Written by Laura Murphy
Spoon Feed
This AHA statement reviews autonomic and arrhythmic manifestations of COVID-19, focusing on epidemiology, pathophysiology, clinical presentation, management with consensus guideline for clinical practice.
Current state – more questions than answers
The authors described various arrhythmic and autonomic complications associated with COVID-19 disease. The mechanisms are multifactorial and are related to factors such as hypoxemia, acidosis, and hemodynamic changes associated with COVID-19 infection, as well as direct viral injury to tissues, inflammatory response, and immune-related causes. Patients with more severe infections are at higher risk for these complications. The most common arrhythmia is atrial fibrillation, but arrhythmic complications range from relatively benign bradycardias to ventricular tachyarrhythmias and sudden cardiac death. Arrhythmia management focuses on treatment of underlying infection as well as evidence-based guidelines for arrhythmia treatment (note that many antiarrhythmic medications have interactions with nirmaltrevir-ritonavir).
Post-acute sequelae of SARS-CoV-2 (PASC, a.k.a. long COVID) occur weeks to months after infection; symptoms can be heterogeneous but often include autonomic dysfunction (PASC-AD). This includes diagnoses such as postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, and inappropriate sinus tachycardia; patients with autonomic complications generally have more severe PASC. The prognosis and treatment of PASC-AD is still not well understood, and more consistent autonomic testing is likely needed to better understand this process, particularly since it can cause long-term symptoms. One major limitation is that many of these studies were done during the pandemic phase of COVID-19, with more virulent strains, and prior to widespread use of disease-specific treatment and vaccination, which may impact incidence and prevalence of cardiovascular complications and PASC.
How will this change my practice?
This review improved my understanding of the cardiovascular complications of COVID-19 infection. Given that more data are needed with regard to updated incidence as well as treatment, I don’t think I’ll be making any big practice changes, but I will be looking out for further studies that shed more light on the optimal treatment strategies for these patients.
Source
Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association. Circulation. 2024 Nov 19;150(21):e449-e465. doi: 10.1161/CIR.0000000000001290. Epub 2024 Oct 14. PMID: 39397661
