Inappropriate Heart Rate Response to Hypotension in Critically Ill COVID-19-Associated Acute Kidney Injury.

Charles Verney,Guillaume Voiriot,Vincent Labbé,David Legouis,Muriel Fartoukh

doi:10.3390/jcm10061317

Abstract

Angiotensin-converting enzyme 2 (ACE2) receptor of severe acute respiratory syndrome coronavirus 2 is involved in baroreflex control mechanisms. We hypothesize that severe coronavirus infectious disease 2019 (COVID-19) patients may show an alteration in baroreflex-mediated heart rate changes in response to arterial hypotension. A pilot study was conducted to assess the response to hypotension in relation to continuous venovenous hemodiafiltration (CVVHDF) in critically ill patients with PCR-confirmed COVID-19 (from February to April 2020) and in critically ill non-COVID-19 patients with sepsis (from February 2018 to February 2020). The endpoint was a change in the heart rate in response to CVVHDF-induced hypotension. The association between COVID-19 status and heart rate change was estimated using linear regression. The study population included 6 COVID-19 patients (67% men; age 58 (53–64) years) and 12 critically ill non-COVID-19 patients (58% men; age 67 (51–71) years). Baseline characteristics, laboratory findings, hemodynamic parameters, and management before CVVHDF-induced hypotension were similar between the two groups, with the exception of a higher positive end-expiratory pressure and doses of propofol and midazolam administered in COVID-19 patients. Changes in the heart rate were significantly lower in COVID-19 patients as compared to critically ill non-COVID-19 patients (−7 (−9; −2) vs. 2 (2;5) bpm, p = 0.003), while the decrease in mean arterial blood pressure was similar between groups. The COVID-19 status was independently associated with a lower change in the heart rate (−11 (−20; −2) bpm; p = 0.03). Our findings suggest an inappropriate heart rate response to hypotension in severe COVID-19 patients compared to critically ill non-COVID-19 patients.

Highlights

To investigate potential baroreflex dysfunction in this context, we studied changes in the heart rate in response to continuous venovenous hemodiafiltration (CVVHDF)-induced hypotension in critically ill COVID-19 patients compared to those in critically ill non-COVID-19 patients
COVID-19 was associated with an inappropriate decrease in the heart rate in response to CVVHDF-induced hypotension in critically ill patients
While numerous COVID-19-related cardiovascular alterations such as myocarditis, arrhythmias, and bradycardia have already been reported in critically ill patients, an inappropriate heart rate response to hypotension has not yet been described [8]

Summary

Introduction

The binding of severe acute respiratory syndrome coronavirus 2 (o the angiotensinconverting enzyme 2 (ACE2) receptor of host cells leads to ACE2 intracellular pathway downregulation [1]. SARS-CoV-2 may alter changes in the heart rate mediated by the baroreflex in response to arterial hypotension in the most severe patients. Severe acute kidney injury (AKI) is a frequent condition in critically ill coronavirus infectious disease 2019 (COVID-19) patients [3]. AKI participates in a specific phenotype of severe disease, associated with higher hospital mortality and length of stay [3,4]. Acute arterial hypotension is a common side effect of continuous venovenous hemodiafiltration with net ultrafiltration (CVVHDF-induced hypotension [5]) usually used for COVID-19associated severe AKI [4,6,7]

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Results

Conclusion