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Wide QRS Complex Transient Pattern in a Patient With Severe COVID-19

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1 Credit CME

A patient in their 60s presented to the emergency department with shortness of breath for a duration of 2 days. The patient had no known medical history and was not vaccinated against the COVID-19 virus. On admission, the patient’s COVID-19 test result was positive, with computed tomography pulmonary angiography results revealing multifocal opacities that were consistent with COVID-19 pneumonia, but no pulmonary embolism. The patient had an unremarkable electrocardiogram (ECG) and echocardiogram results during the first few days of hospitalization. The patient’s illness progressed, and they developed acute respiratory distress syndrome that required intubation and proning. The patient’s course was also complicated by acute kidney failure, ultimately requiring them to undergo hemodialysis. On day 11, the intensive care team noted unusual changes in the patient’s telemetry results (frontal leads II and III) (Figure, A).

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The differential for the widening of the QRS waveform with sinus rhythm includes aberrant conduction, hyperkalemia, accessory pathway conduction, and ischemia. Widening of QRS may also be seen in the antiarrhythmic use of class 1 sodium blockers. Aberrant conduction may occur during atrial tachycardias without adequate time for repolarization of part of the conduction system, which is followed by broader QRS complexes. In this patient with normal baseline ECG results and no known prior conduction disease during a stable sinus rate, it is unlikely aberrant conduction. The transient nature of this rhythm without characteristic peaked T waves and other features, such as PR prolongation, P-wave flattening, or bradycardia, makes hyperkalemia unlikely as the mechanism, and potassium levels were confirmed to be normal. Enhanced accessory pathway conduction may manifest at different heart rates, especially when there is variable conduction velocity within the atrioventricular node, which can result in variability of the QRS duration. However, there was less concern for preexcitation without evidence of a δ wave in this patient. Additionally, this patient was not receiving antiarrhythmic therapy for any effects by sodium channel blockade resulting in QRS widening.

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Article Information

Corresponding Author: Richard Pham, MD, 11100 Euclid Ave, Cleveland, OH 44106 (rpham201@gmail.com).

Published Online: March 4, 2023. doi:10.1001/jamainternmed.2022.6462

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented at the Annual Scientific Session and Expo of the American College of Cardiology; March 4, 2023; New Orleans, Louisiana.

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