John Hopkins Proposes New Echocardiogram Diagnostics That Can identify COVID-19 Patients That Are At Risk Of Developing Atrial Fibrillation

Heart and COVID-19: Considering that a high percentage of COVID-19 patients including those that were deemed as having “recovered” are manifesting atrial fibrillation ie an irregular heartbeat that can increase a person's risk for heart failure and stroke, among other heart issues, researchers from Johns Hopkins Medicine have identified a type of echocardiogram which is a common test to evaluate whether a person's heart is pumping properly to predict which patients with COVID-19 are most at risk of developing atrial fibrillation.

Myocardial injury COVID-19 has been associated with adverse outcomes, however associations between myocardial injury and arrhythmias, such as atrial fibrillation/flutter (AF), in this population are not well established.
 
Recent advances in two dimensional echocardiography (2DE), including speckle-based strain, enable the quantification of left atrial (LA) strain, a measure of atrial deformation that has previously been shown to be predictive of AF and cardiovascular events in stable outpatients.
 
The study team aimed to compare echocardiographic measures of LA function between hospitalized COVID-19 patients and COVID-19-negative controls, to test the hypothesis that COVID-19 patients have reduced LA function as reflected by abnormal LA strain (LAS) and LA emptying fraction (LAEF).
 
The study team found that among COVID-19 patients, left atrial dysfunction and cardiac biomarker elevation are associated with incident atrial fibrillation.
 
The study findings were published in the peer reviewed Journal of the American Society of Echocardiography. https://www.onlinejase.com/article/S0894-7317(21)00497-1/pdf
 
The study findings also suggest that patients with COVID-19 who go on to develop atrial fibrillation more commonly have elevated levels of heart-related proteins called troponin and NT-proBNP in blood test samples.
 
Dr Allison Hays, M.D., medical director of echocardiography programs at The Johns Hopkins Hospital and senior author of the published paper told Thailand Medical News, “If further studies confirm the findings, this could lead to new therapies to prevent strokes and heart attacks in certain COVID-19 patients who are at the highest risk."
 
To date the COVID-19 pandemic has affected more than 186 million people around the world and killed more than 4.02 million individuals.
 
Previous studies of complications and long-term effects of SARS-CoV-2 infection have found that patients who are hospitalized with COVID-19 have more than double the rate of arrhythmias, including atrial fibrillation and atrial flutter, a similar rapid rhythm that can lead to heart failure and stroke.
 
However exactly how the virus causes these heart complications, and who is most at risk of developing atrial fibrillation because of COVID-19, has been poorly understood.
 
For the research, Dr Hays and her colleagues compared 80 patients with COVID-19 with 34 patients who did not have COVID-19 who were also treated at Th e Johns Hopkins Hospital in the intensive or intermediate care units for respiratory issues.
 
None of the patients had a history of heart arrhythmia.
 
During the study carried out between March and June 2020, the researchers analyzed echocardiograms of hospitalized patients, applying a special kind of analysis called speckle-tracking strain to determine how well the left atrium of the heart moves with each heartbeat.
 
The study team found that, overall, patients with COVID-19 had reduced function of their left atrium, the chamber of the heart that receives oxygenated blood from the lungs. Left atrial strain -; a measure of the movement of the left atrium's walls -; was significantly lower in patients with COVID-19 (28.2% compared with 32.6%, p=0.026; normal >38%) and left atrial emptying fraction -; a measure of how much blood the atrium empties with each contraction -; was also lower in the patients with COVID-19 (55.7% compared with 64.1%, p<0.001).
 
Furthermore the left atrial strain was even lower among the 30% of patients with COVID-19 who developed atrial fibrillation or flutter during their hospital stay compared with other patients with COVID-19 (22.3% compared to 30.4%, p<0.001). This suggests that speckle-tracking analysis -; and specifically, left atrial strain measurement -; could be used to predict which patients with COVID-19 are at highest risk of arrhythmias and develop preventive treatments.
 
Dr Erin Goerlich, M.D., Cardiology Fellow, Johns Hopkins University School of Medicine and First Author of the study further added, “Majority of patients already get echocardiograms while in the hospital; the addition of strain analysis requires no extra scanning of the patient. So this is a safe and affordable new data point that can clue us in about who might develop atrial fibrillation."
 
Typically in the United States, echocardiograms cost on average about US$2,000, and are generally covered by health insurance.
 
Interestingly when the researchers looked at the blood of patients with COVID-19 who developed atrial fibrillation, they saw some differences compared with other patients with COVID-19. People who developed atrial fibrillation had higher levels of troponin (0.07 versus 0.03, p=0.011) and NT-proBNP (946 versus 231, p=0.0007), two known markers of heart stress.
 
Dr Goerlich further added, "This tells us that COVID-19 patients with high levels of these biomarkers should be followed more closely and may benefit from an echocardiogram."
 
Dr Hays cautioned that the current study didn't test whether treating patients with COVID-19 with blood thinners could help prevent the complications that can result from atrial fibrillation, which has been suggested by some clinicians.
 
So far blood thinners are generally prescribed to atrial fibrillation patients to lower the risk of blood clots and strokes.
 
But the new study suggests that treating certain individuals ie those with especially low left atrial strain, for instance could be one path forward.
 
Dr Hays added, “More research is needed in this area. We are also actively studying how these effects on the heart might persist after SARS-CoV-2 infection. It's important to know whether those measures of strain and emptying fraction improve over time."
 
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