Peculiar Aspects of Patients with Inherited Arrhythmias during the COVID-19 Pandemic

Since December 2019 we have observed the rapid advance of the severe acute respiratory syndrome caused by the new coronavirus (SARS-CoV-2). The impact of the clinical course of a respiratory infection is little known in patients with hereditary arrhythmias, due to the low prevalence of these diseases. Patients who present with infectious conditions may exacerbate hidden or well-controlled primary arrhythmias, due to several factors, such as fever, electrolyte disturbances, drug interactions, adrenergic stress and, eventually, the septic patient’s own myocardial damage. The aim of this review is to highlight the main challenges we may encounter during the Covid 19 pandemic, specifically in patients with hereditary arrhythmias, with emphasis on the congenital long QT syndrome (LQTS), Brugada syndrome (SBr), ventricular tachycardia polymorphic catecholaminergic (CPVT) and arrhythmogenic right ventricular cardiomyopathy.

Keywords
COVID-19; Aarrhythmogenic Right Ventricular Cardiomyopathy; Brugada Syndrome; Long QT Syndrome; Catecholaminergic Polymorphic Ventricular Tachycardia

Authorship

Luciana Sacilotto

Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil.Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil.BrazilSão Paulo, SP, BrazilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil.

http://orcid.org/0000-0002-3679-5349

Natalia Quintella Sangiorgi Olivetti

Cristiano Faria Pisani

Tan Chen Wu

http://orcid.org/0000-0002-7881-0447

Ludhmila Abrahão Hajjar

http://orcid.org/0000-0001-5645-2055

Sissy Lara de Melo

http://orcid.org/0000-0002-2329-7439

Sávia Christina Pereira Bueno

Esteban Wisnivesky Rocca Rivarola

Muhieddine Omar Chokr

http://orcid.org/0000-0001-6697-7074

Carina Abigail Hardy

Denise Tessariol Hachul

Francisco Carlos da Costa Darrieux

Mauricio Ibrahim Scanavacca Mailing Address: Maurício Ibrahim Scanavacca • Instituto do Coração - Unidade de Arritmia – Av. Dr. Enéas de Carvalho Aguiar, 44. Postal Code 01421-001, São Paulo, SP – Brazil. E-mail: mauricio.scanavacca@incor.usp.br

Mailing Address: Maurício Ibrahim Scanavacca • Instituto do Coração - Unidade de Arritmia – Av. Dr. Enéas de Carvalho Aguiar, 44. Postal Code 01421-001, São Paulo, SP – Brazil. E-mail: mauricio.scanavacca@incor.usp.br

Author contributions

Conception and design of the research: all authors. Writing of the manuscript: Sacilotto L, Olivetti N. Critical revision of the manuscript for intellectual content: Pisani C, Hachul D, Darrieux F, Scanavacca MI.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (4)
Tables (2)

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Figure 1
QT interval measurement in a patient with Long QT Syndrome.

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Figure 2
Placement of precordial leads in a patient with Brugada Syndrome. A) Precordial leads placed at superior intercostal space to increase the detection of Brugada type 1 pattern, as demonstrated in panel B. B) An asymptomatic 26-year-old girl, with a familiar history of sudden cardiac death.

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Figure 3
ECG of a patient with Arrhythmogenic right ventricle cardiomyopathy. A 45-year-old man recovered from sudden cardiac death. Presence of epsilon wave (arrow) and T wave inversion from V1 to V3, both major signals according to task force criteria. There is also low voltage QRS in limb leads, showing a severe ventricular impairment.

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Figure 4
Ventricular arrhythmia prototype in patients with Cathecolaminergic Polymorphic Ventricular Tachycardia. A 26-year-old girl with polymorphic premature beats and non-sustained ventricular tachycardia during treadmill test and a family history of sudden cardiac death in the first decade of life.

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Table 1
Out-of-hospital and inpatient care during COVID-19 pandemic in patients with inherited arrhythmias

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Table 2
Brugada Syndrome phenocopies

Figure 1 QT interval measurement in a patient with Long QT Syndrome.

InCor-HCFMUSP collection.

Figure 2 Placement of precordial leads in a patient with Brugada Syndrome. A) Precordial leads placed at superior intercostal space to increase the detection of Brugada type 1 pattern, as demonstrated in panel B. B) An asymptomatic 26-year-old girl, with a familiar history of sudden cardiac death.

InCor-HCFMUSP collection.

Figure 3 ECG of a patient with Arrhythmogenic right ventricle cardiomyopathy. A 45-year-old man recovered from sudden cardiac death. Presence of epsilon wave (arrow) and T wave inversion from V1 to V3, both major signals according to task force criteria. There is also low voltage QRS in limb leads, showing a severe ventricular impairment.

InCor-HCFMUSP collection.

Figure 4 Ventricular arrhythmia prototype in patients with Cathecolaminergic Polymorphic Ventricular Tachycardia. A 26-year-old girl with polymorphic premature beats and non-sustained ventricular tachycardia during treadmill test and a family history of sudden cardiac death in the first decade of life.

InCor-HCFMUSP collection.

Table 1 Out-of-hospital and inpatient care during COVID-19 pandemic in patients with inherited arrhythmias

Out-of-hospital care

• Avoid emotional stress

• Practice good hygiene and physical distancing

• Check for the risk of social distancing

• Keep beta-blockers and antiarrhythmic drus, as appropriate

• Attention with alarm symptoms (syncope, presyncope and palpitations) and optimal pharmacological treatment and adherence to medication

Out-of-hospital and inpatient care

• Keep euthermia – fever should be treated early, especially in patients with LQTS2 and BrS

• Azithromycin and Hydroxychloroquine/Chloroquine must be discouraged in patients with LQTS

• Avoid the association of hydroxychloroquine with amiodarone or sotalol due to the risk of TdP

• The drugs that may lengthen the QT interval is available on www.credibledrugs.org

• Drugs interactions are available on www.online.epocrates.com

• Be aware of QT control protocols of each hospital

LQTS: Long QT syndrome, BrS: Brugada Syndrome, ARVC: arrhythmogenic right ventricle cardiomyopathy; TdP: Torsades de pointes.

Table 2 Brugada Syndrome phenocopies

Metabolic conditions

Adrenal crisis, metabolic acidosis, hyperglycemia

Electrolyte disturbances

Hyperkalemia, hypokalemia and hyponatremia

Mechanical compression of right ventricle outflow tract

Tumors, pectus excavatum

Others

Myocardial ischemia and pulmonary embolism

Pericarditis and myocarditis

Exogenous Medications and Poisonings

Fonte: www.brugadadrugs.org50

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Peculiar Aspects of Patients with Inherited Arrhythmias during the COVID-19 Pandemic

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[1] Mailing Address: Maurício Ibrahim Scanavacca • Instituto do Coração - Unidade de Arritmia – Av. Dr. Enéas de Carvalho Aguiar, 44. Postal Code 01421-001, São Paulo, SP – Brazil. E-mail: mauricio.scanavacca@incor.usp.br