Zena and Michael A. Wiener Marie-Josée and Henry R.

Kravis
Cardiovascular Institute Center for Cardiovascular Health

Vivek Reddy, M.D. One Gustave L. Levy Place, Box 1030

The Leona M. and Harry B. Helmsley Trust New York, NY 10029-6574
Professor of Medicine in Cardiac Electrophysiology Tel. No: (212) 241-7114
Director, Cardiac Arrhythmia Service Fax No: (646) 537-9691
E-Mail: vivek.reddy@mountsinai.org
March 31, 2020

Dear Colleagues,

As discussed with Dr. Fuster this morning, we are aware that Hydroxychloroquine (Plaquenil) +/-
Azithromycin has now become FDA-approved for the treatment of COVID-19, and is being used
by many on an outpatient basis. As a result, the Electrophysiology Section has continued to receive
multiple questions about the potential for treatment-related arrhythmias – both conduction
abnormalities and QT prolongation culminating in torsades de pointes / cardiac arrest.

Accordingly, we would like to make all aware of an outpatient monitoring strategy that is now
available: briefly, we have organized to provide a BioTel mobile telemetry monitor (up to 2 weeks)
to monitor for both arrhythmias (brady- or tachy- arrhythmias) and for QT changes. This monitor
can either be given i) directly to the patient, for example if they are being discharged from the
hospital and there is residual concern, or ii) it can be mailed to the patient’s home. (Please note that
right now, we have only organized the ability to provide monitors in person at Mount Sinai-East …
for other Mount Sinai institutions, the best approach would be to have it mailed to the patient.) To
organize this, simply send a text to Noelle Langan at 917-363-4434. Once the monitor is sent to
patients, we will be informed if there are any substantial arrhythmias, or increase in QT interval …
which we will then relay to the prescribing physician (but please do know that there may be a time
delay of ~24 hours before this information is relayed, so please inform your patients).

Second, we want to update our previous QT monitoring flowchart (see below). The primary
change is a different approach to adjust for a baseline wide QRS: QTc = QTc – (QRS-100ms). For
example, if the patient has a baseline QRS of 180ms, a QTc of 570ms translates to 490ms [570 –
(180-100)]. This aligns with a recently published paper from Mayo Clinic (Giudicessi et al, Mayo
Clinic Proc). But please recognize that none of these Guidances are based on COVID-specific data.

Finally, please note that this guidance is again neither an endorsement nor a refutation of the use of
hydroxychloroquine/azithromycin in COVID-19. The fact that the FDA has recently approved these
medications for COVID-19 is clearly not based on scientific proof. Indeed, my own opinion is that
the proper interpretations of the sole French study purporting efficacy are: i) inconclusive, or (if
determined to squeeze a conclusion) ii) more suggestive of harm (see Annals-Ideas&Opinions).
Hopefully, ongoing studies will shed definitive light on this issue. However, if this drug is to be
used in a COVID-19 patient, we hope that this guidance will prove helpful. And of course, please
do feel free to contact the Electrophysiology Service for questions on any particular patient.

On behalf of my colleagues in the Electrophysiology Service,

Vivek Reddy

The Leona M. and Harry B. Helmsley Trust Center for Cardiac Electrophysiology