1Department of Inside Medication, All India Institute of Medical Sciences, Rishikesh, 249203, India; 2Department of Inside Medication, Kasturba Medical Faculty, Manipal, 576104, India; 3Consultant Heart specialist, V Care Polyclinic, Dubai, United Arab EmiratesCorrespondence: Gokul Krishnan VSDepartment of Inside Medication, Kasturba Medical Faculty, Degree 3, New OPD Block, Manipal, 576104, IndiaEmail [email protected]Summary: Dengue fever is a prevalent viral illness that primarily impacts tropical nations. Though most symptomatic infections have a comparatively benign course, a small proportion of sufferers expertise extreme scientific signs, similar to bleeding and endothelial dysfunction, which may result in hypovolemic shock and cardiovascular collapse. Dengue fever is now identified to contain the guts by inducing myocardial irritation, arrhythmias, and, in uncommon circumstances, fulminant myocarditis, as much as 13% in extreme dengue. Conduction abnormalities can vary from benign sinus bradycardia to fulminant tachyarrhythmias and atrioventricular blocks. Though most conduction disturbances are benign and transient, they’ll sometimes irritate pre-existing situations and even be deadly. Not like different viral myocarditis like hepatitis C induced myocarditis, dengue causes primarily transient modifications, and long-term problems like dilated cardiomyopathy are usually not famous. There may be certainly a paucity of information on easy methods to assess and deal with people with conduction abnormalities. On this evaluation, the authors have mentioned the big variety of conduction abnormalities seen in dengue, their pathophysiology, scientific penalties, and a technique for evaluating and managing these people.

Dengue fever is among the many world’s most extreme rising viral illnesses.2 In recent times, the prevalence of dengue virus (DENV) an infection has been on the rise. The overwhelming majority of symptomatic infections have a benign scientific trajectory. Some sufferers expertise extreme scientific manifestations similar to bleeding, organ failure, and endothelial dysfunction with elevated capillary permeability, leading to hypovolemic shock and cardiovascular failure. Electrocardiography (ECG) and echocardiography abnormalities are frequent throughout dengue an infection.3,4 Because of the low scientific suspicion index and simultaneous scientific signs, together with hypotension, tachycardia, pulmonary edema, and capillary leak associated with DENV an infection, cardiac exercise in dengue fever is commonly underdiagnosed. Clinically evident coronary heart illness is of low prevalence in any particular person care facility, nevertheless it accounts for a major proportion of significantly unwell sufferers within the combination. Though most sufferers are asymptomatic or transient, life-threatening cardiac involvement is frequent in dengue hemorrhagic fever and dengue shock syndrome. These cardiac problems is likely to be neglected in scientific apply and may contribute to the mortality noticed in dengue.
Dengue Virus
DENV is a single-stranded ribonucleic acid (RNA) virus that exists as 4 distinct serotypes (DENV-1 to −4).5 These DENV serotypes are members of the Flavivirus genus and household Flaviviridae.6 The mature particle of DENV is spherical in form with a diameter of 50nm and comprise a number of copies of the three structural proteins, a host-derived membrane bilayer, and a single positive-sense, single-stranded RNA genome. The genome is cleaved by host and viral proteases in three structural proteins (capsid, C, prM, the precursor of membrane, M, protein and envelope, E) and 7 non-structural proteins (NS).7
Cardiac Involvement in Dengue
The pathophysiology of cardiac illness in dengue an infection is unclear. Quite a lot of components contribute to its pathogenesis, which leads to myocardial damage and subsequent conduction abnormalities (Determine 1). Direct viral invasion of cardiac muscular tissues, cytokine-induced immunological damage, or each could cause cardiac involvement.8,9 Electrolyte imbalance, calcium homeostasis disruption, lactic acidosis, and ischemia as a consequence of hypotension are all thought to play a job within the myocardial dysfunction seen in dengue sufferers. Elevated ranges of proinflammatory cytokines, vasoactive mediators, and cytotoxic components in dengue sufferers can enhance vascular permeability and lead to shock.10,11 These can additional impede coronary blood provide, leading to a cascade of ischemia and subsequent electrophysiological modifications. Pericardial effusion is brought on by elevated vascular permeability and irregular plasma leakage.12 It’s unclear whether or not the myocyte damage is brought on by a direct invasion of the DENV virus or by an immune-mediated mechanism. On cardiac specimens from dengue sufferers, viral antigens similar to dengue capsid protein, non-structural protein 1 (NS1), and viral RNA have been recognized utilizing reverse transcription polymerase chain response.13,14 Immunohistochemistry has additionally revealed dengue capsid protein in a number of cardiac cell varieties, together with cardiomyocytes, myocardial interstitial cells, and myoblasts.15 Post-mortem specimens have additionally revealed interstitial oedema, irritation, and myocardial fibre necrosis.1
Determine 1 Proposed pathogenesis of conduction abnormalities in dengue fever.
Arrhythmias are of pretty frequent prevalence in dengue an infection, and a number of components are predicted to interaction in its pathogenesis.3,4,16 Firstly, modifications in membrane potential can happen because of inflammatory processes and cytokine storms affecting myocytes and the interstitium.17 Arrhythmias will also be triggered by modifications in ventricular dynamics, similar to elevated wall pressure and myocardial oxygen demand. Furthermore, there’s a danger of bleeding in or across the sinoatrial or atrioventricular node as a consequence of low platelet counts, which may trigger conduction defects and arrhythmias.18 Adjustments in autonomic tone and electrolyte imbalances would possibly trigger transient rhythm abnormalities.
Electrocardiographic Adjustments
In people with dengue an infection, research have proven a lot of ECG abnormalities (Desk 1). Based mostly on the findings depicted in Desk 1, electrical disturbances famous in dengue may be broadly categorized into bradyarrhythmias and tachyarrhythmias.
Desk 1 Research of Conduction Abnormalities in Dengue Fever
Following Classification is Proposed
Sinus bradycardia
Junctional rhythm
AV block
First diploma
Second diploma
Third diploma

Bundle department block


Nonspecific ST-T modifications
Bradycardia is the commonest electrical disturbance seen in dengue. Sinus bradycardia is the commonest reason behind bradycardia and is normally benign. Relative bradycardia can also be famous the place dengue circumstances had a lowered coronary heart price response than different febrile diseases. Junctional rhythms have additionally been reported in literature.3 Atrial and ventricular ectopics are seen typically in dengue and are normally benign.3 There have been experiences of a excessive diploma AV block resulting in ventricular asystole, which was managed medically with intravenous atropine and orciprenaline. Conduction blocks are extra life-threatening situations starting from 1st diploma AV block to finish coronary heart block. Usually greater the diploma of the block, extra outstanding is the incidence of problems like asystole, ventricular arrhythmias, hemodynamic compromise and requirement of extra aggressive and invasive interventions within the type of pharmacotherapy, pacing and ICU admission.19
Among the many tachyarrhythmias seen in dengue, the commonest is sinus tachycardia. Others embrace supraventricular arrhythmias like atrial fibrillation and barely ventricular tachycardias.4 They are often managed conservatively, and determination of underlying myocarditis and quantity loss resolves the tachycardia.
ST-T Adjustments
ST-T modifications on ECG in dengue are normally secondary to myocarditis or pericarditis and never major electrical disturbance, not like sinus bradycardia and coronary heart blocks, which may happen even within the absence of myocarditis.20
Medical Implications
Arrhythmias seen in dengue are primarily benign, transient and self-limiting. Nonetheless, they’ll vary from delicate signs to vital contributions to morbidity and mortality in particular subsets. Conduction blocks can irritate current cardiovascular compromise secondary to capillary leak and third area loss. Extreme bradycardia may end up in worsening of hypotension and signs various from presyncope to cardiac arrest. In dengue, the guts is unable to mount a enough chronotropic response to compensate for the hypotension.
The contribution of rhythm disturbances to mortality just isn’t clearly outlined. In accordance with one examine, all of the sufferers who died exhibited aberrant echocardiography or ECG outcomes.27 Throughout an outbreak in Sri Lanka, a examine revealed that these with bradyarrhythmia have been extra more likely to develop hypotension.26 Along with mortality, electrical abnormalities contribute considerably to morbidity within the kind that they require additional analysis, interventions and problems of scientific course. Conduction disturbances are sometimes seen in the direction of the restoration part of dengue when the affected person is enhancing from different dengue-related problems like thrombocytopenia, serositis, and hypotension. The newly showing conduction disturbances can lengthen hospital keep, ICU admission, additional investigations and interventions. Investigations carried out are within the type of holter monitoring, cardiac enzymes and repeat echocardiography. Though {the electrical} abnormalities normally resolve in three weeks, conduction defects have continued in particular people, and circumstances are reported the place it took as much as 5 months for restoration.28 These with symptomatic coronary heart blocks have needed to bear pacing or pharmacotherapy. Pointless interventions, alternatively, for comparatively benign transient rhythm disturbances add to the burden. A problem confronted is in performing pacing amongst these with extreme thrombocytopenia and lively bleeding. There have been reported situations the place pacing needed to be deferred as a consequence of extreme thrombocytopenia.
Some research point out no relationship between the scientific severity of dengue and incidence of cardiac arrhythmia, suggesting that monitoring for cardiac arrhythmias could also be required even in delicate circumstances.21,29 However, Kumar and Yadav et al have discovered a statistically vital relation between ECG abnormalities and warning indicators suggesting nearer follow-up for extreme circumstances.23
The absence of infrastructure for such interventions and monetary constraints provides to the illness burden in low-income international locations. Process-related problems additionally add to a sophisticated hospital keep and the whole value of healthcare.
Analysis and Administration
There are three important facets to managing electrophysiological abnormalities in dengue: monitoring, therapy, and choice concerning discharge (Determine 2). For delicate circumstances, we recommend a minimal of two ECGs – one on the time of admission and one other earlier than discharge. The aim of an ECG at admission is to seek for conduction disturbances and decide whether or not extra monitoring is required. As a result of it’s identified that new-onset conduction anomalies would possibly emerge through the restoration interval, an ECG must be carried out earlier than discharge. Steady monitoring is really useful in troublesome conditions, along with the 2 ECGs. In a excessive dependency unit or ICU surroundings, steady monitoring may be carried out through a monitor. If a monitor just isn’t obtainable, a naked minimal pulse price and rhythm examine twice or thrice each day for one minute every would suffice.
Determine 2 Algorithm of analysis and administration of conduction abnormalities in dengue fever.
For the reason that majority of bradyarrhythmias are benign and ephemeral, therapy is normally conservative. Pharmacotherapy with atropine and orciprenaline has been utilized in such circumstances however is of unproven profit. When there’s a worsening conduction block, pacing must be explored. Invasive interventions similar to pacing could cause thrombocytopenia and bleeding, which can demand platelet transfusion earlier than the surgical procedure. For extreme circumstances, nearer monitoring is warranted. They could be taken up for pacing in a case of bradyarrhythmia within the following situations:
Hypotension not attentive to aggressive hydration.
Worsening pattern of bradycardia (sinus bradycardia degenerating to a primary diploma adopted by second-degree coronary heart block). Such circumstances is likely to be at imminent danger of full coronary heart block, asystole or different deadly arrhythmias.
Administration of myocarditis is a vital level as it’s accountable for conduction disturbance in a number of circumstances. It’s normally managed conservatively, however there have been research exploring the function of steroids, intravenous immunoglobulin (IVIg) and anti-CD3 monoclonal antibody (muromonab) for earlier restoration. ST-T modifications seen in dengue are nearly at all times benign, transient and secondary to myocarditis, not requiring particular intervention.30
Choice on discharge is to be taken primarily based on ECG taken earlier than deliberate day of discharge:
If the ECG is regular, the affected person could also be discharged safely however counselled concerning warning indicators of arrhythmias similar to palpitation, presyncope and syncope as new-onset conduction disturbances could happen throughout a restoration part.
If ECG is irregular, then one ought to ask for signs. If the affected person is symptomatic, it’s advisable to delay discharge, provoke intensive cardiac monitoring and plan for an intervention to be offered if essential. If the affected person is asymptomatic, then the pattern of conduction abnormality must be assessed –
New-onset: Might discharge with recommendation on warning indicators and fast hospital go to if any warning indicators current. It might not be possible to maintain the affected person in hospital till ECG turns into regular, as it might take weeks or months for a decision to happen.
Bettering pattern: Might discharge.
Worsening pattern: To maintain in hospital for additional monitoring and intervention as required.

The spectrum of conduction abnormalities in dengue fever is broad, starting from relative bradycardia to life-threatening arrhythmias. Most electrocardiographic modifications are transient and resolve by three weeks with out requiring any intervention. An intensive analysis is warranted in symptomatic sufferers in addition to non-resolving/worsening rhythm disturbances. Such sufferers may benefit from present modalities of remedy. It’s vital for a doctor to remember concerning electrocardiographic modifications and their administration in dengue sufferers for making higher knowledgeable selections for his or her sufferers.

Writer Contributions
All authors made a major contribution to the work reported, whether or not that’s within the conception, examine design, execution, acquisition of information, evaluation and interpretation, or in all these areas; took half in drafting, revising or critically reviewing the article; gave remaining approval of the model to be revealed; have agreed on the journal to which the article has been submitted; and comply with be accountable for all facets of the work.
The authors declare no conflicts of curiosity on this work.
1. Weerakoon KG, Kularatne SA, Edussuriya DH, et al. Histopathological prognosis of myocarditis in a dengue outbreak in Sri Lanka, 2009. BMC Res Notes. 2011;4(1):268. doi:10.1186/1756-0500-4-268
2. World Well being Group. Dengue Haemorrhagic Fever: Analysis,Remedy,Prevention and Management. Vol. 1. Geneva; 1997:24–30.
3. Poornima H, John J. Cardiac manifestations in dengue sufferers in a rural tertiary care centre in coastal Kerala. Int J Innov Res Med Sci. 2019;4(4). doi:10.23958/ijirms/vol04-i04/628
4. Shah C, Vijayaraghavan G, Kartha CC. Spectrum of cardiac involvement in sufferers with dengue fever. Int J Cardiol. 2021;324:180–185. doi:10.1016/j.ijcard.2020.09.034
5. Halstead SB. Pathogenesis of dengue: challenges to molecular biology. Sci New Ser. 1988;239(4839):476–481.
6. Kurane I. Dengue hemorrhagic fever with particular emphasis on immunopathogenesis. Comp Immunol Microbiol Infect Dis. 2007;30(5–6):329–340. doi:10.1016/j.cimid.2007.05.010
7. Perera R, Kuhn RJ. Structural proteomics of dengue virus. Curr Opin Microbiol. 2008;11(4):369–377. doi:10.1016/j.mib.2008.06.004
8. Restrepo BN, Isaza DM, Salazar CL, Ramírez R, Ospina M, Alvarez LG. Serum ranges of interleukin-6, tumor necrosis factor-alpha and interferon-gamma in infants with and with out dengue. Rev Soc Bras Med Trop. 2008;41(1):6–10. doi:10.1590/S0037-86822008000100002
9. Hober D, Delannoy A-S, Benyoucef S, De Groote D, Wattré P. Excessive ranges of sTNFR p75 and TNFα in dengue-infected sufferers. Microbiol Immunol. 1996;40(8):569–573. doi:10.1111/j.1348-0421.1996.tb01110.x
10. Chen R-F, Yang KD, Wang L, Liu J-W, Chiu C-C, Cheng J-T. Completely different scientific and laboratory manifestations between dengue haemorrhagic fever and dengue fever with bleeding tendency. Trans R Soc Trop Med Hyg. 2007;101(11):1106–1113. doi:10.1016/j.trstmh.2007.06.019
11. Chen R-F, Liu J-W, Yeh W-T, et al. Altered T helper 1 response however not enhance of virus load in sufferers with dengue hemorrhagic fever. FEMS Immunol Med Microbiol. 2005;44(1):43–50. doi:10.1016/j.femsim.2004.11.012
12. Singhi S, Kissoon N, Bansal A. Dengue and dengue hemorrhagic fever: administration points in an intensive care unit. J Pediatr (Rio J). 2007;83(7):22–35. doi:10.2223/JPED.1622
13. de Araújo JMG, Schatzmayr HG, de Filippis AMB, et al. A retrospective survey of dengue virus an infection in deadly circumstances from an epidemic in Brazil. J Virol Strategies. 2009;155(1):34–38. doi:10.1016/j.jviromet.2008.09.023
14. da Lima MRQ, Nogueira RMR, Schatzmayr HG, de Filippis AMB, Limonta D, Dos Santos FB. A brand new strategy to dengue deadly circumstances prognosis: NS1 antigen seize in tissues. PLoS Negl Trop Dis. 2011;5(5):e1147. doi:10.1371/journal.pntd.0001147
15. Salgado DM, Eltit JM, Mansfield Okay, et al. Coronary heart and skeletal muscle are targets of dengue virus an infection. Pediatr Infect Dis J. 2010;29(3):238–242. doi:10.1097/INF.0b013e3181bc3c5b
16. Krishna A, Kumar S, Kumar A, Prasad U. ECG manifestation in dengue fever. Int J Well being Clin Res. 2021;4(1):292–297.
17. Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. Into the attention of the cytokine storm. Microbiol Mol Biol Rev. 2012;76(1):16–32. doi:10.1128/MMBR.05015-11
18. Virk HUH, Inayat F, Rahman ZU. Full coronary heart block in affiliation with dengue hemorrhagic fever. Korean Circ J. 2016;46(6):866. doi:10.4070/kcj.2016.46.6.866
19. Dhariwal AK. Excessive diploma atrioventricular block with ventricular asystole in a case of dengue fever. Indian Coronary heart J. 2016;4:S194–7.
20. Wali JP, Biswas A, Chandra S, et al. Cardiac involvement in dengue haemorrhagic fever. Int J Cardiol. 1998;64(1):31–36. doi:10.1016/S0167-5273(98)00008-4
21. Papalkar P, Sarode R, Acharya S, Kumar S. Cardiac manifestations in dengue. Indian J Med Spec. 2019;10(1):30. doi:10.4103/INJMS.INJMS_34_18
22. Datta G, Mitra PA. Research on cardiac manifestations of dengue fever. J Assoc Physicians India. 2019;67(7):14–16.
23. Kumar S, Yadav RK. To check cardiac manifestations in sufferers presenting with dengue an infection and to search out out the correlation of cardiac manifestations to warning indicators of dengue. Int J Adv Med. 2017;4(2):323. doi:10.18203/2349-3933.ijam20171003
24. Arora M, Patil RS. Cardiac manifestation in dengue fever. J Assoc Physicians India. 2016;64(7):40.
25. Yacoub S, Griffiths A, Hong Chau TT, et al. Cardiac perform in Vietnamese sufferers with totally different dengue severity grades. Crit Care Med. 2012;40(2):477–483. doi:10.1097/CCM.0b013e318232d966
26. La-orkhun V, Supachokchaiwattana P, Lertsapcharoen P, Khongphatthanayothin A. Spectrum of cardiac rhythm abnormalities and coronary heart price variability through the convalescent stage of dengue virus an infection: a Holter Research. Ann Trop Paediatr. 2011;31(2):123–128. doi:10.1179/1465328111Y.0000000008
27. Kularatne SAM, Pathirage MMK, Kumarasiri PVR, Gunasena S, Mahindawanse SI. Cardiac problems of a dengue fever outbreak in Sri Lanka, 2005. Trans R Soc Trop Med Hyg. 2007;101(8):804–808. doi:10.1016/j.trstmh.2007.02.021
28. Taksande A, Suwarnakar Okay. Spontaneous decision of junctional rhythm in a toddler with dengue fever. J Prev Infect Management. 2016;2(1). doi:10.21767/2471-9668.100010
29. Tarique S, Murtaza G, Asif S, Qureshi IH. ECG manifestations in dengue an infection. Ann King Edward Med Univ. 2013;19(4):282. doi:10.21649/akemu.v19i4.528
30. Singh S, Sreenivasulu P, Sud S, Sasidharan S, Gupta A, Uncommon A. Case of dengue hemorrhagic fever with myocarditis and intracranial hemorrhage. J Pediatr Neurosci. 2020;15(3):320–321. doi:10.4103/jpn.JPN_48_20

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