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

As COVID-19 continues to affect the public, healthcare providers are routinely modifying care pathways to provide better treatment for individuals with the infection. ECG is a critical part of the process, but ensuring this diagnostic exam is as accurate as possible can present a challenge, especially if the COVID-19 patient is in respiratory distress.

A prior history of cardiovascular disease is one of the main risk factors for COVID-19 mortality among affected patients, and COVID-19 may exacerbate preexisting heart conditions, adding to the burden of care clinicians must face. Performing an ECG also raises the risk of cross-infection among medical personnel, so physicians should carefully determine when and if ECG is necessary in the course of caring for patients.

Recommendations for ECG Monitoring in COVID-19 Patients

When providers are considering the timing of ECG, it is important to confirm a COVID-19 diagnosis first so that proper resources, such as face masks, may 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 life of the patient

Baseline ECG, which should be obtained upon admission, provides valuable information about a COVID-19 patient's cardiac health and can be extremely beneficial in evaluating response to treatment later on. While clinicians should ultimately use their best judgment to determine how frequently an ECG should be performed, some guidance from AMITA Health may prove useful:

Perform an ECG two to four hours after administration of the second dose of hydroxychloroquine (if used in treatment).
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.

Hydroxychloroquine and Electrophysiological Changes

To date, physicians have noted potentially significant electrophysiological changes associated with COVID-19 and therapies used to combat the disease. According to a recent report in JAMA Cardiology, the administration of hydroxychloroquine places patients at increased risk for cardiac arrhythmias, most notably QTc prolongation and, more rarely, torsades de pointes. When combined with azithromycin, QTc prolongation may be significantly worse.

On June 15, 2020, the US Food and Drug Administration (FDA) revoked the Emergency Use Authorization for hydroxychloroquine based on known cardiac rhythm changes and other findings suggesting that the medication provides no tangible benefit, such as decreased risk of mechanical ventilation, to COVID-19 patients.

Now that this medication is being phased out of treatment regimens, clinicians will need to leverage ECG continually to monitor any cardiac abnormalities associated with alternative or future therapies.

6-Lead vs. 12-Lead ECG

The FDA has cleared several remote 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. 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 also receiving medications which may prolong the QT interval.

While personal ECG devices may prove useful in certain situations during the COVID-19 era, 12-lead ECG monitoring is still standard, as it provides information in three orthogonal directions and generally gives more detailed insights regarding arrhythmias. With that said, using a 12-lead ECG comes with certain risks, most notably machine contamination and the risk of COVID-19 exposure for ECG technicians.

Maximizing ECG Quality

COVID-19 patients may present in respiratory distress, which could affect the quality of any ECG performed. ECG quality is 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 prevent the patient from speaking 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 the procedure. A practice guidelines report in the journal Heart Rhythm details precautions for all electrophysiological procedures, including ECG:

All healthcare providers should 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, this should include assisting cardiac patients by using telemedicine technologies that allow clinicians to monitor data and review test results.
Personal protective equipment, including a gown, gloves, face mask, and protective eyewear, should be utilized for all patient contact. If an N95 face mask is unavailable due to supply chain issues, providers may use a surgical mask and face shield in its place.
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. 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.

Continue to Provide Safe, Timely Care

The pandemic has reinforced the importance of ECG as a diagnostic tool, 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.

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