COVID-19 and Heart Rhythm Disorders

Since the start of the COVID-19 pandemic in 2019, there have been more than 900,000 deaths in the United States and more than 6 million deaths worldwide, with a global case load of 456 million at the time of this writing.^1,2 Cardiac involvement is a significant issue in patients with COVID-19, leading to a more complicated course of illness along with higher morbidity and mortality. Cardiac manifestations may include myocarditis, pericarditis, and myocardial infarction; there are also several nonfatal cardiac manifestations that can have a significant impact on quality of life due to a varying range of symptoms. In addition, cardiac arrhythmias remain a critical manifestation of COVID-19, either as a stand-alone issue or as a part of myocarditis or sequelae.³ In this article, we review various long-term manifestations of COVID-19 related to heart rhythm disorders.

COVID-19 and Heart Rhythm Disorders

The incidence and extent of heart rhythm disorders in COVID-19 is highly variable, and for the large part, remains undetermined. Findings suggest that the incidence of arrhythmia is higher with severe COVID-19 illness, especially in hospitalized patients.⁴ While the majority of the patients do well, close monitoring of heart rhythm may be reasonable.⁵ COVID-19 is also associated with myocarditis and pericarditis; mechanisms could involve injury of cardiac myocytes as well as involvement of microvasculature to cause ischemia.^6,7 Apart from acute inflammatory myocarditis, myocardial scarring can also predispose patients to arrhythmia in healed myocardium.⁸ The type of arrhythmia can vary and may involve more than one type. In addition, there may be a possible link between COVID-19 and the autonomic nervous system, triggering autonomic disorders such as postural orthostatic tachycardia syndrome (POTS).⁹

Bradyarrhythmias

Both sinoatrial and atrioventricular (AV) node dysfunction as well as bundle branch blocks have been noted with COVID-19, regardless of the severity of the disease. Several published case reports and series show the highly unpredictable incidence and course of bradyarrhythmias in COVID-19,^10-20 including presentation in children and adults.^21,22 Therapies such as remdesivir for treating COVID-19 may also cause sinus bradycardia or complete heart block.^23,24 Sinus node dysfunction included severe sinus bradycardia and even sinus arrest. Varying degrees of heart blocks were noted, including complete heart block. The timing for onset of such conduction disturbances during the course of illness was also variable. They could also be part of myocarditis or a stand-alone finding.^25,26 These are usually self-limiting^27,28; however, they can at times be severe and require permanent pacing.^29-31 This was noted more in patients with AV block than those with sinus node dysfunction (70% vs 30%). Long-term prognosis remains to be seen, but severe bradyarrhythmias were felt to be markers of severe COVID-19 and associated with poor outcomes, even with pacemaker implantation.^32,33

Atrial Arrhythmias

Atrial arrhythmias, including atrial tachycardia and atrial fibrillation (AF), are common with COVID-19 infection.³⁴ Hospitalized COVID-19 patients with AF tend to have poor outcomes.³⁵ While AF may be self-limited in most patients, it can persist as either paroxysmal and persistent AF in a significant number of patients.³⁶ In our clinical practice, we have seen cases of AF that started after COVID-19 infection and, despite medical therapy, did not subside for more than a year, eventually requiring ablation. At this time, we do not have large-scale, long-term data to suggest the best waiting period before ablation or overall outcomes for AF triggered by COVID-19 infection. The general consensus appears to be a waiting period of several months until inflammatory response and respiratory symptoms have resolved. We are not aware of any tracking biomarkers to guide this decision. However, it is becoming evident that COVID-19-related AF may not be just a transient phenomenon. While routine anticoagulation is guided by the CHA₂DS₂-VASc score, with the incidence of thromboembolic complications in COVID-19 patients,^37-40 we do not know if it may be reasonable to offer anticoagulation for stroke prevention, even in otherwise low-risk patients.

Ventricular Arrhythmias

Focal ventricular arrhythmias such as premature ventricular contractions and ventricular tachycardia (VT) in COVID-19 are often related to either myocarditis or acute coronary syndrome. Myocarditis may further form scar and lead to a propensity toward reentrant VT. Ventricular arrhythmias can significantly contribute to an increased risk of death in hospitalized patients with COVID-19.⁴¹ The temporal course of these arrhythmias remains to be determined. While most of the arrhythmias tend to be self-limiting, it is reasonable to monitor heart rhythm to determine the course and burden of the arrhythmia.^41,42

Inappropriate Sinus Tachycardia (IST) and POTS

Viral infection is one of the well-known triggers for IST and POTS.^9,43 Autonomic complications are increasingly being observed in both acute and chronic forms of COVID-19.⁴⁴ IST is a common observation in patients with post-COVID-19 syndrome and POTS has also been described in the setting of post-COVID-19 syndrome.⁴⁵ However, there are multiple conditions that can mimic POTS.⁴⁶ Therefore, it is important for clinicians to be cognizant about long COVID syndrome.⁴⁷ Lack of definitive arrhythmias and associated systemic symptoms such as fatigue, brain fog, dyspnea, gastrointestinal symptoms, and anxiety make it challenging to manage such patients. There are several pharmacologic and nonpharmacologic therapies (eg, hydration, structured exercise programs) that can be used to help patients with IST and POTS.^48-50 Regardless, the impact of dysautonomia on recovery, quality of life, and ability to return to work is significant. Response to therapeutic measures and temporal course of the symptoms remains highly variable in our practice.

Inherited Arrhythmia Syndromes

Management of patients with an inherited arrhythmia syndrome such as long QT syndrome, catecholaminergic polymorphic VT (CPVT), or Brugada syndrome (BrS) in the setting of COVID-19 may be challenging and require precautionary measures in order to prevent exacerbation of arrhythmia.⁵¹ Apart from the usual precautions for COVID-19 prevention, measures specific to a particular syndrome may be considered.⁵¹ Antiviral medications such as ritonavir and remdesivir may have QT prolongation effects that could lead to malignant arrhythmias. For CPVT patients, flecainide can also interact with antiviral medications and lead to QT prolongation. Beta-blockers are best continued for protection against arrhythmias. For patients with BrS, especially type 1 BrS, aggressive control of fever is warranted to avoid fever-induced arrhythmias.⁵¹

Risk of Myocarditis and Cardiac Arrhythmia Associated With COVID-19 Vaccination

According to Patone et al, there is a very small increased risk of myocarditis following COVID-19 vaccination; most observed myocarditis events were mild. The risk of serious COVID-19 infection and myocarditis was much higher without vaccination.⁵² There were some incidences of worsening cardiac arrhythmia after the COVID-19 vaccine; however, these were usually self-limiting. Overall, the protective effect of vaccination seems to be far more beneficial to any warrant delaying vaccination in patients with prior history of such arrhythmias.

Clinical Practice Implications

We have seen several implications of the COVID-19 pandemic on day-to-day clinical practice.⁵³ For example, use of video clinic visits and remote follow-up for cardiac devices are at their highest level. In addition, with the increased shortage of hospital beds and staff, we have been using same-day discharge for certain cardiac electrophysiology procedures. There is now very favorable evidence to support same-day discharge for complex procedures such as AF ablation.^54,55

Summary

As the pandemic evolves, we continue to learn more about the impact of COVID-19 on cardiac arrhythmias and make modifications to clinical practice. While most patients diagnosed with COVID-19 on an outpatient basis do not seem to have malignant or sustained arrhythmia, hospitalized patients appear to exhibit various types of arrhythmias with varying degrees of severity that not always correlate with the severity of COVID-19. Arrhythmias appear to be associated with less favorable outcomes for these patients. In addition, there are several patients who go on to have continued long-term arrhythmia symptoms, often requiring further therapy. It is important for the cardiac electrophysiology community to share long-term data on prognosis, management, and outcomes in order to help guide treatment in this population of patients. 

Disclosures: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kotak has no conflicts of interest to report regarding the content herein.   

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