Clinical and cardiac characteristics of COVID-19 mortalities in a diverse New York City Cohort

Abstract

Introduction: Electrocardiographic characteristics in COVID-19-related mortality have not yet been reported, particularly in racial/ethnic minorities.

Methods and results: We reviewed demographics, laboratory and cardiac tests, medications, and cardiac rhythm proximate to death or initiation of comfort care for patients hospitalized with a positive SARS-CoV-2 reverse-transcriptase polymerase chain reaction in three New York City hospitals between March 1 and April 3, 2020 who died. We described clinical characteristics and compared factors contributing toward arrhythmic versus nonarrhythmic death. Of 1258 patients screened, 133 died and were enrolled. Of these, 55.6% (74/133) were male, 69.9% (93/133) were racial/ethnic minorities, and 88.0% (117/133) had cardiovascular disease. The last cardiac rhythm recorded was VT or fibrillation in 5.3% (7/133), pulseless electrical activity in 7.5% (10/133), unspecified bradycardia in 0.8% (1/133), and asystole in 26.3% (35/133). Most 74.4% (99/133) died receiving comfort measures only. The most common abnormalities on admission electrocardiogram included abnormal QRS axis (25.8%), atrial fibrillation/flutter (14.3%), atrial ectopy (12.0%), and right bundle branch block (11.9%). During hospitalization, an additional 17.6% developed atrial ectopy, 14.7% ventricular ectopy, 10.1% atrial fibrillation/flutter, and 7.8% a right ventricular abnormality. Arrhythmic death was confirmed or suspected in 8.3% (11/133) associated with age, coronary artery disease, asthma, vasopressor use, longer admission corrected QT interval, and left bundle branch block (LBBB).

Conclusions: Conduction, rhythm, and electrocardiographic abnormalities were common during COVID-19-related hospitalization. Arrhythmic death was associated with age, coronary artery disease, asthma, longer admission corrected QT interval, LBBB, ventricular ectopy, and usage of vasopressors. Most died receiving comfort measures.

Keywords: COVID-19; arrhythmia; cardiac death; electrocardiography; epidemiology; sudden death.

Figure 1

Pooled electrocardiogram (ECG) comparison at baseline, admission, and before death. Comparisons between the total cohort, arrhythmic death cohort, and nonarrhythmic death cohort for heart rate, PR interval, QRS duration, QT interval, QTc interval, and QTf interval among baseline, admission, and final ECGs. Longer QTc and QTf intervals were associated with arrhythmic death. Statistically significant differences are annotated with p values. Other comparisons were not statistically significant. Normally distributed data as assessed by the Shapiro–Wilks test were reported as a mean with SD. Non‐normally distributed data were reported as a median with interquartile range (IQR). Unpaired comparisons were assessed by the Student t test or the Mann–Whitney U test, as applicable. All p values are two‐tailed

Figure 2

Paired electrocardiogram (ECG) comparison between admission versus baseline and versus last ECG before death. In those for whom the respective ECGs were available, the heart rate, PR interval, QRS duration, QT interval, QTc interval, and QTf interval were compared between admission and baseline (top) and between admission and the last recorded ECG before death (bottom). Statistically significant differences are annotated with p values. Other comparisons were not statistically significant. Normally distributed data as assessed by the Shapiro–Wilks test were reported as a mean with SD. Non‐normally distributed data were reported as a median with interquartile range (IQR). Paired comparisons were assessed by the paired Student's t test or the Wilcoxon signed‐rank test, as applicable. All p values are two‐tailed

Figure 3

Paired comparison of QT Intervals in patients receiving hydroxychloroquine, azithromycin, and both. This paired comparison demonstrates no significant differences in QT, QTc, or QTf intervals between admission and the last electrocardiogram before death in patients receiving hydroxychloroquine, azithromycin, and both. Normally distributed data as assessed by the Shapiro–Wilks test were reported as a mean with SD. Non‐normally distributed data were reported as a median with interquartile range (IQR). Paired comparisons were performed using a paired Student's t test or a Wilcoxon signed‐rank test. All p values are two‐tailed