key: cord-0789805-s61i4vum authors: Rothstein, Eric S.; Welch, Terrence D.; Andrus, Bruce W.; Jayne, John E. title: Management of a patient presenting with anterior STEMI with concomitant COVID‐19 infection early in the course of the U.S. pandemic date: 2020-05-29 journal: Catheter Cardiovasc Interv DOI: 10.1002/ccd.28967 sha: 3fb458f3bd3ab9fc40fa34247edbb635287fa07a doc_id: 789805 cord_uid: s61i4vum The coronavirus disease‐2019 (COVID‐19) is a viral illness with heterogenous clinical manifestations, ranging from mild symptoms to severe acute respiratory distress syndrome and shock caused by the severe acute respiratory syndrome coronavirus‐2. The global healthcare community is rapidly learning more about the effects of COVID‐19 on the cardiovascular system, as well as the strategies for management of infected patients with cardiovascular disease. There is minimal literature available surrounding the relationship between COVID‐19 infection and acute coronary syndrome. We describe the case of a woman who presented with an acute anterior ST‐elevation myocardial infarction managed by primary percutaneous coronary intervention, who subsequently developed severe COVID‐19 infection and ultimately succumbed to multisystem organ failure. A 79-year-old woman with a history of dyslipidemia and diabetes mellitus developed substernal chest pressure associated with nausea and lightheadedness while carrying groceries up her stairs on the afternoon of March 10, 2020. She had been experiencing low-grade fevers (100.0 F) the day prior to presentation with no other symptoms. Her chest pressure persisted through the day and she attributed it to indigestion. After going to bed and waking up the following morning continued chest discomfort, she presented to a nearby nonpercutaneous coronary intervention (non-PCI) capable critical access hospital and a 12-lead ECG was performed revealing Q-waves and ST elevations in the precordial leads consistent with a late presenting anterior ST-elevation myocardial infarction (STEMI) (Figure 1 ). She was noted to have a fever (temperature 100.8 F) upon presentation. The differential diagnosis included STEMI from acute plaque rupture, as well as other STEMI mimickers including viral perimyocarditis, coronary embolism, and stress cardiomyopathy. She was treated with aspirin, clopidogrel, and heparin and then transferred to our PCI capable facility for urgent coronary angiography. The projected door to device time was 150 min. Fibrinolytic therapy was deferred based upon the delay in her presentation, advanced age and minimal expected benefit as shown in Figure 2 . The patient resided in the state of Vermont. As of the date of presentation, there was only one known case of coronavirus disease-2019 (COVID-19) infection in the state (located 50 miles from the patient's residence) so no additional precautions were taken during transport or upon arrival to the cardiac catheterization laboratory. On arrival in the catheterization laboratory, she was hemodynamically stable, oxygenating well on room air and had no chest pain. Coronary angiography performed via the right radial approach revealed a culprit 100% obstructive lesion in the mid left anterior descending artery infection, 8 and now COVID-19 infection. 9 Moreover, the concept that inflammation is a primary driver of atherosclerosis and atherogenesis is supported by several large randomized clinical trials including JUPI-TER 10 and CANTOS. 11 Additionally, it has been shown that an increased inflammatory burden is a significant risk factor for development of MI in patients with autoimmune diseases such as rheumatoid and psoriatic arthritis, and that reduction in inflammation is associated with a reduction in major adverse cardiac events. [12] [13] [14] This case raises the question as to whether the inflammation and cytokine storm that accompany COVID-19 infection leads to enhanced coronary artery plaque susceptibility to rupture in a high flow setting. In addition, increased thrombogenicity driven by inflammation may present another mechanism for acute coronary syndrome due to SARS-CoV-2. 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