Numerous drugs are used these days without in-depth evaluation of efficacy and safety for the treatment of life-threatening complications of COVID-19. Among these, an important number are known for provoking prologation of the QTsegment and eventually life threatening arrhythmias, described by FAZIO et al. in 2013: Fazio G, Vernuccio F, Grutta G, Re GL. Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management. World J Cardiol. 2013 Apr 26;5(4) Article Drugs to be avoided in patients with long QT syndrome: Focus...
PMID: 23675554; PMCID: PMC3653016.
The hype provoked by the President of the United States of America who praised Chloroquin as the number one cure for COVID-19, and the largesse with which of antibiotics such as levofloxacin or azithromycin are used in COVID-19 pneumonia could prove fatal for patients belonging to the risk group of over 65 with their frequent predisposition to cardiovascular events. Does anybody have data on the quantitative aspect of the above-mentionned drug-related risk in connection with the COVID-19 pandemic?
#COVID-19,#drugs,#risk,#chloroquin,#levofloxacin,#azithromycin,,#LQTS,#suddendeath,
Article Acquired Long QT Syndrome: A Review of the Literature
This review discussed the points I outline below.
Several medications that have been recommended for the treatment of Covid-19 are associated with prolongation of the QTc interval and therefore torsade de pointes and sudden cardiac death.
The evidence of the potential benefit of chloroquine and hydroxychloroquine in the treatment of Covid-19 is increasing.
Other medications which may be used in this cohort include the macrolide antibiotics (e.g. azithromycin). These can also prolong the QTc interval. Administering several medications that may prolong the QT interval is associated with a high risk of complications.
In medicine risks and benefits must be balanced. Safety netting is important whenever there is a great potential benefit but also a very significant risk. In that context QTc intervals, renal and liver function must be monitored closely in patients treated with chloroquine and or macrolides. They should probably not be started if the baseline QTc is more than 450 ms. It should probably be stopped if the QTc increases 25% above baseline. It should definitely be stopped if QTc is above 500 ms. This is an evolving situation and recommendations may change as the potential risks and benefits become clearer.
Beta-blockade is used in the treatment of congenital and acquired long QT syndrome, so may be beneficial in this setting.
Article Acquired Long QT Syndrome: A Review of the Literature
This review discussed the points I outline below.
Several medications that have been recommended for the treatment of Covid-19 are associated with prolongation of the QTc interval and therefore torsade de pointes and sudden cardiac death.
The evidence of the potential benefit of chloroquine and hydroxychloroquine in the treatment of Covid-19 is increasing.
Other medications which may be used in this cohort include the macrolide antibiotics (e.g. azithromycin). These can also prolong the QTc interval. Administering several medications that may prolong the QT interval is associated with a high risk of complications.
In medicine risks and benefits must be balanced. Safety netting is important whenever there is a great potential benefit but also a very significant risk. In that context QTc intervals, renal and liver function must be monitored closely in patients treated with chloroquine and or macrolides. They should probably not be started if the baseline QTc is more than 450 ms. It should probably be stopped if the QTc increases 25% above baseline. It should definitely be stopped if QTc is above 500 ms. This is an evolving situation and recommendations may change as the potential risks and benefits become clearer.
Beta-blockade is used in the treatment of congenital and acquired long QT syndrome, so may be beneficial in this setting.
Rodolfo Vega Candelario
Thanks for your answer. Am I right to conclude that you consider the risk of using chloroquin alone without myocardial involvement during COVID-19 being negligeable?
Please see this article when considering treatment for Covid-19
Ventricular Arrhythmia Risk Due to Hydroxychloroquine-Azithromycin Treatment For COVID-19
https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-to-hydroxychloroquine-azithromycin-treatment-for-covid-19
congrats for this important question
I would also recommended the recently published paper in Heart Rhythm entitled SARS-CoV-2, COVID-19 and inherited arrhythmia syndromes
Francisco Marín and Andrei G Dan
thanks for your links and for the interest for my question. In my former medical activity, I was always guided by the latin proverb: QUIDQUID AGIS PRUDENTER AGAS ET RESPICE FINEM. Neglecting side ieffects has done great damage to the image of our profession.
If the baseline QTc is normal, the risk is negligible in a person with no structural heart disease. But the risk tends to be significantly higher in people with baseline QTc prolongation, structural heart disease, heart failure and who are receiving other drugs known to produce QT prolongation. Also, electrolyte abnormalities and several other conditions can increase the risk. The dose of HCQS is also important. The dose recommended for covid prophylaxis- 400 mg twice daily followed by 400 mg at weekly intervals is safe.
The software predicting drug-induced Torsades de Pointes arrhythmias is one of my core research areas for about four years now.
It can predict arrhythmias generated by Chloroquine and Hydroxychloroquine-Azithromycin treatments for COVID-19.
There is available a preprint of the paper dealing exactly with this topic "Application of Machine Learning and Complexity in Medicine: Prediction of Drug-Induced Arrhythmias in Rabbit Model up to One Hour Before Their Onset (early version requested due to COVID-19, unfinished methods & figures)"
https://www.researchgate.net/publication/340460356_Application_of_Machine_Learning_and_Complexity_in_Medicine_Prediction_of_Drug_Induced_Arrhythmias_in_Rabbit_Model_up_to_One_Hour_Before_Their_Onset_early_version_requested_due_to_COVID-19_unfinished_m
Please, feel free to read it and inform me when you have an interest in it. When you provide data in the form of one lead ECG recordings in the native format that were recorded hours before their onset, you can contribute to this research and save a lot of human lives.
It uses a complexity measure and AI to distill predictive characteristics from a database of ECG recordings.
The whole paper is written as the methodic one. It explains all aspects of this research in-depth.
https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-to-hydroxychloroquine-azithromycin-treatment-for-covid-19
Have a look at this article discussing risk of Q-T syndrome in patients with COVID-19 treated with Chloroquine, or hydroxychloroquine (1).
The risk is compounded by old age, comorbidities, ischemic heart disease and combination with macrolides, antidepressants, antipsychotics, antihistamines, and oselamivir.
1. Risk of QT Interval Prolongation Associated With Use of Hydroxychloroquine With or Without Concomitant Azithromycin Among Hospitalized Patients Testing Positive for Coronavirus Disease 2019 (COVID-19).
https://www.ncbi.nlm.nih.gov/pubmed/32356863
"The person who takes medicine must recover twice, once from the disease ,and once from the medicine.”
These are the wise words from father of modern medicine Sir William Osler.
There is need to remember the side-effects of the medications which are being used in the times of COVID-19 pandemic without any definite scientific evidence.
Yes, the risk of prolonged QT and sudden cardiac death by medications used to treat COVID-19. People have been created using these medications, and they know that they do not treat viruses, but only treat germs that cause a second injury and side effects it's dangerous.
Hydroxychloroquine (HCQ)/ Chloroquine (CQ) as well as Azithromycin are used in the treatment of COVID-19. These drugs increase QT interval. HCQ/CQ and Azithromycin should not be advised when baseline QTc is more than 450ms. It should have to be stopped when QTc increases 25% above baseline or QTc above 500ms. In the context of prolonged QTc interval, liver and renal function must have to be monitored closely in patients treated with HCQ/CQ and or macrolides. Otherwise, this might cause Torsade de Pointes or sudden cardiac death.
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