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Management of post-acute covid-19 in primary care

 

BMJ talk medicine · What Do We Know About Long Covid

Delta Rising

The Delta variant is gaining in many countries in Europe and the US https://t.co/QwXCwaCq6c @AnnaSophieGross @labboudles @jburnmurdoch @FT
And in Israel, the most fully vaccinated country, there have been 2 new school Delta outbreakshttps://t.co/rBmPsuntfv @TimesofIsrael pic.twitter.com/UVx27jqpDf

— Eric Topol (@EricTopol) June 20, 2021

We need to build a Delta immunity wall through more vaccination: 47% Americans haven't even had 1 dose
—There has not been any counter-offensive to the anti-vaxx movement
—No statement by FDA about full licensure timeline (review should be done by now) and no coverage by media pic.twitter.com/c4aL3mrrJE

— Eric Topol (@EricTopol) June 19, 2021

Bradycardia in SarsCov2 Infection

Bradycardia i.e. Mobitz 1, Mobitz 2 or complete heart block ,junctional rhythm, sinus bradycardia and/or pauses can be an initial presentation COVID-19. It appears this is actually a marker for poor prognosis. Multiple series have been published on this. Bradycardia is a frequent clinical feature of COVID-19. Actually most patients do not mount a significant tachycardia, compared to sepsis.This may also imply that patient with COVID 19 can have a PEA arrest with no other causes ( hypoxemia, etc)

Typically  heart rates are well below 100-120 bpm. Mechanistic explanation is likely due to direct pathogenic effects on the sinoatrial node and effects of inflammatory cytokines are among the proposed mechanisms. Despite management of bradycardia with temporary or permanent leadless pacemakers, there is a high rate of short‐term morbidity and death due to complications of COVID‐19. 

Interleukin 6 (IL-6) is the cytokine reported to exhibit the strongest correlation with depressed heart rate variability, which in turn may predict relative bradycardia.

I managed last 2 days a patient with significant sinus bradycardia heart rate 30s to 40s, intubated on mechanical ventilation for COVID-19 pneumonia, but on norepinephrine (not hypothermic). She responded well to atropine and heart rate would go up to 75 bpm. However little effect was obtained from switching from norepinephrine to dopamine. 

Below I linked several articles that refer to a very poor prognosis for patients that have early bradycardia and/or persistent bradycardia in the intensive care unit during SARS CoV-2 management. I also attached an article that gives an overview of bradycardia management in general. This is from the European Society of Cardiology published in their 2015 guidelines.

Be aware that Aminophyllin or theophylline, particularly in elderly patients can be used as a temporary measure to manage brady- arrhythmias, provided there is no ischemia and can even placed on an oral regimen of theophylline . Temporary pacemakers in general should be discouraged. They have a significant complication rate and if patient meets pacemaker criteria, he or she should be managed like a STEMI and brought urgently to the EP lab for emergent permanent pacemaker implantation.

Bradycardia in Patients with COVID -19: A Calm Before the Storm 

Reference of the above figures

Hemodynamic Monitoring in the ICU

 

Volume View System   multiple physiologic variables including EVLW ( extra vascular lung water ) 

Argos by Retia Medical   CO monitor 

A global perspective on vasoactive agents in shock

 Excellent article and I have also attached the Webinar discussing protocols

6 Therapies for COVID-19