COVID-19 lengthens the QT interval independent of other factors

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Editor’s Note: Find the latest news and guidance on COVID-19 in Medscape Coronavirus Resource Center.

COVID-19 infection is associated with a significant increase in the corrected QT interval (QTc) in hospitalized patients, regardless of the usual clinical factors associated with QTc prolongation, including hydroxychloroquine and azithromycin treatment, indicates new research.

“Physicians should be aware that COVID-19 infection can prolong corrected QTc in patients,” said Elaine Y. Wan, MD, director of research in electrophysiology, Columbia University Medical Center, New York. theheart.org | Cardiology Medscape.

The results were published online April 23 a JAMA network open.

“We conducted a detailed and comprehensive study in which expert electrophysiologists read all 12-lead electrocardiograms from hospitalized patients with and without COVID-19 infection,” Wan explained.

The cohort involved 965 patients (58% male, 26% black, 20% 80 years and older) hospitalized at Columbia Medical Center Irving Medical Center from March 1 to May 1, 2020; 733 patients (76%) had COVID-19 and 232 (24%) did not.

The main finding, Wan said, is that patients with COVID-19 infection had prolonged QTc on day 2 (mean increase, 24.7 ms) and day 5 (mean increase, 27.3 ms) of hospitalization, compared with patients without COVID-19 infection. , “Even after adjusting for age, sex, and comorbidities, including the use of possible drugs that prolong QT.”

In the multivariate analysis, the factors significantly associated with prolonged QTc in patients with COVID-19 were age at least 80 years, severe kidney disease, high-sensitivity troponin, and elevated lactate dehydrogenase.

Although not the main focus of the study, the use of any combination of hydroxychloroquine with azithromycin, hydroxychloroquine alone, or azithromycin alone was associated with a significant prolongation of QTc, according to the researchers.

What is “most intriguing,” they say, is that 25% of patients with COVID-19 who had not received either drug still had a QTc interval of 500 ms or more, compared to 11% of their parents. COVID-negative.

“In patients with COVID-19, especially those receiving hydroxychloroquine with azithromycin, initial treatment is simply checked. ECG QTc assessment may not be sufficient, ”suggest Wan and colleagues.

“Obtaining 12-lead ECG to follow QTc during hospitalization for COVID-19 infection, especially in those over 80, with severe chronic kidney disease, and those with high troponin levels is a prudent practice, ”they say.

The authors also note that one patient with COVID-19 had Twisted of spikes. This patient had a QTc of 528 ms and a magnesium level of 1.4 mg / dL and received azithromycin intravenously. The incidence of Torsades de punta in the context of COVID-19 infection in recent studies is “similarly low and limited to rare events,” they point out.

Collateral damage

“This is an important and important study,” write Susan P. Etheridge, MD, and S. Yukiko Asaki, MD, University of Utah, Salt Lake City, in a linked publisher.

Emerging data suggest that SARS-CoV-2 leads to decreased cardiac contractility and increased susceptibility to arrhythmias affecting ion channels. Excessive inflammation can further alter the function of several ion channels, specifically the K + and Ca2 + channels, leading to inflammatory cardiac canalopathies, QT prolongation, and arrhythmias.

“This collateral damage from COVID-19 infections highlights the importance of controlling the QT interval during acute illness, correcting all possible contributing factors, such as fever and electrolyte disorders, and avoiding drugs that prolong repolarization.Changes in QT can be a predictor of viral damage to myocytes, a viral canalopathy, and can herald the development of arrhythmias, ”write Etheridge and Asaki.

The finding of prolonged QTc in the context of a COVID-19 infection, they add, “as much to do with this disease, leaves us frustrated about what to do next. Arrhythmias that occur as a result of disordered ventricular repolarization – Twisted toes, polymorphic ventricular tachycardia, i ventricular fibrillation – they are treatable, but a mechanism would be ideal to avoid them “.

“There are data indicating that increasing the serum K + level and certainly avoiding a low K + can shorten the QTc. Sodium blocking agents, such as mexiletina, may shorten the QT interval even in patients without sodium canalopathy. How these strategies can be used in a patient with COVID, the territory remains unknown, ”conclude Etheridge and Asaki.

The study had no commercial funding. Wan has no relevant disclosures. There is a complete list of author disclosures with the original article.

JAMA Netw Open. Published online April 23, 2021. Full text, Editorial





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