Implications of Atrial Fibrillation on the Clinical Course and Outcomes of Hospitalized COVID-19 Patients

Results of rhe Cardio-COVID-italy Multicentre Study

Sara Paris; Riccardo M. Inciardi; Carlo Mario Lombardi; Daniela Tomasoni; Pietro Ameri; Valentina Carubelli; Piergiuseppe Agostoni; Claudia Canale; Stefano Carugo; Giambattista Danzi; Mattia Di Pasquale; Filippo Sarullo; Maria Teresa La Rovere; Andrea Mortara; Massimo Piepoli; Italo Porto; Gianfranco Sinagra; Maurizio Volterrani; Massimiliano Gnecchi; Sergio Leonardi; Marco Merlo; Annamaria Iorio; Stefano Giovinazzo; Antonio Bellasi; Gregorio Zaccone; Rita Camporotondo; Francesco Catagnano; Laura Dalla Vecchia; Gloria Maccagni; Massimo Mapelli; Davide Margonato; Luca Monzo; Vincenzo Nuzzi; Andrea Pozzi; Giovanni Provenzale; Claudia Specchia; Chiara Tedino; Marco Guazzi; Michele Senni; Marco Metra


Europace. 2021;23(10):1603-161. 

In This Article

Abstract and Introduction


Aims: To assess the clinical relevance of a history of atrial fibrillation (AF) in hospitalized patients with coronavirus disease 2019 (COVID-19).

Methods and Results: We enrolled 696 consecutive patients (mean age 67.4 ± 13.2 years, 69.7% males) admitted for COVID-19 in 13 Italian cardiology centres between 1 March and 9 April 2020. One hundred and six patients (15%) had a history of AF and the median hospitalization length was 14 days (interquartile range 9–24). Patients with a history of AF were older and with a higher burden of cardiovascular risk factors. Compared to patients without AF, they showed a higher rate of in-hospital death (38.7% vs. 20.8%; P < 0.001). History of AF was associated with an increased risk of death after adjustment for clinical confounders related to COVID-19 severity and cardiovascular comorbidities, including history of heart failure (HF) and increased plasma troponin [adjusted hazard ratio (HR): 1.73; 95% confidence interval (CI) 1.06–2.84; P = 0.029]. Patients with a history of AF also had more in-hospital clinical events including new-onset AF (36.8% vs. 7.9%; P < 0.001), acute HF (25.3% vs. 6.3%; P < 0.001), and multiorgan failure (13.9% vs. 5.8%; P = 0.010). The association between AF and worse outcome was not modified by previous or concomitant use of anticoagulants or steroid therapy (P for interaction >0.05 for both) and was not related to stroke or bleeding events.

Conclusion: Among hospitalized patients with COVID-19, a history of AF contributes to worse clinical course with a higher mortality and in-hospital events including new-onset AF, acute HF, and multiorgan failure. The mortality risk remains significant after adjustment for variables associated with COVID-19 severity and comorbidities.


The novel coronavirus disease (COVID-19) outbreak, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is deeply influencing worldwide healthcare systems with more than 120 million affected people as of March 2021.[1]

Interstitial pneumonia and acute respiratory distress syndrome represent the most common clinical manifestations.[1] It has been also shown that the cardiovascular (CV) system is often involved and subjects with previous CV disease are at a higher risk of worse events.[2] Atrial fibrillation (AF) represents a well-known CV risk factor and cause of mortality in the general population. Nevertheless, its prevalence and clinical meaning have been less described in COVID-19 patients. Few studies showed that atrial arrhythmias may be a sign of cardiac involvement in COVID-19 disease,[3] and sinus rhythm at admission in COVID-19 patients has been shown to be associated with better prognosis compared with AF rhythm.[4] Also, new-onset AF can occur as a relevant clinical event during the in-hospital course of patients with COVID-19, but its incidence has not been well explored in large cohorts of affected patients.

The aim of our report is to evaluate the clinical and prognostic meaning of pre-existing AF and to assess the incidence of new-onset AF during the clinical course of COVID-19 in patients enrolled in the Cardio-COVID-Italy study, a multicentre retrospective, observational study.[5]