{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,25]],"date-time":"2026-07-25T22:08:38Z","timestamp":1785017318752,"version":"3.55.0"},"reference-count":12,"publisher":"Oxford University Press (OUP)","issue":"FI1","license":[{"start":{"date-parts":[[2020,7,1]],"date-time":"2020-07-01T00:00:00Z","timestamp":1593561600000},"content-version":"vor","delay-in-days":1,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,10,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>COVID-19 infection is the most serious global public health crisis of the century. With no approved treatments against it, investigational treatments are being used despite limited safety data. Besides being at higher risk of complications of COVID-19 infection, patients with underlying cardiovascular disease are more likely to develop cardiac-related side effects of treatment. We present a case of sinus arrest with junctional escape related to lopinavir\u2013ritonavir.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Case summary<\/jats:title>\n                  <jats:p>A 67-year-old man, with underlying stable ischaemic heart disease, acquired COVID-19 infection. He had a prolonged duration of fever and cough. He subsequently developed acute respiratory distress and required intensive care unit (ICU) care. Given his severe infection, he was started on lopinavir\u2013ritonavir. Hydroxychloroquine was not used as he had a prolonged QTc interval. During observation in the ICU, the patient developed recurrent episodes of sinus arrest with junctional escape. Initial concerns were of myocarditis, but he had no ST-segment changes on ECG, with mild elevations of highly sensitive troponin I and a normal transthoracic echocardiogram. A multidisciplinary team discussion involving the intensivist, infectious disease physicians, and cardiologist; the decision was made to stop treatment with lopinavir\u2013ritonavir. Within 48 h, the bradyarrhythmia resolved. The patient did not require transvenous and permanent pacemaker insertion.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Current efficacy and safety evidence of lopinavir\u2013ritonavir as a treatment in COVID-19 patients is limited. Although uncommonly reported, those with underlying cardiovascular disease are at increased risk of bradyarrhythmia-related adverse effects of lopinavir\u2013ritonavir. When initiating investigational therapies, especially in patients with cardiovascular conditions, adequate counselling and close monitoring are required.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytaa171","type":"journal-article","created":{"date-parts":[[2020,7,1]],"date-time":"2020-07-01T03:24:15Z","timestamp":1593573855000},"page":"1-6","source":"Crossref","is-referenced-by-count":7,"title":["COVID-19 treatment with lopinavir\u2013ritonavir resulting in sick sinus syndrome: a case report"],"prefix":"10.1093","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4795-9919","authenticated-orcid":false,"given":"Laureen Yi-Ting","family":"Wang","sequence":"first","affiliation":[{"name":"National University Heart Centre, National University Hospital Singapore, 5 Lower Kent Ridge Rd, Singapore 119074"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7964-3372","authenticated-orcid":false,"given":"Gavin Yeow Ping","family":"Ng","sequence":"additional","affiliation":[{"name":"National University Heart Centre, National University Hospital Singapore, 5 Lower Kent Ridge Rd, Singapore 119074"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,6,30]]},"reference":[{"key":"2021012109425853000_ytaa171-B1","doi-asserted-by":"crossref","DOI":"10.1001\/jama.2020.6019","article-title":"Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review","author":"Sanders","year":"2020","journal-title":"JAMA"},{"key":"2021012109425853000_ytaa171-B2"},{"key":"2021012109425853000_ytaa171-B3","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1136\/thorax.2003.012658","article-title":"Role of lopinavir\/ritonavir in the treatment of SARS: initial virological and clinical findings","volume":"59","author":"Chu","year":"2004","journal-title":"Thorax"},{"key":"2021012109425853000_ytaa171-B4","doi-asserted-by":"crossref","first-page":"1488","DOI":"10.1001\/jama.2020.3204","article-title":"Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore","volume":"323","author":"Young","year":"2020","journal-title":"JAMA"},{"key":"2021012109425853000_ytaa171-B5","article-title":"An exploratory randomized controlled study on the efficacy and safety of lopinavir\/ritonavir or arbidol treating adult patients hospitalized with mild\/moderate COVID-19 (ELACOI)","author":"Li","year":"2020","journal-title":"medRxiv"},{"key":"2021012109425853000_ytaa171-B6","doi-asserted-by":"crossref","first-page":"1787","DOI":"10.1056\/NEJMoa2001282","article-title":"A trial of lopinavir\u2013ritonavir in adults hospitalized with severe Covid-19","volume":"382","author":"Cao","year":"2020","journal-title":"N Engl J Med"},{"key":"2021012109425853000_ytaa171-B7","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1071\/SH09005","article-title":"Transient cardiac arrhythmias related to lopinavir\/ritonavir in two patients with HIV infection","volume":"6","author":"Chaubey","year":"2009","journal-title":"Sex Health"},{"key":"2021012109425853000_ytaa171-B8","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1086\/341975","article-title":"Serious bradyarrhythmia that was possibly induced by lopinavir\u2013ritonavir in 2 patients with acquired immunodeficiency syndrome","volume":"35","author":"Kikuchi","year":"2002","journal-title":"Clin Infect Dis"},{"key":"2021012109425853000_ytaa171-B9","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1161\/CIRCULATIONAHA.105.580811","article-title":"Common sodium channel promoter haplotype in Asian subjects underlies variability in cardiac conduction","volume":"113","author":"Bezzina","year":"2006","journal-title":"Circulation"},{"key":"2021012109425853000_ytaa171-B10","doi-asserted-by":"crossref","DOI":"10.1136\/heartjnl-2020-317056","article-title":"Cardiovascular manifestations and treatment considerations in covid-19","author":"Kang","year":"2020","journal-title":"Heart"},{"key":"2021012109425853000_ytaa171-B11","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1001\/jama.2020.1585","article-title":"Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China","volume":"323","author":"Wang","year":"2020","journal-title":"JAMA"},{"key":"2021012109425853000_ytaa171-B12","doi-asserted-by":"crossref","DOI":"10.1093\/ehjcr\/ytaa132","article-title":"Novel coronavirus 19 (COVID-19) associated sinus node dysfunction: a case series","author":"Peigh","year":"2020","journal-title":"Eur Heart J \u2013 Case Reports"}],"container-title":["European Heart Journal - 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