Right Heart Strain on Presenting 12-Lead Electrocardiogram Predicts Critical Illness in COVID-19

Abstract

Objectives: This study aimed to assess the association of new right heart strain patterns on presenting 12-lead electrocardiogram (RHS-ECG) with outcomes in patients hospitalized with COVID-19.

Background: Cardiovascular comorbidities and complications, including right ventricular dysfunction, are common and are associated with worse outcomes in patients with COVID-19. The data on the clinical usefulness of the 12-lead ECG to aid with prognosis are limited.

Methods: This study retrospectively evaluated records from 480 patients who were consecutively admitted with COVID-19. ECGs obtained at presentation in the emergency department (ED) were considered index ECGs. RHS-ECG was defined by any new right-axis deviation, S₁Q₃T₃ pattern, or ST depressions with T-wave inversions in leads V₁ to V₃ or leads II, III, and aVF. Multivariable logistic regression was performed to assess whether RHS-ECGs were independently associated with primary outcomes.

Results: ECGs from the ED were available for 314 patients who were included in the analysis. Most patients were in sinus rhythm, with sinus tachycardia being the most frequent dysrhythmia. RHS-ECG findings were present in 40 (11%) patients. RHS-ECGs were significantly associated with the incidence of adverse outcomes and an independent predictor of mortality (adjusted odds ratio [adjOR]: 15.2; 95% confidence interval [CI]: 5.1 to 45.2; p < 0.001), the need for mechanical ventilation (adjOR: 8.8; 95% CI: 3.4 to 23.2; p < 0.001), and their composite (adjOR: 12.1; 95% CI: 4.3 to 33.9]; p < 0.001).

Conclusions: RHS-ECG was associated with mechanical ventilation and mortality in patients admitted with COVID-19. Special attention should be taken in patients admitted with new signs of RHS on presenting ECG.

Keywords: COVID-19; ECG; emergency department; right heart strain; right ventricular dysfunction.

Graphical abstract

Figure 1

Incidence of Different Outcomes According to the Presence of RHS Patterns on Presenting 12-Lead ECG Outcomes of patients according to right heart strain−electrocardiograms (RHS-ECGs). Patients with RHS-ECGs had a higher incidence of all primary and secondary outcomes (all p < 0.05). CI = confidence interval; ICU = intensive care unit: Mech Vent = mechanical ventilation.

Central Illustration

Incidence and Survival Curves of Primary Outcomes According to the Presence of Right Heart Strain Patterns on Presenting 12-Lead Electrocardiogram Patients with right heart strain−electrocardiograms (RHS-ECGs) on presentation to the emergency department had a significantly higher incidence of in-patient need for mechanical ventilation (Mech Vent) and/or mortality. The Kaplan-Meier curves illustrate the powerful and early discriminatory ability of the presence of RHS-ECGs for the risk of the composite of mortality and the need for Mech Vent. CI = confidence interval.

Figure 2

Intubation and Mortality Kaplan-Meier Survival-Curves for Patients According to the Presence of RHS Patterns on 12-Lead ECG Comparison of (A) Mech Vent and (B) mortality rates among patients with and without RHS-ECG as obtained in the emergency department. The Kaplan-Meier curves illustrate the powerful and early discriminatory ability of the presence of RHS-ECGs on the risk of (A) Mech Vent and (B) mortality. Abbreviations as in Figure 1.