death]]: failure of [[Cardiopulmonary resuscitation|resuscitatio]]<nowiki/>[[Cardiopulmonary resuscitation|n]] or failure of electrical, mechanical, or CNS function after initial [[resuscitation]]
 === Symptoms ===
-* Symptoms before cardiac arrest in [[COVID-19|covid19]]  may include the following:
+* Symptoms before cardiac arrest in [[COVID-19]]  may include the following:
-*[[Chest pain]]
+**[[Chest pain]]
-*[[Palpitation]]
+**[[Palpitation]]
-*[[Dyspnea]]
+**[[Dyspnea]]
-*[[Lightheadness]]
+**[[Lightheadness]]
 === Physical Examination ===
@@ Line 192: / Line 195: @@
 * An elevated concentration of serum cardiac troponinI was detected in severe [[COVID-19-associated diabetes mellitus|COVID-19]] patients with cardiac complications. <ref name="pmid32382587">{{cite journal |vauthors=Paul P |title=Cardiac Troponin-I may be a predictor of complications and mortality in COVID-19 patients |journal=Curr Med Res Pract |volume= |issue= |pages= |date=May 2020 |pmid=32382587 |pmc=7204698 |doi=10.1016/j.cmrp.2020.05.001 |url=}}</ref>
 === Imaging Findings ===
-* There are no imaging study findings associated with cardiac arrest in [[COVID-19]].
+There are no imaging study findings associated with cardiac arrest in [[COVID-19]].
 ===Electrocardiogram===
-* Findings on [[EKG]]  during [[inhospital cardiac arrest]](IHCA) in covid19  include:[[asystole]](89.7%),[[pulseless electrical activity]](4.4%) shockable  rhythm(5.9%)<ref name="pmid32283117">{{cite journal |vauthors=Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z |title=In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China |journal=Resuscitation |volume=151 |issue= |pages=18–23 |date=June 2020 |pmid=32283117 |pmc=7151543 |doi=10.1016/j.resuscitation.2020.04.005 |url=}}</ref>
+* Findings on [[EKG]] during [[inhospital cardiac arrest|in-hospital cardiac arrest]] (IHCA) with COVID-19 infection include:<ref name="pmid32283117" />
+**[[Asystole]] (89.7%)
+**[[Pulseless electrical activity]] (4.4%)
+**Shockable rhythm (5.9%)
+<br />
 *Other abnormal [[EKG Abnormalities in central nervous system disease|EKG]] findings include [[QT prolongation]]. [[ECG]] shows [[corrected QT interval]] ([[QTc]]) more than 500 ms.<br />
 ==Treatment==
-*The mainstay of therapy for cardiac arrest in [[COVID-19]]  is cardiopulmonary rescucitation with attention to the following points:<ref name="EdelsonSasson2020">{{cite journal|last1=Edelson|first1=Dana P.|last2=Sasson|first2=Comilla|last3=Chan|first3=Paul S.|last4=Atkins|first4=Dianne L.|last5=Aziz|first5=Khalid|last6=Becker|first6=Lance B.|last7=Berg|first7=Robert A.|last8=Bradley|first8=Steven M.|last9=Brooks|first9=Steven C.|last10=Cheng|first10=Adam|last11=Escobedo|first11=Marilyn|last12=Flores|first12=Gustavo E.|last13=Girotra|first13=Saket|last14=Hsu|first14=Antony|last15=Kamath-Rayne|first15=Beena D.|last16=Lee|first16=Henry C.|last17=Lehotsky|first17=Rebecca E.|last18=Mancini|first18=Mary E.|last19=Merchant|first19=Raina M.|last20=Nadkarni|first20=Vinay M.|last21=Panchal|first21=Ashish R.|last22=Peberdy|first22=Mary Ann R.|last23=Raymond|first23=Tia T.|last24=Walsh|first24=Brian|last25=Wang|first25=David S.|last26=Zelop|first26=Carolyn M.|last27=Topjian|first27=Alexis A.|last28=Starks|first28=Monique Anderson|last29=Bobrow|first29=Bentley J.|last30=Chan|first30=Melissa|last31=Berg|first31=Katherine|last32=Duff|first32=Jonathan P.|last33=Joyner|first33=Benny L.|last34=Lasa|first34=Javier J.|last35=Levy|first35=Arielle|last36=Mahgoub|first36=Melissa|last37=O’Connor|first37=Michael F.|last38=Hoover|first38=Amber V.|last39=Rodriguez|first39=Amber J.|last40=Meckler|first40=Garth|last41=Roberts|first41=Kathryn|last42=Mohr|first42=Nicholas M.|last43=Nassar|first43=Boulos|last44=Rubinson|first44=Lewis|last45=Sutton|first45=Robert M.|last46=Schexnayder|first46=Stephen M.|last47=Kleinman|first47=Monica|last48=de Caen|first48=Allan|last49=Morgan|first49=Ryan|last50=Bhanji|first50=Farhan|last51=Fuchs|first51=Susan|last52=Terry|first52=Mark|last53=McBride|first53=Mary|last54=Levy|first54=Michael|last55=Cabanas|first55=Jose G.|last56=Tan|first56=David K.|last57=Moitra|first57=Vivek K.|last58=Szokol|first58=Joseph W.|title=Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19|journal=Circulation|volume=141|issue=25|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047463}}</ref>
+*The mainstay of therapy for [[COVID-19]]-related cardiac arrest is cardiopulmonary resuscitation with attention to the following points:<ref name="EdelsonSasson2020">{{cite journal|last1=Edelson|first1=Dana P.|last2=Sasson|first2=Comilla|last3=Chan|first3=Paul S.|last4=Atkins|first4=Dianne L.|last5=Aziz|first5=Khalid|last6=Becker|first6=Lance B.|last7=Berg|first7=Robert A.|last8=Bradley|first8=Steven M.|last9=Brooks|first9=Steven C.|last10=Cheng|first10=Adam|last11=Escobedo|first11=Marilyn|last12=Flores|first12=Gustavo E.|last13=Girotra|first13=Saket|last14=Hsu|first14=Antony|last15=Kamath-Rayne|first15=Beena D.|last16=Lee|first16=Henry C.|last17=Lehotsky|first17=Rebecca E.|last18=Mancini|first18=Mary E.|last19=Merchant|first19=Raina M.|last20=Nadkarni|first20=Vinay M.|last21=Panchal|first21=Ashish R.|last22=Peberdy|first22=Mary Ann R.|last23=Raymond|first23=Tia T.|last24=Walsh|first24=Brian|last25=Wang|first25=David S.|last26=Zelop|first26=Carolyn M.|last27=Topjian|first27=Alexis A.|last28=Starks|first28=Monique Anderson|last29=Bobrow|first29=Bentley J.|last30=Chan|first30=Melissa|last31=Berg|first31=Katherine|last32=Duff|first32=Jonathan P.|last33=Joyner|first33=Benny L.|last34=Lasa|first34=Javier J.|last35=Levy|first35=Arielle|last36=Mahgoub|first36=Melissa|last37=O’Connor|first37=Michael F.|last38=Hoover|first38=Amber V.|last39=Rodriguez|first39=Amber J.|last40=Meckler|first40=Garth|last41=Roberts|first41=Kathryn|last42=Mohr|first42=Nicholas M.|last43=Nassar|first43=Boulos|last44=Rubinson|first44=Lewis|last45=Sutton|first45=Robert M.|last46=Schexnayder|first46=Stephen M.|last47=Kleinman|first47=Monica|last48=de Caen|first48=Allan|last49=Morgan|first49=Ryan|last50=Bhanji|first50=Farhan|last51=Fuchs|first51=Susan|last52=Terry|first52=Mark|last53=McBride|first53=Mary|last54=Levy|first54=Michael|last55=Cabanas|first55=Jose G.|last56=Tan|first56=David K.|last57=Moitra|first57=Vivek K.|last58=Szokol|first58=Joseph W.|title=Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19|journal=Circulation|volume=141|issue=25|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047463}}</ref>
-*wearing personal protective equipment (PPE) before entering the room or on the scene.
+**Wearing personal protective equipment (PPE) before entering the room or on the scene.
-* limiting the personnel in the room or on the scene
+** Limiting the personnel in the room or on the scene
-*Using high-efficacy particulate air filter for ventilator
+**Using high-efficacy particulate air filter for ventilator
-* Intubatting with a [[cuffed tube]]
+** Intubating with a [[cuffed tube]]
-* Stopping chest compression for intubation
+** Stopping chest compression for intubation
-* Using bag-mask device before intubation
+** Using bag-mask device before intubation
-* Using nonrebreathing face mask instead of bag-mask for short term oxygenation
+** Using non-rebreathing face mask instead of bag-mask for short term oxygenation
 ==Prevention==
-Effective measures for the [[primary prevention]] of [[ventricular arrhythmia]]  during using [[hydroxychloroquine]] in the setting of long QT syndrome or aquired LQTS or heart rate<50/min or recieving azithromycin,redmisivir, lopinavir, ritonavir, include [[EKG]] and [[QTc]] measurement.<ref name="pmid32244059">{{cite journal |vauthors=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM |title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes |journal=Heart Rhythm |volume= |issue= |pages= |date=March 2020 |pmid=32244059 |pmc=7156157 |doi=10.1016/j.hrthm.2020.03.024 |url=}}</ref>
+Effective measures for the [[primary prevention]] of [[ventricular arrhythmia]]  during using [[hydroxychloroquine]] in the setting of long QT syndrome or aquired LQTS or heart rate <50/min or receiving azithromycin, redmisivir, lopinavir, ritonavir, include [[EKG]] and [[QTc]] measurement.<ref name="pmid32244059">{{cite journal |vauthors=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM |title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes |journal=Heart Rhythm |volume= |issue= |pages= |date=March 2020 |pmid=32244059 |pmc=7156157 |doi=10.1016/j.hrthm.2020.03.024 |url=}}</ref>
 * If QTc ≥500 ms, consult with cardiologist.
 * If QTc<500ms, start [[hydroxychloroquine]] and repeat [[EKG]]  after 1-3 days.
@@ Line 215: / Line 225: @@
 **Increased [[QTc]]>60ms
 **[[Ventricular ectopy]]
-* Treatment  of [[hypokalemia]] due to [[diarrhea]] associated [[COVID-19]] ,which prolonges [[QT interval]] is another measurement to be considered.
+* Treatment of [[hypokalemia]] due to [[diarrhea]] associated [[COVID-19]] ,which prolonges [[QT interval]] is another measurement to be considered.
 *Effective measures for the primary prevention of [[ventricular arrhythmia]] in [[brugada]] syndrome is starting [[acetaminophen]] or [[parastamol]] immediately if there is  sign of [[fever]] and also self-isolation.