A new scientific statement from the American Heart Association (AHA) reported that cardiac arrhythmias and autonomic dysfunction were frequent complications during and after COVID-19 infection. The statement, published in Circulation, provided a comprehensive review of the current evidence on arrhythmic and autonomic manifestations associated with COVID-19.
The statement noted that various arrhythmias occurred in COVID-19 patients, ranging from benign sinus bradycardia to life-threatening ventricular tachyarrhythmias and sudden cardiac death. Atrial fibrillation was the most common arrhythmia in acutely ill COVID-19 patients. One study found 17.6% of hospitalized COVID-19 patients experienced atrial fibrillation, with 12.5% being new-onset.
Clinically stable and ambulatory COVID-19-positive individuals had substantially lower arrhythmia risk compared to those with severe infections. Postacute sequelae of SARS-CoV-2 infection (PASC) frequently involved autonomic dysfunction, with postural orthostatic tachycardia syndrome (POTS) occurring in 25% to 35% of PASC patients. Myocarditis was a documented adverse effect of COVID-19 infection but rarely resulted in serious arrhythmias.
The writing committee, chaired by Rakesh Gopinathannair, MD, MA, FAHA, of the Kansas City Heart Rhythm Institute, noted the development of arrhythmias and autonomic dysfunction during and after COVID-19 infection was likely multifactorial in most cases. Proposed mechanisms included direct viral invasion, changes in autonomic tone, hypoxemia, inflammation, and immune-mediated phenomena.
The statement reported bradyarrhythmias tended to occur in severe COVID-19 infections and typically improved with resolution of the infection. In a worldwide retrospective survey of 4,526 COVID-19 patients, 22.6% had bradyarrhythmias, including sinus bradycardia (12.8%), atrioventricular block (8.6%), and pauses >3 seconds (1.2%).
The committee recommended that patients with newly diagnosed atrial fibrillation (AF) during COVID-19 infection should be monitored long-term for recurrence and receive anticoagulation medication per current guidelines. Data from the AHA COVID-19 registry, including 30,999 patients from 120 US centers, showed that new-onset AF was common (5.4%) among patients hospitalized with COVID-19.
The statement emphasized that ventricular arrhythmias and sudden cardiac death occurred at a higher frequency among COVID-19 patients. Pooled data from 21 studies of 132,790 patients with COVID-19 infection revealed a 5% prevalence of ventricular arrhythmias. Ventricular arrhythmias were independently associated with an increased risk of death in patients with COVID-19.
Autonomic dysfunction was reported to occur primarily in the setting of PASC, with the precise cause remaining elusive. The statement noted that many cases of PASC-associated autonomic dysfunction represented POTS, orthostatic hypotension, or inappropriate sinus tachycardia. In one study, 78% of patients with PASC met the criteria for POTS.
The authors highlighted important drug interactions, particularly with ritonavir, a component of the antiviral medication Paxlovid. As a strong inhibitor of CYP-3A4, ritonavir can cause significant drug-drug interactions that clinicians should be aware of when treating COVID-19 patients.
The statement recommended continued long-term arrhythmia surveillance for any patient who develops a COVID-19 infection. However, the authors noted there was currently no consistent evidence demonstrating a heightened risk of arrhythmia or sudden death attributable to COVID-19 vaccination in the general population.
Regarding management, the writing committee suggested arrhythmias and autonomic dysfunction during and after COVID-19 infection should be treated based on current guidelines for the respective conditions.
The statement also identified several knowledge gaps and areas for future research, including:
- The long-term risk of arrhythmia recurrence after COVID-19 infection
- Utility of wearable ambulatory monitors for long-term arrhythmia surveillance post-COVID-19
- Effective treatments for PASC-associated autonomic dysfunction
- Long-term effects of myocarditis and arrhythmia development after COVID-19 vaccination
The writing committee emphasized that as we have transitioned to an endemic phase of the illness, with the discovery of new, less virulent SARS-CoV-2 variants, newer drugs to treat acute COVID-19 infection, and widespread administration of vaccines, healthcare professionals must remain vigilant for changes in the presentation in arrhythmic and dysautonomic manifestations that may occur with this novel disease.
Conflict of interest disclosures can be found in the statement.