Atrial arrhythmia related outcomes in critically ill COVID-19 patients

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.

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.

Cardiovascular System during SARS-CoV-2 Infection

SARS-CoV-2 virus can not only damage the respiratory system but may also pose a threat to other organs, such as the heart or vessels. This review focuses on cardiovascular complications of COVID-19, including acute cardiac injury, arrhythmias, biomarkers, accompanying comorbidities and outcomes in patients diagnosed with SARS-CoV-2 infection. The research was conducted on the databases: PubMed, Springer, ScienceDirect, UpToDate, Oxford Academic, Wiley Online Library, ClinicalKey. Fifty-six publications from 1 November 2020 till 15 August 2021 were included in this study. The results show that cardiac injury is present in about 1 in 4 patients with COVID-19 disease, and it is an independent risk factor, which multiplies the death rate several times in comparison to infected patients without myocardial injury. New-onset cardiac injury occurs in nearly every 10th patient of the COVID-19-suffering population. Comorbidities (such as hypertension, cardiovascular disease and diabetes) severely deteriorate the outcome. Therefore, patients with SARS-CoV-2 infection should be carefully assessed in terms of cardiac medical history and possible cardiological complications.

COVID-19: The Impact on Cardiovascular System

SARS-CoV-2 has been circulating in population worldwide for the past year and a half, and thus a vast amount of scientific literature has been produced in order to study the biology of the virus and the pathophysiology of COVID-19, as well as to determine the best way to prevent infection, treat the patients and eliminate the virus. SARS-CoV-2 binding to the ACE2 receptor is the key initiator of COVID-19. The ability of SARS-CoV-2 to infect various types of cells requires special attention to be given to the cardiovascular system, as it is commonly affected. Thorough diagnostics and patient monitoring are beneficial in reducing the risk of cardiovascular morbidity and to ensure the most favorable outcomes for the infected patients, even after they are cured of the acute disease. The multidisciplinary nature of the fight against the COVID-19 pandemic requires careful consideration from the attending clinicians, in order to provide fast and reliable treatment to their patients in accordance with evidence-based medicine principles. In this narrative review, we reviewed the available literature on cardiovascular implications of COVID-19; both the acute and the chronic.

Atrial arrhythmia related outcomes in critically ill COVID-19 patients

Rationale

Coronavirus disease 2019 (COVID‐19) is associated with many clinical manifestations including respiratory failure and cardiovascular compromise.

Objectives

We examine outcomes in critically ill individuals with COVID‐19 who develop atrial tachyarrhythmias.

Methods

We collected data from electrocardiograms and the electronic medical record of COVID‐19 positive (COVID⁺) and negative (COVID⁻) individuals admitted to our medical intensive care unit between February 29 and June 28, 2020. We compared clinical and demographic characteristics, new onset atrial tachyarrhythmia, hemodynamic compromise following atrial tachyarrhythmia, and in‐hospital mortality in COVID⁺ versus COVID⁻. Hemodynamic compromise was defined as having a new or increased vasopressor requirement or the need for direct current cardioversion for hemodynamic instability within 1 hour of atrial tachyarrhythmia onset.

Results

Of 300 individuals included, 200 were COVID⁺ and 100 were COVID⁻. Mean age was 60 ± 16 years, 180 (60%) were males, and 170 (57%) were African American. New onset atrial tachyarrhythmia occurred in 16% of COVID⁺ and 19% of COVID⁻ individuals (P = .51). When compared to COVID⁻ participants without atrial tachyarrhythmia, COVID⁺ individuals with new onset atrial tachyarrhythmia had higher mortality after multivariable adjustment (OR 5.0, 95% CI 1.9–13.5). New onset atrial tachyarrhythmia was followed by hemodynamic compromise in 18 COVID⁺ but no COVID⁻ participants (P = .0001). COVID⁺ individuals with hemodynamic compromise after atrial tachyarrhythmia required increased ventilatory support at the time of atrial tachyarrhythmia onset.

Conclusions

Atrial tachyarrhythmia is associated with increased mortality in critically ill individuals with COVID‐19, especially those mechanically ventilated. Recognition of this could assist with clinical care for individuals with COVID‐19.