ECG pathology and its association with death in critically ill COVID-19 patients, a cohort study

Electrocardiographic Pathological Findings Caused by the SARS-CoV-2 Virus Infection: Evidence from a Retrospective Multicenter International Cohort Longitudinal Pilot Study of 548 Subjects

COVID-19 has threatened the capability of receiving and allocating patients in emergency departments (EDs) all over the world. This is a retrospective cohort study to explore the role of a simple procedure like an ECG to screen for the severity of COVID-19 on admission to the ED. For this study, 548 consecutive patients were enrolled in a multicenter international registry and stratified upon ECG on admission with a simple distinction between normal vs. abnormal rhythm. Among patients in the abnormal ECG group were those with heart rates higher than 100 beats per minute and/or atrial fibrillation. Survival in patients with normal ECG rhythm was deemed below 75% after 58 days and then stabilized, while survival in patients with abnormal ECG rhythm was deemed below 75% after 11 days and below 50% after 21 days. A multivariate analysis including abnormal rhythm, gender, age, diabetes, obesity, respiratory failure during hospitalization, heart failure during hospitalization, and abnormal rhythm was an independent predictor of death (HR 7.20 95% CI 3.63-14.28, p < 0.01). This finding, if confirmed in large prospective studies, is promising for identifying a cheap and simple procedure for patients in need of a closer look.

Electrocardiographic findings and prognostic values in patients hospitalised with COVID-19 in the World Heart Federation Global Study

BACKGROUND

COVID-19 affects the cardiovascular system and ECG abnormalities may be associated with worse prognosis. We evaluated the prognostic value of ECG abnormalities in individuals with COVID-19.

METHODS

Multicentre cohort study with adults hospitalised with COVID-19 from 40 hospitals across 23 countries. Patients were followed-up from admission until 30 days. ECG were obtained at each participating site and coded according to the Minnesota coding criteria. The primary outcome was defined as death from any cause. Secondary outcomes were admission to the intensive care unit (ICU) and major adverse cardiovascular events (MACE). Multiple logistic regression was used to evaluate the association of ECG abnormalities with the outcomes.

RESULTS

Among 5313 participants, 2451 had at least one ECG and were included in this analysis. The mean age (SD) was 58.0 (16.1) years, 60.7% were male and 61.1% from lower-income to middle-income countries. The prevalence of major ECG abnormalities was 21.3% (n=521), 447 (18.2%) patients died, 196 (8.0%) had MACE and 1115 (45.5%) were admitted to an ICU. After adjustment, the presence of any major ECG abnormality was associated with a higher risk of death (OR 1.39; 95% CI 1.09 to 1.78) and cardiovascular events (OR 1.81; 95% CI 1.30 to 2.51). Sinus tachycardia (>120 bpm) with an increased risk of death (OR 3.86; 95% CI 1.97 to 7.48), MACE (OR 2.68; 95% CI 1.10 to 5.85) and ICU admission OR 1.99; 95% CI 1.03 to 4.00). Atrial fibrillation, bundle branch block, ischaemic abnormalities and prolonged QT interval did not relate to the outcomes.

CONCLUSION

Major ECG abnormalities and a heart rate >120 bpm were prognostic markers in adults hospitalised with COVID-19.

How the Innate Immune System of the Blood Contributes to Systemic Pathology in COVID-19-Induced ARDS and Provides Potential Targets for Treatment

Most SARS-CoV-2 infected patients experience influenza-like symptoms of low or moderate severity. But, already in 2020 early during the pandemic it became obvious that many patients had a high incidence of thrombotic complications, which prompted treatment with high doses of low-molecular-weight heparin (LMWH; typically 150-300IU/kg) to prevent thrombosis. In some patients, the disease aggravated after approximately 10 days and turned into a full-blown acute respiratory distress syndrome (ARDS)-like pulmonary inflammation with endothelialitis, thrombosis and vascular angiogenesis, which often lead to intensive care treatment with ventilator support. This stage of the disease is characterized by dysregulation of cytokines and chemokines, in particular with high IL-6 levels, and also by reduced oxygen saturation, high risk of thrombosis, and signs of severe pulmonary damage with ground glass opacities. The direct link between SARS-CoV-2 and the COVID-19-associated lung injury is not clear. Indirect evidence speaks in favor of a thromboinflammatory reaction, which may be initiated by the virus itself and by infected damaged and/or apoptotic cells. We and others have demonstrated that life-threatening COVID-19 ARDS is associated with a strong activation of the intravascular innate immune system (IIIS). In support of this notion is that activation of the complement and kallikrein/kinin (KK) systems predict survival, the necessity for usage of mechanical ventilation, acute kidney injury and, in the case of MBL, also coagulation system activation with thromboembolism. The general properties of the IIIS can easily be translated into mechanisms of COVID-19 pathophysiology. The prognostic value of complement and KKsystem biomarkers demonstrate that pharmaceuticals, which are licensed or have passed the phase I trial stage are promising candidate drugs for treatment of COVID-19. Examples of such compounds include complement inhibitors AMY-101 and eculizumab (targeting C3 and C5, respectively) as well as kallikrein inhibitors ecallantide and lanadelumab and the bradykinin receptor (BKR) 2 antagonist icatibant. In this conceptual review we discuss the activation, crosstalk and the therapeutic options that are available for regulation of the IIIS.