|Year : 2021 | Volume
| Issue : 3 | Page : 83-87
A novel electrocardiogram characteristic in patients with myocardial injury due to COVID-19
Marzieh Mirtajaddini1, Rezvanieh Salehi2, Maryam Chenaghlou2
1 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
|Date of Submission||17-Apr-2021|
|Date of Acceptance||17-Aug-2021|
|Date of Web Publication||03-Nov-2021|
Dr. Maryam Chenaghlou
Cardiovascular Research Center, Tabriz University of Medical Sciences, Madani Heart Hospital, Daneshgah Street, Tabriz
Source of Support: None, Conflict of Interest: None
Background: Coronavirus disease of 2019 (COVID-19) is a respiratory disease which can lead to cardiovascular complications including myocarditis, myocardial infarction, and heart failure. Electrocardiogram (ECG) may change in patients with COVID-19 with or without heart involvement. In this study, the ECG changes were evaluated in myocardial injuries due to COVID-19. Methods: This study was done on 22 COVID-19 patients with ST segment elevation in ECG and high troponin level. COVID-19 was confirmed using reverse-transcription polymerase chain reaction test. The ECG variables were evaluated by an expert cardiologist. Statistical analyses were carried out on ECG variables where the significance level of 0.05 was assigned. Results: Of 22 patients, 17 cases (77.3%) were male and 6 cases (27.3%) had a history of coronary artery disease. The most common myocardial involvement was extensive anterior type (31.8%), followed by anterior type (22.7%). Sinus rhythm was observed in 95.5% of patients and 54.5% had low voltage ECG in limb leads. No significant correlation was found between low voltage ECG and demonstrable etiologies of low voltage. Conclusion: The prevalence of low voltage ECG was significantly high in limb leads of patients with myocardial injury due to COVID-19 which was considerably greater than that of myocarditis or myocardial infarction patients.
Keywords: COVID-19, electrocardiogram, low voltage, myocardial infarction, myocardial injury, myocarditis
|How to cite this article:|
Mirtajaddini M, Salehi R, Chenaghlou M. A novel electrocardiogram characteristic in patients with myocardial injury due to COVID-19. Res Cardiovasc Med 2021;10:83-7
|How to cite this URL:|
Mirtajaddini M, Salehi R, Chenaghlou M. A novel electrocardiogram characteristic in patients with myocardial injury due to COVID-19. Res Cardiovasc Med [serial online] 2021 [cited 2022 May 22];10:83-7. Available from: https://www.rcvmonline.com/text.asp?2021/10/3/83/329843
| Introduction|| |
Coronavirus disease of 2019 (COVID-19) is a new infectious disease which is the cause of 2020 pandemic. The main system involved by COVID-19 is the respiratory system. However, other organs such as heart could be involved., The cardiovascular complications of COVID-19 include myocardial injury due to myocardial infarction or myocarditis, acute heart failure, cardiac arrhythmia, and sudden cardiac death. Acute myocardial injury due to COVID-19 has multifactorial etiologies including direct virus invasion, autoimmune mechanism, vascular inflammation, coronary spasm, thrombus formation, plaque instability, and cytokine storm.,,, In addition to common electrocardiogram (ECG) changes due to myocardial injury, such as ST segment and T wave changes, COVID-19 can lead to several ECG abnormalities.,, In this study, the ECG changes were evaluated in patients with myocardial injury due to COVID-19.
| Methods|| |
This study is an observational study in patients with myocardial injury due to COVID-19 admitted at Madani hospital, a tertiary center of cardiovascular diseases in northwest of Iran, from April to October, 2020. The COVID-19 diagnosis was confirmed using positive real-time reverse transcription polymerase chain reaction test from nasopharyngeal swab sample of patients. Chest computed tomography (CT) scan had been done before or during patients' hospitalization. ECG and laboratory tests were performed at admission, and transthoracic echocardiography (TTE) was done during hospitalization. In this study, the criteria of myocardial injury due to COVID-19 were ST elevation in at least two contiguous leads equal or more than 1 mm and high troponin level which occurred from 3 to 20 days after positive COVID-19.
The 12-lead ECG was recorded in supine and standard position (25 mm/s and 10 mV/mm) at admission time. All ECGs were analyzed by an expert cardiologist who had no information about patients' characteristics. QRS complex voltage, QRS rate, Cardiac rhythm, QRS axis, P wave morphology, PR interval duration, PR segment depression, ST segment elevation, and corrected QT interval duration based on Fridericia formula were evaluated in ECGs. Each variable was measured in three beats, and the mean of them was recorded.
Myocardial injury were categorized based on location of ST segment elevation, inferior myocardial injury (ST segment elevation in leads II, III and aVF), lateral myocardial injury (ST segment elevation in leads V5 and V6), inferolateral myocardial injury (ST segment elevation in leads II, III, aVF, V5 and V6), septal myocardial injury (ST segment elevation in leads V1-V3), anterior myocardial injury (ST segment elevation in leads V1-V6), and extensive myocardial injury (ST segment elevation in leads V1-V6, I and aVL). Low voltage ECG refers to peak to peak QRS complex <5 mm in limb leads and <10 mm in precordial leads. Twenty-three patients were entered in the study. Left bundle branch block and left ventricular hypertrophy can affect QRS complex amplitude; therefore, one of patients who had left bundle branch block was excluded. No patient had left ventricular hypertrophy. Finally, 22 patients were included in the study.
The statistical analysis was done using Excel and SPSS software. The numerical variables with normal distribution are presented as mean ± standard deviation, and the categorical variables are reported as percentage. Simple linear regression was used for the evaluation of relationship between low voltage ECG in limb leads and pleural effusion in chest CT scan, left ventricular ejection fraction by TTE, or QRS axis deviation. The relationship between low voltage ECG in limb leads and survival was evaluated using Pearson correlation. The P < 0.05 was considered statistically significant.
| Results|| |
The mean age of patients was 69.36 ± 11.32 years. Most of patients were male (87.3%). About 27% of patients had a history of coronary artery disease and only one patient had a history of chronic obstructive pulmonary disease. No patient was under mechanical ventilation at the time of ECG recording. Three patients underwent primary percutaneous intervention and other patients received only medical treatment. The mean of left ventricular ejection fraction by echocardiography was 33% ±9%. Pericardial effusion was not seen in any of patients by echocardiography. Chest CT scan of patients showed pulmonary ground-glass opacity in all patients, and pleural effusion was seen in six patients (27.3%). Demographic, radiographic, and echocardiographic characteristic of patients are summarized in [Table 1].
|Table 1: Demographic, radiographic, and echocardiographic characteristics of patients|
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The blood group of most patients in this study was A+ (36.4%). The laboratory findings are presented in [Table 2].
Extensive anterior myocardial injury was the most common type of cardiac involvement location (31%), followed by anterior, inferior, inferolateral, septal, and lateral regions. The mean QRS rate was 84 ± 23 beat/min. Twelve patients (54.5%) had low voltage ECG in limb leads, one of them had low voltage ECG in precordial leads and one had low voltage ECG in both limb and precordial leads [Figure 1]. The ECG characteristics are summarized in [Table 3].
|Figure 1: Distribution of electrocardiogram voltage findings in patients|
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No associations were found between low voltage ECG in limb leads and QRS axis deviation, left ventricular ejection fraction, or pleural effusion. The in-hospital mortality rate was 59.1%. The correlation between low voltage ECG in limb leads and mortality was rejected.
| Discussion|| |
Various respiratory infections may lead to cardiovascular complications. Kwong et al. found that influenza can result in acute myocardial infarction during 1stt week of infection diagnosis. In the other study, community-acquired pneumonia was recognized as a cause of cardiovascular diseases. COVID-19 as a new respiratory virus can affect cardiovascular system as well.
COVID-19 with or without cardiac involvement may lead to several ECG changes. Angeli et al. showed that pericarditis changes such as PR depression and concave ST segment elevation are the most common COVID-19-induced ECG changes. In several studies, the QT interval prolongation was observed, in spite the fact that some previously prescribed drugs in COVID-19 patients can prolong QT interval.,, The other ECG changes due to COVID-19 include PR interval prolongation, right and left bundle branch blocks., Several ECG patterns have been identified in COVID-19 patients with cardiac involvement. ST segment elevation is commonly observed in COVID-19 patients due to acute myocardial infarction, myocarditis, and Takotsubo syndrome.,,, In a case series, 14 cases of 18 COVID-19 patients with ST segment elevation myocardial infarction had focal ST segment elevation. Coronary angiography was done in only nine patients which showed obstructive coronary artery disease in 6 (67%) patients.
In this study, ECG changes of acute myocardial injury due to COVID-19 were evaluated. Most of patients had sinus rhythm and normal QRS complex axis. The extensive anterior myocardial injury was the most common type of myocardial injury. No patient had PR segment depression as a sign of acute pericarditis.Furthermore, the PR interval was normal without prolongation. The prevalence of low voltage ECG in limb leads was significantly high in our study. Low voltage ECG may have various causes, which alter voltage generation, such as infiltrative cardiomyopathies or defect in voltage transmission to the electrodes in cases with anasarca, obesity, pulmonary hyperinflation, large pleural, and pericardial effusion.,,,, The etiology of low voltage ECG only in limb leads is unknown. Goldberger described that the low amplitude ECG in limb leads and high amplitude in precordial leads can be signs of congestive heart failure. Chinitz et al. showed that nearly 50% of their studied patients with low limb lead voltages had not any demonstrable etiology. More than 20% of these patients had small pericardial effusion and 11% of the patients had evidence of myocardial infarction in ECG. Therefore, pericardial inflammation may lead to low voltage ECG regardless of the effusion size. Acute myocardial infarction with alteration of QRS axis without impairment of voltage generation can result in QRS voltage reduction. In our study, 54.5% of patients with myocardial injury due to COVID-19 had low amplitude QRS in limb leads which was not due to QRS axis deviation. In a study in 1971, 12% of patients with acute myocardial infarction had evidence of low amplitude ECG within 3 days of admission. The incidence of low voltage ECG in myocardial infarction was estimated about 22% in Rotmensch study. Kobayashi et al. showed that 19% of patients with anterior ST elevation myocardial infarction had low QRS voltage in limb and precordial leads and only 6% had low ECG voltage in limb leads.
Pure myocarditis is the other cause of low voltage ECG through various mechanisms including myocardial and pulmonary edema., Nakashima et al. showed that 18% of patients with myocarditis had low amplitude QRS in limb and precordial leads. The reduction of QRS amplitude due to COVID-19 has been reported in some studies. Angeli et al. showed that Cornell voltage (the sum of the R wave amplitudes in aVL and S wave amplitude in V3) was significantly reduced in COVID-19 patients. In Bertini study, low QRS amplitude in limb leads was observed in 5% of the COVID-19 patients due to mechanical ventilation, chronic pulmonary disease, and myocardial edema. Two cases of the Takotsubo syndrome have been reported due to COVID-19 where the ST elevation and low amplitude ECG in limb leads were detected in their ECGs. It should be noted that one of these cases had hemorrhagic tamponade., Low voltage ECG was reported in 3.4% of COVID-19 patients by Elias et al. Bergamaschi et al. demonstrated the prevalence of low voltage ECG in limb leads as 5.6% due to COVID-19.
In our study in addition to high incidence of low voltage ECG in limb leads, we showed that there is no association between low voltage ECG in limb leads and left ventricular ejection fraction, pleural, or pericardial effusion. Despite the high incidence of low voltage ECG in limb leads in this study. No correlation was found with in-hospital mortality of patients which is in contrast with the results of some previous studies. Kobayashi showed that low voltage ECG may be correlated with multivessel disease and in-hospital CABG; while it was not confirmed in the Tan study. In concordance with our study, Bergamaschi et al. and Elias et al. found that low voltage ECG at the admission time, is not a prognostic factor in patients with COVID-19.,
| Conclusion|| |
This study showed high prevalence of low voltage ECG in limb leads in patients with acute myocardial injury due to COVID-19. The prevalence is higher than low voltage ECG in patients with acute myocardial infarction or myocarditis in previous studies. This finding may be related to more myocardial edema in patient with COVID-19 in comparison with other etiologies.
The sample size is limited in our study. The absence of confirmatory modalities for defining the exact etiology of myocardial involvement including cardiac magnetic resonance imaging, myocardial biopsy, or autopsy are the other limitations of the current study.
The consent was obtained from the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al.
Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8:420-2.
Hoeper MM, Kramer T, Pan Z, Eichstaedt CA, Spiesshoefer J, Benjamin N, et al.
Mortality in pulmonary arterial hypertension: Prediction by the 2015 European pulmonary hypertension guidelines risk stratification model. Eur Respir J 2017;50:1700740.
Prabhu SD. Cytokine-induced modulation of cardiac function. Circ Res 2004;95:1140-53.
Levi M, van der Poll T, Büller HR. Bidirectional relation between inflammation and coagulation. Circulation 2004;109:2698-704.
Fauci AS, Lane HC, Redfield RR. COVID-19 – Navigating the uncharted. N Engl J Med 2020;382:1268-9.
Mogensen TH. Pathogen recognition and inflammatory signaling in innate immune defenses. Clin Microbiol Rev 2009;22:240-73.
Long B, Brady WJ, Bridwell RE, Ramzy M, Montrief T, Singh M, et al.
Electrocardiographic manifestations of COVID-19. Am J Emerg Med 2021;41:96-103.
Angeli F, Spanevello A, De Ponti R, Visca D, Marazzato J, Palmiotto G, et al.
Electrocardiographic features of patients with COVID-19 pneumonia. Eur J Intern Med 2020;78:101-6.
Mehraeen E, Seyed Alinaghi SA, Nowroozi A, Dadras O, Alilou S, Shobeiri P, et al
. A systematic review of ECG findings in patients with COVID-19. Indian Heart J 2020;72:500-7.
Wagner GS. Marriott's Practical Electrocardiography. 11th
ed. Philadelphia: Lippincott Williams and Wilkins; 2007.
Kwong JC, Schwartz KL, Campitelli MA, Chung H, Crowcroft NS, Karnauchow T, et al.
Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018;378:345-53.
Corrales-Medina VF, Alvarez KN, Weissfeld LA, Angus DC, Chirinos JA, Chang CC, et al.
Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA 2015;313:264-74.
Ramireddy A, Chugh H, Reinier K, Ebinger J, Park E, Thompson M, et al.
Experience with hydroxychloroquine and azithromycin in the coronavirus disease 2019 pandemic: Implications for QT interval monitoring. J Am Heart Assoc 2020;9:e017144.
Chen L, Feng Y, Tang J, Hu W, Zhao P, Guo X, et al.
Surface electrocardiographic characteristics in coronavirus disease 2019: Repolarization abnormalities associated with cardiac involvement. ESC Heart Fail 2020;7:4408-15.
Bertini M, Ferrari R, Guardigli G, Malagù M, Vitali F, Zucchetti O, et al.
Electrocardiographic features of 431 consecutive, critically ill COVID-19 patients: An insight into the mechanisms of cardiac involvement. Europace 2020;22:1848-54.
Dabbagh MF, Aurora L, D'Souza P, Weinmann AJ, Bhargava P, Basir MB. Cardiac tamponade secondary to COVID-19. JACC Case Rep 2020;2:1326-30.
Minhas AS, Scheel P, Garibaldi B, Liu G, Horton M, Jennings M, et al.
Takotsubo syndrome in the setting of COVID-19. JACC Case Rep 2020;2:1321-5.
Siripanthong B, Nazarian S, Muser D, Deo R, Santangeli P, Khanji MY, et al.
Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm 2020;17:1463-71.
Bangalore S, Sharma A, Slotwiner A, Yatskar L, Harari R, Shah B, et al.
ST-segment elevation in patients with COVID-19 – A case series. N Engl J Med 2020;382:2478-80.
Bruch C, Schmermund A, Dagres N, Bartel T, Caspari G, Sack S, et al.
Changes in QRS voltage in cardiac tamponade and pericardial effusion: Reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol 2001;38:219-26.
Sivaram CA, Jugdutt BI, Amy RW, Basualdo CA, Haraphongse M, Shnitka TK. Cardiac amyloidosis: Combined use of two-dimensional echocardiography and electrocardiography in noninvasive screening before biopsy. Clin Cardiol 1985;8:511-8.
Alpert MA, Terry BE, Cohen MV, Fan TM, Painter JA, Massey CV. The electrocardiogram in morbid obesity. Am J Cardiol 2000;85:908-10.
Sorbello A, Giudice JC, Papa LA. The relationship of low voltage on the electrocardiogram and chronic obstructive pulmonary disease. Clin Cardiol 1982;5:657-60.
Madias JE, Bazaz R, Agarwal H, Win M, Medepalli L. Anasarca-mediated attenuation of the amplitude of electrocardiogram complexes: A description of a heretofore unrecognized phenomenon. J Am Coll Cardiol 2001;38:756-64.
Barold SS, Goldberger AL. A specific ECG triad associated with congestive heart failure. Pacing Clin Electrophysiol 1982;5:593-9.
Chinitz JS, Cooper JM, Verdino RJ. Electrocardiogram voltage discordance: Interpretation of low QRS voltage only in the limb leads. J Electrocardiol 2008;41:281-6.
Gardberg M, Ashman R. The QRS complex of the electrocardiogram. Arch Intern Med 1943;72:210-30.
Fox KM, Tomlinson IW, Meek DR, Portal RW, Aber CP. Low voltage electrocardiogram after acute myocardial infarction. Br Heart J 1975;37:748-51.
Rotmensch HH, Meytes I, Terdiman R, Laniado S. Incidence and significance of the low-voltage electrocardiogram in acute myocardial infarction. Chest 1977;71:708-11.
Kobayashi A, Misumida N, Aoi S, Kanei Y. Low QRS voltage on presenting electrocardiogram predicts multi-vessel disease in anterior ST-segment elevation myocardial infarction. J Electrocardiol 2017;50:870-5.
Nakashima H, Honda Y, Katayama T. Serial electrocardiographic findings in acute myocarditis. Intern Med 1994;33:659-66.
Lee JM, Seo SM, Seo MJ, Min HK, Cho MJ, Kim YS, et al
. A case of reversible very low voltage electrocardiogram in fulminant myocarditis. Korean Circ J 2013;43:565-8.
Casale PN, Devereux RB, Kligfield P, Eisenberg RR, Miller DH, Chaudhary BS, et al.
Electrocardiographic detection of left ventricular hypertrophy: Development and prospective validation of improved criteria. J Am Coll Cardiol 1985;6:572-80.
Elias P, Poterucha TJ, Jain SS, Sayer G, Raikhelkar J, Fried J, et al.
The prognostic value of electrocardiogram at presentation to emergency department in patients with COVID-19. Mayo Clin Proc 2020;95:2099-109.
Bergamaschi L, D'Angelo EC, Paolisso P, Toniolo S, Fabrizio M, Angeli F, et al.
The value of ECG changes in risk stratification of COVID-19 patients. Ann Noninvasive Electrocardiol 2021;26:e12815.
Tan NS, Goodman SG, Yan RT, Tan MK, Fox KA, Gore JM, et al.
Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes. Int J Cardiol 2015;190:34-9.
[Table 1], [Table 2], [Table 3]