New arrhythmias
Of the study cohort, 28/390 patients (7.2%) presented or developed new
arrhythmias during hospitalization (Table 2). Seven of these 28 patients
(25%) had previous documented arrhythmias. There were 3 cases of
bradyarrhythmias and 25 tachyarrhythmias. The first bradyarrhythmic
patient was a 92-year-old woman who presented with complete AV block
associated with a QT of 550 ms and normal electrolytes; the second case
was a 51-year-old man who presented with 2:1 AV block with left bundle
branch block (LBBB) and developed complete AVB within hours from his
admission. Notably, the patient had narrow complex QRS on a clinic visit
two years earlier. Both patients did not receive any negative
dromotropic drugs; laboratory examinations revealed normal electrolytes,
mildly elevated hsTnI (100 and 83 ng/L, respectively; normal values for
men women < 35ng/L and 20ng/L, respectively) and elevated CRP
(15 and 4.5 mg/dl, respectively; normal value < 0.5 mg/dL).
Both had pacemakers implanted during their index hospitalization. A
third patient was a 33 year-old man who presented in sinus rhythm
without any conduction abnormality and who developed on day 2 transient
sinus bradycardia with slow ventricular escape rhythm that resolved
within a few hours (Figures 1A and 1B). Notably, the patient’s
O2 saturation at that time was 84% and later rose to
90%, his electrolytes were normal and no drugs with negative
chronotropic effects were given. Laboratory examinations revealed
elevated CRP of 16.58 mg/dl and normal hsTnI (10 ng/L).
There were 25 patients with new tachyarrhythmias: 24 of them had new
atrial tachyarrhythmias including 20 with paroxysmal AF. Of the 24
patients with atrial tachyarrhythmias, 7 had a prior history of similar
arrhythmias. Notably, during his index hospitalization, one of these
patients with new-onset AF also had a documented ventricular
fibrillation which was successfully cardioverted (Table 2). This patient
did not have prolonged QT and his electrolytes were normal; however, he
did have elevated hsTnI of 7049 ng/L and mildly elevated CRP (6.8
mg/dl). Three patients had atrial flutter and 1 patient had an SVT
episode (narrow complex regular tachycardia of 195 bpm seen on monitor
and terminated with a Valsalva maneuver). Lastly, there was a patient
with ventricular tachycardia (VT) storm (Table 1). This patient had an
ischemic cardiomyopathy for which he was previously implanted with an
ICD. He presented with normal sinus rhythm, however, a week later had
respiratory deterioration necessitating mechanical ventilation. He was
transferred to ICU where he developed ventricular bigeminy (Figures 1 C
and 1D) which deteriorated within an hour to recurrent monomorphic VT
episodes. The patient received multiple ICD therapies and his VT’s
eventually resolved after intravenous lidocaine and amiodarone. Notably,
the patient did not receive ionotropic medications, his QTc was stable
around 480 ms and electrolytes were normal, hsTnI increased to 17,578
ng/L and his maximal CRP was 16.58 mg/dL. Importantly, none of the new
arrhythmias were discovered by Holter.