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from asymptomatic or mild flu-like symptoms to acute severe respiratory distress syndrome and systemic complications impacting several organs&#46; Cardiovascular complications from COVID-19 infection are being reported more frequently&#44; ranging from silent myocardial injury to thromboembolic events&#44; acute coronary syndromes&#44; cardiogenic shock and arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Arrhythmias have been described in 17&#37; of the hospitalized cases and in almost 50&#37; of patients in the intensive care units &#40;ICU&#41;&#44; probably with a potential contribution to a higher risk of adverse outcomes&#44; with an increased risk of in-hospital death&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> There are various reported series of different types of arrhythmias&#44; including bradycardia &#40;less common&#41;&#44; sinus tachycardia and atrial arrhythmias &#40;atrial fibrillation &#91;AF&#93; and atrial flutter&#41; and ventricular dysrhythmias&#44; including cardiac arrest&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the study &#8220;Cardiac arrhythmias in patients presenting with COVID-19 treated in Portuguese hospitals&#46; A national registry from Portuguese Association of Arrhythmology&#44; Pacing and Electrophysiology&#8221;&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Dinis Mesquita et al&#46; present the results of a survey conducted by the Portuguese Association of Arrhythmology&#44; Pacing and Electrophysiology to assess the occurrence of arrhythmias in COVID-19 patients in 20 Portuguese hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> They report data from 692 hospitalized patients&#44; with arrhythmic episodes in 11&#46;7&#37; of the cases&#44; including paroxysmal supraventricular tachycardia&#44; atrial flutter and AF &#40;the most common&#44; being recurrence of previously existing arrhythmia in 35&#46;9&#37;&#41;&#44; bradycardia and ventricular tachycardia&#46; Surprisingly&#44; none had arrhythmia-related complications nor arrhythmic death despite their elderly age &#40;mean 73&#46;5 years&#59; minimum 61&#44; maximum 80&#46;3&#41;&#44; associated comorbidities in a large majority of the reported arrhythmias &#40;79&#46;7&#37;&#41;&#44; and more severe COVID-19 disease&#44; with mechanical ventilation&#44; hemodynamic instability and multiple organ failure &#40;in those patients with supraventricular arrhythmias&#41; and high mortality rate &#40;31&#46;3&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although continuous cardiac rhythm monitoring was obtained only in the subgroup of 393 patients admitted to the ICU or with continuous cardiac monitoring&#44; with detailed information available limited to 79&#37; of the cases with documented arrhythmias&#44; these are useful real clinical data for our understanding of the severity and impact of arrhythmias in COVID-19 infection&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The survey also reports the assessment of QT interval during hospital admission in 443 patients under therapy with ritonavir&#47;lopinavir&#44; hydroxychloroquine or azithromycin&#46; Interestingly&#44; despite medication capable of QT prolongation in 76&#46;6&#37; of the cases with arrhythmias&#44; only seven patients &#40;10&#46;9&#37;&#41; had an increased QTc interval &#40;ranging between 480 ms and 596 ms&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As pointed out by the authors&#44; the availability of continuous cardiac monitoring in only 56&#46;8&#37; of the population poses strong limitations to the conclusions of the registry&#46; Of course&#44; it seems that the occurrence of arrhythmias &#40;mostly supraventricular&#41; is a common finding&#44; particularly in patients with co-morbidities and more severe COVID-19 manifestations&#44; but data from the whole population could identify clinical variables associated with higher risk of new onset &#40;or reappearance&#41; of arrhythmias&#44; and contribute to a better approach to this specific group of patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the most recent literature&#44; risk factors for the appearance of arrhythmias are&#58; respiratory insufficiency&#44; myocardial strain and ischemia or myocarditis&#44; cardiogenic shock&#44; sepsis or systemic inflammation&#44; hyperactivity of the sympathetic nervous system&#44; hypercoagulability status&#44; electrolyte disturbances&#44; and proarrhythmic drug side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6&#44;8</span></a> Therefore&#44; the incidence of arrhythmias in patients with COVID-19 is a likely consequence of systemic illness and not solely the direct cardiac effect of the infection&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Arrhythmias in COVID-19. Do they influence outcomes in hospitalized patients?
Arritmias na COVID-19. Têm impacto prognóstico nos doentes hospitalizados?
Mário Oliveiraa,b,c
a Central University Hospital Center, Lisbon, Portugal
b Hospital CUF Tejo, Lisbon, Portugal
c Institute of Physiology and Centro Cardiovascular da Universidade de Lisboa, Faculty of Medicine of Lisbon, Lisbon, Portugal
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    "titulo" => "Arrhythmias in COVID-19&#46; Do they influence outcomes in hospitalized patients&#63;"
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        "titulo" => "Arritmias na COVID-19&#46; T&#234;m impacto progn&#243;stico nos doentes hospitalizados&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The SARS-CoV-2 pandemic infection has been reported in 223 countries&#44; with about 136 million cases and almost 3 million deaths since December 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Although the real mortality associated with COVID-19 remains unknown&#44; the current global case fatality reported across countries ranges from 0&#46;2&#37; &#40;in Germany&#41; to 7&#46;7&#37; &#40;in Italy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Cardiovascular disease&#44; diabetes and age have been outlined as risk factors for poorer outcomes in COVID-19 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical presentation varies widely&#44; from asymptomatic or mild flu-like symptoms to acute severe respiratory distress syndrome and systemic complications impacting several organs&#46; Cardiovascular complications from COVID-19 infection are being reported more frequently&#44; ranging from silent myocardial injury to thromboembolic events&#44; acute coronary syndromes&#44; cardiogenic shock and arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Arrhythmias have been described in 17&#37; of the hospitalized cases and in almost 50&#37; of patients in the intensive care units &#40;ICU&#41;&#44; probably with a potential contribution to a higher risk of adverse outcomes&#44; with an increased risk of in-hospital death&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> There are various reported series of different types of arrhythmias&#44; including bradycardia &#40;less common&#41;&#44; sinus tachycardia and atrial arrhythmias &#40;atrial fibrillation &#91;AF&#93; and atrial flutter&#41; and ventricular dysrhythmias&#44; including cardiac arrest&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the study &#8220;Cardiac arrhythmias in patients presenting with COVID-19 treated in Portuguese hospitals&#46; A national registry from Portuguese Association of Arrhythmology&#44; Pacing and Electrophysiology&#8221;&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Dinis Mesquita et al&#46; present the results of a survey conducted by the Portuguese Association of Arrhythmology&#44; Pacing and Electrophysiology to assess the occurrence of arrhythmias in COVID-19 patients in 20 Portuguese hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> They report data from 692 hospitalized patients&#44; with arrhythmic episodes in 11&#46;7&#37; of the cases&#44; including paroxysmal supraventricular tachycardia&#44; atrial flutter and AF &#40;the most common&#44; being recurrence of previously existing arrhythmia in 35&#46;9&#37;&#41;&#44; bradycardia and ventricular tachycardia&#46; Surprisingly&#44; none had arrhythmia-related complications nor arrhythmic death despite their elderly age &#40;mean 73&#46;5 years&#59; minimum 61&#44; maximum 80&#46;3&#41;&#44; associated comorbidities in a large majority of the reported arrhythmias &#40;79&#46;7&#37;&#41;&#44; and more severe COVID-19 disease&#44; with mechanical ventilation&#44; hemodynamic instability and multiple organ failure &#40;in those patients with supraventricular arrhythmias&#41; and high mortality rate &#40;31&#46;3&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although continuous cardiac rhythm monitoring was obtained only in the subgroup of 393 patients admitted to the ICU or with continuous cardiac monitoring&#44; with detailed information available limited to 79&#37; of the cases with documented arrhythmias&#44; these are useful real clinical data for our understanding of the severity and impact of arrhythmias in COVID-19 infection&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The survey also reports the assessment of QT interval during hospital admission in 443 patients under therapy with ritonavir&#47;lopinavir&#44; hydroxychloroquine or azithromycin&#46; Interestingly&#44; despite medication capable of QT prolongation in 76&#46;6&#37; of the cases with arrhythmias&#44; only seven patients &#40;10&#46;9&#37;&#41; had an increased QTc interval &#40;ranging between 480 ms and 596 ms&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As pointed out by the authors&#44; the availability of continuous cardiac monitoring in only 56&#46;8&#37; of the population poses strong limitations to the conclusions of the registry&#46; Of course&#44; it seems that the occurrence of arrhythmias &#40;mostly supraventricular&#41; is a common finding&#44; particularly in patients with co-morbidities and more severe COVID-19 manifestations&#44; but data from the whole population could identify clinical variables associated with higher risk of new onset &#40;or reappearance&#41; of arrhythmias&#44; and contribute to a better approach to this specific group of patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the most recent literature&#44; risk factors for the appearance of arrhythmias are&#58; respiratory insufficiency&#44; myocardial strain and ischemia or myocarditis&#44; cardiogenic shock&#44; sepsis or systemic inflammation&#44; hyperactivity of the sympathetic nervous system&#44; hypercoagulability status&#44; electrolyte disturbances&#44; and proarrhythmic drug side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;6&#44;8</span></a> Therefore&#44; the incidence of arrhythmias in patients with COVID-19 is a likely consequence of systemic illness and not solely the direct cardiac effect of the infection&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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