COVID-19-associated cardiac arrest

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For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

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Evidence Based Medicine

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Ongoing Trials on COVID-19-associated cardiac arrest at Clinical Trials.gov

Trial results on COVID-19-associated cardiac arrest

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US National Guidelines Clearinghouse on COVID-19-associated cardiac arrest

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Risk calculators and risk factors for COVID-19-associated cardiac arrest

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Symptoms of COVID-19-associated cardiac arrest

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D. Ayesha Farheen, MBBS[2]

Overview

Sudden cardiac death is defined as natural death from cardiac causes developed by abrupt loss of consciousness within one hour of onset of acute change in cardiovascular status. Preexisting heart disease may or may not be present at the time of the cardiac arrest. Sudden onset of chest pain, dyspnea or palpitations and other symptoms of arrhythmia may precede the onset of cardiac arrest. During the outbreak of COVID-19, the number of out-of-hospital cardiac arrests in Italy increased and prognosis of in-hospital cardiac arrest was generally poor. Factors related to medical services restriction, as well as the side effects of drugs and thrombotic complications related to COVID-19, increased the number of cardiac arrest during COVID-19 pandemic.

Historical Perspective

  • In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.[1]
  • In January 2020, the first COVID-19 case was documented in the United States.[2]
  • On February 20, 2020, the first case of COVID-19 was documented in the Province of Lodi in Italy.[3]
  • In April 2020, an increase in out-of-hospital cardiac arrest was reported during the COVID-19 pandemic.

Classification

Cardiac arrest associated with COVID-19 may be classified into three subtypes:

Causes

The potential causes of ventricular tachyarrhythmia and sudden cardiac death in COVID-19 include:[4]

Pathophysiology

Differentiating inherited cardiac arrest from other causes of cardiac arrest

  • To view the differential diagnosis of COVID-19-associated cardiac arrest click here.
  • To view the differential diagnosis of COVID-19 click here.

Epidemiology and Demographics

Incidence

  • During the COVID-19 pandemic, the incidence of out-of-hospital Sudden cardiac arrests (OHCA) has been 2 times greater compared to the non-pandemic time period.
  • According to a study done in China, about 12% of patients with COVID-19 without a history of heart problems experience cardiac arrest during their hospitalization.[10]
  • In a study done among 761 Chinese patients with severe COVID-19, about 20% patients developed in-hospital cardiac arrest within 40 days of their hospitalization course.[11]

Mortality

Age

Gender

Race

Risk Factors

Screening

Natural History, Complications, and Prognosis

  • Mortality rate of patients with COVID-19 is approximately 1-2%[18]

Diagnosis

Diagnostic Criteria

  • The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:
  • Prodromes phase occurring weeks or months before an event includes: new or worsening cardiovascular symptoms(chest pain, dyspnea, palpitations, fatigability)
  • Onset of terminal event occurring one hour before cardiac arrest includes: abrupt change in clinical status(arrhythmia, hypotension, chest pain, dyspnea, lightheadness)
  • Cardiac arrest includes: sudden collapse, loss of effective circulation, loss of consciousness
  • Biologic death: failure of resuscitation or failure of electrical, mechanical, or CNS function after initial resuscitation

Symptoms

Physical Examination

There is no specific finding associated with physical examination with cardiac arrest in COVID-19.

Laboratory Findings

  • An elevated concentration of serum cardiac troponinI was detected in severe COVID-19 patients with cardiac complications. [19]

Imaging Findings

There are no imaging study findings associated with cardiac arrest in COVID-19.

Electrocardiogram


Treatment

  • The mainstay of therapy for COVID-19-related cardiac arrest is cardiopulmonary resuscitation with attention to the following points:[20]
    • Wearing personal protective equipment (PPE) before entering the room or on the scene.
    • Limiting the personnel in the room or on the scene
    • Using high-efficacy particulate air filter for ventilator
    • Intubating with a cuffed tube
    • Stopping chest compression for intubation
    • Using bag-mask device before intubation
    • Using non-rebreathing face mask instead of bag-mask for short term oxygenation

Prevention

Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in the setting of long QT syndrome or aquired LQTS or heart rate <50/min or receiving azithromycin, redmisivir, lopinavir, ritonavir, include EKG and QTc measurement.[14]

References

  1. Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.
  2. Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.
  3. Baldi, Enrico; Sechi, Giuseppe M.; Mare, Claudio; Canevari, Fabrizio; Brancaglione, Antonella; Primi, Roberto; Klersy, Catherine; Palo, Alessandra; Contri, Enrico; Ronchi, Vincenza; Beretta, Giorgio; Reali, Francesca; Parogni, Pierpaolo; Facchin, Fabio; Bua, Davide; Rizzi, Ugo; Bussi, Daniele; Ruggeri, Simone; Oltrona Visconti, Luigi; Savastano, Simone (2020). "Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy". New England Journal of Medicine. doi:10.1056/NEJMc2010418. ISSN 0028-4793.
  4. Giudicessi JR, Roden DM, Wilde A, Ackerman MJ (May 2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 Check |pmid= value (help). Vancouver style error: initials (help)
  5. Mehra, Mandeep R; Desai, Sapan S; Ruschitzka, Frank; Patel, Amit N (2020). "RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis". The Lancet. doi:10.1016/S0140-6736(20)31180-6. ISSN 0140-6736.
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  11. Shao, Fei; Xu, Shuang; Ma, Xuedi; Xu, Zhouming; Lyu, Jiayou; Ng, Michael; Cui, Hao; Yu, Changxiao; Zhang, Qing; Sun, Peng; Tang, Ziren (2020). "In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China". Resuscitation. 151: 18–23. doi:10.1016/j.resuscitation.2020.04.005. ISSN 0300-9572.
  12. 12.0 12.1 12.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check |pmc= value (help). PMID 32473113 PMID: 32473113 Check |pmid= value (help).
  13. Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ (2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 PMID: 32380288 Check |pmid= value (help).
  14. 14.0 14.1 Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde A (March 2020). "SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes". Heart Rhythm. doi:10.1016/j.hrthm.2020.03.024. PMC 7156157 Check |pmc= value (help). PMID 32244059 Check |pmid= value (help). Vancouver style error: initials (help)
  15. Tam, Chor-Cheung Frankie; Cheung, Kent-Shek; Lam, Simon; Wong, Anthony; Yung, Arthur; Sze, Michael; Lam, Yui-Ming; Chan, Carmen; Tsang, Tat-Chi; Tsui, Matthew; Tse, Hung-Fat; Siu, Chung-Wah (2020). "Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006631. ISSN 1941-7713.
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  18. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui D, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS (April 2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N. Engl. J. Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help). Vancouver style error: initials (help)
  19. Paul P (May 2020). "Cardiac Troponin-I may be a predictor of complications and mortality in COVID-19 patients". Curr Med Res Pract. doi:10.1016/j.cmrp.2020.05.001. PMC 7204698 Check |pmc= value (help). PMID 32382587 Check |pmid= value (help).
  20. Edelson, Dana P.; Sasson, Comilla; Chan, Paul S.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bradley, Steven M.; Brooks, Steven C.; Cheng, Adam; Escobedo, Marilyn; Flores, Gustavo E.; Girotra, Saket; Hsu, Antony; Kamath-Rayne, Beena D.; Lee, Henry C.; Lehotsky, Rebecca E.; Mancini, Mary E.; Merchant, Raina M.; Nadkarni, Vinay M.; Panchal, Ashish R.; Peberdy, Mary Ann R.; Raymond, Tia T.; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis A.; Starks, Monique Anderson; Bobrow, Bentley J.; Chan, Melissa; Berg, Katherine; Duff, Jonathan P.; Joyner, Benny L.; Lasa, Javier J.; Levy, Arielle; Mahgoub, Melissa; O’Connor, Michael F.; Hoover, Amber V.; Rodriguez, Amber J.; Meckler, Garth; Roberts, Kathryn; Mohr, Nicholas M.; Nassar, Boulos; Rubinson, Lewis; Sutton, Robert M.; Schexnayder, Stephen M.; Kleinman, Monica; de Caen, Allan; Morgan, Ryan; Bhanji, Farhan; Fuchs, Susan; Terry, Mark; McBride, Mary; Levy, Michael; Cabanas, Jose G.; Tan, David K.; Moitra, Vivek K.; Szokol, Joseph W. (2020). "Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19". Circulation. 141 (25). doi:10.1161/CIRCULATIONAHA.120.047463. ISSN 0009-7322.