European Heart Journal - Case Reports CASE REPORT

doi:10.1093/ehjcr/ytaa131 Coronary heart disease

Case report of anterior ST-elevation myocardial

infarction in a patient with coronavirus

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disease-2019
Quentin Fischer *, Arthur Darmon , Grégory Ducrocq , and
Laurent Feldman
Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, DHU FIRE, INSERM U-1148, Université de Paris, Paris, France

Received 30 March 2020; first decision 3 April 2020; accepted 28 April 2020

Background Coronavirus disease-2019 (COVID-19) is an infectious disease appeared in China in December 2019 and, since
then, has spread worldwide at a rapid pace.
...................................................................................................................................................................................................
Case summary A patient with COVID-19 was hospitalized in our institution for a diabetic foot ulcer and presented afterwards a
pulmonary oedema and concomitant anterior ST-segment elevation myocardial infarction. We report here on the
initial presentation, coronary care and intervention, and clinical course of this patient.
...................................................................................................................................................................................................
Discussion Emergent percutaneous coronary intervention is feasible and safe in COVID-19 patients but requires a multidiscip-
linary effort involving caregivers from infectious disease, intensive care, and cardiology teams.
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Keywords Acute coronary syndrome • Coronavirus • Percutaneous coronary intervention • Case report
..
..
Learning points ..
• Coronavirus disease-2019 (COVID-19) screening by naso-pha- ..
..
..
Introduction
ryngeal swab was not systematically performed at admission
.. Coronavirus disease-2019 (COVID-19) is an infectious disease
and should not delay emergent cardiological care in ST-eleva- ..
tion myocardial infarction or high-risk non-ST-elevation myo- .. caused by severe acute respiratory syndrome coronavirus 2 (SARS-
..
cardial infarction. .. CoV-2). The outbreak of COVID-19 appeared in China in December
• The occurrence of acute coronary syndrome will increase in ... 2019 and, since then, has spread worldwide at a rapid pace and has
COVID-19 pandemic, due to several parameters such as the .. been declared a global pandemic by the World Health Organization
..
profound inflammatory response and cytokine storm syn- .. as of 11 March 2020.1
drome associated with severe acute respiratory syndrome .. Patients with hypertension, diabetes, or cardiovascular disease
..
coronavirus 2 infection. .. are at high risk of being affected by COVID-192 and have more
• A standardized protocol for emergent percutaneous coronary .. severe outcomes.3 Cardiovascular complications of COVID-19
..
intervention should be established in each cathlab including .. include myocardial injury, myocarditis, type 1 or type 2 myocar-
protective measures in order to reduce the time to myocardial .. dial infarction, heart failure, cardiogenic shock, severe arrhyth-
..
reperfusion in COVID-19 patients, without putting the care- .. mias, and venous thrombo-embolic disease.4 Specifically, the
givers at excessive risk of contamination. .. occurrence of acute coronary syndromes (ACS) in COVID-19
..

* Corresponding author. Tel: þ33140256658, Email: [email protected]

Handling Editor: Riccardo Liga
Peer-reviewers: Riccardo Liga; Marco De Carlo
Compliance Editor: Christian Fielder Camm
Supplementary Material Editor: Ross Thomson
C The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
V
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which
permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
[email protected]
2 Q. Fischer et al.

..
patients may have significant implications both for patient care .. Case presentation
and caregiver safety.5
..
..
While the general management of ACS has been well-defined in .. A 63-year-old male patient was hospitalized for a neuro-ischaemic
.. diabetic foot ulcer in the diabetology department of our institution
international guidelines, reports of ACS in COVID-19 patients are ..
scarce, and there is no clear recommendation as regard to optimal .. on 18 March 2020. He had several cardiovascular risk factors, includ-
.. ing type-2 diabetes mellitus, hypertension, dyslipidaemia, and was an
treatment in such patients.4 ..
.. active smoker. He had no history of heart disease, but had undergone
... percutaneous transluminal angioplasty of the right femoral artery
..

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.. 5 years earlier.
Timeline .. The patient reported no respiratory symptoms upon admission,
..
.. but had complained of mild fever (38.5 C) for the last 5 days. Three
.. days before hospitalization, he was prescribed a combination of
..
.. amoxicillin 1000 mg and clavulanic acid 125 mg t.i.d. with no effect on
Time Events .. fever.
................................................................................................. ..
13 March First symptoms: mild fever (<_38.5 C) without
.. Shortly after admission, the patient became severely breathless
.. and hypoxic (Sp02 85%) with a severe increase in blood pressure
dyspnoea ..
.. (226/118 mmHg). Physical examination showed normal cardiac mur-
15 March Introduction of a combination of amoxicillin 1000 mg .. murs, tachypnoea, and crackles in both lung fields without any other
and clavulanic acid 125 mg t.i.d. ..
.. signs of congestion. No significant repolarization abnormality was
18 March The patient was hospitalized for a neuro-ischaemic .. observed on electrocardiogram (ECG). An echocardiography
19:00 diabetic foot ulcer in the diabetology department ..
.. showed normal left ventricular ejection fraction (LVEF), high left ven-
18 March The patient became severely breathless and hypoxic .. tricular filling pressure (E/E0 ratio at 23), and systolic pulmonary ar-
22:00 (Sp02 85%) and was transferred to the intensive ..
.. tery pressure (45 mmHg). The chest X-ray showed bilateral perihilar
care unit (ICU) with strict respiratory isolation. A ..
diagnosis of acute pulmonary oedema was made, .. airspace opacity with dilatation of the main pulmonary artery
.. (Figure 1). Based on the clinical presentation, a diagnosis of acute pul-
and the patient improved on continuous positive ..
airway pressure non-invasive ventilation, nitrates, .. monary oedema was made and the patient was transferred to the in-
.. tensive care unit (ICU) with strict respiratory isolation. The patient
and diuretics. An electrocardiogram (ECG) ..
showed no significant repolarization abnormality. .. recovered within an hour on continuous positive airway pressure
.. non-invasive ventilation, nitrates, and diuretics, allowing for complete
19 March Naso-pharyngeal swab resulted positive for severe ..
02:00 acute respiratory syndrome coronavirus 2.
.. oxygen weaning. Because of systematic suspicion of COVID-19 in
.. patients with respiratory failure and fever, polymerase chain
19 March The respiratory state of the patient deteriorated with ..
09:30 persistent hypoxaemia despite ventilation with a ... reaction was performed on a naso-pharyngeal swab and returned
.. positive for -CoV-2. In addition, blood tests showed a biological
high oxygen concentration mask (6 L/min). ..
Although the patient had no chest pain, an ECG ..
..
showed transient anterior ST-segment elevation. ..
19 March Emergent coronary angiography showed a tight sten- ..
..
12:00 osis of the mid-portion of the left anterior ..
descending artery (LAD) with normal (TIMI 3) ..
..
flow. In addition to this culprit LAD stenosis, a ..
tight ostial stenosis of the obtuse marginal branch ..
..
and an intermediate stenosis of the dominant mid- ..
circumflex artery were observed but were not ..
..
considered as related to the ACS. A biodegradable ..
polymer, everolimus-eluting stent was deployed at
..
..
the culprit site with an optimal result. ..
19 March The patient was sent back to the ICU after percutan-
..
..
13:00 eous coronary intervention. The ECG normalized ..
and the patient’s respiratory condition significantly
..
..
improved without recurrent pulmonary oedema ..
or need for non-invasive ventilation.
..
..
20 March High-sensitivity troponin I peaked at 8.8 mg/L ..
(99th upper reference limit 0.045 mg/L).
.. Figure 1 Chest X-ray recorded during the first episode of acute
..
Echocardiography depicted a limited apical akinesia .. respiratory failure, showing dilated upper pulmonary veins and bilat-
.. eral perihilar airspace opacity with dilatation of the main pulmonary
and mild anterior hypokinesia of the left ventricle ..
with a left ventricular ejection fraction of 45%. . artery.
21 March Patient was transferred in another institution.
Case report of anterior STEMI in a patient with COVID-19 3

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Figure 2 Electrocardiogram recorded during the second episode of acute respiratory failure. ST-segment elevation is present in leads V1 to V4
with reciprocal ST changes in leads II, II, V5, and V6.

inflammatory syndrome [leucocytes 18 G/L, C-reactive protein

.. tight ostial stenosis of the obtuse marginal branch and an intermedi-
..
143 mg/L (N < 6 mg/L)], with negative cardiac troponin <0.015 mg/L .. ate stenosis of the dominant mid-circumflex artery were observed. A
..
(99th upper reference limit 0.045 mg/L) and elevated N-terminal-pro- .. biodegradable polymer, everolimus-eluting stent (Synergy, Boston
B-type natriuretic peptide (2733 ng/L). ..
.. Scientific) was deployed at the culprit site 37 min after the arrival in
Twelve hours later, the respiratory state of the patient deterio- ..
rated with persistent hypoxaemia (PaO2 57 mmHg) despite ventila- .. the cathlab with an optimal result (Figure 3). No attempt was made to
..
tion with a high oxygen concentration mask (6 L/min). Although the .. stent non-culprit stenosis.
patient had no chest pain, an ECG showed anterior ST-segment ele- ..
..
vation. The patient received 4000 IU of intravenous unfractionated .. The ECG normalized within an hour after percutaneous coronary
heparin, 250 mg of intravenous aspirin, and 180 mg of oral ticagrelor,
..
.. intervention (PCI) and the patient’s respiratory condition significantly
and the patient was taken to the cathlab 150 min after the first abnor- .. improved, without recurrent pulmonary oedema or need for non-
mal ECG for emergent coronary angiography. The ECG recorded
..
.. invasive ventilation. High-sensitivity troponin I peaked at 8.8 mg/L
upon arrival in the cathlab showed persistent ST-segment elevation ..
.. (99th upper reference limit 0.045 mg/L). Echocardiography depicted a
in the anterior leads with reciprocal changes in the inferior and lateral ..
leads (Figure 2). The patient wore a surgical mask during the coronary .. limited apical akinesia and mild anterior hypokinesia with a LVEF of
..
angiography, while the interventional cardiologist and cathlab nurses .. 45%. Given the favourable clinical course, no specific treatment
wore protective equipments—including N95 mask, mobcap, ..
.. of COVID-19 was introduced and the patient was transferred
gloves, plastic glasses, overshoes, and sterile gowns above the lead ... to another institution 2 days after PCI. Unfortunately, respiratory
aprons—as advised by the local infection control unit, which was pre- ..
sent during the procedure. A tight stenosis of the mid-portion of the .. condition of the patient deteriorated 8 days after diagnosis of
..
left anterior descending artery (LAD) was found, with normal (TIMI .. COVID-19 and he required sedation, intubation for mechanical venti-
coronary grade flow 3) flow. In addition to the culprit LAD stenosis, a
.. lation and died 6 days later of refractory hypoxaemia.
4 Q. Fischer et al.

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Figure 3 Coronary angiography. (A) Right coronary artery (left anterior oblique view). (B) Left coronary artery (right anterior oblique caudal
view). Intermediate stenosis of the dominant mid-circumflex artery (white arrow) and tight ostial stenosis of the obtuse marginal branch (with arrow-
head). (C) Left coronary artery (right anterior oblique cranial view). Tight stenosis of the mid-left anterior descending artery (white arrow). (D) Same
view as in C after stent implantation in the left anterior descending artery (white arrowheads).

.. recently.6 In the present case, the transfer of the patient from the ICU
Discussion ..
.. to the cathlab took 150 min, an unusually long time for an inpatient
In this case report, the occurrence of an acute respiratory distress in a ... presenting with ST-elevation ACS in a tertiary hospital with round-
patient with infected diabetic foot ulcer, led to the simultaneous diag- .. the-clock cathlab availability. This long delay was attributed to the ex-
..
nosis of COVID-19 and high-risk ACS. The medical teams involved .. tremely tensed medical activity at the start of COVID-19 epidemics,
with the care of the patient had to deal with several challenges.
..
.. especially in the ICU. However, the cathlab team took advantage of
First, establish a formal diagnosis of COVID-19 and prevent .. this long transfer to receive proper training by the infection control
COVID-19 transmission to the caregivers. Of note, COVID-19
..
.. unit, such that appropriate protective measures had been imple-
screening was not performed upon initial admission since the .. mented and PCI could be rapidly performed. In order to prevent time
..
patient’s fever was attributed to his foot infection and he had no re- .. delay for emergent PCI, our current policy is to refer all patients with
spiratory symptoms. However, it was systematically performed when .. very-high risk ACS and suspected COVID-19 directly to the cathlab
..
his respiratory condition deteriorated, leading to implement the pro- .. and to transfer them immediately afterward to the ICU.
tective measures, pending the results of the naso-pharyngeal swab. .. Fourth, even though it is unclear whether the ACS could be classified
..
Second, understand the aetiology of the two episodes of re- .. as a type 1 or type 2 myocardial infarction, the persistence of ST-
spiratory failure, which were not related to COVID-19, as sug- .. segment elevation before PCI despite a patent LAD suggests that a pro-
..
gested by the favourable clinical course on diuretics and .. found imbalance between oxygen supply and demand was the key de-
oxygenation after the first episode, and the efficacy of PCI on .. terminant of this ACS. Alternatively, a vasospasm cannot be ruled out.
..
symptoms after the second. .. Fifth, due to potential infectious hazards related to the close exposure
Third, to perform emergent PCI in a safe environment in a patient
.. to the COVID-19 patient, it was decided not to perform further imaging
..
with COVID-19, which has been recognized as a medical challenge . of the culprit atherosclerotic plaque with intravascular ultrasound or
Case report of anterior STEMI in a patient with COVID-19 5

..
optical coherence tomography. Hence, it was impossible to assess .. Supplementary material
whether atherosclerotic plaque rupture or erosion was present at the ..
..
culprit site. The profound inflammatory response and cytokine storm .. Supplementary material is available at European Heart Journal - Case
syndrome associated with SARS-CoV-2 infection may confer a greater
.. Reports online.
..
risk for atherosclerotic plaque rupture in susceptible patients,7 and high .. Slide sets: A fully edited slide set detailing this case and suitable
..
prothrombotic state leading to transient occlusive arterial thrombosis.8 .. for local presentation is available online as Supplementary data.
Finally, there are reports of individual centres developing alternate ..
.. Consent: The authors confirm that written consent for submis-
strategies in the setting of the COVID-19 crisis, such as preferential ..
.. sion and publication of this case report including images and

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use of fibrinolytic therapy in patients with ST-elevation myocardial in- .. associated text has been obtained from the patient in line with
farction.9 However, interventional approaches are more likely to im- ..
prove the patient outcomes and should be preferred, provided they
.. COPE guidance.
..
can be applied timely and without putting the caregivers at excessive .. Conflict of interest: none declared.
..
risk of contamination. ..
.. References
.. 1. World Health Organization. WHO Director-General’s opening remarks at the
..
.. media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speeches/
Conclusion .. detail/whodirector-general-s-opening-remarks-at-the-media-briefing-on-covid-
.. 19—11-March-2020 (12 March 2020).
Emergent PCI for ACS is feasible and safe in COVID-19 patients but .. 2. Li B, Yang J, Zhao F, Zhi L, Wang X, Liu L, Bi Z, Zhao Y. Prevalence and impact of
.. cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol 2020;
requires a multidisciplinary effort involving caregivers from infectious ..
disease, intensive care, and cardiology teams.
.. 3. 109:531–538. Wu Z, McGoogan JM. Characteristics of and important lessons from the corona-
..
.. virus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314
.. cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;
.. 323:1239.

Lead author biography .. 4. Driggin E, Madhavan M V, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, Brown T
.. S, Der Nigoghossian C, Zidar D A, Haythe J, Brodie D, Beckman J A, Kirtane A J,
.. Stone G W, Krumholz H M, Parikh S A. Cardiovascular Considerations for
Quentin Fischer is a 31-year-old inter- .. Patients, Health Care Workers, and Health Systems During the COVID-19
..
ventional cardiologist working in .. Pandemic. J Am Coll Cardiol2020;75:2352–2371.

Bichat Hospital, Paris, France. He per- .. 5. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system.
.. Nat Rev Cardiol 2020;17:259–260.
formed a fellowship in the Quebec .. 6. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L,
Heart & Lung Institute, Quebec city,
.. Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. Clinical course and risk
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Canada. His research interests include .. spective cohort study. The Lancet 2020;395:1054–1062.
..
optimizing myocardial revasculariza- .. 10.1016/S0140-6736(20)30566-3

tion in ST-segment elevation myocar- .. 7. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated
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