How to manage tachycardia (rapid heart rate) or bradycardia (slow heart rate) in patients with COVID-19 (Coronavirus disease 2019)?

Management of Tachycardia and Bradycardia in COVID-19 Patients

COVID-19 can cause both tachycardia and bradycardia, which should be managed according to the underlying mechanism, severity of cardiac involvement, and hemodynamic stability of the patient.

Cardiovascular Manifestations in COVID-19

COVID-19 can affect the cardiovascular system through multiple mechanisms:

• Direct viral and cytopathic effects
• Systemic inflammation and cytokine release
• Hypoxemia from respiratory disease
• Autonomic dysfunction
• Medication side effects

Types of Arrhythmias in COVID-19

1. Tachyarrhythmias:

   • Persistent sinus tachycardia (unexplained by fever, hypoxia, or hypotension) 1
   • Atrial fibrillation/flutter 1
   • Ventricular tachycardia/fibrillation 1

2. Bradyarrhythmias:

   • Sinus bradycardia 2, 3
   • Atrioventricular blocks
   • Asystole 1

Diagnostic Approach

1. Initial Assessment:

   • ECG to determine type of arrhythmia
   • Laboratory tests: cardiac troponin, inflammatory markers
   • Evaluate for hypoxemia, fever, electrolyte abnormalities
   • Assess hemodynamic stability

2. Further Evaluation:

   • Echocardiogram to assess cardiac function and rule out myocarditis
   • Consider ambulatory rhythm monitoring for intermittent arrhythmias
   • Cardiac MRI if myocardial involvement is suspected 1

Management of Tachycardia in COVID-19

1. Persistent Sinus Tachycardia

• Rule out hypoxia, fever, hypotension, and anemia as causes 1
• If hemodynamically stable:
  • Beta-blockers may be considered in patients with supraventricular tachycardia if hemodynamically stable 1
  • Low-dose metoprolol can be used (may improve respiratory status in mechanically ventilated patients) 1
  • Caution: Avoid beta-blockers in patients with compromised cardiac function as they can precipitate cardiogenic shock 1

2. Atrial Fibrillation/Flutter

• Rate control with beta-blockers if hemodynamically stable
• Consider anticoagulation based on CHA₂DS₂-VASc score
• Monitor for QT prolongation if using antiarrhythmic medications

3. Ventricular Arrhythmias

• Urgent cardioversion if unstable
• Evaluate for myocardial injury/myocarditis
• Consider antiarrhythmic therapy under cardiac monitoring

Management of Bradycardia in COVID-19

1. Sinus Bradycardia

• If hemodynamically stable and asymptomatic:
  • Close monitoring
  • Consider temporary discontinuation of medications that may worsen bradycardia
  • Recognize that transient sinus bradycardia may be a manifestation of COVID-19 2

2. Symptomatic Bradycardia or Heart Blocks

• If hemodynamically unstable:
  • Atropine for temporary management
  • Consider temporary pacing if persistent and symptomatic
  • Vasopressors may be required to maintain adequate blood pressure 2

Special Considerations

1. Myocardial Injury

• Elevated troponin is common in COVID-19 patients (5-25%) 1
• Mild elevations (<2-3 times upper limit) may not require specific cardiac intervention 1
• Marked elevations (>5 times upper limit) may indicate:
  • Severe respiratory failure
  • Tachycardia
  • Systemic hypoxemia
  • Myocarditis
  • Type 1 MI 1

2. Hospitalization Criteria

• Patients with definite myocarditis (mild or moderate) should be hospitalized, ideally at an advanced heart failure center 1
• Patients with fulminant course (cardiogenic shock, sustained ventricular arrhythmias, advanced AV block) should be managed at centers with expertise in advanced heart failure 1

3. Treatment of Underlying COVID-19

• Corticosteroids for patients with myocarditis and COVID-19 pneumonia requiring supplemental oxygen 1
• For patients with pericardial involvement, NSAIDs may help alleviate chest pain 1
• Low-dose colchicine or prednisone may be added for persistent chest pain 1

Follow-up Recommendations

• Consider follow-up testing (ECG, echocardiogram, ambulatory rhythm monitor, CMR) 3-6 months after presentation, particularly in those with ongoing cardiac symptoms 1
• Avoid strenuous physical activity for 3-6 months in patients with myocarditis 1

Warning Signs and Pitfalls

• Bradycardia may be a warning sign of an impending cytokine storm 2
• Tachycardia that persists despite resolution of fever may indicate myocardial injury
• Be cautious with medications that can prolong QT interval
• Consider drug interactions when using antiarrhythmic medications
• Beta-blockers can worsen respiratory status in some COVID-19 patients

Conclusion

The management of arrhythmias in COVID-19 patients requires careful assessment of the underlying mechanism and hemodynamic status. Treatment should focus on maintaining hemodynamic stability while addressing the underlying COVID-19 infection and any associated cardiac involvement.