New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.
Related Articles: Diagnostic ECG
Considering the impact COVID-19 has been shown to have on the cardiovascular system, cardiac disease management remains a key focus. ECG is a critical part of the process, but ensuring this diagnostic exam does not expose patients and providers to cross-infection in the acute phase can present a challenge, especially if the COVID-19 patient is in respiratory distress and being transferred quickly.
A prior history of cardiovascular disease is one of the main risk factors for COVID-19 mortality among affected patients. COVID-19 may exacerbate preexisting heart conditions, adding to the burden of care. Physicians should carefully determine when and if ECG is necessary in the course of caring for COVID-19 patients.
Recommendations for ECG Monitoring in Acute COVID-19
When providers are considering the timing of ECG, it is important to confirm a COVID-19 diagnosis first so that proper personal protective equipment can be utilized. While exact guidance concerning the timing and frequency of ECG is still unclear, physicians should prioritize ECG for patients in certain scenarios, including:
- When the patient's symptoms are particularly severe or rapidly worsening
- When the patient is at high risk of permanent dysfunction of an organ system or extremity
- When postponing the procedure may threaten the patient's life
A baseline ECG, which should be obtained upon admission, provides valuable information about a COVID-19 patient's cardiac health. This baseline can also help with evaluating response to various treatments later on. While clinicians should ultimately use their best judgment to determine how frequently ECG should be utilized, some guidance from AMITA Health may prove useful:1
- If the patient is on telemetry, check their QTc every day.
- If the patient is not on telemetry, daily ECGs may be helpful in evaluating their response to treatment and in identifying arrhythmias early.
- A final ECG should be performed before the patient is discharged.
COVID-19 exposure for ECG technicians.
Maximizing ECG Quality
Acute COVID-19 patients may present in respiratory distress, which could affect the quality of any ECG performed. ECG quality can be influenced by many factors, including:
- Body position
- Breathing rate
- Retractions
- Sweating
If a patient is in respiratory distress, good skin preparation and proper placement of electrodes may help to minimize waveform artifacts. Electrodes with conductive gel may be preferred over standard electrodes, but neither should be placed over bony prominences. It is important to reduce patient movements as much as possible and ask the patient not to speak during the examination.
Other Safety Tips
Certain steps should be taken to minimize technician exposure to COVID-19, including thoroughly disinfecting all ECG equipment immediately after use. Practice guidelines published in the journal Heart Rhythm detail precautions for all electrophysiological procedures, including ECG:8
- All healthcare providers should continue to maintain a high degree of suspicion with regard to COVID-19 infection for any and all patients.
- Contact between providers and patients positively diagnosed with COVID-19 should be minimized, and social distancing guidelines should be followed. Wherever possible, utilize telemedicine options that allow clinicians to monitor data and review test results.
- ECG procedures should be triaged according to the risk to the patient.
- Use disinfectants approved by the US Environmental Protection Agency on all ECG machines, including connecting wires, amplifiers, and storage and transmission devices.9 Whenever possible, use single-use ECG wires and diagnostic electrodes that allow for easy disposal.
- If possible, schedule the COVID-19 patient as the last case of the day to ensure proper cleaning and disinfection of the examination room after the procedure is completed.
ECG: Is Remote Monitoring an Option?
The FDA has cleared several remote ECG monitoring devices to detect arrhythmias and measure QTc prolongation, including the KardiaMobile 6L by AliveCor (which uses only six ECG leads) as well as PhysiolGuard, VSMS ECG Patch, and VitalPatch Biosensor.2,3,4,5 According to the FDA, devices like the KardiaMobile 6L should only be used to measure QTc in the specific case where a patient is diagnosed with COVID-19 and is also receiving medications that may prolong the QT interval.
A few other promising remote ECG monitoring devices are still in development. The portable D-Heart smartphone-operated ECG device, which has not been cleared by the FDA, was evaluated in a study published in the European Heart Journal in nonhospitalized patients with COVID-19.6 Home monitoring with the device identified disease-related cardiac complications and significant QTc prolongation in some patients. The presence of ECG abnormalities also helped to predict the risk of being hospitalized within the first 10 days, researchers found.
Home-based physiological monitoring can help "stem the flow of patients to the hospital during the pandemic," according to researchers writing in the Southwest Journal of Pulmonary, Critical Care & Sleep. However, these devices "require additional evidence related to improvement in patient outcomes."7 This assessment looked at not only remote ECG devices, but also at-home monitoring of respiratory rate, pulse oximetry, temperature, and glucose.
While personal ECG devices may prove useful in monitoring patients outside the hospital, 12-lead ECG is still the gold standard. A 12-lead reading provides information in three orthogonal directions and offers more detailed insights regarding arrhythmias.
Continue to Provide Safe, Timely Care
With proper precautions in place, ECG monitoring can be a vital source of information for COVID-19 patients' care teams. In a separate study in Heart Rhythm, researchers from Yale University implemented enhanced ECG monitoring of patients with COVID-19 using a system that tagged ECGs with QT prolongation.10 Of all ECGs obtained, 19.7% had QT prolongation, triggering appropriate interventions. Arrhythmias were rarely observed, and no patients developed torsades de pointes.
The pandemic has reinforced the importance of ECG as a diagnostic tool in cardiac disease management, especially since preexisting cardiovascular issues appear to increase the risk of profoundly negative outcomes. When an ECG is warranted during clinical care, taking steps to protect clinicians and disinfect equipment can help reduce the risk of COVID-19 contamination and exposure. Please continue to follow the latest practice guidelines to help ensure the safety of your team and your patients.
References:
1. AMITA Health. Cardiac monitoring and QTc assessment guidelines. AmitaHealth.org. https://www.amitahealth.org/assets/documents/covid-19-playbook/amita-covid-19-cardiac-monitoring-and-qtc-assessment-guidelines-4-9-2020rev-final.pdf. Accessed April 27, 2022.
2. AliveCor. New FDA guidance allows use of KardiaMobile 6L to measure QTc in COVID-19 patients. AliveCor.com. https://www.alivecor.com/press/press_release/new-fda-guidance-allows-use-of-kardiamobile-6l-to-measure-qtc-in-covid-19-patients/. Accessed April 27, 2022.
3. US Food and Drug Administration. Fact sheet for healthcare providers: PhysiolGuard ECG-QT analysis system. FDA.gov. https://www.fda.gov/media/137691/download. Accessed April 27, 2022.
4. US Food and Drug Administration. FDA.gov. https://www.fda.gov/media/138105/download. Accessed April 27, 2022.
5. US Food and Drug Administration. FDA.gov. https://www.fda.gov/media/137397/download. Accessed April 27, 2022.
6. Maurizi N, Fumagalli C, Cecchi F, Olivotto I. Use of smartphone-operated ECG for home ECG surveillance in COVID-19 patients. European Heart Journal – Digital Health. January 2021; 2(1): 175-178. https://academic.oup.com/ehjdh/article/2/1/175/6123744
7. Warrier A, Sood A. Home-based physiological monitoring of patients with COVID-19. Southwest Journal of Pulmonary, Critical Care & Sleep. September 2021; 23(3): 76-88. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8452235/
8. Lakkireddy DR, Chung MK, Gopinathannair R, et al. Guidance for cardiac electrophysiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Heart Rhythm. April 2020; 17(9): e233-e241. https://www.heartrhythmjournal.com/article/S1547-5271%2820%2930289-7/fulltext
9. US Environmental Protection Agency. About list N: disinfectants for coronavirus (COVID-19). EPA.gov. https://www.epa.gov/coronavirus/about-list-n-disinfectants-coronavirus-covid-19-0. Accessed April 27, 2022.
10. Jain S, Workman V, Ganeshan R, et al. Enhanced electrocardiographic monitoring of patients with coronavirus disease 2019. Heart Rhythm. May 2020; 17(9): 1417-1422. https://www.heartrhythmjournal.com/article/S1547-5271(20)30421-5/fulltext
