Penn Study Evaluates COVID-19-Associated Arrhythmias in Urban Populations

A recent, observational study from Penn Medicine's renowned Electrophysiology Division featured a population composed predominantly of African American and female participants. The study, COVID-19 and Cardiac Arrhythmias, published in Heart Rhythm, was performed to systematically evaluate the risk of cardiac arrest and arrhythmias in a large, urban patient population hospitalized for COVID-19 disease.

COVID-19 and Cardiac Arrhythmias

Penn Medicine is situated in one of the nation's largest urban communities in Philadelphia, Pennsylvania. Penn has served as a regional epicenter for the COVID-19 pandemic since early March 2020, when the city's first patient infected with SARS-CoV-2 arrived at the Hospital of the University of Pennsylvania (HUP).

Penn Medicine is also home to one of the nation's leading electrophysiology programs under the leadership of Francis Marchlinski, MD.

The Rate of Arrhythmia in COVID-19 Patients

Arrhythmia has been reported in hospitalized patients with COVID-19 since the disease emerged in China in late 2019. This also has been observed in both Italy and the United States.

The rate of a patient's arrhythmia increases with symptomatic severity, apparently, with a higher arrhythmia rate (44 percent) reported in COVID-19 patients admitted to intensive care units (ICUs). However, the details of the burden and type of arrhythmia (e.g., ventricular tachycardia/ventricular fibrillation, atrial fibrillation, bradyarrhythmias, and nonsustained ventricular tachycardia) in the intensive care population have not been elucidated.

To address this disparity, a team of Penn EP researchers* issued a report in June that, in addition to evaluating the risk of cardiac arrest and arrhythmias in an in-patient cohort of 700 urban patients with COVID-19, assessed correlations between the presence of these arrhythmias and acute, in-hospital mortality.

The cohort included all patients admitted at HUP between March 6, 2020, and May 19, 2020, with confirmed SARS-CoV-2 infection by polymerase chain reaction nasal swab testing. Patients had a mean age of 50±18 years; 55 percent were female and 71 percent were African American. Only 6 percent had a pre-existing history of atrial fibrillation.

The incidence of cardiac arrests, arrhythmias and in-patient mortality was evaluated throughout hospitalization. Logistic regression was applied to assess the association, in either univariate or mean variance analyses, between cardiac arrhythmias and age, sex, race, body mass index, disease burden, and ICU status.

Following an extensive evaluation, it became clear, according to co-author Rajat Deo, MD, MTR, that among the variables assessed, including age, sex, race, BMI, and disease burden, only admission to the ICU had an independent association with arrhythmia risk. In unadjusted analysis, admission to the ICU was associated with greater than 10-fold odds of developing each arrhythmia. (Arrthymia including incident atrial fibrillation, bradycardias and non-sustained ventricular tachycardia.)

A Link Between COVID-19, the ICU and Arrhythmia

By comparison to patients initially admitted to a non-ICU ward for COVID-19, ICU patients were more likely to die in-hospital. In addition, all cardiac arrests during the study period occurred in patients admitted to the ICU, and the majority of these patients survived. Further, no significant association was observed between the other arrhythmias that were evaluated and in-hospital mortality.

"From these findings, we think it's likely that systemic infection, inflammation and other non-cardiac causes are contributing more to the occurrence of cardiac arrest and arrhythmias than damaged or infected heart cells due to the viral infection," Dr. Deo observed.

In addition, although 65 percent of patients admitted to the ICU for COVID-19 disease were African American, and almost half were women, these factors were not directly associated with arrhythmia risk.

Pre-Existing Disease and Severe COVID-19

"What was notable about the 11 percent of patients admitted to the ICU was the burden of pre-existing disease," says Dr. Deo. "ICU patients were older; more than three-quarters had hypertension, and 44 percent had diabetes. In addition, more than half had either coronary disease or heart failure.

In addition to Dr. Deo, the report authors included Francis Marchlinski, MD; Benjamin S. Abella, MD, MPhil; John R Bullinga, MD; David Callans, MD; Sanjay Dixit, MD; Andrew E. Epstein, MD; David S. Frankel, MD; Fermin Garcia, MD; Ramanan Kumareswaram, MD; David Lin, MD; Saman Nazarian, MD, PhD; Michael P. Riley, MD, PhD; Pasquale Santangeli, MD, PhD; Robert D. Schaller, DO; and Gregory E. Supple, MD.