# Noninvasive Ambulatory Electrocardiographic Markers from Patients with COVID-19 Pneumonia: A Report of Three Cases

## TL;DR

This paper reports three cases where noninvasive ambulatory ECG markers were found in COVID-19 patients who later died, suggesting these markers could predict risk early in the disease.

## Contribution

Identifies potential early electrocardiographic risk markers for mortality in COVID-19 patients without structural heart disease.

## Key findings

- Positive late potentials and T-wave alternans were observed in all three patients.
- Abnormal heart rate variability and heart rate turbulence were detected in early stages of admission.
- All three patients died from respiratory failure despite no significant structural heart disease.

## Abstract

Coronavirus disease 2019 (COVID-19) has affected medical practice. More than 7,000,000 patients died worldwide after being infected with COVID-19; however, no specific laboratory markers have yet been established to predict death related to this disease. In contrast, electrocardiographic changes due to COVID-19 include QT prolongation and ST-T changes; however, there have not been studies on the ambulatory electrocardiographic markers of COVID-19. We encountered three patients diagnosed as having COVID-19 who did not have a prior history of significant structural heart diseases. All patients had abnormalities in ambulatory echocardiogram parameters detected by high-resolution 24 h electrocardiogram monitoring: positive late potentials (LPs) and T-wave alternans (TWA), abnormal heart rate variability (HRV), and heart rate turbulence (HRT). Case 1 involved a 78-year-old woman with a history of chronic kidney disease, Case 2 involved a 76-year-old man with hypertension and diabetes, and Case 3 involved a 67-year-old man with renal cancer, lung cancer, and diabetes. None of them had a prior history of significant structural heart disease. Although no significant consistent increases in clinical markers were observed, all three patients died, mainly because of respiratory failure with mild heart failure. The LP, TWA, HRV, and HRT were positive in all three cases with no significant structural cardiac disease at the initial phase of admission. The further accumulation of data regarding ambulatory electrocardiographic markers in patients with COVID-19 is needed. Depending on the accumulation of data, the LP, TWA, HRV, and HRT could be identified as potential risk factors for COVID-19 pneumonia in the early phase of admission.