Vol. 52 | No. 2 | July-December 2024 Back

Open Access

Association of Electrocardiographic Abnormalities With In-hospital Mortality in Adult Patients With COVID-19 Infection

Abstract

OBJECTIVES: The study aimed to determine the association of electrocardiographic (ECG) abnormalities and in-hospital mortality of patients with coronavirus disease 2019 (COVID-19) infection admitted in a tertiary care hospital in the Philippines.

METHODS: We conducted a retrospective study of confirmed COVID-19–infected patients. Demographic and clinical characteristics and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated.

RESULTS: A total of 163 patients were included in the study; most were female (52.7%) with a median age of 55 years. Sinus rhythm with any ECG abnormality (65%), nonspecific ST and T-wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients, and it was significantly associated with in-hospital mortality (P = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (P = 0.002),
supraventricular tachycardia (P = 0.011), ventricular tachycardia (P = 0.011), third-degree atrioventricular block (P = 0.011), T-wave inversion (P = 0.005), and right ventricular hypertrophy (P = 0.011).

CONCLUSION: The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. Electrocardiographic abnormalities that were associated with mortality were atrial fibrillation or flutter, supraventricular tachycardia, ventricular tachycardia, third-degree atrioventricular block, T-wave inversion, and right ventricular hypertrophy.

KEYWORDS: COVID-19, electrocardiography, mortality, Philippines

  1. World Health Organization. Coronavirus disease 2019 (COVID-19) situation report. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.
  2. Republic of the Philippines Department of Health. COVID 19 case tracker. https://doh.gov.ph/2019-ncov. 
  3. Hui KPY, Cheung M-C, Perera RA, et al. Tropism,  replication competence, and innate immune response of  the coronavirus SARS-CoV-2 in human respiratory tract and conjunctiva: an analysis in ex-vivo and in-vitro cultures.  Lancet Respir Med 2020;8:687–695. 
  4. Wiersinga W, Rhodes A, Cheng A, et al. Pathophysioloogy,  transmission, diagnosis, and treatment of coronavirus  disease 2019 (COVID-19). A review. JAMA 2020;324(8):782–793.  
  5. Parasher A. COVID-19: current understanding of its  pathophysiology, clinical presentation and treatment. Postgrad Med J 2021;97:312–320. 
  6. Macedo A, Goncalves N, Febra C. COVID-19 fatality rates  in hospitalized patients: systematic review and meta analysis. Ann Epidemiol 2021;57:14–21.  
  7. Oliveira E, Parik A, Lopez-Ruiz A, et al. ICU outcomes  and survival in patients with severe COVID-19 in the  largest health care system in central Florida. PLoS One 2021;16(3):e0249038.  
  8. Salamat M, Malundo A, Abad C, et al. Characteristics and  factors associated with mortality of 200 COVID-19 patients  at a Philippine COVID-19 tertiary referral center. Acta Med Philipp 2021;55:173–182.  
  9. Li B, Yang J, Zhao F, et al. Prevalence and impact of  cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol 2020;109(5):531–538. 
  10. Abraha H, Gessesse Z, Gebrecherkos T, et al. Clinical  features and risk factors associated with morbidity and  mortality among patients with COVID-19 in northern  Ethiopia. Int J Infect Dis 2021;105:776–783.  
  11. Lee KH, Kim JS, Hong SH, et al. Risk factors of COVID 19 mortality: a systematic review of current literature  and lessons from recent retracted articles. Eur Rev Med  Pharmacol Sci 2020;24:13089–13097. 
  12. Pishgahi M, Yousefifard M, Safari S, Ghorbanpouryami F.  Electrocardiographic findings of COVID-19 patients and  their correlation with outcome: a prospective study. Adv J  Emerg Med 2021;5(2):Spring (April).  
  13. Ranard L, Fried J, Abdalla M, et al. Approach to acute  cardiovascular complications in COVID-19 infection. Circ  Heart Fail 2020;13:167–176. 
  14. Iqubal A, Kashif Iqubal M, Hoda F, et al. COVID-19  and cardiovascular complications: an update from  the underlying mechanism to consequences and  possible clinical intervention. Expert Rev Anti Infect Ther 2021;19(9):1083–1092. doi:10.1080/14787210.2021.189 3692. 
  15. Long B, Brady W, Koyfman A, et al. Cardiovascular  complications in COVID-19. Am J Emerg Med 2020:38:1504–1507. 
  16. Lee C, Ali K, Connell D, et al. COVID-19 associated  cardiovascular complications. Diseases 2021;9:47.
  17. Li L, Zhang S, He B, et al. Risk factors and  electrocardiogram characteristics for mortality in critical  inpatients with COVID-19. Clin Cardiol 2020;43:1624–1630.
  18. Li Y, Liu T, Tse G, et al. Electrocardiographic characteristics  in patients with coronavirus infection: a single-center  observational study. Ann Noninvasive Electrocardiol 2020;25:e12805. 
  19. Guo T, Fan Y, Chen M, et al. Cardiovascular implications of  fatal outcomes of patients with coronavirus disease 2019  (COVID-19). JAMA Cardiol 2020;5(7):811–818. 
  20. de Vita A, Ravenna S, Covino M, et al. Electrocardiographic  findings and clinical outcome in patients with COVID-19  or other acute infectious respiratory diseases. J Clin Med 2020;9:3647. 
  21. Mason JW, Hancock EW, Gettes LS. Recommendations  for the standardization and interpretation of the electrocardiogram: part II: electrocardiography diagnostic  statement list. A scientific statement from the American  Heart Association Electrocardiography and Arrhythmias  Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2007;49:1128–1135. 
  22. Mason JW, Hancock EW, Gettes LS. Recommendations  for the standardization and interpretation of the electrocardiogram: part II: electrocardiography diagnostic  statement list. Circulation 2007; 115(10). https://doi. org/10.1161/CIRCULATIONAHA.106.180201 
  23. Surawicz B, Childers R, Deal BJ, et al. AHA/ACCF/HRS  recommendations for the standardization and interpretation  of the electrocardiogram: part III: intraventricular conduction  disturbances. J Am Coll Cardiol 2009;53: 976–981. 
  24. Rautaharju PM, Surawicz B, Gettes LS. AHA/ACCF/HRS  recommendations for the standardization and interpretation  of the electrocardiogram: part IV: the ST segment, T and  U waves, and the QT interval. J Am Coll Cardiol 2009;53:  982–991. 
  25. Hancock EW, Deal BJ, Mirvis DM, et al. AHA/ACCF/HRS  recommendations for the standardization and interpretation  of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy. J Am Coll Cardiol 2009;53:992–1002. 
  26. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/ HRS recommendations for the standardization and  interpretation of the electrocardiogram: part VI: acute ischemia/infarction. J Am Coll Cardiol 2009;53:1003–1011. 
  27. Chen L, Li X, Chen M, et al. The ACE2 expression I human  heart indicates new potential mechanism of heart injury  among patients infected with SARS-CoV-2. Cardiovasc Res 2020;116(12):1994.  
  28. Iqubal A, Iqubal MK, Hoda F, Najmi AK, Haque SE.  COVID-19 and cardiovascular complications: an update  from the underlying mechanism to consequences and  possible clinical intervention. Expert Rev Anti Infect Ther 2021;19(9):1083–1092.  
  29. Kochi A, Tagliari AP, Forleo, G, et al. Cardiac and arrhythmic  complications in patients with COVID-19. J Cardiovasc  Electrophysiol 2020;31:1003–1008.
  30. Cho JH, Namazi A, Shelton R, et al. Cardiac arrhythmias  in hospitalized patients with COVID-19: a prospective  observational study in the western United States. PLoS One 2020;15(12). 
  31. Ozaeta MK, dela Cruz FD, Sombrero MC, et al.  Electrocardiogram and echocardiographic findings of  COVID-19 in Makati Medical Center. ASEAN Heart J 2020;29:1–7. 
  32. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular  considerations for patients, health care workers, and health  systems during the coronavirus disease 2019 (COVID-19)  pandemic. J Am Coll Cardiol 2020;75(18):2352–2371.  
  33. Kho J, Ioannou A, van den Abbeele K, Mandal AKJ,  Missouris CG. Pulmonary embolism in COVID-19: clinical  characteristics and cardiac implications. Am J Emerg Med  2020;38(10):2142–2146. 
  34. Wang D, Hu B, Hu C, et al. Clinical characteristics of  138 hospitalized patients with 2019 novel coronavirus– infected pneumonia in Wuhan, China. JAMA 2020;323(11):1061–1069. 
  35. Denegri A, Pezzuto G, D’Arienzo M, et al. Clinical and  electrocardiographic characteristics at admission of COVID 19/SARS-CoV2 pneumonia infection. Intern Emerg Med 2021;16(6):1451–1456. 
  36. Yuan M, Zathar Z, Nihaj F, et al. ECG changes in  hospitalised patients with COVID-19 infection. Br J Cardiol 2021;28(2):24. 
  37. Bertini M, Ferrari R, Guardigli G, et al. Electrocardiographic  features of 431 consecutive, critically ill COVID-19 patients:  an insight into the mechanisms of cardiac involvement.  Europace 2020;22(12):1848–1854. 
  38. Stone E, Kiat H, McLachlan C. Atrial fibrillation in COVID 19: a review of possible mechanisms. Fed Am Soc Exp Biol 2020;34:11347–11354.
  39. Wanamaker B, Cascino T, McLaughlin V, Oral H,  Latchamsetty R, Siontis KC. Atrial arrhythmias in pulmonary  hypertension: pathogenesis, prognosis and management.  Arrhythm Electrophysiol Rev 2018;7(1):43–48. 
  40. Whitman I, Patel V, Soliman E, Bluemke D, Praestgaard  A, Jain A. Validity of the surface electrocardiogram criteria  for right ventricular hypertrophy: the MESA—right ventricle  study. J Am Coll Cardiol 2014;63:672–681. 
  41. Repessé X, Charron C, Viellard-Baron A. Right ventricular  failure in acute lung injury and acute respiratory distress  syndrome. Minerva Anestesiol 2012;78:941–948. 
  42. Martínez-Mateo V, Fernández-Anguita MJ, Paule A.  Electrocardiographic signs of acute right ventricular  hypertrophy in patients with COVID-19 pneumonia: a  clinical case series. J Electrocardiol 2020;62:100–102. 
  43. Pavri B, Kloo J, Farzad D, Riley J. Behavior of the PR  interval with increasing heart rate in patients with COVID 19. Heart Rhythm 2020;17(9):1434–1438. 
  44. Sacher F, Fauchier L, Boveda S, et al, Working Group  of Pacing, Electrophysiology of the French Society  of Cardiology, the Board of the French Society of  Cardiology. Use of drugs with potential cardiac effect in  the setting of SARS-CoV-2 infection. Arch Cardiovasc Dis 2020;113(5):293–296. 
  45. Cipriani A, Zorzi A, Ceccato D, et al. Arrhythmic profile and  24-hour QT interval variability in COVID-19 patients treated  with hydroxychloroquine and azithromycin. Int J Cardiol 2020;316:280–284. 
  46. Roterberg G, El-Battrawy I, Veith M, et al. Arrhythmic  events in Brugada syndrome patients induced by fever. Ann  Noninvasive Electrocardiol 2019;25:e12723. 
  47. Zimmermann P, Aberer F, Braun M, Sourij H, Moser O. The  arrhythmogenic face of COVID-19: Brugada ECG pattern in  SARS-CoV-2 infection. J Cardiovasc Dev Dis 2022;9(4):96.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, which permits use, share — copy and redistribute the material in any medium or format, adapt — remix, transform, and build upon the material, as long as you give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. You may not use the material for commercial purposes. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/.