Off-label drug therapies in COVID-19 may lead to arrythmias

| Written by Padayon UP

Screenshot from the replay of "COVID-19 and the Heart", available on TVUP’s YouTube channel. (
Screenshot from the replay of “COVID-19 and the Heart”, available on TVUP’s YouTube channel.


The use of antivirals and antimalarials as off-label therapies in the treatment of COVID-19 may result in arrythmias or heartbeat irregularities, according to Dr. Chito Permejo, a UP Manila College of Medicine 2001 graduate who is a cardiology intensivist at the Philippine Heart Center.

In his talk, “COVID-19 and the Heart”, the eighth installment of UP’s STOP COVID DEATHS webinar series streamed on June 12, Permejo said these medications should be used with caution and extreme care in patients with preexisting cardiac issues who have contracted COVID-19. These drug therapies are linked to QTc interval prolongation, which may lead to arrythmias, including life-threatening torsades de pointes.


Screenshot of Dr. Chito Permejo in "COVID-19 and the Heart" from the replay on TVUP’s YouTube channel. (
Screenshot of Dr. Chito Permejo in “COVID-19 and the Heart” from the replay on TVUP’s YouTube channel.


The side effect of these drugs, along with COVID-19-related cardiac injury and the cytokine storm resulting from the body’s abnormal immune response, may be fatal and thus necessitates careful management and monitoring by doctors.

It is acknowledged that those with heart conditions are at a higher risk for severe illness if they are infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. Cardiac involvement figures prominently in the disease.

Based on the studies that Permejo has read, he enumerated the most likely causes of cardiac injury in COVID-19 patients: increased cardiac stress due to respiratory failure and hypoxemia or low oxygen levels in the blood; direct myocardial injury; indirect injury from systemic inflammatory response; or, the combination of all three. He revealed that studies have shown acute cardiac injury in COVID-19 patients, preceded by sepsis and acute respiratory distress syndrome.


Screenshot of Permejo's presentation slide in "COVID-19 and the Heart" showing the likely causes of cardiac injury in COVID-19 patients.
Screenshot of Permejo’s presentation slide in “COVID-19 and the Heart” showing the likely causes of cardiac injury in COVID-19 patients.


For those with co-morbidities in particular, he said the link between COVID-19 and angiotensin-converting enzyme 2 (ACE2) provides “a good theoretical mechanism for cardiac dysfunction.” While cellular ACE2 is associated with positive qualities, such as “vasorelaxation, cardioprotection, anti-oxidant, anti-inflammation, anti-Angiotensin II-induced signaling, and anti-fibrosis”, it is also the binding site of SARS-CoV-2, like SARS-CoV, because of the transmembrane protease serine 2 receptor.

ACE2 is found in the heart, brain, vessels, kidneys, testes, intestines, and lungs. It is expressed abundantly in the last two. Permejo posited, “ACE2 downregulation leads to cardiac dysfunction because they’re being used up by COVID-19.”

In the management of COVID-19 in patients with cardiac issues, he advised weighing drug potential against cardiovascular risk. He also emphasized the importance of regular diagnostics to monitor the patient’s condition and be alerted to a possible cardiac event.

To view Permejo’s “COVID-19 and the Heart” in full, go to this link.

The UP webinar series “STOP COVID DEATHS: Clinical Management Updates” is held in partnership with the Philippine Health Insurance Corporation (PhilHealth) and the UP Manila NIH National Telehealth Center. The series is scheduled every Friday from 12nn to 2pm, with the next webinar on July 3 focusing on “Rehabilitation for Critical Care Survivors of COVID19”. Dr. Celso F. Bate, physiatrist of The Medical City and VRP Medical Center, will be the guest speaker.

Register here:


(This was originally posted on the UP System website on July 2, 2020)