Electrocardiogram Analysis in COVID-19 Patients

In the early months of 2020, SARS-CoV-2 virus infection quickly spread around the world to a
pandemic. On 2 April 2020, confirmed cases of coronavirus disease 2019 (COVID-19) worldwide
exceeded one million and an unprecedented health crisis has occurred in recent history.

SARS-CoV-2 disease can lead to the development of even severe pneumonia with the need for
ventilatory support and in some cases fatal outcome.

From the data currently present in the literature, important relationships emerge between
infection and cardiovascular diseases. COVID-19 patients with underlying pre-existing heart
disease or cardiovascular risk factors have a more severe course of the disease and are more
at risk of adverse outcomes and death than individuals with no history of heart disease or
risk factors.

During the course of the infection, some patients even without previous heart disease may
experience myocardial injury and this leads to a significant increase in in-hospital
mortality. Myocardial pain during SARS-CoV-2 infection is associated with cardiac dysfunction
and arrhythmias.

To date, there are no data on the role of the electrocardiogram neither in the diagnosis of
cardiac involvement nor in predicting the prognosis of patients with SARS-CoV-2 infection.

Whether there are basal electrocardiographic features capable of correlating with the course
of the disease and the prognosis is currently unknown. The development of
electrocardiographic changes during the course of the disease and their possible prognostic
significance has not currently been described.

The present study involves three different phases of evaluation of the electrocardiographic
(ECG) traces of hospitalized patients with SARS-CoV-2 infection.

- Phase 1: it is proposed to collect and retrospectively analyze the ECGs of hospitalized
patients with severe SARS-CoV-2 infection which led to invasive ventilation or patient
death as a consequence and, if available, also possible troponin dosage;

- Phase 2: aims to collect and analyze the ECGs of consecutive hospitalized patients with
SARS-CoV-2 infection and evaluate their relationship with the course of the disease,
cardiac involvement and prognosis;

- Phase 3: it is proposed to repeat ECG and to carry out echocardiogram to patients with
SARS-CoV-2 infection after 3 months from hospital discharge by simultaneously
performing, if deemed clinically indicated, also cardiac magnetic resonance. In this
phase, any evolutions of ECG alterations of the acute phase will be described and the
relationship with cardiac involvement will be assessed.

Phase 1 Retrospective, multicentric, cohort study Phase 2 and 3 prospective, multicentric,
cohort study

Phase 1:

• Describe the ECG characteristics in patients presenting with severe form of SARS-CoV-2
infection

Phase 2:

- To evaluate the correlation between ECG signs and cardiac involvement in the acute phase

- Assess the correlation between ECG signs and mortality/invasive mechanical ventilation
in the acute phase secondary:

- To evaluate the prevalence of ECG changes in the enrolled population

- Analyze the prevalence of various cardiovascular risk factors in the enrolled population

- Examine the impact of ECG changes on the short-term prognosis

- Explore new possible prognostic risk factors

Phase 3:

- To evaluate the correlation between acute phase ECG signs and chronic phase cardiac
involvement

- To evaluate the appearance, in the short-term follow-up, of signs of cardiac involvement
(cardiomyopathies and conduction disorders in particular)

Data collected:

- demographic characteristics

- cardiovascular risk factors

- comorbidities

- blood tests including cardiac markers (troponin, BNP) collected in multiple points if
available

- radiographic examinations and echocardiogram (if performed)

- ECG traces performed at onset, worsening and / or troponin peak

- length of hospital stay

- treatments administered

- complications

- clinical outcome

Enrolled patients will be followed clinically until the day of discharge as per care
practice. A 3-month follow-up is foreseen to evaluate the outcome and repeat the ECG. At the
discretion of the clinician who manages the patient, transthoracic echocardiogram and / or
cardiac magnetic resonance imaging will also be performed.

A formal calculation of the sample size is not possible due to the total lack of data.
Furthermore, since it is an observational project, the calculation of the sample size is not
mandatory. However, based on similar studies, it is believed that the minimum samples for the
various phases are:

80 patients for Phase 1 study objectives, 800 patients for Phase 2 study objectives and 300
patients for Phase 3 study objectives