Remdesivir-associated bradycardia might be a sign of good prognosis in COVID-19 patients

To the Editor

We have read with great interest the recent comment by Dr Dauby considering cardiovascular side effects of remdesivir [1] that might call into question its role in the treatment of patients with severe coronavirus disease 2019 (COVID-19) [2]. At the moment, bradycardia is considered the most frequent cardiovascular side effect of remdesivir and occurs owing to undisclosed mechanism. However, as recently shown, patients with COVID-19 who develop bradycardia during remdesivir treatment experience a more favourable disease course that features less respiratory deterioration and is less likely to result in death, phenomenon-independent of COVID-19 disease severity, age, and comorbidity burden [3]. It can be speculated that patients who develop bradycardia possibly have less sympathetic–adrenergic stimulation or a higher concentration of specific drug metabolites that have both antiviral and chronotropic effects.

Thus, although it is the most frequent adverse cardiovascular side effect of remdesivir, bradycardia can be considered a desirable feature and a sign of good prognosis, but it certainly mandates increased measures of patient surveillance. Of note, other reported potentially severe cardiovascular side effects [4] are of uncertain clinical significance, and it is unknown to what extent they would reflect on clinical outcomes in large cohorts of patients (i.e. do potential risks outweigh the benefits of remdesivir use). Certainly, patients with COVID-19 who would benefit the most from or need to avoid remdesivir are yet to be recognized by future studies that are highly needed.

Contribution

ML and PB drafted the comment, revised if for critical content and approved the final version.

Transparency declaration

The authors have no conflicts of interest or sources of support to disclose.

Editor: L Leibovici