SINUS PAUSE SECONDARY TO ACUTE COVID-19 INFECTION

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sinus pause/arrest most commonly occurs in medication toxicity, cardiac ischemia, infiltrative or fibrotic disease of SA node, structural heart disease, PE, sleep apnea, electrolyte disturbance (hyperkalemia), Lyme disease. We present to you a case of sinus pause/arrest in a patient with COVID-19 infection. CASE PRESENTATION: Patient is a 59 year male who presented to hospital with complaints of chest pain and dyspnea. Past medical history was significant for recent COVID-19 infection one week ago. Vital signs and physical examination on presentation were normal. Initial workup including CBC, INR, PTT, CMP, troponin and EKG were normal. Chest x-ray was remarkable for reticular nodular infiltrate in the right perihilar lung field. Patient was started on IV antibiotic for suspected pneumonia. On day 1, patient started experiencing skipped heartbeats. Cardiac telemetry demonstrated multiple sinus pauses with greatest pause duration of about 5 seconds. EKG showed normal sinus rhythm without any significant ST/T wave changes, Recent transthoracic echocardiogram was normal. Upon literature review, it was noted that there were cases of severe COVID-19 infection affecting the electrical system of the heart, resulting in sinus pauses. Hence, after ruling out some of the common differential diagnosis for sinus pauses including medications, ischemia, inflammatory, infiltrative or fibrotic disease of the SA node, structural heart disease, PE, OSA (obstructive sleep apnea), electrolyte disturbance (especially hyperkalemia), Lyme disease, patient's sinus pauses were attributed to underlying COVID-19 infection. Patient was discharged with 30 days cardiac event monitor which showed sinus rhythm with no significant pauses. DISCUSSION: SA nodal dysfunction typically results from either abnormality in impulse generation by the P cells or abnormalities in conduction across perinodal transitional (T cells). Hypoxemia, cytokine storm, direct viral infiltration, myocardial inflammation are thought to be responsible for sinus pause in COVID-19 disease, although exact mechanism is not known. Patients are symptomatic when longer episodes of sinus arrest occur resulting in dizziness, syncope, and death. Asymptomatic patients with SA nodal pauses or arrest often do not require treatment. Symptomatic patients are treated with a permanent pacemaker placement. CONCLUSIONS: Moderate to severe COVID-19 infection could be an uncommon cause of sinus pauses. However, before attributing COVID-19 as a cause of sinus pauses, common differential diagnosis for sinus pauses including medications toxicity (digoxin, antiarrhythmics-procainamide, quinidine), cardiac ischemia, infiltrative or fibrotic disease of SA node, structural heart disease, PE, sleep apnea, electrolyte disturbance and Lyme disease should be ruled out. REFERENCE #1: Peigh, Graham, et al. 'Novel Coronavirus 19 (COVID-19) Associated Sinus Node Dysfunction: A Case Series'. European Heart Journal - Case Reports, vol. 4, no. FI1, Oct. 2020, pp. 1–6. Silverchair, doi:10.1093/ehjcr/ytaa132. REFERENCE #2: Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, Jain SS, Burkhoff D, Kumaraiah D, Rabbani L, Schwartz A, Uriel N. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation 2020;doi: 10.1161/CIRCULATIONAHA.120.046941 REFERENCE #3: Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020;17:259–260. DISCLOSURES: No relevant relationships by Luna Khanal, source=Web Response No relevant relationships by Adarsha Ojha, source=Web Response