COVID-19 Prolongs QT Interval Independent of Other Factors
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COVID-19 infection is associated with a significant increase in the corrected QT interval (QTc) in hospitalized patients, independent of common clinical factors associated with QTc prolongation, including hydroxychloroquine and azithromycin treatment, new research indicates.

Critical illness, a marked inflammatory response, and viruses such as SARS-CoV-2 may prolong corrected QT interval (QTc).

This study aimed to evaluate baseline QTc interval on 12-lead electrocardiograms (ECGs) and ensuing changes among patients with and without COVID-19.

This cohort study included 3050 patients aged 18 years and older who underwent SARS-CoV-2 testing and had ECGs at Columbia University Irving Medical Centre. Patients were analyzed by treatment group over 5 days, as follows: hydroxychloroquine with azithromycin, hydroxychloroquine alone, azithromycin alone, and neither hydroxychloroquine nor azithromycin. ECGs were manually analyzed by electrophysiologists masked to COVID-19 status. Multivariable modeling evaluated clinical associations with QTc prolongation from baseline.

-- A total of 965 patients had more than 2 ECGs and were included in the study, with 561 (58.1%) men, 198 (26.2%) Black patients, and 191 (19.8%) aged 80 years and older.

-- There were 733 patients (76.0%) with COVID-19 and 232 patients (24.0%) without COVID-19.

-- The major finding is that patients with COVID-19 infection had prolonged QTc at day 2 (mean increase, 24.7 ms) and at day 5 (mean increase, 27.3 ms) of hospitalization, compared with patients without COVID-19 infection, even after adjusting for age, gender, and comorbidities, including use of possible QT prolonging drugs.

-- In multivariate analysis, factors significantly associated with prolonged QTc in COVID-19 patients were age of at least 80 years, severe kidney disease, elevated high sensitivity troponin, and elevated lactate dehydrogenase.

-- Although not the primary focus of the study, the use of any combination of hydroxychloroquine with azithromycin, hydroxychloroquine alone, or azithromycin alone was associated with significant QTc prolongation.

-- 25% of patients with COVID-19 who had not received either drug still had a QTc interval of 500 ms or greater, compared with 11% of their COVID-negative peers.

-- In patients with COVID-19, especially those receiving hydroxychloroquine with azithromycin, simply checking a baseline pretreatment ECG assessment of QTc may not be sufficient.

-- Obtaining 12-lead ECGs to follow the QTc during hospitalization for COVID-19 infection, especially in those older than 80 years, with severe chronic kidney disease, and those with elevated troponin levels is prudent practice.

-- One patient with COVID-19 had Torsades de pointes. This patient had a QTc of 528 ms and a magnesium level of 1.4 mg/dL and received intravenous azithromycin.

-- The incidence of Torsades de pointes in the setting of COVID-19 infection in recent studies is "similarly low and limited to rare events".

Conclusively, in this cohort study, COVID-19 infection was independently associated with significant mean QTc prolongation at days 5 and 2 of hospitalization compared with day 0. More patients with COVID-19 had QTc of 500 milliseconds or greater compared with patients without COVID-19.

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