key: cord-0693216-9b4lknhx authors: Akhtar, Zaki; Leung, Lisa WM; Kontogiannis, Christos; Zuberi, Zia; Bajpai, Abhay; Sharma, Sumeet; Chen, Zhong; Beeton, Ian; Sohal, Manav; Gallagher, Mark M. title: Prevalence of bradyarrhythmias needing pacing in COVID‐19 date: 2021-07-19 journal: Pacing Clin Electrophysiol DOI: 10.1111/pace.14313 sha: edfe6688811bfe9c5fdbfdbafd9a1bd01f211f9d doc_id: 693216 cord_uid: 9b4lknhx BACKGROUND: The Sars‐Cov‐2 infection is a multisystem illness that can affect the cardiovascular system. Tachyarrhythmias have been reported but the prevalence of bradyarrhythmia is unclear. Cases have been described of transient high‐degree atrioventricular (AV) block in COVID‐19 that were managed conservatively. METHOD: A database of all patients requiring temporary or permanent pacing in two linked cardiac centers was used to compare the number of procedures required during the first year of the pandemic compared to the corresponding period a year earlier. The database was cross‐referenced with a database of all patients testing positive for Sars‐Cov‐2 infection in both institutions to identify patients who required temporary or permanent pacing during COVID‐19. RESULTS: The number of novel pacemaker implants was lower during the COVID‐19 pandemic than the same period the previous year (540 vs. 629, respectively), with a similar proportion of high‐degree AV block (38.3% vs. 33.2%, respectively, p = .069). Four patients with the Sars‐Cov‐2 infection had a pacemaker implanted for high‐degree AV block, two for sinus node dysfunction. Of this cohort of six patients, two succumbed to the COVID‐19 illness and one from non‐COVID sepsis. Device interrogation demonstrated a sustained pacing requirement in all cases. CONCLUSION: High‐degree AV block remained unaltered in prevalence during the COVID‐19 pandemic. There was no evidence of transient high‐degree AV block in patients with the Sars‐Cov‐2 infection. Our experience suggests that all clinically significant bradyarrhythmia should be treated by pacing according to usual protocols regardless of the COVID status. We examined the rate of presentation with AV block in the first year of the pandemic, compared to the same period a year earlier, to look for evidence of a surge in cases in response to the virus. We reviewed the COVID-19 status and clinical outcome of all patients presenting with AV block during this period, to determine the prevalence of COVIDassociated AV block and to determine whether AV block was reversible in these cases. Data on all patients requiring pacing therapy was obtained from catheter lab records across two linked institutions for 2 years to the end of March 2021. All referrals for temporary pacing and all new implantations of a permanent pacemaker (urgent and elective) were included and the cases of high-degree AV block were sieved. Data were collected for all patients who were admitted to hospital with a Sars-Cov-2 infection between March 2020 and February 2021. All cases were confirmed with a reverse-transcriptase-PCR test on a nasopharyngeal specimen collected by a healthcare professional. A g e 2 diabetes in two patients and ischemic heart disease in one; two were clinically obese (BMI >30 kg/m 2 ) and none were known to have preexisting cardiac conduction abnormalities. Bradycardia was due to high-degree AV block in most cases (4/6; 66.7%), the remainder were sinus node dysfunction and one patient had a short episode of bradycardia-induced non-sustained polymorphic ventricular tachycardia ( Patients one and two (Table 1) were admitted with pre-syncope or syncope associated with the high-degree AV block and the COVID-19 status was subsequently established from the swab performed on admis- We found no evidence of a surge in AV block attributable to COVID- (p = .02). Personal experience suggests that this was related to patient behavior: many patients avoided all healthcare settings when infection was most prevalent, 9 resulting in a catch-up surge in cases of other conditions when concern about COVID waned (Figure 2 ). There were similarities in the patient cohorts: one required temporary pacing, two patients managed with a broad escape rhythm and one patient had a mildly elevated hs-TrI. Our more interventionist approach to pacing in this group appears to have been vindicated by the high pacing burden confirmed on subsequent device interrogation. All patients have continued to require pacing, indicating that the initial abnormality has persisted. The lack of follow-up data in previously reported cases of COVID-19 associated AV block raises uncertainty regarding the completeness of reversibility. There has been speculation regarding the mechanism of transient AV block in COVID-19. A systemic inflammatory burden causing injury to the myocytes disrupting intrinsic conduction has been proposed. 6 Viral myocarditis causing local injury to the conduction system has also been suggested, 6 It is possible that the severe-acute-respiratory-syndrome coronavirus-2 selectively affects the conduction system as seen in other infectious aetiologies of cardiac conduction defect. Lyme carditis is an established cause of reversible AV block, though a proportion of patients require permanent pacing. 12 The key difference between the management of Lyme carditis and COVID-19 associated AV block is the well-established nature of the former. Lyme disease is a familiar infection; the nature of the illness, the natural history and the response to treatment have been observed over decades and are well understood. AV block occurs at the level of the AV compact node and is associated with the host immune response to the spirochete. 13 Antibiotic treatment is proven and the reversibility of Lyme carditis is predictable. 14 In contrast, the Sars-Cov-2 infection is novel and the full impact of this infection on the heart and its treatment is yet to be determined; the long-term effects are currently unpredictable. The previous severe acute respiratory syndrome (SARS) outbreak is the closest indicator of the long-term course of COVID-19 illness and during that pandemic, bradycardia was uncommon. 15 It is plausible that the COVID-19 infection has revealed an underlying cardiac conduction tissue anomaly in our patients, rather than causing it. Our cohort was older than that of Dagher et al. and therefore more likely to have had pre-existing conduction tissue fibrosis. 16 The infection may have precipitated an increase in cardiac demand, accelerating the identification of a pre-existing conduction abnormality. It is also possible that our cases represent pure co-incidence: In the past year, COVID-19 has been very common in our region, and clinically significant bradycardia is always common; co-existence of the conditions is inevitable. We also cannot rule out the possibility that COVID-19 infection brought to our attention patients with pre-existing bradycardia who had previously gone undiagnosed. We do not believe that any [18] [19] [20] Transient AV block has been previously described in patients with fibrous conduction tissue and may go on to produce persistent block. 16 AV block is dangerous but easily treatable by pacemaker implantation; omission of this normal treatment of requires a high burden of evidence. The full long-term effect of COVID-19 on the heart is currently undetermined; long-term follow-up data is required. Clinically important bradycardia has remained a common problem during the COVID-19 pandemic. COVID-19 has been prevalent in our region in the past year and occurred in association with clinically important bradycardia in a small number of patients. We did not identify any case of transient AV block associated with COVID-19, suggesting that it is an unusual phenomenon. Data is on file and available upon reasonable request. Christos Kontogiannis MD https://orcid.org/0000-0001-7485-6440 Mark M. 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Long-term progression of rhythm and conduction disturbances in pacemaker recipients: findings from the Pacemaker Expert Programming study Prevalence of bradyarrhythmias needing pacing in COVID-19