Presidents of leading cardiac organisations, including the American Heart Association (AHA), the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS), have published a statement that cautions against the use of hydroxychloroquine and azithromycin for the treatment of COVID-19.
Hydroxychloroquine is an oral prescription drug that has been used for the treatment of malaria and certain inflammatory conditions. It is currently under investigation in clinical trials for pre-exposure or post-exposure prophylaxis of SARS-CoV-2 infection, and treatment of patients with mild, moderate, and severe COVID-19. Azithromycin is an antibiotic that iswidely used to treat chest infections.
The guidance paper, published today in the AHA journal Circulation, notes that both drugs are listed as definite causes of torsade de pointes and arrhythmia. Therefore, it advises against their usage.
Thepaper has been co-authored by Dan Roden (Vanderbilt University, Nashville, USA), as well as the AHA president Robert Harrington (Stanford University, Stanford, USA), ACC president Athena Poppas (Brown University School of Medicine, Providence, USA) and HRS president Andrea Russo (Rowan University, Camden, USA). In addition to being published in Circulation, it will be subsequently published in the Journal of the American College of Cardiology (JACC), and the Heart Rhythm Journal (HRJ) The AHA, the ACC and the HRS guidance for healthcare professionals includes additional mechanisms to reduce the risk of arrhythmias. Steps outlined include:
- Electrocardiographic/QT interval monitoring;
- Withhold hydroxychloroquine and azithromycin in patients with baseline QT prolongation (e.g. QTc ≥500 msec) or with known congenital long QT syndrome;
- Monitor cardiac rhythm and QT interval; withdrawal of hydroxychloroquine and azithromycin if QTc exceeds a present threshold of 500 msec;
- In patients critically ill with COVID-19 infection, frequent caregiver contact may need to be minimised, so optimal electrocardiographic interval and rhythm monitoring may not be possible;
- Correction of hypokalaemia >4mEq/L and hypomagnesemia >2mg/dL; and
- Avoid other QTc prolonging agents whenever feasible.
The statement also includes a table rating potential adverse cardiac events of medications currently being repurposed for COVID-19 treatment, such as chloroquine and lopinavir/ritonavir (antimalarial and antiviral agents, respectively).
“The urgency of COVID-19 must not diminish the scientific rigor with which we approach COVID-19 treatment. While these medications may work against COVID-19 individually or in combination, we recommend caution with these medications for patients with existing cardiovascular disease,” says Harrington in a press statement.
Poppas, who took the ACC presidency last month, comments: “We are united in our mission to achieve optimal, quality care for our patients, and we must continue to be vigilant in assessing the potential complications of all medications during this crisis.”
“Given the potential for increased risks related to combinations of medications that prolong the QT interval, we urge careful consideration to ensure patients with cardiovascular disease or others at increased risk can be monitored appropriately,” states Russo.