Discussions
To our knowledge, this is the first study to investigate the correlation
between psychological distress and resting palpitations in patients
recovering from severe COVID-19. The major findings of the present study
are as follows: (1) symptom of resting palpitations is not uncommon
(8.3%) among patients recovering from severe COVID-19; (2) sinus
tachycardia is the most common (77.3%) arrhythmia in the recovered
patients with resting palpitations; (3) anxiety (68.2%) and depression
(59.1%) are also prevalent among these patients, and strong
correlations were observed between the psychological burden and the
frequency of palpitations episodes.
In this prospective cohort study, we found that 24 (8.3%) of 289
patients had resting palpitations symptoms. It should be noted that all
the included patients denied having previous similar episodes of
palpitations. Palpitations symptoms occurred during hospitalization and
remained after recovery from severe COVID-19.
Palpitation is a common symptom, and often poses a clinical challenge
due to the wide differential diagnosis 15. Cardiac
arrhythmias and psychological distress are the most common causes in
patients presenting with palpitations 8. The results
of two-hour resting ECG monitoring in this study showed that the large
majority of the enrolled patients (81.8%) had cardiac arrhythmias.
Among them, the most common was sinus tachycardia (77.3%). However,
patients with sinus tachycardia had a similar frequency of palpitations
episodes compared to those without sinus tachycardia, suggesting that
there might be other factors, in addition to sinus tachycardia,
affecting the palpitations episodes. All the recovered patients did not
have any active diseases that might cause sinus tachycardia, such as
thyroid dysfunction, haematological disorders, and severe heart failure
(left ventricular ejection fraction <30%). Nevertheless, it
was a pity that pulmonary function was not evaluated in the present
study since this examination was not opened to COVID-19 patients in our
hospital, even to those just recovered. Indeed, impaired pulmonary
function has been reported in recovered COVID-19 and severe acute
respiratory syndrome (SARS) patients, and affected patients’ exercise
capacity 16, 17. However, none of the enrolled
participants complained of any shortness of breath or dyspnea when they
were at rest. Therefore, we speculated that the effects of impaired
pulmonary function on the resting palpitations symptoms were negligible.
As described above, in addition to arrhythmias, psychological distress
is another common cause of palpitations. The prevalence of anxiety and
depression was detected by using HADS-A and HADS-D in this study,
respectively. The results showed that 68.2% of patients show anxiety
symptoms (HADS-A ≥ 8), while 59.1% show depression symptoms (HADS-D ≥
8). Given the relatively high mortality rate associated with this novel
disease, it was not surprising that substantial panic and stress were
caused in the early stage of COVID-19 outbreak. Actually, several
studies in China have investigated the mental problems in not only
COVID-19 patients 18, 19, but also those COVID-19
negative 20, and the healthcare workers21. They also reported that people in Wuhan or Hubei
province were prone to higher levels of psychological distress than
those in other regions of China 20. Female sex,
disease duration, levels of inflammatory markers and self-perceived
illness severity were proposed to be the factors that could predict the
severity of patients’ mental symptoms 19. In the
present cohort study, all patients recovered from severe COVID-19 in
Wuhan, China, with high incidence of various complications (54.5%) and
with very long hospital stay (median [IQR] 24 days [19-28
days]), which might lead to both physical deconditioning and
psychological distress.
Psychological distress, such as anxiety and depression-related
symptomatology, was frequent among patients with a complaint of
palpitation. Alijaniha et al. 9 showed that 85.4% of
the patients with palpitations had psychological disorders and this
frequency was twice that of the healthy group (43.6%). Another study
investigating the etiologies of palpitations suggested that up to a
third of the patients presenting with palpitations were finally
identified to be caused by psychological disorders 22.
On the other hand, symptom of resting palpitations was also one of the
most common somatic symptoms associated with anxiety and depression23. A recent study by Yuan et al. 24found that somatic symptoms are related to the levels of anxiety during
the early stage of the COVID-19 outbreak. Consistently with previous
studies, we have found that patients with anxiety/depression had a
higher frequency of palpitations episodes when compared to those
without. Moreover, a close positive correlation between the levels of
anxiety/depression and the frequency of palpitations episodes was
observed in the present study. These findings suggested that anxiety and
depression might be responsible, at least in part, for the resting
palpitations symptoms in recovered COVID-19 patients. Importantly, a
recent retrospective study from Mayo Clinic showed that anxiety and
depression are the most common comorbid conditions in patients with
inappropriate sinus tachycardia 25, proposing a
possible link between psychological distress and sinus tachycardia.