Rakesh Gopinathannair, MD, on Managing Cardiac Arrhythmias During the COVID-19 Pandemic
To better understand the prevalence of cardiac arrhythmias and treatment strategies used among patients hospitalized with COVID-19, the Heart Rhythm Society (HRS) recently distributed a survey1 to electrophysiology (EP) professionals worldwide.
In all, 1197 EP professionals from 76 countries completed the survey between March 27, 2020, and April 13, 2020. Of these respondents, 50% were from outside the United States and 76% reported having patients with COVID-19 in their hospitals.
The survey contained questions that asked respondents about the management strategies they have implemented among patients with COVID-19, including the use of anticoagulants, hydroxychloroquine (HCQ), chloroquine, and azithromycin (AZM). The survey also canvassed the EP professionals about the arrhythmia characteristics that they have witnessed among their patients, and the results confirmed adverse cardiac events due to COVID- 19 treatments.
According to the results, atrial fibrillation (AF) was the most commonly reported tachyarrhythmia, and severe sinus bradycardia and complete heart block were the most commonly reported bradyarrhythmias.
Rakesh Gopinathannair, MD, a clinical cardiac EP specialiast at the Kansas City Heart Rhythm Institute and a professor of medicine at the University of Missouri-Columbia, was the lead author of the survey. He answered our questions about the results, as well as what they suggest about the management challenges that still need to be overcome.
CARDIOLOGY CONSULTANT: The US Food and Drug Administration has recently cautioned against the use of HCQ or chloroquine for many patients with COVID-19.2 What do your survey results suggest about this decision? And where does the use of AZM fit into this?
Rakesh Gopinathannair: In our survey, of 511 respondents, 171 (33.5%) reported having patients on HCQ/chloroquine, whereas 155 (31%) respondents reported using HCQ/chloroquine in combination with AZM. Based on our results, use of either HCQ or HCQ in combination with AZM appears to be more common in the United States compared with outside the United States.
Of 508 respondents, 254 (50%) reported using an electrocardiogram monitoring protocol to monitor QTc intervals among patients receiving HCQ/chloroquine, with no significant difference between those from the United States vs outside the United States (49% vs 51%, p=0.59). QTc prolongation of 500 ms or greater (≥550 ms with QRS duration >120 ms) was reported by 80 of 477 respondents (17%). Sixty (12.3%) of 489 respondents reported having to discontinue combination therapy with HCQ/chloroquine and AZM due to significant QTc prolongation. Twenty (4.1%) respondents reported cases of potentially life-threatening polymorphic ventricular tachycardia (Torsade de Pointes) among patients receiving HCQ/chloroquine or AZM.
Being a survey, our data do not represent patient-level information. However, the reported information from our survey regarding adverse events associated with HCQ/chloroquine and AZM were similar to data from 2 recent studies3,4 and shows that the risk of arrhythmic adverse events are not inconsequential. The information also suggests for a cautious approach and close monitoring of QTc when using these therapies, the efficacy of which have not been proven.
CARDIO CON: Your results highlight the need for clarity regarding safe treatment plans for patients with COVID-19 who have heart rhythm disorders. As information continuously develops and changes, what steps do you suggest practitioners take—both in and out of the clinic—to ensure that they make the optimal management decisions for their patients?
RG: There is still much to be understood regarding mechanisms of arrhythmias in hospitalized patients with COVID-19 and what the optimal prophylactic and therapeutic strategies are among these patients. Research is ongoing, and the information is changing rapidly as the United States continues to be in the grip of this pandemic. A recently published document5 from the HRS and American Heart Association Electrocardiography and Arrhythmias Committee—endorsed by the American College of Cardiology—provides guidance on how to “reboot” EP through the COVID-19 pandemic, outlining steps to be taken both in the outpatient and procedural settings as we continue to provide necessary heart rhythm care to our patients.
CARDIO CON: The results of the survery showed that 22% of respondents had prescribed anticoagulation therapy to patients with COVID-19 who did not otherwise have an indication for such therapy. What does this suggest about where practitioners’ concern lies and what else needs to be studied—especially considering the presence of AF?
RG: This finding highlights the concern regarding the increasing risk of thrombosis among patients with COVID-19. The relatively common presence of AF among this patient population further raises the need to address anticoagulation. Studies have shown that COVID-19 has been associated with increased risk of thrombosis, and authors of a recent observational study6 found that anticoagulation therapy was associated with improved outcomes. The need for continued anticoagulation following recovery from COVID-19 requires further study.
CARDIO CON: Based on the survey’s results, what do you think is the biggest challenge currently facing the EP community? Why so, and how do you think it can be overcome?
RG: The authors of this manuscript feel that the biggest challenge for the EP community at present is how to get back to some state of “normalcy” doing elective procedures with COVID-19 cases still waxing and waning. This is especially concerning in elderly patients with multiple comorbidities who are vulnerable to severe infection if exposed to the novel coronavirus. Availability of testing remains a challenge. We need to strive to create a safe environment for our patients so that they can continue to receive necessary heart rhythm care in a timely fashion.
CARDIO CON: Can you describe a challenging case that you have seen of a patient with COVID-19 that touches on any of the survey findings?
RG: One of most challenging situations to face is a patient with COVID-19 who develops complete heart block in the hospital, requiring either temporary or permanent pacing. This is a challenge because the manifest heart block may be due to underlying myocardial inflammation and, therefore, recovery of conduction can happen as the infection resolves. Thus, it is hard to know how long to wait before placing a permanent device, as one also has to consider potential exposure to the physician and laboratory staff.
- Gopinathannair R, Merchant FM, Lakkireddy DR, et al. COVID-19 and cardiac arrhythmias: a global perspective on arrhythmia characteristics and management strategies. J Interv Card Electrophysiol. 2020:1-8. doi:10.1007/s10840-020-00789-9
- Coronavirus (COVID-19) update: FDA revokes emergency use authorization for chloroquine and hydroxychloroquine. June 15, 2020. Accessed July 15, 2020. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-revokes-emergency-use-authorization-chloroquine-and
- Chorin E, Dai M, Shulman E, et al. The QT interval in patients with COVID-19 treated with hydroxychloroquine and azithromycin. Nat Med. 2020;26(6):808-809. doi:10.1038/s41591-020-0888-2
- Borba MGS, Val FFA, Sampaio VS, et al; CloroCovid-19 team. Effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a randomized clinical trial. JAMA Netw Open. 2020;3(4):e208857. doi:10.1001/jamanetworkopen.2020.8857
- Lakkireddy DR, Chung MK, Deering TF, et al. Guidance for rebooting electrophysiology through the COVID-19 pandemic from the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: endorsed by the American College of Cardiology. Published online June 12, 2020. Heart Rhythm. doi:10.1016/j.hrthm.2020.06.012
- Paranjpe I, Fuster V, Lala A, et al. Association of treatment dose anticoagulation with in-hospital survival among hospitalized patients with COVID-19. J Am Coll Cardiol. 2020;76(1):122-124. doi:10.1016/j.jacc.2020.05.001