The Prognostic Value of Electrocardiogram at Presentation to Emergency Department in Patients With COVID-19

Abstract

Objective: To study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication.

Methods: This study analyzed 1258 adults with coronavirus disease 2019 who were seen at three hospitals in New York in March and April 2020. Electrocardiograms at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs.

Results: At 48 hours, 73 of 1258 patients (5.8%) had died and 174 of 1258 (13.8%) were alive but receiving mechanical ventilation with 277 of 1258 (22.0%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (odds ratio [OR], 2.5; 95% CI, 1.1 to 6.2), right ventricular strain (OR, 2.7; 95% CI, 1.3 to 6.1), and ST segment abnormalities (OR, 2.4; 95% CI, 1.5 to 3.8) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 breaths/min and saturation >95%), only 5 (4.6%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31.5%) having both ECG and respiratory vital sign abnormalities.

Conclusion: The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with coronavirus disease 2019 and may assist with patient triage.

Figure 1

Patient outcomes at 14 days after coronavirus disease 2019 diagnosis.

Figure 2

Electrocardiogram (ECG) abnormalities at time of presentation are prognostic of mechanical ventilation or death at 48 hours. The ability to prognosticate 48-hour outcome was assessed using the first ECG and vital signs recorded in the emergency department. Electrocardiogram abnormality was defined as the presence of atrial fibrillation or flutter, right ventricular hypertrophy or S1Q3T3, or any ST elevation or depression in two contiguous leads. Respiratory vital sign abnormality was defined as a respiratory rate greater than 20 breaths/min, saturation less than or equal to 95%, or requiring oxygen therapy by non-rebreather or full face mask. The absence of any of these ECG abnormalities and any respiratory abnormality made the likelihood of intubation or death at 48 hours less than 5%.

Figure 3

Sankey diagram represents patient flow from 3 days before severe acute respiratory coronavirus 2 diagnosis to 14 days after. All unique patient visits to the emergency department (ED) and inpatient (INPT) were included. On any given day, the patient’s location (home in green, ED in blue, INPT in yellow), if they were currently on a ventilator (No Vent or Vent), and if they were deceased (Died in red) were assessed. An interactive version of this diagram can be found at https://pelias1525.github.io/COVID_1200.html.