Approach to identify patients at risk of drug-induced sudden
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SARS-CoV-2, the virus that causes COVID-19, continues to spread, leading to more than 20,000 deaths worldwide in less than four months. Efforts are progressing to develop a COVID-19 vaccine, but it's still likely 12 to 18 months away.

Some of the medications being used to treat COVID-19 are known to cause drug-induced prolongation of the QTc of some people. The QTc is an indicator of the health of the heart's electrical recharging system. Patients with a dangerously prolonged QTc are at increased risk for potentially life-threatening ventricular rhythm abnormalities that can culminate in sudden cardiac death.

"Correctly identifying which patients are most susceptible to this unwanted, tragic side effect and knowing how to safely use these medications is important in neutralizing this threat," says Michael J. Ackerman, M.D., Ph.D., a Mayo Clinic genetic cardiologist.

Guidelines for QTc monitoring during treatment

- The antimalarial drugs chloroquine and hydroxychloroquine, as well as the HIV drugs lopinavir and ritonavir, all carry a known or possible risk of drug-induced ventricular arrhythmias and sudden cardiac death. Prior to starting treatment with these medications, it is important to get a baseline ECG to be able to measure changes. This starting point measurement could be from a standard 12-lead ECG, telemetry or a smartphone-enabled mobile ECG device.

- On Monday, March 20, the Food and Drug Administration (FDA) granted emergency approval of AliveCor's Kardia 6L mobile ECG device as the only FDA-approved mobile device for QTc monitoring with COVID-19.

- The mobile device's ability to remotely provide the patient's heart rhythm and QTc value does not require an extra ECG technician to take the measurement in person, thus saving increased exposure to COVID-19 and the need for more personal protective equipment.

Using the algorithm developed by Dr. Ackerman and colleagues, the potential risk of drug-induced arrhythmias can be rated and used to modify treatment accordingly. Simple QTc countermeasures can be implemented for patients with a cautionary "red light" QTc status if the decision is made to proceed with the intended COVID-19 therapies.

Information guides decisions

-It will take careful consideration of COVID-19 patients' circumstances for treating clinicians and patients to decide on the use of drugs or drug combinations that may treat their infection, but which potentially could cause harmful drug-induced side effects.

"Importantly, the vast majority of patients ― about 90% ― are going to be QTc cleared with a 'green light go' and can proceed, being at extremely low risk for this side effect," says Dr. Ackerman.

Ultimately, the weighing of risks to benefits depends on whether hydroxychloroquine, with or without azithromycin, is truly an effective treatment against COVID-19.

"If it is, we hope that this simple QTc surveillance strategy, enabled by innovation and the FDA's emergency approval, will help prevent or at least significantly minimize drug-induced ventricular arrhythmias and sudden cardiac death, particularly if the treatment is widely adopted and used to treat COVID-19," says Dr. Ackerman.

About Mayo Clinic
Mayo Clinic is a nonprofit organization committed to innovation in clinical practice, education and research, and providing compassion, expertise and answers to everyone who needs healing.

Note: This list is a brief compilation of some of the key recommendations included in the Guideline and is not exhaustive and does not constitute medical advice.

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