Enhanced electrocardiographic monitoring of patients with Coronavirus Disease 2019

Abstract

Background: Many of the drugs being used in the treatment of the ongoing pandemic coronavirus disease 2019 (COVID-19) are associated with QT prolongation. Expert guidance supports electrocardiographic (ECG) monitoring to optimize patient safety.

Objective: The purpose of this study was to establish an enhanced process for ECG monitoring of patients being treated for COVID-19.

Methods: We created a Situation Background Assessment Recommendation tool identifying the indication for ECGs in patients with COVID-19 and tagged these ECGs to ensure prompt over reading and identification of those with QT prolongation (corrected QT interval > 470 ms for QRS duration ≤ 120 ms; corrected QT interval > 500 ms for QRS duration > 120 ms). This triggered a phone call from the electrophysiology service to the primary team to provide management guidance and a formal consultation if requested.

Results: During a 2-week period, we reviewed 2006 ECGs, corresponding to 524 unique patients, of whom 103 (19.7%) met the Situation Background Assessment Recommendation tool-defined criteria for QT prolongation. Compared with those without QT prolongation, these patients were more often in the intensive care unit (60 [58.3%] vs 149 [35.4%]) and more likely to be intubated (32 [31.1%] vs 76 [18.1%]). Fifty patients with QT prolongation (48.5%) had electrolyte abnormalities, 98 (95.1%) were on COVID-19-related QT-prolonging medications, and 62 (60.2%) were on 1-4 additional non-COVID-19-related QT-prolonging drugs. Electrophysiology recommendations were given to limit modifiable risk factors. No patient developed torsades de pointes.

Conclusion: This process functioned efficiently, identified a high percentage of patients with QT prolongation, and led to relevant interventions. Arrhythmias were rare. No patient developed torsades de pointes.

Keywords: COVID-19; ECG; Hydroxychloroquine; QT prolongation; Torsades de pointes.

Figure 1

Situation Background Assessment Recommendation tool for the management of QT prolongation in COVID-19 patients. COVID-19 = coronavirus disease 2019; ECG = electrocardiogram; EP = electrophysiology; ID = infectious disease; QTc = corrected QT.

Figure 2

Electrocardiograms screened throughout the study period. COVID-19 = coronavirus disease 2019.

Figure 3

Box plot of QTc intervals for the initial ECG, peak value, and final ECG. Compared with the initial QTc interval, the QTc interval was significantly longer at peak (470.6 ± 35.9 ms vs 520.6 ± 36.7 ms; P < .001). Compared with the peak QTc interval, there was a significant decrease in QTc interval by the final ECG (520.6 ± 36.7 ms vs 478.9 ± 31.0 ms; P < .001). There was also a difference noted between the initial QTc interval and the final QTc interval (470.6 ± 35.9 ms vs 478.9 ± 31.1 ms; P = .026). ECG = electrocardiogram; QTc = corrected QT.