Incidence and impact of cardiac arrhythmias in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

Short-Term Outcomes of Cardiac Arrhythmias Among COVID-19 Patients: A Propensity Matched National Study

The risk of arrhythmia is high in patients with COVID-19. The current literature is limited in understanding the clinical impact of arrhythmias and the extent of healthcare utilization in COVID-19 patients. The Nationwide In-patient Sample Database (NIS) from 2019 to 2020 was queried to identify COVID-19 patients who developed arrhythmias vs those without. Multivariate regression for adjusted odds ratios (aOR) and propensity score matching (PSM) were done to compare outcomes among both cohorts. A total of 1,664,240 patients (weighted) were hospitalized with COVID-19 infection, 380,915 (22.89%) of whom were diagnosed with an arrhythmia. After propensity matching COVID-19 with arrhythmias had higher rates of in-hospital mortality (22.4% vs 13.5%, P < 0.001), acute kidney injury (PSM 39.4% vs 35.7%, P < 0.001), acute heart failure (AHF) (18.2% vs 12.6%, P < 0.001), acute stroke (0.76% vs 0.57%, P < 0.001), cardiogenic shock (1.38% vs 0.5%, P < 0.001), cardiac arrest (5.26% vs 2.3%, P < 0.001) acute myocardial infarction (AMI) (12.8% vs 7.8%, P < 0.001), intracerebral hemorrhage (0.63% vs 0.45%, P < 0.001), major bleeding (2.6% vs 1.8%, P < 0.001) and endotracheal intubation (17.04% vs 10.17% < 0.001) compared to arrhythmias without COVID-19. This cohort also had lower odds of receiving interventions such as cardiac pacing (aOR 0.15 95% Cl 0.13-0.189 P < 0.001), cardioversion (aOR 0.43 95% CI 0.40-0.46, P < 0.001), and defibrillator (aOR 0.087 95% Cl 0.061-0.124, P < 0.001) compared to arrhythmia patients without COVID-19. Cardiac arrhythmias associated with COVID-19 resulted in longer length of hospital stay and higher total costs of hospitalizations. Arrhythmias associated with COVID-19 had worse clinical outcomes with an increased rate of in-hospital mortality, longer length of hospital stay, and higher total cost. These patients also had lower odds of receiving interventions during the index hospitalization.

The association between mean platelet volume and poor outcome in patients with COVID-19: Systematic review, meta-analysis, and meta-regression

INTRODUCTION

This study aims to assess the association between mean platelet volume (MPV) and poor outcome in patients with COVID-19.

METHODS

We performed a comprehensive literature search using the PubMed, Embase and Scopus databases with keywords "2019-nCoV" OR "SARS-CoV-2" OR "COVID-19" AND "mean platelet volume" OR "MPV" on 8 July 2021. The primary outcome was composite poor outcome, defined as severe COVID-19 or mortality. The pooled effect estimate was reported as mean differences in terms of MPV between the group with and without outcome.

RESULTS

There were 17 studies which consist of 4549 patients with COVID-19 were included in this study. The incidence of poor outcome was 25% (20%-30%). Mean MPV was found to be higher in the poor outcome group in compare to no poor outcome group (10.3 ± 1.9 fL vs 9.9 ± 1.7 fL). The mean MPV difference between both group was 0.47 fL [95% CI 0.27, 0.67], p < 0.001; I2: 62.91%, p < 0.001). In the sub-group analysis, patients with severe COVID-19 had higher MPV (mean difference 0.54 fL [95% CI 0.28, 0.80], p < 0.001; I2: 54.84%, p = 0.014). Furthermore, MPV was also higher in the mortality group (mean difference 0.54 fL [95% CI 0.29, 0.80], p = 0.020; I2: 71.11%, p = 0.004). Meta-regression analysis showed that the association between MPV and poor outcome was not affected by age (p = 0.789), gender (p = 0.167), platelets (p = 0.056), white blood cells (p = 0.639), and lymphocytes (p = 0.733).

CONCLUSION

This meta-analysis indicated that increased MPV was associated with severity and mortality in patients with COVID-19. Further research is needed to determine the optimum cut-off point.

Long-Term Mortality after New-Onset Atrial Fibrillation in COVID-19

Background: Atrial fibrillation (AF) has been described as a common cardiovascular manifestation in patients suffering from coronavirus disease 2019 (COVID-19) and has been suggested to be a potential risk factor for a poor clinical outcome. Methods: In this observational study, all patients hospitalized due to COVID-19 in 2020 in the Cantonal Hospital of Baden were included. We assessed clinical characteristics, in-hospital outcomes as well as long-term outcomes with a mean follow-up time of 278 (±90) days. Results: Amongst 646 patients diagnosed with COVID-19 (59% male, median age: 70 (IQR: 59-80)) in 2020, a total of 177 (27.4%) patients were transferred to the intermediate/intensive care unit (IMC/ICU), and 76 (11.8%) were invasively ventilated during their hospitalization. Ninety patients (13.9%) died. A total of 116 patients (18%) showed AF on admission of which 34 (29%) had new-onset AF. Patients with COVID-19 and newly diagnosed AF were more likely to require invasive ventilation (OR: 3.5; p = 0.01) but did not encounter an increased in-hospital mortality. Moreover, AF neither increased long-term mortality nor the number of rehospitalizations during follow-up after adjusting for confounders. Conclusions: In patients suffering from COVID-19, the new-onset of AF on admission was associated with an increased risk of invasive ventilation and transfer to the IMC/ICU but did not affect in-hospital or long-term mortality.

Screening of Cardiac Rhythm Disorders in Women Working at Information Technology Sector Using Continuous Ambulatory Wireless Cardiac Monitoring – A Community-Based Study

Objectives:

The role of screening cardiac arrhythmias provides continuum of care to rediscover the causes and prevention strategies. This study was taken up to screen women working in the information and technology sector for cardiac rhythm disorders using continuous ambulatory cardiac monitoring and asses various risk factors along with work-related stress.

Materials and Methods:

A cross-sectional study was taken up at the workplace to screen women for cardiac rhythm disorders using wireless continuous ambulatory cardiac monitoring. Various risk factors and work-related stress were assessed using a standardized questionnaire. Differences in ECG parameters such as heart rate, heart rate variability (HRV), and frequency corrected QT (QTc) were compared on working and non-working days.

Results:

A total of 109 women were screened to find a proportion of 4.58% having cardiac arrhythmias. We found two cases of second-degree AV block (type 1), two cases of atrial tachycardia in the age group of 21–30 years, and one case of sinus pauses. Risk factors such as alcohol usage were statistically associated with cardiac arrhythmias. Others included a sedentary lifestyle, being underweight, a lesser number of sleep hours, no physical activity, work-related stress, and the presence of past-COVID-19 infection, but these were not statistically significant. There were significant changes in heart rate, HRV, and QTc prolongation on working day compared to non-working days. Among the domains of work-related stress, the influence at work and perceived stress due to individual demands and commitments contributed the highest mean score. Moreover, those with higher work-related stress scores were at 3.66 times the increased risk of QTc prolongation.

Conclusion:

The present study implies the combination of the need for the screening tool in younger age groups and lifestyle factors with more elucidation of work-related stress on autonomic cardiac function.

Cell-free circulating mitochondrial DNA: An emerging biomarker for airborne particulate matter associated with cardiovascular diseases

The association of airborne particulate matter exposure with the deteriorating function of the cardiovascular system is fundamentally driven by the impairment of mitochondrial-nuclear crosstalk orchestrated by aberrant redox signaling. The loss of delicate balance in retrograde communication from mitochondria to the nucleus often culminates in the methylation of the newly synthesized strand of mitochondrial DNA (mtDNA) through DNA methyl transferases. In highly metabolic active tissues such as the heart, mtDNA's methylation state alteration impacts mitochondrial bioenergetics. It affects transcriptional regulatory processes involved in biogenesis, fission, and fusion, often accompanied by the integrated stress response. Previous studies have demonstrated a paradoxical role of mtDNA methylation in cardiovascular pathologies linked to air pollution. A pronounced alteration in mtDNA methylation contributes to systemic inflammation, an etiological determinant for several co-morbidities, including vascular endothelial dysfunction and myocardial injury. In the current article, we evaluate the state of evidence and examine the considerable promise of using cell-free circulating methylated mtDNA as a predictive biomarker to reduce the more significant burden of ambient air pollution on cardiovascular diseases.

Is T-Wave Alternans a Repolarization Abnormality Marker in COVID-19? An Investigation on the Potentialities of Portable Electrocardiogram Device

Background

Cardiac arrhythmias are significantly associated with poor outcomes in coronavirus disease 2019 (COVID-19) patients. Microvolt T-wave alternans (TWA) can be automatically quantified and has been recognized as a representation of repolarization heterogeneity and linked to arrhythmogenesis in various cardiovascular diseases. This study aimed to explore the correlation between microvolt TWA and COVID-19 pathology.

Methods

Patients suspected of COVID-19 in Mohammad Hoesin General Hospital were consecutively evaluated using Alivecor^® Kardiamobile 6L™ portable electrocardiogram (ECG) device. Severe COVID-19 patients or those who are unable to cooperate in active ECG self-recording were excluded from the study. TWA was detected and its amplitude was quantified using the novel enhanced adaptive match filter (EAMF) method.

Results

A total of 175 patients, 114 COVID-19 patients (polymerase chain reaction (PCR)-positive group), and 61 non-COVID-19 patients (PCR-negative group) were enrolled in the study. PCR-positive group was subdivided according to the severity of COVID-19 pathology into mild and moderate severity subgroups. Baseline TWA levels were similar between both groups during admission (42.47 ± 26.52 µV vs. 44.72 ± 38.21 µV), but higher TWA levels were observed during discharge in the PCR-positive compared to the PCR-negative group (53.45 ± 34.42 µV vs. 25.15 ± 17.64 µV, P = 0.03). The correlation between PCR-positive result in COVID-19 and TWA value was significant, after adjustment of other confounding variables (R² = 0.081, P = 0.030). There was no significant difference in TWA levels between mild and moderate severity subgroups in patients with COVID-19, both during admission (44.29 ± 27.14 µV vs. 36.75 ± 24.46 µV, P = 0.34) and discharge (49.47 ± 33.62 µV vs. 61.09 ± 35.99 µV, P = 0.33).

Conclusions

Higher TWA values can be observed on follow-up ECG obtained during discharge in the PCR-positive COVID-19 patients.

Dose response relationship between D-dimer level and mortality in critically ill COVID-19 patients: a retrospective observational study

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a global pandemic. Coagulopathy is one of the most common complications characterized by increased D-dimer level. We aimed to investigate the dose-response relationship between elevated D-dimer level and mortality in critically ill COVID-19 patients.

METHODS

This was a retrospective observational study in 259 critically ill COVID-19 patients requiring intensive care unit admission between March and December 2020. We compared the mortality rate between patients with and without elevated D-dimer. Receiver operating characteristic (ROC) curve analysis, Fagan's nomogram, and dose-response relationship were performed to determine the association between D-dimer level and mortality.

RESULTS

Overall mortality rate was 40.9% (106 patients). Median D-dimer level was higher in non-survivor group (10,170 ng/mL vs 4,050 ng/mL, p=0.028). The association remained significant after multivariate logistic regression analysis (p=0.046). The optimal cut-off for D-dimer level to predict mortality from ROC curve analysis was 9,020 ng/mL (OR (odds ratio) 3.73 [95% CI (confidence interval) 1.91 - 7.28], p<0.001). D-dimer level >9,020 ng/mL confers 67% posterior probability of mortality and D-dimer level <9,020 ng/mL had 35% probability of mortality.

CONCLUSIONS

There was a non-linear dose-response relationship between D-dimer level and mortality with P nonlinearity of 0.004. D-dimer level was associated with mortality in critically ill COVID-19 patients in the non-linear dose-response relationship.

Endothelial Dysfunction in COVID-19: Potential Mechanisms and Possible Therapeutic Options

SARS-CoV-2, a novel coronavirus found in Wuhan (China) at the end of 2019, is the etiological agent of the current pandemic that is a heterogeneous disease, named coronavirus disease 2019 (COVID-19). SARS-CoV-2 affects primarily the lungs, but it can induce multi-organ involvement such as acute myocardial injury, myocarditis, thromboembolic eventsandrenal failure. Hypertension, chronic kidney disease, diabetes mellitus and obesity increase the risk of severe complications of COVID-19. There is no certain explanation for this systemic COVID-19 involvement, but it could be related to endothelial dysfunction, due to direct (endothelial cells are infected by the virus) and indirect damage (systemic inflammation) factors. Angiotensin-converting enzyme 2 (ACE2), expressed in human endothelium, has a fundamental role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In fact, ACE2 is used as a receptor by SARS-CoV-2, leading to the downregulation of these receptors on endothelial cells; once inside, this virus reduces the integrity of endothelial tissue, with exposure of prothrombotic molecules, platelet adhesion, activation of coagulation cascades and, consequently, vascular damage. Systemic microangiopathy and thromboembolism can lead to multi-organ failure with an elevated risk of death. Considering the crucial role of the immunological response and endothelial damage in developing the severe form of COVID-19, in this review, we will attempt to clarify the underlying pathophysiological mechanisms.

Sofosbuvir with daclatasvir and the outcomes of patients with COVID-19: a systematic review and meta-analysis with GRADE assessment

PURPOSE

This systematic review and meta-analysis aimed to evaluate the effect of sofosbuvir/daclatasvir (SOF/DCV) on mortality, the need for intensive care unit (ICU) admission or invasive mechanical ventilation (IMV) and clinical recovery in patients with COVID-19.

METHODS

We performed a systematic literature search through the PubMed, Scopus and Embase from the inception of databases until 6 April 2021. The intervention group was SOF/DCV, and the control group was standard of care. The primary outcome was mortality, defined as clinically validated death. The secondary outcomes were (1) the need for ICU admission or IMV and (2) clinical recovery. The pooled effect estimates were reported as risk ratios (RRs).

RESULTS

There were four studies with a total of 231 patients in this meta-analysis. Three studies were randomised controlled trial, and one study was non-randomised. SOF/DCV was associated with lower mortality (RR: 0.31 (0.12, 0.78); p=0.013; I2: 0%) and reduced need for ICU admission or IMV (RR: 0.35 (0.18, 0.69); p=0.002; I2: 0%). Clinical recovery was achieved more frequently in the SOF/DCV (RR: 1.20 (1.04, 1.37); p=0.011; I2: 21.1%). There was a moderate certainty of evidence for mortality and need for ICU/IMV outcome, and a low certainty of evidence for clinical recovery. The absolute risk reductions were 140 fewer per 1000 for mortality and 186 fewer per 1000 for the need for ICU/IMV. The increase in clinical recovery was 146 more per 1000.

CONCLUSION

SOF/DCV may reduce mortality rate and need for ICU/IMV in patients with COVID-19 while increasing the chance for clinical recovery.

PROTOCOL REGISTRATION

PROSPERO: CRD42021247510.

Endotheliopathy marked by high von Willebrand factor (vWF) antigen in COVID-19 is associated with poor outcome: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to compare the levels of von Willebrand Factor (vWF) antigen in patients with coronavirus disease 2019 (COVID-19) with a poor outcome compared with those with a good outcome, and explored factors that may affect the difference in terms of vWF antigen between the two groups.

METHODS

A comprehensive literature search of PubMed, Embase and Scopus databases was undertaken from inception until 7 April 2021. The primary outcome was poor outcome, which is a composite of mortality and severity of COVID-19.

RESULTS

Ten studies including a total of 996 patients were included in this systematic review and meta-analysis. vWF antigen was higher in patients with poor outcomes [standardized mean difference (SMD) 0.84 [0.45-1.23], P<0.001; I2=87.3, P<0.001). For subgroup analysis on studies that reported the vWF antigen level as a percentage, the mean difference was 121.6 [(53.7-189.4), P<0.001; I2=92.0, P<0.001]. Meta-regression showed that the SMD between poor outcome and good outcome was affected by the platelet count (coefficient 0.0061, P=0.001), d-dimer level (coefficient 0.0007, P=0.026) and factor VIII level (coefficient 0.0057, P=0.031), but not by age (coefficient -0.0610, P=0.440), gender (coefficient 0.0135, P=0.698), obesity (coefficient 0.0282, P=0.666), hypertension (coefficient 0.0273, P=0.423), diabetes (coefficient 0.0317, P=0.398) or malignancy (coefficient 0.0487, P=0.608).

CONCLUSION

This meta-analysis showed that the level of vWF antigen was significantly higher in patients with COVID-19 with a poor outcome, signalling marked endotheliopathy. Meta-regression showed that the differences became larger as the platelet count, d-dimer level and factor VIII level increased.

Long COVID-19 and Postural Orthostatic Tachycardia Syndrome- Is Dysautonomia to Be Blamed?

While the increased arrhythmic tendency during acute COVID-19 infection is recognised, the long-term cardiac electrophysiological complications are less well known. There are a high number of patients reporting ongoing symptoms post-infection, termed long COVID. A recent hypothesis is that long COVID symptoms could be attributed to dysautonomia, defined as malfunction of the autonomic nervous system (ANS). The most prevalent cardiovascular dysautonomia amongst young people is postural orthostatic tachycardia syndrome (POTS). Numerous reports have described the development of POTS as part of long COVID. Possible underlying mechanisms, although not mutually exclusive or exhaustive, include hypovolaemia, neurotropism, inflammation and autoimmunity. Treatment options for POTS and other long COVID symptoms are currently limited. Future research studies should aim to elucidate the underlying mechanisms of dysautonomia to enable the development of targeted therapies. Furthermore, it is important to educate healthcare professionals to recognise complications and conditions arising from COVID-19, such as POTS, to allow prompt diagnosis and access to early treatment.

COVID-lateral damage: cardiovascular manifestations of SARS-CoV-2 infection

Early in the pandemic, concern that cardiovascular effects would accompany COVID-19 was fueled by lessons from the first SARS epidemic, knowledge that the SARS-COV2 entry receptor (Angiotensin-converting enzyme 2, ACE2) is highly expressed in the heart, early reports of myocarditis, and first-hand accounts by physicians caring for those with severe COVID-19. Over 18 months, our understanding of the cardiovascular manifestations has expanded greatly, leaving more new questions than those conclusively answered. Cardiac involvement is common (∼20%) but not uniformly observed in those who require treatment in a hospitalized setting. Cardiac MRI studies raise the possibility of manifestations in those with minimal symptoms. Some appear to experience protracted cardiovascular symptoms as part of a larger syndrome of post-acute sequelae of COVID-19. Instances of vaccine induced thrombosis and myocarditis are exceedingly rare but illustrate the need to monitor the cardiovascular safety of interventions that induce inflammation. Here, we will summarize the current understanding of potential cardiovascular manifestations of SARS-COV2. To provide proper context, paradigms of cardiovascular injury due to other inflammatory processes will also be discussed. Ongoing research and a deeper understanding COVID-19 may ultimately reveal new insight into the mechanistic underpinnings of cardiovascular disease. Thus, in this time of unprecedented suffering and risk to global health, there exists the opportunity that well conducted translational research of SARS-COV2 may provide health dividends that outlast the current pandemic.

COVID-19 Cardiovascular Connection: A Review of Cardiac Manifestations in COVID-19 Infection and Treatment Modalities

The coronavirus pandemic has crippled healthcare system since its outbreak in 2020, and has led to over 2.6 million deaths worldwide. Clinical manifestations of COVID-19 range from asymptomatic carrier to severe pneumonia, to life-threatening acute respiratory distress syndrome (ARDS). The early efforts of the pandemic surrounded treating the pulmonary component of COVID-19, however, there has been robust data surrounding the cardiac complications associated with the virus. This is suspected to be from a marked inflammatory response as well as direct viral injury. Arrhythmias, acute myocardial injury, myocarditis, cardiomyopathy, thrombosis, and myocardial fibrosis are some of the observed cardiac complications. There have been high morbidity and mortality rates in those affected by cardiac conditions associated with COVID-19. Additionally, there have been documented cases of patients presenting with typical cardiac symptoms who are subsequently discovered to have COVID-19 infection. In those who test positive for COVID-19, clinical awareness of the significant cardiac components of the virus is pertinent to prevent morbidity and mortality. Unfortunately, treatment and preventative measures developed for COVID-19 have been shown to be also be associated with cardiac complications. This is a comprehensive review of the cardiac complications and manifestations of COVID-19 infection in addition to those associated with both treatment and vaccination.

Dipeptidyl peptidase-4 (DPP-IV) inhibitor was associated with mortality reduction in COVID-19 - A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to synthesize the latest evidence on the effect of dipeptidyl peptidase-4 (DPP-IV) inhibitor in patients with COVID-19.

METHODS

We performed a systematic literature search from the PubMed, Scopus, Embase, and Clinicaltrials.gov up until 15 July 2021. Studies that met the following criteria were included: prospective or retrospective observational studies or case series or randomized controlled trials (RCTs) reporting DPP-IV inhibitor use in patients with COVID-19 and mortality. The intervention group was patients receiving DPP-IV inhibitor. The control group was patients that did not receive DPP-IV inhibitor. The outcome was mortality reported as odds ratio (OR).

RESULTS

There were 11 studies consisting of 5950 patients in this meta-analysis. DPP-IV inhibitor use was associated with reduced mortality (OR 0.75 [0.56, 0.99], p = 0.043, I2: 42.9, p = 0.064) compared to those that did not receive DPP-IV inhibitor. Sensitivity analysis using the fixed-effect model (OR 0.75 [0.63, 0.88], p < 0.001, I2: 42.9, p = 0.064) also showed mortality benefit. The association between DPP-IV inhibitor and mortality was not significantly affected by age (p = 0.540), sex (p = 0.054), hypertension (p = 0.320), location (continent; p = 0.532), and retrospective/prospective nature of the study (p = 0.840). However, the association was affected by metformin (OR 1.03 [95% CI 1.01, 1.06], p = 0.010) and ACEI/ARB use (OR 1.06 [95% CI 1.02, 1.10], p = 0.004).

CONCLUSION

This meta-analysis showed that DPP-IV inhibitor was associated with reduced mortality in patients with COVID-19.

Effect of colchicine on mortality in patients with COVID-19 - A systematic review and meta-analysis

BACKGROUND AND AIM

This systematic review and meta-analysis aimed to evaluate the latest evidence on the association between colchicine and mortality in patients with COVID-19.

METHODS

We performed a comprehensive literature search from the PubMed, Scopus, Embase, EuropePMC, and Clinicaltrials.gov up until 02 January 2022. We include randomized controlled trials (RCTs) and observational studies reporting colchicine use in patients with COVID-19 and mortality within 30 days. The intervention group was patients given colchicine during the course of treatment. The control group was patients given placebo or standard of care at the respective institutions. The outcome was mortality. The effect estimate was reported as risk ratio (RR).

RESULTS

There were 12 studies comprising of 6953 patients included in this meta-analysis. Mortality rate was 0.18 [95%CI 0.10, 0.26] in the colchicine group and 0.26 [95%CI 0.15, 0.38] in the control group. Colchicine was associated with reduction in mortality (RR 0.66 [95%CI 0.53, 0.83], p < 0.001; I2: 42%). Sensitivity analysis using fixed-effect model (RR 0.73 [95%CI 0.63, 0.83], p < 0.001; I2: 42%. Subgroup analysis on the four RCTs showed non-significant result (RR 0.81 [95%CI 0.54, 1.20], p = 0.29; I2: 10%). Meta-regression showed that the association between colchicine and reduced mortality was not affected by age (p = 0.613) [Fig. 3], sex (p = 0.915), diabetes (p = 0.795), and hypertension (p = 0.403).

CONCLUSION

Though the meta-analysis showed decreased mortality with colchicine in patients with COVID-19, the meta-analysis of randomized trials did not show any significant effect of colchicine on mortality.

Cardiac Dysfunction and Arrhythmias 3 Months After Hospitalization for COVID‐19

Background

The extent of cardiac dysfunction post‐COVID‐19 varies, and there is a lack of data on arrhythmic burden.

Methods and Results

This was a combined multicenter prospective cohort study and cross‐sectional case‐control study. Cardiac function assessed by echocardiography in patients with COVID‐19 3 to 4 months after hospital discharge was compared with matched controls. The 24‐hour ECGs were recorded in patients with COVID‐19. A total of 204 patients with COVID‐19 consented to participate (mean age, 58.5 years; 44% women), and 204 controls were included (mean age, 58.4 years; 44% women). Patients with COVID‐19 had worse right ventricle free wall longitudinal strain (adjusted estimated mean difference, 1.5 percentage points; 95% CI, −2.6 to −0.5; P=0.005) and lower tricuspid annular plane systolic excursion (−0.10 cm; 95% CI, −0.14 to −0.05; P<0.001) and cardiac index (−0.26 L/min per m²; 95% CI, −0.40 to −0.12; P<0.001), but slightly better left ventricle global strain (−0.8 percentage points; 95% CI, 0.2–1.3; P=0.008) compared with controls. Reduced diastolic function was twice as common compared with controls (60 [30%] versus 29 [15%], respectively; odds ratio, 2.4; P=0.001). Having dyspnea or fatigue were not associated with cardiac function. Right ventricle free wall longitudinal strain was worse after intensive care treatment. Arrhythmias were found in 27% of the patients, mainly premature ventricular contractions and nonsustained ventricular tachycardia (18% and 5%, respectively).

Conclusions

At 3 months after hospital discharge with COVID‐19, right ventricular function was mildly impaired, and diastolic dysfunction was twice as common compared with controls. There was little evidence for an association between cardiac function and intensive care treatment, dyspnea, or fatigue. Ventricular arrhythmias were common, but the clinical importance is unknown.

Registration

URL: http://clinicaltrials.gov. Unique Identifier: NCT04535154.

Cardiac Manifestations in Patients with COVID-19: A Scoping Review

Background

Coronavirus disease 2019 (COVID-19), commonly affects the lungs, but the involvement of other organs, particularly the heart, is highly prevalent as has been reported in several studies. The overall aim of this review was to provide an in-depth description of the available literature related to the cardiac system and COVID-19 infection. It focuses on type and the frequency of cardiac manifestations, clinical parameters and cardiac biomarkers that support the prognosis of COVID-19 patients, and the cardiac adverse events and outcomes related to pharmacotherapy.

Methods

A scoping review was conducted searching Embase, PubMed, Epistomonikos, Medrxiv, BioRxiv databases, up to November 2020, for systematic reviews relevant to cardiac manifestations in adult COVID-19 patients. Relevant articles were screened and extracted to summarize key outcomes and findings.

Results

A total of 63 systematic reviews met the inclusion criteria. The overall frequency of acute cardiac injury ranged from 15% to 33% in the reporting studies. The main cardiac complications were arrhythmias (3.1% to 6.9% in non-severe patients, 33.0% to 48.0% in severe disease), acute coronary syndromes (6% to 33% in severe disease), and myocarditis. Most studies found no association with the use of Renin-angiotensin-aldosterone system inhibitors (RAASI) with COVID-19 outcomes such as susceptibility to infection, hospitalization, severity, and mortality.

Conclusion

This study provided an overview of the several cardiac complications associated with Covid-19. Cardiac injury, arrhythmias, myocarditis, cardiac failure, and acute coronary syndrome, are prevalent and clinically significant and associated with COVID-19 disease severity and mortality. Other studies are needed to clearly identify what is the part of viral heart infection and what is the part of cardiac injury secondary to acute respiratory failure and inflammation. In the therapeutic field, these systematic reviews gave heterogenous results. This underlines the importance of randomized trials to determine the right therapeutic approach.

Incidence of cardiac complications following COVID-19 infection: An umbrella meta-analysis study

Background

COVID-19 causes fatal cardiac damages. Despite many overwhelming meta-analysis related to cardiac complications following COVID-19 disease, no umbrella meta-analysis study has been conducted.

Objectives

We aimed to report the summarized pooled incidences of cardiac complications in the overall, critically ill, and deceased patients, compare the cardiac complications between the severe/non-severe or deceased/non-deceased patients, and also compare poor outcomes between patients with/without acute myocardial injury (AMI).

Methods

PubMed, Scopus, web of science, Cochrane, ProQuest, Springer, Sage journals were searched before April 2021. After assessing the quality and duplicate data, data were run by the random/fixed-effect models, I2 heterogeneity index, Egger's test, and sensitivity analysis.

Results

After removing duplicate data, in the overall COVID-19 patients, the pooled incidence of AMI, heart failure, arrhythmia, cardiac arrest, and acute coronary syndrome (ACS) were 21%, 14%, 16%, 3.46%, and 1.3%, respectively. In the patients with severe disease, the pooled incidence of AMI and shock were 33 and 35%, respectively. Similarly, in the deceased COVID-19 patients, the pooled incidence rate of AMI and arrhythmia were 56% and 47.5%, respectively. The patients with severe disease were at higher risk of AMI (RR = 5.27) and shock (OR = 20.18) compared with the non-severe cases. Incidence of AMI was associated with transfer to the intensive care units (ICU) (RR = 2.92) and mortality (RR = 2.57, OR = 8.36), significantly.

Conclusion

Cardiac complications were found to be increased alarmingly in COVID-19 patients. Baseline and during hospitalization checking with electrocardiography, echocardiography, and measuring of cardiac biomarkers should be applied.

Models for COVID-19 Early Cardiac Pathology Following SARS-CoV-2 Infection

OBJECTIVES

The clinical manifestations of COVID-19 associated cardiac complications are heterogeneous, ranging from asymptomatic to severe symptoms, including arrhythmias and cardiogenic shock. For COVID-19 patients with cardiac sequela, only a small subset of patients have myocarditis; the pathogenesis of cardiac sequela caused by SARS-CoV-2 other than microthrombi associated sequela remains to be determined.

METHODS

Retrospective analysis of 71 heart autopsy specimens from COVID-19 and putative COVID-19 in the NIH COVID Digital Pathology Repository.

RESULTS

The most consistent observation was localized myocardial cell death not associated with either myocarditis or microthrombi. Red blood cells were typically absent from capillaries but, when observed, were predominately in linear clusters (stacks) of adjacent cells.

CONCLUSIONS

Based on our retrospective analysis, we propose that localized ischemia and subsequent cell death by anoxia contributes to the cardiac pathogenesis in some COVID-19 patients. We propose two new models predicting vasoconstriction of cardiac pericyte cells induced by elevated histamine from hyper-activated mast cells or direct infection. We propose that impeded blood flow and cell death by anoxia are initial steps in the development of SARS-CoV-2 induced cardiac injury in COVID-19 patients independent of microthrombi or myocarditis.

COVID-19 and Cardiovascular Complications: An Updated Review

COVID-19 has become a global pandemic. Patients with pre-existing comorbidities such as hypertension, diabetes, and cardiovascular disease (CVD) are associated with greater severity and higher mortality. COVID-19 can cause cardiovascular complications, including myocardial injury, myocarditis, heart failure, acute coronary syndrome, and coagulation abnormalities. Possible pathophysiology and molecular pathways driving these disease processes are cytokine release syndrome, RAAS system dysregulation, plaque destabilization and coagulation disorders  Myocarditis is one concern among persons who received mRNA-Based COVID-19 vaccines. There are several cardiovascular complications that are possibly caused by COVID-19 treatments, such as QT interval prolongation, arrhythmia, and hypotension. Due to increasingly recognized CVD damage in COVID-19, we need to understand about COVID-19 related to cardiovascular complications and treatment strategies.

Cardiac complications during the active phase of COVID-19: review of the current evidence

Growing reports since the beginning of the pandemic and till date describe increased rates of cardiac complications (CC) in the active phase of coronavirus disease 2019 (COVID-19). CC commonly observed include myocarditis/myocardial injury, arrhythmias and heart failure, with an incidence reaching about a quarter of hospitalized patients in some reports. The increased incidence of CC raise questions about the possible heightened susceptibility of patients with cardiac disease to develop severe COVID-19, and whether the virus itself is involved in the pathogenesis of CC. The wide array of CC seems to stem from multiple mechanisms, including the ability of the virus to directly enter cardiomyocytes, and to indirectly damage the heart through systemic hyperinflammatory and hypercoagulable states, endothelial injury of the coronary arteries and hypoxemia. The induced CC seem to dramatically impact the prognosis of COVID-19, with some studies suggesting over 50% mortality rates with myocardial damage, up from ~ 5% overall mortality of COVID-19 alone. Thus, it is particularly important to investigate the relation between COVID-19 and heart disease, given the major effect on morbidity and mortality, aiming at early detection and improving patient care and outcomes. In this article, we review the growing body of published data on the topic to provide the reader with a comprehensive and robust description of the available evidence and its implication for clinical practice.

Cardiac arrhythmias associated with COVID-19 infection: state of the art review

INTRODUCTION

COVID-19 infection is associated with many different systemic complications. Among these, cardiovascular system complications are particularly important as these are associated with significant mortality. There are many different subgroups of cardiovascular complications, with Arrhythmias being one of them. Arrhythmias are especially important as there are a substantial percentage of patients who have arrhythmia after a COVID-19 infection, and these patients are seen with an increased mortality rate. The main interest of this review is understanding some of the specific post-COVID-19 arrhythmic complications and their predisposing factors.

AREAS COVERED

This paper will highlight the findings of studies on cardiovascular system disease after COVID-19 infection, different specific arrhythmic complications of COVID-19, and changes in electrophysiologic interventions post-COVID-19 outbreak in different centers around the world. An extensive literature search was made to find pertinent articles.

EXPERT OPINION

Studies show us that a significant percentage of COVID-19 patients have arrhythmia. Many distinct types of arrhythmias are associated with COVID-19 infection, and specific risk factors of these arrhythmias are important as this information can be used to detect and prioritize certain at-risk patients for early treatment, which can mean life or death in some cases.

Pre-existing health conditions and severe COVID-19 outcomes: an umbrella review approach and meta-analysis of global evidence

BACKGROUND

This study applies an umbrella review approach to summarise the global evidence on the risk of severe COVID-19 outcomes in patients with pre-existing health conditions.

METHODS

Systematic reviews (SRs) were identified in PubMed, Embase/Medline and seven pre-print servers until December 11, 2020. Due to the absence of age-adjusted risk effects stratified by geographical regions, a re-analysis of the evidence was conducted. Primary studies were extracted from SRs and evaluated for inclusion in the re-analysis. Studies were included if they reported risk estimates (odds ratio (OR), hazard ratio (HR), relative risk (RR)) for hospitalisation, intensive care unit admission, intubation or death. Estimated associations were extracted from the primary studies for reported pre-existing conditions. Meta-analyses were performed stratified for each outcome by regions of the World Health Organization. The evidence certainty was assessed using GRADE. Registration number CRD42020215846.

RESULTS

In total, 160 primary studies from 120 SRs contributed 464 estimates for 42 pre-existing conditions. Most studies were conducted in North America, European, and Western Pacific regions. Evidence from Africa, South/Latin America, and the Eastern Mediterranean region was scarce. No evidence was available from the South-East Asia region. Diabetes (HR range 1.2-2.0 (CI range 1.1-2.8)), obesity (OR range 1.5-1.75 (CI range 1.1-2.3)), heart failure (HR range 1.3-3.3 (CI range 0.9-8.2)), COPD (HR range 1.12-2.2 (CI range 1.1-3.2)) and dementia (HR range 1.4-7.7 (CI range 1.2-39.6)) were associated with fatal COVID-19 in different regions, although the estimates varied. Evidence from Europe and North America showed that liver cirrhosis (OR range 3.2-5.9 (CI range 0.9-27.7)) and active cancer (OR range 1.6-4.7 (CI range 0.5-14.9)) were also associated with increased risk of death. Association between HIV and undesirable COVID-19 outcomes showed regional heterogeneity, with an increased risk of death in Africa (HR 1.7 (CI 1.3-2.2)). GRADE certainty was moderate to high for most associations.

CONCLUSION

Risk of undesirable COVID-19 health outcomes is consistently increased in certain patient subgroups across geographical regions, showing high variability in others. The results can be used to inform COVID-19 vaccine prioritisation or other intervention strategies.

Challenge in diagnosis of COVID-19 in hemodialysis patient: a case report and brief review of the literature

Diagnosis of COVID-19 in end-stage kidney disease (ESKD) patients on hemodialysis is challenging,  as the symptoms are often atypical. Herein, we reported a confimed case of COVID-19 in a patient on maintenance hemodialysis. A 38-year-old man with ESKD on regular hemodialysis initially presented with progressive shortness of breath and dry cough, without fever. He had lymphopenia, and chest X-ray suggested pulmonary edema with cardiomegaly and suspected bilateral bronchopneumonia. The patient clinically improved after 7 days of hospitalization, and was subsequently discharged from hospital. Ten days after being discharged, the patient was re-admitted with progressive shortness of breath and dry cough, without fever. SARS-CoV-2 infection was later confirmed by a qualitative RT-PCR test and the diagnosis COVID-19 pneumonia was established. We presented a case of atypical presentation of COVID-19 in an ESKD patient on maintenance hemodialysis with a brief review of the current literature.

ANMCO POSITION PAPER: cardio-oncology in the COVID era (CO and CO)

The COVID-19 pandemic and its impact on patients with cancer and cardiovascular disease have confirmed the particular vulnerability of these populations. Indeed, not only a higher risk of contracting the infection has been reported but also an increased occurrence of a more severe course and unfavourable outcome. Beyond the direct consequences of COVID-19 infection, the pandemic has an enormous impact on global health systems. Screening programmes and non-urgent tests have been postponed; clinical trials have suffered a setback. Similarly, in the area of cardiology care, a significant decline in STEMI accesses and an increase in cases of late presenting heart attacks with increased mortality and complication rates have been reported. Health care systems must therefore get ready to tackle the 'rebound effect' that will likely show a relative increase in the short- and medium-term incidence of diseases such as heart failure, myocardial infarction, arrhythmias, and cardio- and cerebrovascular complications. Scientific societies are taking action to provide general guidance and recommendations aimed at mitigating the unfavourable outcomes of this pandemic emergency. Cardio-oncology, as an emerging discipline, is more flexible in modulating care pathways and represents a beacon of innovation in the development of multi-specialty patient management. In the era of the COVID-19 pandemic, cardio-oncology has rapidly modified its clinical care pathways and implemented flexible monitoring protocols that include targeted use of cardiac imaging, increased use of biomarkers, and telemedicine systems. The goal of these strategic adjustments is to minimize the risk of infection for providers and patients while maintaining standards of care for the treatment of oncologic and cardiovascular diseases. The aim of this document is to evaluate the impact of the pandemic on the management of cardio-oncologic patients with the-state-of-the-art knowledge about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease (COVID-19) in order to optimize medical strategies during and after the pandemic.

Ivermectin and mortality in patients with COVID-19: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

AIMS

This systematic review and meta-analysis aims to investigate the effect of ivermectin on mortality in patients with COVID-19.

METHODS

A comprehensive systematic literature search was performed using PubMed, Scopus, Embase, and Clinicaltrials.gov from the inception of databases up until April 9, 2021. The intervention group was ivermectin and the control group was standard of care or placebo. The primary outcome was mortality reported as risk ratio (RR).

RESULTS

There were 9 RCTs comprising of 1788 patients included in this meta-analysis. Ivermectin was associated with decreased mortality (RR 0.39 [95% 0.20-0.74], p = 0.004; I2: 58.2%, p = 0.051). Subgroup analysis in patients with severe COVID-19 showed borderline statistical significance towards mortality reduction (RR 0.42 [95% 0.18-1.00], p = 0.052; I2: 68.3, p = 0.013). The benefit of ivermectin and mortality was reduced by hypertension (RR 1.08 [95% CI 1.03-1.13], p = 0.001); but was not influenced by age (p = 0.657), sex (p = 0.466), diabetes (p = 0.429). Sensitivity analysis using fixed-effect model showed that ivermectin decreased mortality in general (RR 0.43 [95% CI 0.29-0.62], p < 0.001) and severe COVID-19 subgroup (RR 0.48 [95% CI 0.32-0.72], p < 0.001).

CONCLUSIONS

Ivermectin was associated with decreased mortality in COVID-19 with a low certainty of evidence. Further adequately powered double-blinded placebo-controlled RCTs are required for definite conclusion.

Active prescription of low-dose aspirin during or prior to hospitalization and mortality in COVID-19: A systematic review and meta-analysis of adjusted effect estimates

BACKGROUND

This study aimed to investigate whether the active prescription of low-dose aspirin during or prior to hospitalization affects mortality in patients with coronavirus disease 2019 (COVID-19). Aspirin is often prescribed for secondary prevention in patients with cardiovascular disease and other comorbidities that might increase mortality, and may therefore falsely demonstrate increased mortality. To reduce bias, only studies that performed an adjusted analysis were included in this review.

METHODS

A systematic literature search of PubMed, Scopus, Embase and Clinicaltrials.gov was performed, from inception until 16 April 2021. The exposure was active prescription of low-dose aspirin during or prior to hospitalization. The primary outcome was mortality. The pooled adjusted effect estimate was reported as relative risk (RR).

RESULTS

Six eligible studies were included in this meta-analysis, comprising 13,993 patients. The studies had low-to-moderate risk of bias based on the Newcastle-Ottawa Scale. The meta-analysis indicated that the use of low-dose aspirin was independently associated with reduced mortality {RR 0.46 [95% confidence interval (CI) 0.35-0.61], P < 0.001; I2 = 36.2%}. Subgroup analysis on in-hospital low-dose aspirin administration also showed a significant reduction in mortality [RR 0.39 (95% CI 0.16-0.96), P < 0.001; I2 = 47.0%].

CONCLUSION

Use of low-dose aspirin is independently associated with reduced mortality in patients with COVID-19, with low certainty of evidence.

Prognostic performance of troponin in COVID-19: A diagnostic meta-analysis and meta-regression

BACKGROUND

Cardiac injury is frequently encountered in patients with coronavirus disease 2019 (COVID-19) and is associated with increased risk of mortality. Elevated troponin may signify myocardial damage and is predictive of mortality. This study aimed to assess the prognostic value of troponin above the 99th percentile upper reference limit (URL) for mortality, and factors affecting the relationship.

METHODS

A comprehensive literature search of PubMed (MEDLINE), Scopus and Embase was undertaken, from inception of the databases until 16 December 2020. The key exposure was elevated serum troponin, defined as troponin (of any type) above the 99th percentile URL. The outcome was mortality due to any cause.

RESULTS

In total, 12,262 patients from 13 studies were included in this systematic review and meta-analysis. The mortality rate was 23% (20-26%). Elevated troponin was observed in 31% (23-38%) of patients. Elevated troponin was associated with increased mortality [odds ratio (OR) 4.75, 95% confidence interval (CI) 4.07-5.53; P < 0.001; I2 = 19.9%]. Meta-regression showed that the association did not vary with age (P = 0.218), male gender (P = 0.707), hypertension (P = 0.182), diabetes (P = 0.906) or coronary artery disease (P = 0864). The association between elevated troponin and mortality had sensitivity of 0.55 (0.44-0.66), specificity of 0.80 (0.71-0.86), positive likelihood ratio of 2.7 (2.2-3.3), negative likelihood ratio of 0.56 (0.49-0.65), diagnosis odds ratio of 5 (4-5) and area under the curve of 0.73 (0.69-0.77). The probability of mortality was 45% in patients with elevated troponin and 14% in patients with non-elevated troponin.

CONCLUSION

Elevated troponin was associated with mortality in patients with COVID-19 with 55% sensitivity and 80% specificity.

Arrhythmias in patients with coronavirus disease 2019 (COVID-19) in Wuhan, China: Incidences and implications

BACKGROUND

Coronavirus disease 2019 (COVID-19) continues to impact populations around the globe. Information regarding the incidences and implications of arrhythmias in COVID-19 is limited.

METHODS

A total of 463 patients with COVID-19 and who had at least one electrocardiogram recording from February 1 to March 19, 2020, in Wuhan Union Hospital were enrolled in the study.

RESULTS

Arrhythmias occurred in 85 of 463 (18.4%) patients: atrial arrhythmias in 10.2%, junctional arrhythmias in 0.2%, ventricular arrhythmias in 3.5%, and conduction block in 7.3%. Compared with patients without arrhythmias, those with arrhythmias had higher mortality, both during the time from symptom onset (p < 0.001) and from admission to follow-up (p < 0.001). The frequencies of severe COVID-19 (44.7% vs. 21.2%; p < 0.001) and death (25.9% vs. 10.1%; p < 0.001) were higher in patients with arrhythmias than in those without arrhythmias. Atrial arrhythmias and ventricular arrhythmias could predict severity and mortality, their odds ratios (OR) were 4.45 (95% confidence interval [CI] 2.35 to 8.40), 5.80 (95% CI 1.89 to 17.76) respectively for severity, and were 3.51 (95% CI 1.74 to 7.08), 3.41 (95% CI 1.13 to 10.24) respectively for mortality. High levels of interleukin-6 (IL-6) and IL-10 were associated with the occurrence of arrhythmias (all p < 0.05).

CONCLUSION

Arrhythmias were significantly associated with COVID-19 severity and mortality. Atrial arrhythmia was the most frequent arrhythmia type. IL-6 and IL-10 levels can predict the risk of arrhythmias in COVID-19 patients.

Hypocalcemia is associated with severe COVID-19: A systematic review and meta-analysis

BACKGROUND AND AIMS

Hypocalcemia is commonly in critically ill patients and studies have shown that hypocalcemia is prevalent in patients with COVID-19. This meta-analysis aimed to evaluate the prognostic performance of hypocalcemia in patients with coronavirus disease 2019 (COVID-19).

METHODS

We performed a systematic literature search on PubMed, Scopus, and Embase with keywords "SARS-CoV-2″ OR″COVID-19″ OR ″2019-nCoV" AND "hypocalcemia" up until 10 December 2020. The key exposure was hypocalcemia, defined as serum calcium below study-defined cut-off points. The main outcome was poor outcome, which was a composite of mortality and severity. The effect estimate of the main outcome was reported as odds ratio (OR) and its 95% confidence interval (95% CI). We also generate sensitivity, specificity, positive and negative likelihood ratio (PLR & NLR), diagnostic odds ratio (DOR), and area under curve (AUC).

RESULTS

There are 2032 patients from 7 studies included in this systematic review and meta-analysis. The incidence of poor outcome in this study was 26%. Serum calcium was lower in patients with poor outcome (mean difference -0.173 mmol/L [-0.259, -0.087], p < 0.001; I2: 31.3%). Hypocalcemia was associated with poor outcome (OR 3.19 [2.02, 5.06], p < 0.001; I2: 32.86%); with sensitivity of 0.74 [0.53, 0.88], specificity of 0.54 [0.29, 0.77], PLR of 1.6 [1.1, 2.3], NLR of 0.49 [0.35, 0.66], DOR of 3 [2, 5], and AUC of 0.70 [0.66, 0.74]. In this pooled analysis, the post-test probability was 36% in patients with hypocalcemia and 15% in patients without hypocalcemia.

CONCLUSION

Hypocalcemia was associated with poor outcome in COVID-19 patients.

PROSPERO ID

CRD42020225506.

Lethal Arrhythmia (Torsade de Pointes) in COVID-19: An Event Synergistically Induced by Viral Associated Cardiac Injury, Hyperinflammatory Response, and Treatment Drug?

Arrhythmias in patients with coronavirus disease 2019 (COVID-19) are prevalent and deserve special attention because they are associated with an increased risk of fatal outcome. The mechanism of arrhythmia in COVID-19 remains unclear. Here, we report our first case of confirmed COVID-19 with documented Torsade de Pointes (TdP). A 64-year-old woman, previously healthy, presented to our emergency department with progressive shortness of breath, dry cough, and 1 week of fever. She was treated with chloroquine phosphate, meropenem, and ciprofloxacin. After 5 days of admission, her condition deteriorated and she was admitted to the intensive care unit. The patient had two episodes of malignant arrhythmias within 24 hours. The former was TdP, and the latter was a fatal pulseless ventricular tachycardia that occured even after chloroquine was discontinued. There was evidence of cardiac injury shown by increased serum level of troponin I. We propose a synergistic concept of lethal arrhythmia due to direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2-associated cardiac injury, hyperinflammatory response, and drug-induced arrhythmia.