The Prognostic Value of Electrocardiogram at Presentation to Emergency Department in Patients With COVID-19

Elias, Pierre; Poterucha, Timothy J.; Jain, Sneha S.; Sayer, Gabriel; Raikhelkar, Jayant; Fried, Justin; Clerkin, Kevin; Griffin, Jan; DeFilippis, Ersilia M.; Gupta, Aakriti; Lawlor, Matthew; Madhavan, Mahesh; Rosenblum, Hannah; Roth, Zachary B.; Natarajan, Karthik; Hripcsak, George; Perotte, Adler; Wan, Elaine Y.; Saluja, Deepak; Dizon, Jose; Ehlert, Frederick; Morrow, John P.; Yarmohammadi, Hirad; Kumaraiah, Deepa; Redfors, Bjorn; Gavin, Nicholas; Kirtane, Ajay; Rabbani, Leroy; Burkhoff, Dan; Moses, Jeffrey; Schwartz, Allan; Leon, Martin; Uriel, Nir

ABSTRACT Background Rapid risk stratification is essential during the COVID-19 pandemic. We aimed to study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication. Methods 1,258 adults with COVID-19 seen at three hospitals in New York in March and April 2020 were analyzed. ECGs at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs. Results At 48 hours, 73 patients (6%) had died and 174 (14%) were alive but receiving mechanical ventilation with 277 (22%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (OR 2.5, 95% CI [1.1-6.2]), right ventricular strain (OR 2.7, 95% CI [1.3-6.1]), and ST segment abnormalities (OR 2.4, 95% CI [1.5-3.8]) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 and saturation >95%), only 5 (5%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31%) having both ECG and respiratory vital sign abnormalities. Conclusions The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with COVID-19 and may assist with patient triage.