Key details associated with the treatment of COVID-induced arrhythmias
The American Heart Association (AHA) recently issued a comprehensive scientific statement on the cardiac arrhythmias and autonomic dysfunction associated with COVID-19.[1] Writing group chair Rakesh Gopinathannair, MD, director of cardiac electrophysiology laboratories at the Kansas City Heart Rhythm Institute, spoke with Cardiovascular Business about the key insights for healthcare providers who manage patients with lingering cardiac issues following a COVID-19 infection.
"The pandemic phase is over, but COVID-19 infections persist in this endemic phase, and there are heart rhythm disturbances still happening in these patients," explained Gopinathannair. "The other important part is the so-called long-COVID or what we call autonomic dysfunction associated with COVID, and we still see patients with that."
He said the scientific statement is important because of these ongoing issues cardiologists are still seeing, and the information offers practicing physicians a needed update on the latest data, new treatments, known drug interactions and how they can do surveillance on these patients. While acute COVID-19 cases rarely require hospitalization due to advancements in treatment, the lingering effects—primarily cardiac arrhythmias—remain a pressing concern.
"We summarize our implications or suggestions for clinical practice, and we identify a lot of gaps in knowledge that we still need to study, but we have come a long way from the acute phase of the pandemic," he explained.
The AHA statement notes that COVID is known to cause both atrial and ventricular arrhythmias, atrioventricular conduction abnormalities and sinus node dysfunction/asystole.
Key recommendations on treating patients with COVID-caused arrhythmias
Gopinathannair summarized some key findings from the scientific statement:
• The development of arrhythmias and autonomic dysfunction (AD) during and after COVID-19 infection is likely multifactorial in most cases.
• Bradyarrhythmias during COVID-19 infection tend to occur in severe infections and improve with resolution of the infection, with most patients not requiring permanent pacemakers.
• Patients with newly diagnosed atrial fibrillation (AFib) during a COVID-19 infection should be monitored long term for recurrence and receive anticoagulation per current guidelines.
• Ventricular arrhythmias and sudden cardiac death occur at a higher frequency among patients with COVID-19, and the best treatment is prompt treatment of COVID-19.
• AD occurs primarily in the setting of post-acute sequelae of SARS-CoV-2 (PASC), which is the National Institutes of Health (NIH) name for long-COVID. The precise cause of PASC remains elusive, the authors wrote.
• Many cases of PASC-AD represent postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, or inappropriate sinus tachycardia.
• The COVID treatment Paxlovid is a strong inhibitor of CYP-3A4 and can cause significant drug-drug interactions. Paxlovid is not supposed to be taken if a patient is already on the antiarrhyrthmic drugs amiodarone, propafenone, flecainide, dronedarone, or other common cardiovascular medications such as simvastatin, lovastatin and colchicine.
• Continued long-term arrhythmia surveillance is prudent in any patient who develops a COVID infection.
• Myocarditis is a well-documented adverse effect of COVID-19 infection, but seldom results in serious arrhythmias. There is currently no consistent evidence to demonstrate a heightened risk of arrhythmia or sudden death attributable to COVID-19 vaccination in the general population.
• Clinically stable and ambulatory COVID-19–positive individuals are at substantially reduced risk for arrhythmias compared to those with severe infections.
• Management of arrhythmias/AD during and after COVID-19 infection should be based on current guidelines.
• Mechanisms include direct viral infiltration of the heart via ACE receptors, systemic inflammation and myocarditis-induced scarring, which predispose patients to arrhythmias.
• The statement highlights persistent arrhythmias in patients beyond one year of infection.
• Studies indicate a two-fold increase in AFib, and a 1.5-fold rise in ventricular arrhythmias in individuals with prior COVID-19 compared to those who never had the virus.
Treatment considerations for COVID patients with arrhythmias
Gopinathannair said COVID-induced arrhythmias are generally treated like any other arrhythmias with conventional methods, such as ablation or antiarrhythmic drugs. However, any COVID treatment medications being taken need to be consider, because they can interact with several drugs used to treat heart rhythm issues, including anticoagulants.
For example, he said the drug Paxlovid, used to treat COVID and prevent symptoms from getting worse, is a combination of two medications that actually interact a lot with blood thinners, some antibiotics and antiarrhythmic medications. He suggests speaking with a pharmacist about the potential interactions.
Early involvement of electrophysiologists is also recommended for timely detection, monitoring and treatment.
Many patients with long COVID exhibit symptoms of autonomic dysfunction, such as fatigue, brain fog, dizziness and fainting, Gopinathannair said. Treatment strategies involve approaches used for other autonomic disorders, but may necessitate long-term care and attention. But encouragingly, he said many patients eventually recover from these symptoms.
"It's a constellation of symptoms that typically starts to happen a few weeks after COVID infection. The exact mechanisms and how it happens is debated, but some of these patients can be very debilitated and they end up seeing a lot of doctors," he explained.
Implications for clinical practice
The AHA statement underscores the importance of surveillance and early intervention for patients with suspected COVID-related cardiac issues. Gopinathannair highlighted that arrhythmias linked to COVID-19 might persist even in patients who appeared to have fully recovered. He said it is crucial not to dismiss arrhythmias as incidental problem and approach the issue with vigilance.
"It's important to have some sort of surveillance and not assume that everything is okay," he said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com