ritonavir and Myocarditis

The coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has been rapidly escalating, becoming a relevant threat to global health. Being a recent virus outbreak, there are still no available therapeutic regimens that have been approved in large randomised trials and so patients are currently being treated with multiple drugs. This raises concerns regarding drug interaction and their implication in arrhythmic burden. In fact, two of the actually used drugs against SARS-CoV2, such as chloroquine and the combination lopinavir/ritonavir, might determine a QT (the time from the start of the Q wave to the end of the T wave) interval prolongation and they show several interactions with antiarrhythmic drugs and antipsychotic medications, making them prone to an increased risk of developing arrhythmias. This brief review focuses the attention on the most relevant drug interactions involving the currently used COVID-19 medications and their possible association with cardiac rhythm disorders, taking into account also pre-existing condition and precipitating factors that might additionally increase this risk. Furthermore, based on the available evidence and based on the knowledge of drug interaction, we propose a quick and simple algorithm that might help both cardiologists and non-cardiologists in the management of the arrhythmic risk before and during the treatment with the specific drugs used against SARS-CoV2.

Topics: Adenosine Monophosphate; Alanine; Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Antiviral Agents; Arrhythmias, Cardiac; Chloroquine; COVID-19 Drug Treatment; Drug Combinations; Drug Interactions; Electrocardiography; Heart Failure; Humans; Hydroxychloroquine; Hypoxia; Inflammation; Long QT Syndrome; Lopinavir; Myocarditis; Myocardium; Precipitating Factors; Receptors, Interleukin-6; Respiratory Distress Syndrome; Ribavirin; Ritonavir; SARS-CoV-2; Water-Electrolyte Imbalance

Coronavirus disease 2019 (COVID-19) has been demonstrated to be the cause of pneumonia. Nevertheless, it has not been reported as the cause of acute myocarditis or fulminant myocarditis.. A 63-year-old male was admitted with pneumonia and cardiac symptoms. He was genetically confirmed as having COVID-19 according to sputum testing on the day of admission. He also had elevated troponin I (Trop I) level (up to 11.37 g/L) and diffuse myocardial dyskinesia along with a decreased left ventricular ejection fraction (LVEF) on echocardiography. The highest level of interleukin-6 was 272.40 pg/ml. Bedside chest radiographs showed typical ground-glass changes indicative of viral pneumonia. Laboratory test results for viruses that cause myocarditis were all negative. The patient conformed to the diagnostic criteria of the Chinese expert consensus statement for fulminant myocarditis. After receiving antiviral therapy and mechanical life support, Trop I was reduced to 0.10 g/L, and interleukin-6 was reduced to 7.63 pg/mL. Moreover, the LVEF of the patient gradually recovered to 68%. The patient died of aggravation of secondary infection on the 33rd day of hospitalization.. COVID-19 patients may develop severe cardiac complications such as myocarditis and heart failure. This is the first report of COVID-19 complicated with fulminant myocarditis. The mechanism of cardiac pathology caused by COVID-19 needs further study.

Topics: Acute Disease; Antiviral Agents; Bacteroides Infections; Betacoronavirus; Biomarkers; Candidiasis; Coronavirus Infections; COVID-19; Drug Combinations; Echocardiography; Fatal Outcome; Humans; Interleukin-6; Lopinavir; Male; Middle Aged; Myocarditis; Pandemics; Piperacillin, Tazobactam Drug Combination; Pneumonia, Viral; Ritonavir; SARS-CoV-2; Stroke Volume; Tomography, X-Ray Computed; Troponin I

Topics: Anti-HIV Agents; Arrhythmias, Cardiac; Autopsy; Coronary Angiography; Creatine Kinase; Deoxycytidine; Drug Combinations; Electrocardiography; Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination; Fatal Outcome; HIV Infections; Humans; Lopinavir; Magnetic Resonance Imaging, Cine; Male; Middle Aged; Muscular Diseases; Myocarditis; Myocardium; Organophosphorus Compounds; Pulmonary Edema; Ritonavir