A new potential risk of COVID-19: Sudden cardiac death

By Paul Basilio, MDLinx
Published March 26, 2020

Key Takeaways

As of Thursday afternoon, the total number of confirmed COVID-19 cases is 521,086, with 23,568 deaths globally. In the United States, the number of cases has increased to 79,785, with 1,124 deaths across all 50 states plus Washington, DC.

While researchers and physicians on the front lines gather more data on the virus and the disease, new complications are starting to come into focus—specifically involving the heart. 

Matters of the heart 

In Italy, officials state that of the 355 people who had died as of March 17, more than 75% had hypertension and 33% had heart disease. Infections are typically difficult to treat in people who have underlying health conditions, but SARS-CoV-2 may be particularly dangerous for such individuals.

The virus attaches to angiotensin-converting enzyme 2 (ACE2), which is found in the cells of the lungs. This allows the virus to invade and cause respiratory illness.

But, ACE2 is also found in heart muscles and the cells that line blood vessels. In addition, ACE2 is part of the renin-angiotensin-aldosterone system, which regulates cardiovascular function, kidney function, and blood pressure.

Given the association with ACE2, researchers are suggesting that COVID-19 can damage the heart directly. In a study conducted in Wuhan Province, China, nearly 20% of hospitalized patients with COVID-19 showed signs of heart damage. Half of the patients with heart damage died, compared with 4.5% of COVID-19 patients without heart damage.

ACE inhibitors and angiotensin II receptor blockers are commonly prescribed for patients with underlying cardiovascular symptoms. However, some animal models show that the use of these drugs may increase the risk of severe disease in patients with COVID-19.

“If you look at the mechanistic rationale for concern…it’s there,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health in Bethesda, MD, during a recent webcast. He added that at this point, that conclusion is an “extrapolation.”

Drug-induced complications

Now, researchers are also finding out that some of the medications that are being used to treat COVID-19 may be leaving patients at increased risk of sudden cardiac death. Medications such as hydroxychloroquine, lopinavir, and ritonavir, which are being used off-label for compassionate use, may cause drug-induced prolongation of the QTc in some patients. Dangerously prolonged QTc can lead to life-threatening ventricular rhythm abnormalities that can cause sudden death.

Cardiologists and physician-scientists from the Mayo Clinic have provided guidance on using 12-lead electrocardiography (ECG), telemetry, or smartphone-enabled mobile ECG applications for determining QTc and including the results in the vital signs. 

“Right now, it is the Wild West out there, ranging from doing no QTc surveillance whatsoever and just accepting this potential tragic side effect as part of ‘friendly fire,’ to having ECG technicians going into the room of a patient with COVID-19 daily, exposing them to coronavirus and consuming personal protective equipment,” said Michael J. Ackerman, MD, PhD, a Mayo Clinic genetic cardiologist.

Dr. Ackerman and colleagues have provided an algorithm to determine the potential risk of drug-induced arrhythmia. Treatment can then be modified accordingly. 

COVID-19 complications 

It appears the treatments are not the only risk factors for severe cardiac complications in patients with COVID-19.

Today, it was reported that a 52-year-old airport worker at Newark Liberty International Airport died from COVID-19 complications after being released from the hospital two weeks prior. The patient was otherwise healthy, a nonsmoker, and described to be the “athletic” type. 

Carlos Consuegra, from Union City, NJ, had no underlying health issues, according to his wife, Vazquez Consuegra. Initially, Mr. Consuegra had been diagnosed with an ear infection and sent home. But after two weeks, his breathing became labored and he was taken to a different hospital, where he died from what his wife described as a COVID-19 complication: heart failure.

Mrs. Consuegra said that high-risk employees at the airline were not given protective gear or adequate warning.

Mr. Consuegra was not the only patient to die from heart-related problems associated with COVID-19. A 69-year-old man from Little Ferry, NJ, was the state’s first death from the disease on March 10. 

John Brennan had several underlying medical conditions, such as emphysema, diabetes, and hypertension, according to New Jersey Health Commissioner Judith Persichilli, RN, BSN. 

Mr. Brennan suffered two heart attacks while hospitalized, the second of which was fatal.

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