key: cord-0944099-ef5fdami
authors: Ehrman, Robert R.; Brennan, Erin E.; Creighton, Terrence; Ottenhoff, Jakob; Favot, Mark J.
title: ST Elevation in the COVID-19 Era: A Diagnostic Challenge
date: 2020-07-16
journal: J Emerg Med
DOI: 10.1016/j.jemermed.2020.07.033
sha: 5379e04c7e56d5e293ba28f8beb9da03e6aa1d41
doc_id: 944099
cord_uid: ef5fdami

Abstract Background SARS-CoV-2 induces a marked pro-thrombotic state with varied clinical presentations, including acute coronary artery occlusions leading to ST-elevation myocardial infarction (STEMI). However, while STEMI on ECG is not always associated with acute coronary occlusion, this diagnostic uncertainty should not delay cardiac catheterization. Case Report: We present two cases of patients with COVID-19 that presented with STEMI on ECG. While both patients underwent cardiac catheterization, a delay in time to intervention in the patient found to have acute coronary artery occlusion may have contributed to a poor outcome. Why Should an Emergency Physician be Aware of This? These cases highlight the fact that while not all COVID-19 patients with STEMI on ECG will have acute coronary artery occlusions, there is continued need for prompt PCI during the SARS-CoV-2 pandemic.

There have been myriad consequences resulting from the outbreak of the novel coronavirus 14 SARS-CoV-2 causing the pandemic characterized by the coronavirus disease 2019 (COVID-19). The 15 impact on cardiovascular care has been multifaceted and profound. The direct impact of COVID-19 on 16 the cardiovascular system has been described with one study observing an in-hospital mortality rate of 17 51.2% in patients with myocardial injury, versus 4.5% in patients without myocardial injury (1) . The 18 pro-thrombotic, pro-inflammatory state caused by COVID-19 has been associated with the development 19

of an Acute COVID-19 Cardiovascular Syndrome (ACovCS) which has been described as most 20 commonly presenting as acute cardiac injury with cardiomyopathy, ventricular arrhythmias and 21 hemodynamic instability in the absence of obstructive coronary artery disease (CAD) (2). In this report 22

we present 2 cases of patients with symptoms compatible with COVID-19 (both of whom would go on 23 to test positive for the disease) that presented to the emergency department (ED) with ST-segment 24 elevation myocardial infarction (STEMI) on their initial electrocardiograms (ECG). The cases illustrate the challenge in managing patients with STEMI during the COVID-19 pandemic as the differences 26 between COVID-19 patients with ACovCS and coronary artery occlusions from CAD can be extremely 27 difficult to identify. 28

The patient is a 51-year-old male with past medical history of hypertension, CAD, hyperlipidemia, 31 previous MI, and diabetes who presented to the ED for chest pain and shortness of breath. The patient 32 described chest pain similar to his prior MI, with onset 1 hour prior to arrival. Vital signs on presentation 33

showed blood pressure of 165/112 mm Hg, heart rate of 110 beats-per-minute (BPM), respiratory rate of 34 22, temperature of 36.9 C, and pulse oximetry of 91% on non-rebreather mask (NRB). Chest team re-evaluated the patient, who was then intubated and taken emergently to the cardiac catheterization laboratory (CCL). Angiography revealed a 100% occlusion of the proximal circumflex 48 with TIMI grade 0 flow. Two drug-eluting stents were deployed in the circumflex with TIMI grade III 49 flow after procedure; there was also severe LAD disease. The patient then went into cardiac arrest (pulseless electrical activity) before the right-sided coronary circulation could be assessed. The CCL 51 team performed cardiopulmonary resuscitation for 33 minutes before the patient was declared deceased. 52

Coronavirus PCR swab later resulted as positive. 53

The patient is a 67 year-old male with no reported past medical history who presented with 3 55 days of worsening dyspnea. He had vague chest pain that resolved on the day prior to presentation. Vital Conversely, Case 2 presented with primary respiratory symptoms and with STEMI on ECG but 97 absence of chest pain. The patient was taken urgently to the CCL and found to have non-obstructive 98 suggests that while elevation of these markers portend a worse prognosis, laboratory testing by itself 103 cannot reliably identify patients requiring emergent PCI. This lends further support to the joint society 104 statement that expeditious transfer to the CCL is indicated in cases of suspected STEMI (3). 105

These cases highlight the extraordinary challenges of caring for COVID-19 patients, as despite 107 appropriate treatment, both patients expired. Morbidity and mortality from COVID-19 is high, likely 108 multi-factorial, and varied from patient-to-patient. Thus, while no single treatment may prevent poor 109 outcomes, aggressive efforts should be made to deliver interventions with known efficacy-in this case, 110 PCI for STEMI-to maximize chances for survival. 

Association of cardiac injury with mortality in 115 hospitalized patients with COVID-19 in Wuhan, China

Description and proposed management of 118 the acute COVID-19 cardiovascular syndrome

ST-Segment Elevation 125 in Patients with Covid-19 -A Case Series. The New England journal of medicine