Diagnostic utility of electrocardiogram for screening of cardiac injury on cardiac magnetic resonance in post-hospitalised COVID-19 patients: a prospective multicenter study.

BACKGROUND: The role of ECG in ruling out myocardial complications on cardiac magnetic resonance (CMR) is unclear. We examined the clinical utility of ECG in screening for cardiac abnormalities on CMR among post-hospitalised COVID-19 patients. METHODS: Post-hospitalised patients (n = 212) and age, sex and comorbidity-matched controls (n = 38) underwent CMR and 12­lead ECG in a prospective multicenter follow-up study. Participants were screened for routinely reported ECG abnormalities, including arrhythmia, conduction and R wave abnormalities and ST-T changes (excluding repolarisation intervals). Quantitative repolarisation analyses included corrected QT (QTc), corrected QT dispersion (QTc disp), corrected JT (JTc) and corrected T peak-end (cTPe) intervals. RESULTS: At a median of 5.6 months, patients had a higher burden of ECG abnormalities (72.2% vs controls 42.1%, p = 0.001) and lower LVEF but a comparable cumulative burden of CMR abnormalities than controls. Patients with CMR abnormalities had more ECG abnormalities and longer repolarisation intervals than those with normal CMR and controls (82% vs 69% vs 42%, p < 0.001). Routinely reported ECG abnormalities had poor discriminative ability (area-under-the-receiver-operating curve: AUROC) for abnormal CMR, AUROC 0.56 (95% CI 0.47-0.65), p = 0.185; worse among female than male patients. Adding JTc and QTc disp improved the AUROC to 0.64 (95% CI 0.55-0.74), p = 0.002, the sensitivity of the ECG increased from 81.6% to 98.0%, negative predictive value from 84.7% to 96.3%, negative likelihood ratio from 0.60 to 0.13, and reduced sex-dependence variabilities of ECG diagnostic parameters. CONCLUSION: Post-hospitalised COVID-19 patients have more ECG abnormalities than controls. Normal ECGs, including normal repolarisation intervals, reliably exclude CMR abnormalities in male and female patients.

A rash and a rare cause of unilateral diaphragmatic paralysis.

A 61-year-old man who was an ex-heavy smoker presented to our ambulatory care centre with a 4-week history of dyspnoea on mild exertion. 2 weeks prior to his symptoms, he had developed right-sided cervical herpes zoster for which he was prescribed oral acyclovir by his general practitioner. On examination, a rash over the right C4-5 dermatomes was noted and dullness on percussion of the right mid and lower zones with markedly reduced air entry. His chest radiograph showed a raised right hemi-diaphragm with associated right middle and lower lobe collapse. Further investigation with CT and bronchoscopy did not identify a cause and showed no evidence of underlying malignancy or endobronchial obstruction. An ultrasound 'sniff test' was performed to confirm diaphragmatic paralysis. We present a rare case of cervical herpes-induced diaphragmatic paralysis, and summarise our approach and the current understanding of this interesting condition.