key: cord-0772865-b1xw9uii
authors: Beri, Abhimanyu; Kotak, Kamal
title: Cardiac injury, Arrhythmia and Sudden death in a COVID-19 patient
date: 2020-05-13
journal: HeartRhythm Case Rep
DOI: 10.1016/j.hrcr.2020.05.001
sha: e3ce3eadea88ad3226c20904359a7d6dda7ef308
doc_id: 772865
cord_uid: b1xw9uii

nan

As the COVID-19 (Corona Virus Disease 2019) pandemic spreads globally, our knowledge about its myriad presentations continues to evolve. Here we present a case of a patient with COVID-19 who rapidly succumbed to death after presenting to the emergency room (ER) with apparent acute myocardial infarction (MI).

A 72-year-old man with history of hypertension presented to the ER in early April of 2020 via ambulance with complaints of chest tightness and a feeling of impending doom. He described shortness of breath, cough, fatigue and intermittent diarrhea for the preceding few days. He had not sought any prior regular medical care.

Paramedic evaluation demonstrated an afebrile male in obvious distress with chest pain and shortness of breath. EKG done in the field was interpreted as acute ST elevation MI. On arrival in the ER, the initial EKG is shown in Figure 1 . Blood pressure was 158/110. He was hypoxic and was placed on high flow oxygen. He was moved to a respiratory isolation room while being prepared for emergent cardiac catheterization.

Within a few minutes of arrival in the ER, the patient suddenly became unresponsive and pulseless. Resuscitation was started and was emergently intubated. He had brief return of spontaneous circulation (ROSC) at which time a second EKG was done shown in Figure 2 . However, he was persistently hypotensive and eventually became pulseless again. After 45 minutes of rigorous efforts, resuscitation was terminated after team discussion and the patient was pronounced dead. At the coroner's request, a sample for SARS Cov-2 was sent which subsequently returned positive. Other labs could not be drawn prior to the patient deteriorating hemodynamically. Autopsy was not performed.

This case shows rapid deterioration, sustained ventricular tachycardia and sudden cardiac death in a COVID-19 patient. It is likely that COVID-19 appears to be a significant factor in the clinical course. Figure 1 shows a wide-complex tachycardia at rate of 134 beats per minute (bpm) and QRS width of 140 milliseconds (msec). P waves are noted at cycle length of 1200 msec (50 bpm) and AV dissociation is noted. This is consistent with ventricular tachycardia (VT) and not a supraventricular rhythm with ST-elevation MI. The QRS morphology suggests origin from inferoseptal left ventricle. A junctional ectopic tachycardia with V-A block is also a less likely possibility. Figure 2 shows that a slower tachycardia (123 bpm) with QRS width of 148 msec. There is a significant loss of R wave across precordial leads and no discernible P-waves noted. Premature ventricular contractions are noted which appear to reset the tachycardia which could suggest a reentrant mechanism vs. fortuitous cycle length variation. There is no prior history of MI or Q waves in inferior leads. This is likely ventricular tachycardia originating from inferoapical left ventricular septum.

It is noteworthy that during the SARS outbreak of 2002, extrapulmonary manifestations were common, but cardiac manifestation were not very prominent. (1) Transient arrhythmias, cardiomegaly and ventricular dysfunction were reported but were selflimiting or required minimal intervention and myocarditis was not mentioned. (2, 3) During the MERS (Middle East Respiratory Syndrome) outbreak, a case of myocarditis was reported. (4) Acute viral myocarditis can be fulminant and may sometimes mimic acute MI and cause arrhythmias. (5) Patients with COVID-19 can deteriorate rapidly with shock and multi-organ failure. There are also reports suggesting significant cardiac injury and arrhythmias in COVID-19 patients (6, 7) . Fulminant myocarditis has been reported in COVID-19 patients (8) While it is possible that COVID-19 was a mere bystander in this patient, his history of COVID-19 related symptoms, acute respiratory failure, atypical EKG findings as well a precipitous course point towards myocarditis.

Timely recognition and treatment of acute cardiac events in ER during COVID-19 pandemic presents a unique challenge. Based on the limited clinical and published data, we suspect that our patient may have had acute cardiac injury and myocarditis masquerading as acute MI likely due to COVID-19 leading to malignant ventricular tachycardia and finally sudden death. Careful attention should be given to COVID-19 as a possible etiology and prophylactic personal protective equipment be used in patients presenting with suspected acute MI, acute heart failure and ventricular arrhythmias.

The hidden burden of influenza: a review of the extra-pulmonary complications of influenza infection

Cardiovascular complications of severe acute respiratory syndrome

Bernard Prendergast et al Coronaviruses and the cardiovascular system: acute and long-term implications

Acute myocarditis associated with novel Middle East respiratory syndrome coronavirus

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirusinfected pneumonia in Wuhan

1: Initial Electrocardiogram Figure 2: Electrocardiogram after brief ROSC during the resuscitation Cardiac injury

Key Teaching Points 1. Acute cardiac injury, ST elevation and ventricular arrhythmias can occur in myocarditis especially in association with acute viral illnesses such as COVID-19

Acute cardiac present like this can lead to very rapid deterioration and death 3. It is important to keep viral myocarditis in differential diagnosis in critically ill patients especially during a pandemic such as