Megan Feeney, BCCCP, PharmD
Boston Medical Center
Boston, Massachusetts
Disclosure information not submitted.
Title: Oral Albuterol to Wean from Isoproterenol in the Setting of COVID-19 Induced Bradycardia
Case Report Body:
Introduction: Cardiovascular complications in the setting of Coronavirus 2019 (COVID-19) infection is now a well-known phenomenon however few have described bradycardia in the literature. Though the mechanism of COVID-19 induced bradycardia is not known, some hypotheses have been proposed. These include increased vagal tone due to increased intrathoracic pressure and inflammatory cytokines, direct toxic neurologic effects of SARS-CoV-2 disturbing autonomic control of heart rate, and modulation of cardiac function through angiotensin-converting-enzyme 2 (ACE-2) receptors on cardiac cells. The resulting bradycardia can progress to the requirement of vasopressors or ionotropic agents.
Description: We describe a COVID-19 positive 51-year-old male admitted for hypoxia and worsening respiratory status. Within 24 hours of admission, the patient’s heart rate declined from 78 beats per minute (bpm) to 49 bpm where it held steady. The patient remained bradycardic over the next few days, with lowest rates in the high 20s. When using incentive spirometry, the patient persistently experienced 6-8 second pauses accompanied by lightheadedness. Cardiology was consulted to help determine the cause of the patient’s symptomatic bradycardia. The best working theory presented was significant congestion and persistent cough leading to increased vagal tone. The patient was transferred to the medical intensive care unit (MICU) and an isoproterenol drip was initiated raising the patient’s heart rate from 41 to 82 within one hour. The patient continued to be dependent on the isoproterenol drip at 0.5-1 mcg/min over the coming days until it was decided to start oral albuterol at 4 mg every 6 hours. The patient’s heart rate at the time of the first dose of albuterol was 78 bpm. An hour after the first dose of albuterol was administered, the isoproterenol drip was shut off and the patient maintained his heart rate within 49-87 bpm until oral albuterol was weaned off over the next three days.
Discussion: COVID-19 leading to symptomatic bradycardia is a serious complication that may persist for the duration of COVID-19 symptoms or longer. If not properly managed, decreased quality of life and even cardiac arrest or death may occur. This case describes the successful use of oral albuterol to facilitate transition off of isoproterenol.