Introduction
During the ongoing COVID-19 pandemic, limitations in health care resources and extensive protections against viral dissemination forced novel approaches to previously routine patient management. Patients with COVID-19 infection are at risk for various cardiovascular and arrhythmic complications.1 In addition, medications indicated to treat COVID-19 infection carry risk of cardiac complications, particularly QT prolongation and ventricular arrhythmia.2 Several of the most commonly utilized medications at this time, such as chloroquine, hydroxychloroquine, azithromycin, and famotidine, carry a risk of QT prolongation. This risk is heightened when such medications are used concomitantly, in patients with cardiac comorbidities, or in the setting of acute medical illness such as sepsis.3
Hospitalized patients with COVID-19 infection have been monitored for QT prolongation and arrhythmias through the use of serial ECGs, telemetry, as well as ambulatory telemetry monitors.4 However, limited availability of such resources due to high demand, and precautions set in place to protect health care providers from contact with contagious patients, has precluded standard monitoring even in hospitalized patients. Furthermore, most patients with COVID-19 infection are treated as outpatients, employing self-isolation to reduce the risk of nosocomial and community spread.5 There is therefore a sudden and dramatic reliance on telehealth and remote ECG monitoring to manage patients at home.
Wearable and “smart” cardiac monitoring devices, such as the Apple Watch series 4 and the AliveCor Kardia system (AliveCor Inc. Mountain View, California), have the ability to record a rhythm strip essentially equivalent to lead I on a standard ECG, and allow for electronic transmission of results. While these devices are validated for their ability to monitor heart rates and differentiate sinus rhythm from atrial fibrillation6, the accuracy for other ECG interpretation purposes has not been well studied. The waveforms produced have been shown to correlate reasonably well with standard ECG intervals including QTc,7 and have previously been used to detect drug-induced QT interval prolongation.8
As patients with COVID-19 infection continue to overwhelm our global health care system and resources, the ability to remotely monitor patients for cardiac complications of COVID-19 infection, and ensure safety of pharmacologic treatment, has become increasingly important. Currently available wearable cardiac monitoring devices, such as the Apple Watch Series 4, and the Kardia system, may therefore have an important role in the management of patients in this Pandemic.
We report herein a case of a patient with COVID-19 infection who was treated with a QT prolonging medication and was able to be managed remotely with the assistance of a smart device.