DISCUSSION
Patients with advanced cardiac disease are at high risk of arrhythmic
events that may impact prognosis, such as AF, VT and VF. In this study
we have shown that during the 56 days long lockdown due to COVID-19
epidemics, the incidence of both atrial and ventricular arrhythmias was
significantly increased in subjects with AICD and ICD/CRT. These data
were available through remote device monitoring and raise some
interesting issues regarding both cardiac pathophysiology and patients’
clinical management.
In order to contrast the spread of the new COVID-19 epidemic, at the
beginning of March 2020 the Italian Government decided for more
restrictive containment measures: a sudden and radical change has
occurred in the habits and lifestyles of the population, with a drastic
reduction of any form of personal contacts and socialisation with
relevant social ed economic consequences. These preventive measures did
limit the spread of this contagious disease in southern Italy. The
effects of lockdown period were explored in different contexts and
terms: eating habits and lifestyle changes,10approaches implemented to support teleconsultations and management of AF
and heart failure patients.11,12 new-onset of
arrhythmic events such as atrial fibrillation,3 impact
on interventional electrophysiology units routine and emergency
work,13 .
It is well established that patients affected by COVID-19 infection may
develop cardiac complications, also in terms of both atrial and
ventricular arrhythmias. Such complications are more frequent in
severely ill subjects and may represent a negative prognostic factor in
terms of morbidity and mortality14 This created major
concern for the patients with chronic heart disease. However even in
cardiopathic subjects who were not affected by COVID-19 related
pneumonia, restrictive measures created distress and cardiac
complications.
In our study we investigated the effects of lockdown period in in a
cohort of stable patients followed up through AICD and CRT-D remote
monitoring in terms of incidence rate of cardiac arrhythmias, by
comparing these data with data from the same period in
2019. Study population has shown
an increase in the incidence of arrhythmias: during lockdown period
VT/VF occurred in 4.8% and new-onset AF in 8.2% of study patients,
while the same arrhythmias were respectively observed in 2.3% and 5.2%
of subjects during the corresponding 2019 period. These results were
strengthened in terms of number of arrhythmic events: VT, VF and AF
episodes were recorded during the lockdown time interval much more
frequently than the correspondent reference period.
Our study method, based on diagnosis obtained through continuous remote
monitoring, has allowed to eliminate the “issue” of potential and
dangerous underdiagnosis associated with the routine discontinuous
in-office clinical assessment; this issue has become more relevant
during the recent COVID-19 pandemic outbreak because of the widely
reported patients’ tendency to avoid hospitalization during the epidemic
peak phase (Russo, Danish e qualcos’altro) and to the reduction of
hospitals’ accessibility. In fact the data of the Danish Registry have
shown a 47% drop in registered diagnosed new-onset AF cases, revealing
a potential and “dangerous” risk of undiagnosed AF with potential
detrimental prognostic effects3 . This tendency, that
could possible cause underdiagnosis and underreporting,
was bypassed in our investigation
by continuous remote monitoring that allowed us to quantify the real
arrhythmic burden associated to lockdown in terms of higher incidence of
relevant arrhythmias.
To the best of our knowledge, this is the first study to report on the
incidence of cardiac arrhythmias related to the COVID-19 outbreak in
AICD patients on such a large sample size. Our results are in agreement
with the recently published data of a multi-center study performed in
our region, that show a significant increase in the number of
hospitalizations through the emergency department due to clinically
relevant arrhythmias during the lockdown time interval, despite the
reduced number of scheduled hospital admissions and rhythm management
procedures4.
The increased incidence of dysrhythmias during lockdown may be related
to “high-stress conditions” that have characterized lockdown period.
As the strict lockdown measures were associated to change in daily
habits, social discomfort, economic recession and jobs lay-offs, it is
not surprising that in the Italian general population high rates of
negative mental health outcomes and different COVID-19 related risk
factors were reported15 . Several studies, both in
animal models and humans, suggest that emotions and mental stress play a
significant role in the onset of arrhythmias and the occurrence of
sudden death due to “the heart-brain
interaction”.16-18 Emotions and mental stress can
influence heart rhythm in several ways, including impaired
sympathetic/parasympathetic balance, alterations in the spatial
distribution of autonomic input to the heart, or by causing coronary
arterial vasoconstriction and ischemia. Anger has been shown to be the
commonest emotion prior to the onset of ventricular arrhythmia also in
patients with ICD.16,18 Mental stress and anger
predispose to atrial arrhythmias particularly in younger patients with
‘lone’ AF; furthermore stress increases both the frequency of cardiac
rhythm disturbances and the lethality of ventricular
arrhythmias17,18 . Specific regions in the brain may
be responsible for mediating the pro-arrhythmic effects of
emotions.18 This functional connection between the
brain and the heart may be the cause of the increased incidence of
arrhythmias in our study population that have experienced
lockdown-related stressful life. It is conceivable that this phenomenon,
assessed for the general population,18 may be even
more pronounced in a population with advanced cardiac disease and might
play a causative role of new-onset arrhythmias.
In this context, a potential role
of disorders of metabolic and hormonal homeostasis caused by mental and
psychological stress was not investigated and it cannot be ruled out.
As a change in the incidence of neither atrial nor ventricular
arrhythmias was recorded in the year preceding lockdown, it is unlikely
that our findings are due to cardiac disease progression.
Our experience confirmed how the use of remote monitoring, recognized as
“the new standard of care” for patients with cardiac implantable
electronic devices by HRS Expert Consensus Statement5plays an even more crucial role during the current pandemic as clinical
follow-up during a period of social distancing and limited access to
health facilities represent a difficult challenge for subjects who
require regular and/or continuous surveillance.19