key: cord-342206-mitfgsdo
authors: Asif, Talal; Ali, Zafar
title: Transient ST Segment Elevation in Two Patients with COVID-19 and a Normal Transthoracic Echocardiogram
date: 2020-04-23
journal: Eur J Case Rep Intern Med
DOI: 10.12890/2020_001672
sha: 
doc_id: 342206
cord_uid: mitfgsdo

We continue to learn about cardiac involvement in patients with COVID-19. These patients can develop acute coronary syndrome and severe myocarditis with a reduced ejection fraction. We describe two critically ill COVID-19 patients who developed ST elevation that resolved on repeat ECG without any intervention. LEARNING POINT: ST elevation may occur in critically ill COVID-19 patients.

Coronavirus disease 2019 (COVID-19) is the result of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1] . Cardiac involvement in COVID-19 is being increasingly recognized and may indicate a poor outcome [2] . While patients with COVID-19 can develop acute coronary syndrome, ST segment elevation on electrocardiogram (ECG) has been mainly described in patients with COVID-19-related acute myocarditis and severely reduced left ventricular ejection fraction (LVEF) [2] [3] [4] [5] . We describe two cases of transient ST segment elevation in patients with preserved LVEF. Our goal is to raise awareness of this aspect of cardiovascular involvement in COVID-19 and prevent unnecessary catheterization.

A 64-year-old male patient with a medical history of hypertension and hyperlipidaemia presented to the emergency room with a 3-day history of dyspnoea. His blood pressure at presentation was 85/51 mmHg, heart rate was 80 beats per minute, respiratory rate was 36 breaths per minute and oxygen saturation was 70% on room air. The patient was intubated, mechanically ventilated, started on norepinephrine for hypotension and admitted to the medical intensive care unit (MICU). The patient's chest x-ray is shown in Fig. 1 .

A baseline ECG showed non-specific T wave changes but did not demonstrate acute ischaemic changes or arrhythmia (Fig. 2) . The patient's baseline troponin was 0.17 ng/ml. On day 2 of hospitalization, the patient's hypoxia worsened, requiring maximum ventilatory support and sedation. A repeat ECG showed ST segment elevation i

 leads I, aVL and V1-V4 and reciprocal ST depression in leads II, III and aVF (Fig. 3) . Due to the patient's life-threatening respiratory failure, it was decided not to pursue reperfusion therapy. After administration of loading doses, aspirin 81 mg, clopidogrel 75 mg and a heparin drip were initiated. The patient's other medications included azithromycin, hydroxychloroquine, meropenem, tocilizumab, norepinephrine, phenylephrine, vasopressin, atracurium, propofol and fentanyl.

European Journal of Case Reports in Internal Medicine © EFIM 2020 Case 2 A 71-year-old female patient with a medical history of multiple myeloma treated with bortezomib, was admitted with a 1-day history of fever, cough and dyspnoea. She tested positive for SARS-CoV-2. Her initial ECG at presentation is shown in Fig. 6 . On day 2 of admission, the patient became acutely hypotensive and hypoxic with a blood pressure of 70/41 mmHg, a heart rate of 125 beats per minute, a respiratory rate of 33 breaths per minute and oxygen saturation of 70% on 4 l/min of oxygen by nasal cannula. Her chest x-ray showed bilateral alveolar and interstitial opacities (Fig. 7) . She was intubated, initiated on mechanical ventilation and transferred to the 

A transthoracic echocardiogram (TTE) showed a vigorous ejection fraction of 70-75% with no regional wall motion abnormalities (Fig. 4) .

Repeat troponins obtained 6 hours apart were 0.056 ng/ml, 0.123 ng/ml and 0.11 ng/ml, respectively. A repeat ECG after 12 hours showed resolution of the ST elevation (Fig. 5) . Unfortunately, patient did not recover and died 24 hours later. MICU for further treatment including vasopressor support. A repeat ECG showed new 1 mm ST elevation in leads V2-V6 with associated Q waves in leads V4-V6 (Fig. 8) .

Again, due to the patient's life-threatening respiratory failure, it was decided not to pursue reperfusion therapy. After completing loading doses, she was started on aspirin 81 mg, clopidogrel 75 mg and a heparin drip. Her other medications included azithromycin, cefepime, vancomycin, tocilizumab, norepinephrine, phenylephrine, midazolam and fentanyl. A TTE showed an ejection fraction of 65-70% with no regional wall motion abnormalities (Fig. 9) . The patient's baseline troponin of 1.6 ng/ml declined to 1.5 ng/ml after 6 hours and then to 1.1 ng/ml after another 6 hours. A repeat ECG after 12 hours showed complete resolution of the ischaemic changes (Fig. 10) . Patient was still on mechanical ventilation at the time of writing. 

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DISCUSSION We describe two cases of transient ST elevation on ECG in patients with normal left ventricular (LV) function and COVID-19. All previously described cases of COVID-19-related ST elevation involved patients with fulminant myocarditis and a severely reduced LV ejection fraction [2-5] . These cases add to our understanding of cardiac involvement in active COVID-19, especially given the uncertainty in proceeding with invasive coronary angiography and the need to balance staff exposure with patient benefit

Acute coronary syndrome type 1 also remains a possibility given the systemic proinflammatory stimulation and hypercoagulability in patients with acute COVID-19 [7] . Management of patients should be based on a multidisciplinary approach and any reperfusion therapy should follow the guidelines of the American College of Cardiology's Interventional Council and the Society of Cardiovascular Angiography and Intervention