Theophylline in Treatment of COVID-19 Induced Sinus Bradycardia

Oral theophylline corrects sinus node dysfunction in acute on chronic lithium toxicity: case report and systematic review of lithium-induced Sinus node dysfunction

Introduction

Lithium is a well-known agent to cause systemic toxicity with its narrow therapeutic window. Toxic cardiac effects are known but seldomly reported and can manifest as sinus node dysfunction (SND) ranging from delayed conduction to sinus arrest with the potential to induce asystole. Theophylline a positive chronotropic agent has been previously used for correction of sinus node dysfunction but never been utilized for the correction of lithium-induced SND. We report the first successful use of Theophylline for rate/rhythm correction of SND in a patient presenting with acute lithium toxicity along with a review summarizing the clinical features of all published literature regarding lithium-induced SND.

Methods

Case report and systematic review of the literature are presented. Three independent scientific databases were queried for reports of lithium-induced SND. A clinical compendium was then generated detailing associated clinical data and descriptive statistics were performed.

Results

1,117 reports were initially retrieved with full-text review yielding a cohort of 49 unique, independent studies. (61.4%) of patients presented with a supratherapeutic lithium level, 12 (21.1%) were normotherapeutic, and 11 (19.3%) were subtherapeutic. EKG findings varied but most commonly described sinus node dysfunction with a variable degree of sinoatrial block with sinus bradycardia (54.39%) and sinus arrest (29.82%) predominating. Twelve patients (21.1%) required inotrope or vasopressor support. 10 (17.5%) of patient required temporary pacing while 7 (12.3%) required permanent pacemaker implantation. In the majority of cases no significant permanent sequelae were reported as 50 (87.7%) patients recovered, 2 (3.5%) patients had persistent sinus node dysfunction, and 2 (3.5%) patients expired as a result of acute lithium toxicity.

Discussion & conclusion

In this review we report the most up-to-date and comprehensive clinical compendium of lithium-associated sinus node dysfunction along with describing a novel treatment methodology to rapidly correct lithium-induced cardiac toxicity in a patient with long-standing bipolar disorder on chronic lithium treatment. We have reviewed the available literature and provide a comprehensive summary detailing symptomatology of presentation, treatments utilized, electrocardiographic findings and patient prognoses. We have concluded that under the presumptive conditions that transient sinus node dysfunction will resolve with elimination of toxic concentrations of lithium, temporary chronotropic support provided by theophylline administration would be preferable to more invasive measures such as hemodialysis, temporary pacing, or implantation of a permanent pacemaker.

Use of Epic Electronic Health Record System for Health Care Research: Scoping Review

BACKGROUND

Electronic health records (EHRs) enable health data exchange across interconnected systems from varied settings. Epic is among the 5 leading EHR providers and is the most adopted EHR system across the globe. Despite its global reach, there is a gap in the literature detailing how EHR systems such as Epic have been used for health care research.

OBJECTIVE

The objective of this scoping review is to synthesize the available literature on use cases of the Epic EHR for research in various areas of clinical and health sciences.

METHODS

We used established scoping review methods and searched 9 major information repositories, including databases and gray literature sources. To categorize the research data, we developed detailed criteria for 5 major research domains to present the results.

RESULTS

We present a comprehensive picture of the method types in 5 research domains. A total of 4669 articles were screened by 2 independent reviewers at each stage, while 206 articles were abstracted. Most studies were from the United States, with a sharp increase in volume from the year 2015 onwards. Most articles focused on clinical care, health services research and clinical decision support. Among research designs, most studies used longitudinal designs, followed by interventional studies implemented at single sites in adult populations. Important facilitators and barriers to the use of Epic and EHRs in general were identified. Important lessons to the use of Epic and other EHRs for research purposes were also synthesized.

CONCLUSIONS

The Epic EHR provides a wide variety of functions that are helpful toward research in several domains, including clinical and population health, quality improvement, and the development of clinical decision support tools. As Epic is reported to be the most globally adopted EHR, researchers can take advantage of its various system features, including pooled data, integration of modules and developing decision support tools. Such research opportunities afforded by the system can contribute to improving quality of care, building health system efficiencies, and conducting population-level studies. Although this review is limited to the Epic EHR system, the larger lessons are generalizable to other EHRs.

Methylxanthine Derivatives in the Treatment of Sinus Node Dysfunction: A Systematic Review

While the chronotropic effects of theophylline and aminophylline are well-known, their clinical application in the treatment of sinus node dysfunction has not been established in a review. The purpose of this systematic review is to evaluate the efficacy and safety of methylxanthines in the treatment of bradyarrhythmias associated with sinus node dysfunction. A systematic review was conducted in accordance with PRISMA guidelines on Embase, PubMed, MEDLINE, Cochrane Central, Web of Science, SciELO, Korean Citation Index, Global Index Medicus, and CINAHL through June 2023. A total of 607 studies were identified through the literature search. After applying the inclusion and exclusion criteria, 14 studies were included in this review. The causes of bradyarrhythmias involving the sinoatrial node included acute cervical spinal cord injury, coronavirus disease of 2019, carotid sinus syncope, chronotropic incompetence, heart transplant, and chronic sinus node dysfunction. Theophylline and aminophylline were shown to be effective for increasing heart rate and reducing the reoccurrence of bradyarrhythmias. The data on symptom resolution was conflicting. While many case studies reported a resolution of symptoms, a randomized controlled trial reported no significant difference in symptom scores between the control, theophylline, and pacemaker groups in the treatment of sick sinus syndrome. The incidence of adverse effects was low across all study designs. The data suggests methylxanthines may be useful as an alternative or bridge to nonpharmacologic pacing; however, dosing has yet to be established for various indications. Overall, methylxanthines proved safe and effective as a pharmacologic therapy for bradyarrhythmic manifestations of sinus node dysfunction.

The Impact of COVID-19 on the Cardiovascular Health of Emerging Adults Aged 18-25: Findings From a Scoping Review

There is limited knowledge regarding the cardiovascular impact of coronavirus disease 2019 (COVID-19) on emerging adults aged 18-25, a group that disproportionately contracts COVID-19. To guide future cardiovascular disease (CVD) research, policy, and practice, a scoping review was conducted to: (i) examine the impact of the COVID-19 pandemic on the cardiovascular health of emerging adults; and (ii) identify strategies to screen for and manage COVID-19-related cardiovascular complications in this age group. A comprehensive search strategy was applied to several academic databases and grey literature sources. An updated search yielded 6738 articles, 147 of which were extracted and synthesized. Reports identified COVID-19-associated cardiac abnormalities, vascular alterations, and multisystem inflammatory syndrome in emerging adults; based on data from student-athlete samples, prevalence estimates of myocarditis and cardiac abnormalities were 0.5%-3% and 0%-7%, respectively. Obesity, hypertension, CVD, congenital heart disease, and marginalization are potential risk factors for severe COVID-19, related cardiovascular complications, and mortality in this age group. As a screening modality for COVID-19-associated cardiac involvement, it is recommended that cardiac magnetic resonance imaging be indicated by a positive cardiac history and/or abnormal "triad" testing (cardiac troponin, electrocardiogram, and transthoracic echocardiogram) to improve diagnostic utility. To foster long-term cardiovascular health among emerging adults, cardiorespiratory fitness, health literacy and education, and telehealth accessibility should be priorities of health policy and clinical practice. Ultimately, surveillance data from the broader emerging adult population will be crucial to assess the long-term cardiovascular impact of both COVID-19 infection and vaccination, guide screening and management protocols, and inform CVD prevention efforts.

Pacemaker implantation for persistent sinus node dysfunction in a patient with COVID-19

A 46-year-old woman was admitted with coronavirus disease-2019 infection. Symptomatic sinus bradycardia occurred, followed by congestive heart failure. Therapeutics such as isoproterenol, theophylline, and cilostazol could not safely improve her symptoms. She underwent pacemaker implantation 53 days after admission. Atrial pacing remained was at 60% after 6 months.