Higher Incidence of Stroke in Severe COVID-19 Is Not Associated With a Higher Burden of Arrhythmias: Comparison With Other Types of Severe Pneumonia

Abstract

Aims: Thromboembolic events, including stroke, are typical complications of COVID-19. Whether arrhythmias, frequently described in severe COVID-19, are disease-specific and thus promote strokes is unclear. We investigated the occurrence of arrhythmias and stroke during rhythm monitoring in critically ill patients with COVID-19, compared with severe pneumonia of other origins. Methods and Results: This retrospective study included 120 critically ill patients requiring mechanical ventilation in three European tertiary hospitals, including n =60 COVID-19, matched according to risk factors for the occurrence of arrhythmias in n = 60 patients from a retrospective consecutive cohort of severe pneumonia of other origins. Arrhythmias, mainly atrial fibrillation (AF), were frequent in COVID-19. However, when compared with non-COVID-19, no difference was observed with respect to ventricular tachycardias (VT) and relevant bradyarrhythmias (VT 10.0 vs. 8.4 %, p = ns and asystole 5.0 vs. 3.3%, p = ns) with consequent similar rates of cardiopulmonary resuscitation (6.7 vs. 10.0%, p = ns). AF was even more common in non-COVID-19 (AF 18.3 vs. 43.3%, p = 0.003; newly onset AF 10.0 vs. 30.0%, p = 0.006), which resulted in a higher need for electrical cardioversion (6.7 vs. 20.0%, p = 0.029). Despite these findings and comparable rates of therapeutic anticoagulation (TAC), the incidence of stroke was higher in COVID-19 (6.7.% vs. 0.0, p = 0.042). These events also happened in the absence of AF (50%) and with TAC (50%). Conclusions: Arrhythmias were common in severe COVID-19, consisting mainly of AF, yet less frequent than in matched pneumonia of other origins. A contrasting higher incidence of stroke independent of arrhythmias also observed with TAC, seems to be an arrhythmia-unrelated disease-specific feature of COVID-19.

Keywords: COVID-19; anticoagulation; arrhythmias; atrial fibrillation; pneumonia; stroke; ventricular tachycardia.

Figure 1

Incidence of relevant cardiac arrhythmias during intensive care (ICU) rhythm monitoring in COVID-19 vs. non-COVID-19: (A) incidence of atrial fibrillation (AF) and (B) newly diagnosed AF was high in both groups. However, non-COVID-19 patients presented a higher burden of AF and newly diagnosed AF, (C) while the total duration of AF was not different in affected patients. (D) The incidence of sustained VTs/ventricular fibrillation (VF) was similar in both groups (E) and the frequency of asystole was also not significantly different. *p < 0.050.

Figure 2

Preventive strategies and characteristics of stroke/TIA events: (A) despite high but not different rates of therapeutic anticoagulation (TAC) in the total population and in patients with atrial fibrillation (AF) during rhythm monitoring as well as (B) similar CHA2DS2-Vasc Scores in this subgroup, (C) incidence of stroke/TIA events was significantly higher in COVID-19. (D) These events were also observed with AC (50%) and with continuous sinus rhythm (SR; 50%) during rhythm monitoring. noAC, no application of TAC. *p < 0.05.