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Case report
peer-reviewed

Disrupting the Electrical Circuit: New Onset Atrial Fibrillation in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)



Abstract

In December 2019, an outbreak of pneumonia cases in Wuhan, China was attributed to a novel coronavirus that was eventually recognized as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently identified as coronavirus disease 2019 (COVID-19), it has been declared a pandemic by the World Health Organization given its rapid global transmission. Various cardiovascular complications have been reported, including heart failure, myocarditis, acute coronary syndrome and arrhythmias, both atrial and ventricular. Regarding arrhythmias, onset from time of infection is variable but usually ranges from several days to a week. We hereby present a case of a COVID-19 positive patient presenting with new onset atrial fibrillation.

Introduction

In December 2019, a cluster of cases of pneumonia of unknown cause were identified in Wuhan, Hubei, China that was eventually attributed to a novel enveloped coronavirus, currently named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Now identified as coronavirus disease 2019 (COVID-19), the World Health Organization has declared SARS-CoV-2 a public health emergency and pandemic given its rapid spread across several countries worldwide [2]. Several cardiovascular manifestations have been reported so far, including arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis and acute coronary syndrome [3]. Several reports worldwide have demonstrated a high incidence of arrhythmias, specifically supraventricular, in the setting of widespread and systemic inflammation associated with COVID-19. The prevalence of arrhythmias and conduction system disease in patients with COVID-19 varies from population to population [4]. Several case reports have shown that onset of atrial fibrillation may vary from a few days up to a week from acquiring the infection; however, sometimes may be longer [5,6]. Regarding the mechanism, hypoxia and electrolyte abnormalities, both known to contribute to the development of acute arrhythmias, have been frequently reported in the acute phase of COVID-19 illness [4]. We hereby present a case of a COVID-19 positive patient presenting with new onset atrial fibrillation and shed light on the current literature and the proposed mechanisms and etiology.

Case Presentation

A 37-year-old male patient with no significant past medical history presented to the emergency department with left foot pain of one-day duration following direct trauma. No other symptoms were reported on presentation, including palpitations, chest pain, shortness of breath or dizziness. Of importance, the patient reports multiple family members testing positive for SARS-CoV-2 two weeks ago as well as himself having experienced mild flu-like symptoms several days ago. Regarding social history, the patient denied any current or prior tobacco smoking, alcohol consumption or other drug abuse. Initial vital signs were notable for heart rate of 90 beats per minute, blood pressure of 152/89 mmHg, respiratory rate of 20 breaths per minute and an oxygen saturation of 100% on room air. The patient's weight is 86 kilograms with a calculated body mass index of 26.8. A 12-lead electrocardiogram demonstrated an irregularly irregular rhythm consistent with atrial fibrillation (Figure 1).

No baseline electrocardiogram was present in the medical chart. Pertinent diagnostic laboratory investigations demonstrated a normal level of troponin I, thyroid-stimulating hormone, hemoglobin and electrolytes, including potassium, magnesium and calcium (Table 1).

Test Value Reference Range
Cardiac testing    
Troponin I (ng/mL) <0.017 0.000–0.045
General chemistry    
Sodium (mmol/L) 139 137–145
Potassium (mmol/L) 4.1 3.5–5.1
Chloride (mmol/L) 105 98–107
Sodium bicarbonate (mmol/L) 21 21–32
Blood urea nitrogen (mg/dL) 11 9–20
Creatinine (mg/dL) 0.77 0.66–1.50
Glucose (mg/dL) 131 65–140
Calcium (mg/dL) 9.0 8.5–10.1
Magnesium (mg/dL) 2.1 1.6–2.3
Hematology    
White blood cell count (k/µL) 8.4 4.0–10.8
Hemoglobin (g/dL) 14.7 12.5–16.5
Hematocrit (%) 43.5 37.5–49.5
Platelets (k/µL) 303 145–400
Endocrinology    
Thyroid-stimulating hormone (uIU/mL) 1.150 0.400–4.000
Infectious disease    
SARS-CoV-2 RNA PCR Positive Negative

Initial evaluation by the podiatric surgery team revealed a left fifth proximal phalanx displaced fracture. Decision was to take the patient to the operating theater for open reduction internal fixation of this fracture. Per our hospital's policy for surgical procedures, a SARS-CoV-2 polymerase chain reaction test was done and resulted as positive. He eventually underwent the procedure without any complications. Unfortunately, no echocardiogram was obtained to investigate the presence of structural heart disease. No rate control agents were required throughout his hospitalization. CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [double score], diabetes, prior stroke or transient ischemic attack [TIA; double score], vascular disease, age 65-74 years, sex class [female]) score for atrial fibrillation was zero, and therefore anticoagulation was not indicated. The patient was eventually discharged home with a new diagnosis of atrial fibrillation. Despite it being difficult to establish a causation between COVID-19 and atrial fibrillation in our patient, especially in the absence of an echocardiogram, this report aims to highlight the possible association between those two conditions.

Discussion

Cardiac arrhythmias have been reported in several recent reports in the literature in relation to hospitalized patients with COVID-19. Additionally, it was demonstrated to be associated with a higher risk of mortality [7]. However, the exact arrhythmic risk related to COVID-19 in patients with less severe illness or those who recover from the acute phase of the severe illness is currently unknown [4]. In regards to incidence, a report on 138 hospitalized COVID-19 patients in China has shown that 16.7% of patients developed cardiac arrhythmias [8]. Unfortunately, the exact nature of those cardiac arrhythmias was not reported in this study. However, given that sepsis in general has been associated with an increased rate of atrial arrhythmias, one would expect that those associated with COVID-19 to be mostly atrial as well [9]. Different types of arrhythmias have been reported so far including atrial fibrillation, atrial flutter, ventricular tachycardia as well as ventricular fibrillation. Interestingly, one report showed that arrhythmias were observed in 7% of patients who did not require intensive care unit treatment and in 44% of those who did [10].

Regarding pathophysiology, multiple mechanisms exist in which COVID-19 can trigger cardiac arrhythmias. Potential contributing factors include metabolic derangements, acidosis and hypoxia [11]. Moreover, the associated neurohormonal and catecholaminergic stress is thought to play a major role [11]. Similar to sepsis, the inflammatory cytokines and autonomic dysfunction associated with COVID-19 is thought to be a significant trigger for arrhythmias, especially atrial ones. Specifically, atrial fibrillation as a sequela of critical illness has been reported to occur in almost 10% of intensive care unit patients [12]. In addition, supraventricular tachyarrhythmias such as atrial fibrillation are associated more frequently with sympathetic nervous system activity in comparison to ventricular ones. Consequently, this explains the high prevalence of supraventricular tachyarrhythmias in patients with COVID-19 given the associated hyperbolic sympathetic activity [13].

It is noteworthy to mention that malignant cardiac arrhythmias, such as sustained ventricular tachycardia and ventricular fibrillation, have been observed in hospitalized patients with COVID-19. Despite the limited clinical and published data, this most likely occurs in the setting of COVID-19-associated acute cardiac injury and myocarditis [14]. Moreover, patients with inherited arrhythmia syndromes, such as long QT syndrome, may be at an increased proarrhythmic risk in the setting of COVID-19 infection, necessitating specialized care [15]. Improved understanding of this issue is critical, and further research is needed in guiding the need for additional arrhythmia monitoring post discharge and whether cardioverter defibrillators will be required in those with impaired left ventricular function attributed to COVID-19 [4].

Conclusions

In light of the emerging pandemic of COVID-19, several cardiovascular complications including arrhythmias are gaining worldwide recognition. Awareness of such entities and their theoretical pathophysiology is required for early recognition. Future research is needed to further investigate those observations and the associated clinical outcomes.


References

  1. Guan WJ, Ni ZY, Hu Y, et al.: Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020, 382:1708-1720. 10.1056/NEJMoa2002032
  2. World Health Organization. Coronavirus disease (COVID-19) outbreak. (2020). Accessed: July 8, 2020: https://www.who.int.
  3. Sellers SA, Hagan RS, Hayden FG, Fischer WA II: The hidden burden of influenza: a review of the extra-pulmonary complications of influenza infection. Influenza Other Respir Viruses. 2017, 11:372-393. 10.1111/irv.12470
  4. Lakkireddy DR, Chung MK, Gopinathannair R, et al.: Guidance for cardiac electrophysiology during the coronavirus (COVID-19) pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association [Epub ahead of print]. Heart Rhythm. 2020, e1-e9. 10.1016/j.hrthm.2020.03.028
  5. Taha ME, Alsafi W, Taha M, Eljack A, Ibrahim H: Coronavirus disease and new-onset atrial fibrillation: two cases. Cureus. 2020, 12:e8066. 10.7759/cureus.8066
  6. Kochav SM, Coromilas E, Nalbandian A, et al.: Cardiac arrhythmias in COVID-19 infection. Circ Arrhythm Electrophysiol. 2020, 13:e008719. 10.1161/CIRCEP.120.008719
  7. Shi S, Qin M, Shen B, et al.: Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China [Epub ahead of print]. JAMA Cardiol. 2020, 10.1001/jamacardio.2020.0950
  8. Wang D, Hu B, Hu C, et al.: Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020, 323:1061-1069. 10.1001/jama.2020.1585
  9. Cheng P, Zhu H, Witteles RM, Wu JC, Quertermous T, Wu SM, Rhee JW: Cardiovascular risks in patients with COVID- 19: potential mechanisms and areas of uncertainty. Curr Cardiol Rep. 2020, 22:34. 10.1007/s11886-020-01293-2
  10. Liu K, Fang YY, Deng Y, et al.: Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. Chin Med J. 2020, 133:1025-1031. 10.1097/CM9.0000000000000744
  11. Kuipers S, Klouwenberg PMK, Cremer OL: Incidence, risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis: a systematic review. Crit Care. 2014, 18:688. 10.1186/s13054-014-0688-5
  12. Seguin P, Launey Y: Atrial fibrillation is not just an artefact in the ICU. Crit Care. 2010, 14:182. 10.1186/cc9093
  13. Otake H, Suzuki H, Honda T, Maruyama Y: Influences of autonomic nervous system on atrial arrhythmogenic substrates and the incidence of atrial fibrillation in diabetic heart. Int Heart J. 2009, 50:627-641. 10.1536/ihj.50.627
  14. Beri A, Kotak K: Cardiac injury, arrhythmia and sudden death in a COVID-19 patient [Epub ahead of print]. HeartRhythm Case Rep. 2020, 10.1016/j.hrcr.2020.05.001
  15. Wu CI, Postema PG, Arbelo E, et al.: SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes [Epub ahead of print]. Heart Rhythm. 2020, 10.1016/j.hrthm.2020.03.024
Case report
peer-reviewed

Disrupting the Electrical Circuit: New Onset Atrial Fibrillation in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)


Author Information

Sohab Radwan Corresponding Author

Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA

Owen Schwartz

Internal Medicine/Hospital Medicine, MedStar Washington Hospital Center, Washington, DC, USA


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Case report
peer-reviewed

Disrupting the Electrical Circuit: New Onset Atrial Fibrillation in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)


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