Medical Management/Treatment

Treatment for cardiac dysrhythmias in the setting of COVID-19 infection remains the same as current established treatment guidelines for cardiac dysrhythmias without coexisting infection. Sinus tachycardia is considered a compensatory mechanism and will usually resolve once the underlying pathophysiology (ie, hypoperfusion, fever, hypoxia, and anxiety) has been corrected. If dysrhythmias are accompanied by elevated serum troponin levels, then myocardial injury, acute myocarditis, and acute coronary syndrome should be considered in the differential diagnosis and appropriate evaluation should ensue.4 Advanced cardiac life support protocols are recommended if a patient becomes hemodynamically unstable. Instability may present as tachypnea, pallor, clamminess, shortness of breath, chest pain, and/or altered mental status.

When addressing atrial tachycardias, the focus is on controlling the heart rate before conversion of dysrhythmia unless the patient becomes unstable. Treatment for AF and atrial flutter with rapid ventricular response initially focuses on control of the ventricular rate. Initial intravenous pharmacologic management with atrial ventricular nodal blocking properties includes the use of beta-blockers and calcium channel blockers (CCB). If the patient has a known reduction in left ventricular function, it is recommended to avoid CCBs.2 Examples of beta-blocker and CCB treatment regimens for AF or atrial flutter in the hospital setting include2,5:

  • Diltiazem 0.25 mg/kg bolus over 5 minutes, followed by 5 to 15 mg/h via infusion. Oral conversion to 60 mg oral (short-acting) diltiazem divided into 3 doses per day to 360 mg (extended acting) daily, or
  • Metoprolol tartrate 2.5 to 5.0 mg intravenous bolus, for up to a total of 4 doses. Oral conversion 25 to 100 mg oral (immediate-release) metoprolol tartrate divided into 2 doses.

Additional treatment options may include amiodarone, dofetilide, flecainide, ibutilide, and propafenone.5 


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Atrial fibrillation also increases the risk for a thromboembolic event. A systematic approach is used to calculate the risk for stroke. One tool for determining the need for long-term anticoagulation is the CHA2DS2-VASc. For a score of 0 in men or 1 in women (low risk), there is no need for oral anticoagulation.6 Patients with a score of 1 in men or 2 in women (intermediate risk) may be treated with aspirin therapy or oral anticoagulation.6 If the score is 2 or greater in men or 3 or greater in women, oral anticoagulation regimen is recommended to reduce the risk for stroke.6 Oral anticoagulants include apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin.6

Ventricular polymorphic tachycardia and sustained monomorphic ventricular tachycardia are treated with amiodarone 150-mg bolus followed by 1 mg/min infusion for 6 hours, then decrease to 0.5 mg/min for 18 hours.7 Amiodarone has the potential for causing QTc prolongation; therefore, close monitoring is warranted. Another option is the use of lidocaine 1 to 1.5-mg/kg bolus dose followed by a repeated dose of 0.5-0.75 mg/kg every 5 to 10 minutes (max cumulative dose 3 mg/kg) followed by an infusion of 0.5 to 4 mg/min. Lidocaine should be carefully monitored due to the prolonged effects in the setting of liver dysfunction or severe heart failure. Any electrolyte imbalances of potassium and magnesium should be corrected.7

Serial 12-lead ECGs must be obtained frequently to evaluate for QTc prolongation, which is a common concern with current drugs used to treat COVID-19.2 If QTc is ≥470 ms in males or ≥480 ms in females but <500 ms, monitor the QTc closely and withhold any QTc prolonging medications.1,3

Discussion/Follow-up Care

Typically, new-onset AF is more amenable to conversion back to normal sinus rhythm. Patients with new-onset AF need to be reevaluated within 24 to 48 hours. Whether conversion to normal sinus rhythm is obtained the patient will be managed with a selected atrial ventricular nodal blocker and anticoagulants based on individuals’ risk for stroke. Any patients on atrial ventricular nodal blockers, which are metabolized in the liver, will need to have liver enzymes drawn within the first 4 to 8 weeks of therapy. An ECG should also be performed during the early weeks of therapy with serial ECGs taken every 3 to 6 weeks to monitor for complications such as QT prolongation.8 Patients started on warfarin, which is limited by a narrow therapeutic level, require frequent INR monitoring with dosing adjustments.2 The goal INR in these patients is between 2.0 to 3.0.2

Ventricular polymorphic tachycardia typically presents as an unstable rhythm and should be treated immediately. Once the patient is stabilized, underlying disorders such as acute coronary ischemia should be addressed. As with ventricular polymorphic tachycardia, underlying reversible causes (ie, anemia, electrolyte imbalances, heart failure, myocardial ischemia) should be identified and treated in patients with sustained monomorphic ventricular tachycardia once they have been stabilized. However, further testing should include evaluation and diagnosis of any underlying structural heart disease as this is a common cause of dysrhythmia.5 Whether the patient is diagnosed with ventricular polymorphic tachycardia or sustained monomorphic tachycardia, they should be followed closely by a cardiologist upon discharge.

Conclusion

Palpitation, tachycardia, and dysrhythmia have been associated with COVID-19 infection. Sinus tachycardia is the most reported rhythm disturbance and usually results from a variety of causes including hypoperfusion, fever, hypoxia, and anxiety.4 Other dysrhythmias include AF, atrial flutter, and ventricular tachycardia. Clinicians should be alert to these potential complications and prepared to identify and manage them when present.4

Deedra Harrington, DNP, MSN, APRN, ACNP-BC, is associate professor at the College of Nurse and Allied Health Professions, University of Louisiana at Lafayette. Dr Harrington is an advanced practice registered nurse-acute care who works with an inpatient cardiology intensivist group in Louisiana.

Frances Stueben, DNP, RN, CHSE, is an assistant professor and simulation program coordinator at the University of Louisiana at Lafayette. She teaches in the graduate and undergraduate nursing programs.

Christy L. McDonald Lenahan, DNP, FNP-BC, ENP-C, CNE, is an advanced practice registered nurse in family and emergency medicine who works for an emergency medicine and hospitalist staffing agency. She is also an associate professor at the University of Louisiana at Lafayette and teaches in the masters and doctoral programs

To read the first article in this series, on management of NSTEMI/STEMI in patients with COVID-19, click here. To read the second article in this series, on venous thromboembolism management in patients with COVID-19, click here.

References

1. Dhakal BP, Sweitzer, NK, Indik, JH, et al. SARS-CoV-2 infection and cardiovascular disease: COVID-19 heart. Heart Lung Circ. 2020;29(7):973-987. doi.10.1016/j.hlc.2020.101

2. Hindricks G, Potpara, T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Euro Heart J. 2020;42:373-498. doi:10.1093/eurheartj/ehaa612

3. Aehlert, BJ. ECGs Made Easy. 6th ed. Mosby; 2017.

4. Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Amer J Emerg Med. 2020:38(7):1504-1507. doi.10.16/j.ajum.2020.04.048

5. Desai AD, Boursiquot BC, Melki L, et al. Management of arrhythmias associated with COVID-19. Curr Cardiol Rep. 2021;23(1):2. doi:10.1007/s11886-020-01434-7

6. January CT, Wann LS, Calkins H, et al. AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2019;74(1):104-132. doi.org/10.1016/j.jacc.2019.01.011

7. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol, 2018;72(14):e91-220. doi.org/10.1016/j.jacc.2017.10.054

8. Cash JC, Gunter D. Chapter 10: Cardiovascular guidelines. In: Cash JG, Glass CA, Mullen J, eds. Family Practice Guidelines. 5th ed. Springer; 2021:219-271.

This article originally appeared on Clinical Advisor