AF, atrial flutter in COVID-19 may be tied to inflammation
New-onset atrial fibrillation and atrial flutter are as common in hospitalized patients with influenza as with COVID-19, suggesting the connection between the arrhythmias and COVID-19 is related to the general inflammatory state.
Although COVID-19 was known to increase inflammatory markers associated with atrial arrhythmias, the relationship of the inflammation to COVID-19 was not known, so the researchers conducted a retrospective analysis comparing incidence, predictors and outcomes of AF or atrial flutter in patients with COVID-19 and patients with influenza, another viral disease that increases inflammatory markers.
“When we started out, it wasn’t clear whether or not the SARS-CoV-2 virus actually had a direct effect on the myocardium, causing arrhythmias. One of the ways to try and look at this was to see if another severe respiratory illness, not COVID, affected people and increased their atrial fibrillation and mortality,” Vivek Y. Reddy, MD, director of cardiac arrhythmia services for The Mount Sinai Hospital and the Mount Sinai Health System and the Leona M. and Harry B. Helmsley Charitable Trust Professor of Medicine in Cardiac Electrophysiology at Icahn School of Medicine at Mount Sinai, told Healio.
‘A negative biomarker’
Reddy said the researchers found that AF was also occurring in patients with influenza and contributed to an increase in their mortality.
“From a relative perspective, AF seems be a significant independent negative biomarker that predicts mortality. The fact that it occurs in both COVID and influenza is more consistent with the mechanism of worse outcomes being more from the generalized poor inflammatory state than being something very specific to COVID,” Reddy told Healio.
Among 3,970 patients with COVID-19 admitted to Mount Sinai system hospitals from Feb. 4 to April 22, 2020 (mean age, 66 years; 59% men), 10% had AF or atrial flutter, and among those who had no history of atrial arrhythmias, 4% had AF or atrial flutter, the researchers wrote, noting that in a manual review of 1,110 patients, the incidence rate of AF or atrial flutter was 13%.
Among those with COVID-19, patients with new-onset AF or atrial flutter were older, had increased inflammatory markers, including interleukin-6 (93 pg/mL vs. 68 pg/mL; P < .01), had more myocardial injury as assessed by troponin I (0.2 ng/mL vs. 0.06 ng/mL; P < .01) and had higher rates of mortality (46% vs. 26%; P < .01) compared with those without new-onset AF or atrial flutter, according to the researchers.
Among 1,420 patients with influenza hospitalized from 2017 to Jan. 1, 2020 (mean age, 66 years; 42% men), the rate of AF or atrial flutter was 12% (P vs. COVID-19 cohort = .03) and the rate of new-onset AF or atrial flutter was 4% (P vs. COVID-19 cohort = .93), the researchers wrote, though noting the absolute in-hospital mortality rate was lower in the influenza cohort than in the COVID-19 cohort (9% vs. 29%; P < .01).
Presence of AF or atrial flutter correlated with worsened mortality in both the COVID-19 cohort (RR = 1.77) and the influenza cohort (RR = 1.78), Reddy and colleagues wrote.
The take-home message from the study is that a patient who is hospitalized with COVID-19 or influenza and develops AF is at very high risk, Reddy said in an interview.
“We believe that this worsened outcome with AF in these patients is probably not related to a direct myocardial effect of the viral disease state but rather the generalized inflammatory situation,” Reddy told Healio.
Reddy noted that intensifying therapy, whether anti-inflammatory agents, antivirals or a combination, should be considered in patients who present to the hospital with COVID-19 and an atrial arrhythmia.
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Vivek Y. Reddy, MD, can be reached at email@example.com.