New-onset atrial fibrillation in critically ill patients with coronavirus disease 2019 (COVID-19)

Complications of new-onset atrial fibrillation in critically ill COVID-19 patients admitted to the intensive care unit (ICU): a meta-analysis

BACKGROUND

COVID-19 infections can result in severe acute respiratory distress syndrome (ARDS) requiring admission to the intensive care unit (ICU). Cardiovascular manifestation or exacerbation of cardiovascular diseases could be another complication. Cardiac arrhythmias including New-Onset Atrial Fibrillation (NOAF), have been observed in hospitalized patients with COVID-19 infections. In this analysis, we aimed to systematically compare the complications associated with NOAF in critically ill COVID-19 patients admitted to the ICU.

METHODS

MEDLINE, EMBASE, Web of Science, the Cochrane database, http://www.

CLINICALTRIALS

gov , Google Scholar and Mendeley were searched for relevant publications based on COVID-19 patients with NOAF admitted to the ICU. Complications including in-hospital mortality, ICU mortality, patients requiring mechanical ventilation, acute myocardial infarction, acute kidney injury, renal replacement therapy and pulmonary embolism were assessed. This is a meta-analysis and the analytical tool which was used was the RevMan software version 5.4. Risk ratios (RR) and 95% confidence intervals (CIs) were used to represent the data post analysis.

RESULTS

In critically ill COVID-19 patients with NOAF admitted to the ICU, the risks of ICU mortality (RR: 1.39, 95% CI: 1.07 - 1.80; P = 0.01), in-hospital mortality (RR: 1.56, 95% CI: 1.20 - 2.04; P = 0.001), patients requiring mechanical ventilation (RR: 1.32, 95% CI: 1.04 - 1.66; P = 0.02) were significantly higher when compared to the control group without AF. Acute myocardial infarction (RR: 1.54, 95% CI: 1.31 - 1.81; P = 0.00001), the risk for acute kidney injury (RR: 1.31, 95% CI: 1.11 - 1.55; P = 0.002) and patients requiring renal replacement therapy (RR: 1.83, 95% CI: 1.60 - 2.09; P = 0.00001) were also significantly higher in patients with NOAF.

CONCLUSIONS

Critically ill COVID-19 patients with NOAF admitted to the ICU were at significantly higher risks of developing complications and death compared to similar patients without AF.

A Pragmatic Study of Cardiovascular Disease During Long-Term COVID-19

BACKGROUND

Many patients diagnosed with COVID-19 have persistent cardiovascular symptoms, but whether this represents a true cardiac process is unclear. This study assessed whether symptoms associated with long COVID among patients referred for cardiovascular evaluation are associated with objective abnormalities on cardiac testing to explain their clinical presentation.

METHODS

A retrospective cohort study of 40,462 unique patients diagnosed with COVID-19 at our tertiary referral was conducted and identified 363 patients with persistent cardiovascular symptoms a minimum of 4 weeks after polymerase chain reaction confirmed COVID-19 infection. Patients had no cardiovascular symptoms prior to COVID-19 infection. Each patient was referred for cardiovascular evaluation at a tertiary referral center. The incidence and etiology of abnormalities on cardiovascular testing among patients with long COVID symptoms are reported here. The cohort was subsequently divided into 3 categories based on the dominant circulating severe acute respiratory syndrome coronavirus 2 variant at the time of initial infection for further analysis.

RESULTS

Among 40,462 unique patients diagnosed with COVID-19 at our tertiary referral center from April 2020 to March 2022, 363 (0.9%) patients with long COVID were evaluated by Cardiology for possible cardiac sequelae from COVID and formed the main study cohort. Of these, 229 (63%) were vaccinated and 47 (12.9%) had severe initial infection, receiving inpatient treatment for COVID prior to developing long COVID symptoms. Symptoms were associated with a cardiac cause in 85 (23.4%), of which 52 (14.3%) were attributed to COVID; 39 (10.7%) with new cardiac disease from COVID, and 13 (3.6%) to worsening of pre-existing cardiac disease after COVID infection. The median troponin change in 45 patients with troponin measurements within 4 weeks of acute infection was +4 ng/dL (9 to 13 ng/dL). Among the total cohort with long COVID, 83.7% were diagnosed during the pre-Delta phase, 13.2% during the Delta phase, and 3.1% during the Omicron phase of the pandemic. There were 6 cases of myocarditis, 11 rhythm disorders, 8 cases of pericarditis, 5 suspected cases of endothelial dysfunction, and 33 cases of autonomic dysfunction.

CONCLUSION

This pragmatic retrospective cohort study suggests that patients with long COVID referred for cardiovascular evaluation infrequently have new, objective cardiovascular disease to explain their clinical presentation. A multidisciplinary, patient-centered approach is warranted for symptom management along with conservative use of diagnostic testing.

A systematic review and meta-analysis of new-onset atrial fibrillation in the context of COVID-19 infection

New-onset atrial fibrillation (NOAF) in COVID-19 raises significant clinical and public health issues. This systematic review and meta-analysis aims to compile and analyze the current literature on NOAF in COVID-19 and give a more comprehensive understanding of the prevalence and outcomes of NOAF in COVID-19. A comprehensive literature search was carried out using several databases. The random effect model using inverse variance method and DerSimonian and Laird estimator of Tua2 was used to calculate the pooled prevalence and associated 95% confidence interval (CI). Results for outcome analysis were presented as odds ratios (ORs) with 95% CI and pooled using the Mantel-Haenszel random-effects model. The pooled prevalence of NOAF in COVID-19 was 7.8% (95% CI: 6.54%-9.32%),a pooled estimate from 30 articles (81 929 COVID-19 patients). Furthermore, our analysis reported that COVID-19 patients with NOAF had a higher risk of developing severe disease compared with COVID-19 patients without a history of atrial fibrillation (OR = 4.78, 95% CI: 3.75-6.09) and COVID-19 patients with a history of pre-existing atrial fibrillation (OR = 2.75, 95% CI: 2.10-3.59). Similarly, our analysis also indicated that COVID-19 patients with NOAF had a higher risk of all-cause mortality compared with, COVID-19 patients without a history of atrial fibrillation (OR = 3.83, 95% CI: 2.99-4.92) and COVID-19 patients with a history of pre-existing atrial fibrillation (OR = 2.32, 95% CI: 1.35-3.96). The meta-analysis did not reveal any significant publication bias. The results indicate a strong correlation between NOAF and a higher risk of severe illness and mortality. These results emphasize the importance of careful surveillance, early detection, and customized NOAF management strategies to improve clinical outcomes for COVID-19 patients.

New-onset atrial fibrillation among COVID-19 patients: A narrative review

Over the last three years, research has focused on examining cardiac issues arising from coronavirus disease 2019 (COVID-19) infection, including the emergence of new-onset atrial fibrillation (NOAF). Still, no clinical study was conducted on the persistence of this arrhythmia after COVID-19 recovery. Our objective was to compose a narrative review that investigates COVID-19-associated NOAF, emphasizing the evolving pathophysiological mechanisms akin to those suggested for sustaining AF. Given the distinct strategies involved in the persistence of atrial AF and the crucial burden of persistent AF, we aim to underscore the importance of extended follow-up for COVID-19-associated NOAF. A comprehensive search was conducted for articles published between December 2019 and February 11, 2023, focusing on similarities in the pathophysiology of NOAF after COVID-19 and those persisting AF. Also, the latest data on incidence, morbidity-mortality, and management of NOAF in COVID-19 were investigated. Considerable overlaps between the mechanisms of emerging NOAF after COVID-19 infection and persistent AF were observed, mostly involving reactive oxygen pathways. With potential atrial remodeling associated with NOAF in COVID-19 patients, this group of patients might benefit from long-term follow-up and different management. Future cohort studies could help determine long-term outcomes of NOAF after COVID-19.

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit

New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

Has COVID-19 changed the spectrum of arrhythmias and the incidence of sudden cardiac death?

Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction abnormalities, ventricular tachyarrhythmias, sudden cardiac arrest, and cardiovascular dysautonomias including the so-called long COVID syndrome. Various pathophysiological mechanisms have been implicated, such as direct viral invasion, hypoxemia, local and systemic inflammation, changes in ion channel physiology, immune activation, and autonomic dysregulation. The development of atrial or ventricular arrhythmias in hospitalized COVID-19 patients has been shown to portend a higher risk of in-hospital death. Management of these arrhythmias should be based on published evidence-based guidelines, with special consideration of the acuity of COVID-19 infection, concomitant use of antimicrobial and anti-inflammatory drugs, and the transient nature of some rhythm disorders. In view of new SARS-CoV‑2 variants that may evolve, the development and use of newer antiviral and immunomodulator drugs, and the increasing adoption of vaccination, clinicians must remain vigilant for other arrhythmic manifestations that may occur in association with this novel but potentially deadly disease.

Interaction of COVID-19 With Common Cardiovascular Disorders

The onset and widespread dissemination of the severe acute respiratory syndrome coronavirus-2 in late 2019 impacted the world in a way not seen since the 1918 H1N1 pandemic, colloquially known as the Spanish Flu. Much like the Spanish Flu, which was observed to disproportionately impact young adults, it became clear in the early days of the coronavirus disease 2019 (COVID-19) pandemic that certain groups appeared to be at higher risk for severe illness once infected. One such group that immediately came to the forefront and garnered international attention was patients with preexisting cardiovascular disease. Here, we examine the available literature describing the interaction of COVID-19 with a myriad of cardiovascular conditions and diseases, paying particular attention to patients diagnosed with arrythmias, heart failure, and coronary artery disease. We further discuss the association of acute COVID-19 with de novo cardiovascular disease, including myocardial infarction due to coronary thrombosis, myocarditis, and new onset arrhythmias. We will evaluate various biochemical theories to explain these findings, including possible mechanisms of direct myocardial injury caused by the severe acute respiratory syndrome coronavirus-2 virus at the cellular level. Finally, we will discuss the strategies employed by numerous groups and governing bodies within the cardiovascular disease community to address the unprecedented challenges posed to the care of our most vulnerable patients, including heart transplant recipients, end-stage heart failure patients, and patients suffering from acute coronary syndromes, during the early days and height of the COVID-19 pandemic.

Prevalence and clinical implications of atrial fibrillation in patients hospitalized due to COVID-19: Data from a registry in Poland

Background

Atrial fibrillation (AF) is a common arrhythmia with increasing prevalence with respect to age and comorbidities. AF may influence the prognosis in patients hospitalized with Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence of AF among patients hospitalized due to COVID-19 and the association of AF and in-hospital anticoagulation treatment with prognosis.

Methods and results

We assessed the prevalence of AF among patients hospitalized due to COVID-19 and the association of AF and in-hospital anticoagulation treatment with prognosis. Data of all COVID-19 patients hospitalized in the University Hospital in Krakow, Poland, between March 2020 and April 2021, were analyzed. The following outcomes: short-term (30-days since hospital admission) and long-term (180-days after hospital discharge) mortality, major cardiovascular events (MACEs), pulmonary embolism, and need for red blood cells (RBCs) transfusion, as a surrogate for major bleeding events during hospital stay were assessed. Out of 4,998 hospitalized patients, 609 had AF (535 pre-existing and 74 de novo). Compared to those without AF, patients with AF were older and had more cardiovascular disorders. In adjusted analysis, AF was independently associated with an increased risk of short-term {p = 0.019, Hazard Ratio [(HR)] 1.236; 95% CI: 1.035–1.476} and long-term mortality (Log-rank p < 0.001) as compared to patients without AF. The use of novel oral anticoagulants (NOAC) in AF patients was associated with reduced short-term mortality (HR 0.14; 95% CI: 0.06–0.33, p < 0.001). Moreover, in AF patients, NOAC use was associated with a lower probability of MACEs (Odds Ratio 0.3; 95% CI: 0.10–0.89, p = 0.030) without increase of RBCs transfusion.

Conclusions

AF increases short- and long-term risk of death in patients hospitalized due to COVID-19. However, the use of NOACs in this group may profoundly improve prognosis.

Incidence and Clinical Outcomes of New-Onset Atrial Fibrillation in Critically lll Patients with COVID-19: A Multicenter Cohort Study - New-Onset Atrial Fibrillation and COVID-19

Atrial fibrillation (Afib) can contribute to a significant increase in mortality and morbidity in critically ill patients. Thus, our study aims to investigate the incidence and clinical outcomes associated with the new-onset Afib in critically ill patients with COVID-19. A multicenter, retrospective cohort study includes critically ill adult patients with COVID-19 admitted to the intensive care units (ICUs) from March, 2020 to July, 2021. Patients were categorized into two groups (new-onset Afib vs control). The primary outcome was the in-hospital mortality. Other outcomes were secondary, such as mechanical ventilation (MV) duration, 30-day mortality, ICU length of stay (LOS), hospital LOS, and complications during stay. After propensity score matching (3:1 ratio), 400 patients were included in the final analysis. Patients who developed new-onset Afib had higher odds of in-hospital mortality (OR 2.76; 95% CI: 1.49-5.11, P = .001). However, there was no significant differences in the 30-day mortality. The MV duration, ICU LOS, and hospital LOS were longer in patients who developed new-onset Afib (beta coefficient 0.52; 95% CI: 0.28-0.77; P < .0001,beta coefficient 0.29; 95% CI: 0.12-0.46; P < .001, and beta coefficient 0.35; 95% CI: 0.18-0.52; P < .0001; respectively). Moreover, the control group had significantly lower odds of major bleeding, liver injury, and respiratory failure that required MV. New-onset Afib is a common complication among critically ill patients with COVID-19 that might be associated with poor clinical outcomes; further studies are needed to confirm these findings.

Impact of COVID-19 on Cardiovascular Disease

Coronavirus disease 2019 (COVID-19) is a viral infection with the novel severe acute respiratory distress syndrome corona virus 2 (SARS-CoV-2). Until now, more than 670 million people have suffered from COVID-19 worldwide, and roughly 7 million death cases were attributed to COVID-19. Recent evidence suggests an interplay between COVID-19 and cardiovascular disease (CVD). COVID-19 may serve as a yet underappreciated CVD risk modifier, including risk factors such as diabetes mellitus or arterial hypertension. In addition, recent data suggest that previous COVID-19 may increase the risk for many entities of CVD to an extent similarly observed for traditional cardiovascular (CV) risk factors. Furthermore, increased CVD incidence and worse clinical outcomes in individuals with preexisting CVD have been observed for myocarditis, acute coronary syndrome, heart failure (HF), thromboembolic complications, and arrhythmias. Direct and indirect mechanisms have been proposed by which COVID-19 may impact CVD and CV risk, including viral entry into CV tissue or by the induction of a massive systemic inflammatory response. In the current review, we provide an overview of the literature reporting an interaction between COVID-19 and CVD, review potential mechanisms underlying this interaction, and discuss preventive and treatment strategies and their interference with CVD that were evaluated since the onset of the COVID-19 pandemic.

Incident Atrial Fibrillation and In-Hospital Mortality in SARS-CoV-2 Patients

(1) Background: Among the different cardiovascular (CV) manifestations of the coronavirus disease 2019 (COVID-19), arrhythmia and atrial fibrillation (AF) in particular have recently received special attention. The aims of our study were to estimate the incidence of AF in patients hospitalized for COVID-19, and to evaluate its role as a possible predictor of in-hospital all-cause mortality. (2) Methods: We enrolled 3435 people with SARS-CoV2 infection admitted to three hospitals in Northern Italy from February 2020 to May 2021. We collected data on their clinical history, laboratory tests, pharmacological treatment and intensive care unit (ICU) admission. Incident AF and all-cause in-hospital mortality were considered as outcomes. (3) Results: 145 (4.2%) patients developed AF during hospitalization, with a median time since admission of 3 days (I-III quartile: 0, 12). Patients with incident AF were admitted more frequently to the ICU (39.3 vs. 12.4%, p < 0.001), and more frequently died (37.2 vs. 16.9%, p < 0.001). In the Cox regression model, the significant determinants of incident AF were age (HR: 1.041; 95% CI: 1.022, 1.060 per year), a history of AF (HR: 2.720; 95% CI: 1.508, 4.907), lymphocyte count (HR: 0.584; 95% CI: 0.384, 0.888 per 103/µL), estimated glomerular filtration rate (eGFR, HR: 0.988; 95% CI: 0.980, 0.996 per mL/min) and ICU admission (HR: 5.311; 95% CI: 3.397, 8.302). Incident AF was a predictor of all-cause mortality (HR: 1.405; 95% CI: 1.027, 1.992) along with age (HR: 1.057; 95% CI: 1.047, 1.067), male gender (HR: 1.315; 95% CI: 1.064; 1.626), dementia (HR: 1.373; 95% CI: 1.045, 1.803), lower platelet (HR: 0.997; 95% CI: 0.996, 0.998 per 103/µL) and lymphocyte counts (HR: 0.843; 95% CI: 0.725, 0.982 per 103/µL), C-Reactive protein values (HR: 1.004; 95% CI: 1.003, 1.005 per mg/L), eGFR (HR: 0.990; 95% CI: 0.986, 0.994 per mL/min), and ICU admission (HR: 1.759; 95% CI: 1.292, 2.395). (4) Conclusions: Incident AF is a common complication in COVID-19 patients during hospitalization, and its occurrence strongly predicts in-hospital mortality.

Incidence, clinical predictors, and clinical effect of new-onset atrial fibrillation in myocardial infarction patients: A retrospective cohort study

OBJECTIVES

To calculate the incidence of new-onset atrial fibrillation (NOAF) in myocardial infarction (MI) patients and examine associated predictors and clinical outcomes of NOAF patients.

METHODS

A retrospective cohort study was used to carry out this study. All MI patients admitted to King Khaled University Hospital, Riyadh, Saudi Arabia, between January 2015 to 2020 were eligible for inclusion. The study excluded those with a previous diagnosis of atrial fibrillation and patients who died at presentation.

RESULTS

A total of 281 patients were analyzed with a mean age of 58.7±12.7. Incidence of NOAF was 7.8%. Significant predictors identified by multivariate logistic regression analysis included older age (p=0.004), history of MI (p=0.012), and undergoing coronary artery bypass graft surgery (CABG) as treatment (p=0.016). New-onset atrial fibrillation was associated with higher odds of major adverse cardiovascular event (p=0.039), ventricular tachycardia (p=0.001), and mortality (p=0.031).

CONCLUSION

New-onset atrial fibrillation is a relatively common complication of MI, and in our study, it was associated with higher odds of further complications including death. Therefore, identification of MI patients at risk of developing NOAF is crucial. Our study suggests that older age, a previous history of MI, and undergoing CABG are significant predictors of NOAF development.

New-Onset Atrial Fibrillation in Patients With Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease - Insights From the CLAVIS-COVID Registry

BACKGROUND

Both pre-existing atrial fibrillation (AF) and new-onset AF (NOAF) are observed in patients with coronavirus disease 2019 (COVID-19); however, the effect of AF on clinical outcomes is unclear. This study aimed to investigate the effect of AF, especially NOAF, on the outcomes of hospitalized patients with COVID-19.

METHODS AND RESULTS

This study analyzed 673 COVID-19 patients with cardiovascular diseases and risk factors (CVDRF). Patients were divided into 3 groups; pre-existing AF (n=55), NOAF (n=28), and sinus rhythm (SR) (n=590). The baseline characteristics and in-hospital outcomes were evaluated. The mean age of the patients was 68 years, 65.4% were male, and the in-hospital mortality rate was 15.6%. The NOAF group demonstrated a higher in-hospital mortality rate (42.9%) than the pre-existing AF (30.9%) and SR (11.2%) groups (P<0.001). Patients with NOAF had a higher incidence of acute respiratory syndrome, multiple organ disease, hemorrhage, and stroke than those with pre-existing AF and NOAF. NOAF was independently associated with in-hospital mortality after adjusting for pre-existing AF and 4C mortality score (odds ratio [95% confidence interval]: 4.71 [1.63-13.6], P<0.001).

CONCLUSIONS

Patients with NOAF had significantly worse outcomes as compared to patients with pre-existing AF and SR. The incidence of NOAF would be a useful predictor of clinical outcomes during hospitalization.

New-onset atrial fibrillation in critically ill patients with coronavirus disease 2019 (COVID-19)

Background

Mortality in critically ill patients with coronavirus disease 2019 (COVID-19) is high, therefore, it is essential to evaluate the independent effect of new-onset atrial fibrillation (NOAF) on mortality in patients with COVID-19. We aimed to determine the incidence, risk factors, and outcomes of NOAF in a cohort of critically ill patients with COVID-19.

Methods

We conducted a retrospective study on patients admitted to the intensive care unit (ICU) with a diagnosis of COVID-19. NOAF was defined as atrial fibrillation that was detected after diagnosis of COVID-19 without a prior history. The primary outcome of the study was the effect of NOAF on mortality in critically ill COVID-19 patients.

Results

NOAF incidence was 14.9% (n = 37), and 78% of patients (n = 29) were men in NOAF positive group. Median age of the NOAF group was 79.0 (interquartile range, 71.5-84.0). Hospital mortality was higher in the NOAF group (87% vs 67%, respectively, P = .019). However, in multivariate analysis, NOAF was not an independent risk factor for hospital mortality (OR 1.42, 95% CI 0.40-5.09, P = .582).

Conclusions

The incidence of NOAF was 14.9% in critically ill COVID-19 patients. Hospital mortality was higher in the NOAF group. However, NOAF was not an independent risk factor for hospital mortality in patients with COVID-19.