ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION SECONDARY TO COVID-19

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease (COVID-19) is known to cause severe respiratory pathology such as acute respiratory distress syndrome. Although the pathophysiology of this lethal virus is still not fully understood, it has been suspected to attach to the ACE2 receptors leading to its deadly pathogenesis. Found to be the cause of venous thrombotic and embolic events, arterial thrombotic events such as ST-segment elevation myocardial infarction (STEMI) have been an unusual phenomenon. CASE PRESENTATION: A 37-year-old female with a past medical history of COVID-19 infection 12 days prior to admission presented to the emergency department (ED) complaining of shortness of breath for 2 to 3 days prior to admission. In the ED she was hypoxic with an oxygen saturation of 80% on room air for which she was placed on 90% FiO2 via OptiFlow and nonrebreather mask. Her D-Dimer on admission was noted to be 506 ng/mL (normal value <500 ng/mL). Unfortunately, due to worsening respiratory distress the decision was made to intubate the patient and she was transferred to the intensive care unit (ICU) for further management. An electrocardiogram was also obtained showing ST-segment elevations in leads II, III, aVF, and V1-V6 (Figure 1). An emergent bedside echocardiogram was obtained showing wall motion abnormalities consistent septal and anterior apical hypokinesis. A cardiac troponin level was obtained and was >80.00 ng/mL (normal value <0.04 ng/mL). The decision was made to proceed with cardiac catheterization for which complete stenosis of the left anterior descending (LAD) artery was noted. She received one drug eluding stent to the proximal LAD and due to severe cardiogenic shock an Impella was placed for hemodynamic support. Despite aggressive intervention and multiple vasopressors and Impella support she continued to decompensate and ultimately succumbed to her condition. DISCUSSION: STEMI is a rare complication of COVID-19 infection with an incidence of about 1%. The pathophysiology of STEMI in this setting is still not yet understood; however, COVID-19 infection is known to cause a hypercoagulable state through cytokine and complement activation as well as endothelial damage. CONCLUSIONS: Although uncommon, COVID-19 should be considered as a cause for arterial thrombotic events such as STEMI. It is imperative that clinicians are aware of the complications of this deadly virus and aggressively manage the hypercoagulable state observed in these patients to prevent morbidity and mortality. REFERENCE #1: Lodigiani C, Iapichino G, Carenzo L, et al. Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024. REFERENCE #2: Abou-Ismail MY, Diamond A, Kapoor S, at al. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management . Thromb Res. 2020;194:101-115. REFERENCE #3: Bangalore S, Sharma A, Slotwiner A, et al. ST-Segment Elevation in Patients with Covid-19 - A Case Series. N Engl J Med. 2020;382(25):2478-2480. doi:10.1056/NEJMc2009020 DISCLOSURES: No relevant relationships by Nasam Alfraji, source=Web Response No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Eric Costanzo, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by matthew meleka, source=Web Response No relevant relationships by Matthew Saybolt, source=Web Response