Covid-19 outbreak and arrhythmias
Currently, little is known about the psychological impact and mental health of the general public during the peak of the COVID-19 epidemic.1,2,3 This is especially pertinent with the uncertainty surrounding an outbreak of such unparalleled magnitude.
Wang and coworkers analyzed the psychological impact of COVID 19 epidemic in China and suggest that with respect to the initial psychological responses of the general public between 31 January and 2 February 2020, just two weeks into the country’s outbreak of COVID-19 and one day after the WHO declared a public health emergency of international concern, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% of respondents reported moderate to severe depressive symptoms; 28.8% of respondents reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. 7
Varshney M and coworkers reported a lower psychological impact of COVID-19. They found that 33.2% of respondents to the questionnaire showed significant (mild / moderate /severe) psychological impact regarding COVID-19. However, as these results were registered during the initial phase of the COVID-19 epidemic in the country, it is likely that they may have changed over time and should therefore be interpreted accordingly. 8
Depression, anxiety and post-traumatic stress symptoms are known risk factors for adverse events in patients with chronic heart disease. Interestingly, much less is known about the effect of stress on the incidence and course of arrhythmias.
Baldi and coworkers found an increased number of out of hospital cardiac arrests in northern Italy that matched the same geographical areas most harshly affected by the pandemia. [9] A significant increase in SCD events (58%) was reported in this region and these investigators attribute this spike to late complications of myocardial infract or ischemia, as patients were more likely to remain at home and avoid hospitalization for fear of COVID-19 infection. 9
Similarly, a significant reductions in the overall number of hospital admissions in patients presenting with acute coronary syndromes has been reported. 10,11
The responses to chronic stress also include a number of modifying lifestyle behaviors such as increased alcohol consumption, heavier smoking, and diet high in sugar and fat. 2,12 Together with sedentary lifestyle these unhealthy changes in diet contribute to excess energy intakes and weight gain. Unhealthy lifestyle increases oxidative stress and inflammation. 2,12 When subjects respond to stress by eating more, substantial anecdotal evidence suggests the foods selected are typically high in sugar and fat. This phenomenon has been described as “Food craving”. Food craving has been defined as a multidimensional experience since it includes cognitive (e.g., thinking about food), emotional (e.g., desire to eat), behavioral (e.g., seeking and consuming food), and physiological (e.g., salivation) aspects. 12,13 Food craving can be associated with a reduced intake of fruit and vegetables. However, a plant-based diet, rich in anti-inflammatory and anti-oxidative components, has been shown to significantly affect the most common cardiovascular risk factors in a positive way.
Sedentary life also contributes to an increase in cardiovascular risk.
While the positive effects of exercise are well studied also in the elderly less attention was dedicated to the impact of detraining in the elderly, although the worsening of dynamic balance found in patients aged 75 as a consequence of a 3-month period of detraining may have an impact not only on quality of life but also on exercise-induced cardiovascular adaptations and probably stress-induced arrhythmogenesis.2,14
We expect an increase in arrhythmic phenomena following quarantine due to higher stress levels and an unhealthy lifestyle that heightens the overall cardiovascular risk factor. In addition, stress related to quarantine induces a change in lifestyle and nutritional habits:, which is mainly due to reduced availability of goods, limited access to food, and reduction of outdoor physical activity. (figure 1)