Table 3

(A) Table outlining strategies to limit arrhythmia risk and burden in patients with COVID-19. (B) Emergent or urgent indications for electrophysiology procedures during COVID-19

Strategies to minimise arrhythmia risk in patients with COVID-19
Withhold drugs associated with QTc prolongation in those with baseline QTc ≥500 msec OR with known long QT syndromes (eg, for nausea/vomiting in an intensive care unit patient, avoid ondansetron)
Monitor cardiac rhythm and QT interval, withdrawing QT prolonging drugs if QTc >500 msec
Correct hypokalaemia to levels of >4 mEq/L and hypomagnesaemia to >2 mg/dL, and keep calcium levels in the normal range
Avoid other QTc prolonging agents where possible
Drugs/agents used in patients with COVID-19 (for specific treatment or supportive care) that are associated with QT prolongation, VT, VF, LQT
  • Chloroquine (proposed as an antiviral treatment)

  • Hydroxychloroquine (proposed as an antiviral treatment)

  • Lopinavir/Ritonavir (proposed as an antiviral treatment)

  • Azithromycin (proposed as an antiviral treatment)

  • COVID-Organics herbal tea (artemisia derived; projected as an antiviral treatment)

  • Nigella Sativa (projected as an antiviral treatment)

  • Citalopram, escitalopram and sertraline (used for depression symptoms in patients with COVID-19; increased use in general public during the pandemic)

  • Fluoroquinolones (used commonly in patients in ICU with confirmed COVID-19 pneumonia)

  • Miscellaneous: alcohol or grapefruit ingestion can interact with certain medications and increase the risk of arrhythmias

HRS-ACC-AHAESC
  1. VT ablation for medically uncontrolled electrical storm in a hemodynamically compromised patient

  2. Catheter ablation of incessant, hemodynamically significant, severely symptomatic tachycardia not responding to antiarrhythmic drugs, rate control and/or cardioversion

  3. Catheter ablation for Wolff Parkinson White syndrome or pre-excited Atrial Fibrillation with syncope or cardiac arrest

  4. Lead revision for malfunction in a pacemaker-dependent patient or patient on ICD receiving inappropriate therapy

  5. Generator change in pacemaker-dependent patients who are at ERI or at device EOL

  6. Pacemaker or ICD generator change with minimal battery remaining, depending on specific clinical situations

  7. Secondary prevention ICD

  8. Pacemaker implant for complete heart block, Mobitz II AVB, or high grade AVB with symptoms or severe symptomatic sino-atrial node dysfunction with long pauses

  9. Lead/device extraction for infection, including patients not responding to antibiotics or for endocarditis, bacteremia or pocket infection

  10. Cardiac resynchronisation therapy in the setting of severe refractory heart failure in guideline indicated patients

  11. Cardioversion for highly symptomatic atrial arrhythmias or rapid ventricular rates not controlled with medications

  12. Transesophageal echocardiography for patients who need urgent cardioversion

Catheter ablation:
  1. VT/VF ablation for electric storm

  2. AF causing syncope or tachycardiomyopathy

  3. WPW syndrome with fast pre-excited AF and/or syncope and/or cardiac arrest


CIED:
  1. Urgent pacemaker implantation for symptomatic high-degree AVB or sinus node dysfunction with long asystolic pauses

  2. Urgent secondary prevention ICD implantation for cardiac arrest or VT

  3. ICD/pacemaker battery replacement for imminent or actual EOL in pacemaker dependent patients

  4. Lead extraction for infection

  5. Lead revision for symptomatic malfunction


Cardioversion/other electrophysiology procedures:
  1. Highly symptomatic, medically refractory atrial fibrillation/ atrial flutter

  • AF, atrial fibrillation; AVB, atrioventricular block; CIED, cardiac implantable electronic devices; EOL, End Of Life; ERI, elective replacement indicator; ICD, implantable cardiac defibrillator; LQT, long QT; VT, ventricular tachycardia.