ST Elevation in the COVID-19 Era: A Diagnostic Challenge

A 51-year-old man with a medical history of hypertension, CAD, hyperlipidemia, previous MI, and diabetes presented to the ED for chest pain and shortness of breath. The patient described chest pain similar to his previous MI, with onset 1 h before arrival. Vital signs on presentation showed a blood pressure of 165/112 mm Hg, a heart rate of 110 beats/min, a respiratory rate of 22 breaths/min, a temperature of 36.9°C, and pulse oximetry of 91% on nonrebreather mask (NRB). Chest radiography (CXR) and a 12-lead ECG were performed as well as a bedside cardiac ultrasound. The ECG revealed 1- to 2-mm ST elevations in leads V5 and V6 (Figure 1). CXR revealed multifocal airspace disease consistent with COVID-19 pneumonia. Point-of-care cardiac ultrasound revealed severely depressed left ventricular ejection fraction (LVEF) by visual estimation, with a previously documented LVEF of 35–40%. In consultation with interventional cardiology the patient initially underwent a medical management strategy because of concerns that the primary cause of the presentation was infection from COVID-19. The patient received 325 mg aspirin, 40 mg lasix, and 1 mg nitroglycerin intravenously. The patient was then given a bolus dose of heparin and started on a continuous heparin infusion. Initial high sensitivity troponin was 175 ng/L. A repeat ECG obtained approximately 90 min after presentation showed >2 mm ST elevation in leads V5, V6, II, III, and arteriovenous fistula. There were reciprocal ST segment depressions in leads I, aVL, V1, V2, and V3 (Figure 2). The interventional cardiology team re-evaluated the patient, who was then intubated and taken emergently to the cardiac catheterization laboratory (CCL). Angiography revealed 100% occlusion of the proximal circumflex with Thrombolysis In Myocardial Infarction grade 0 flow. Two drug-eluting stents were deployed in the circumflex with Thrombolysis In Myocardial Infarction grade III flow after procedure; there was also severe left anterior descending coronary artery disease. The patient then went into cardiac arrest (pulseless electrical activity) before the right-sided coronary circulation could be assessed. The CCL team performed cardiopulmonary resuscitation for 33 min before the patient died. A coronavirus polymerase chain reaction swab was positive.

A 67-year-old man with no reported medical history presented with a 3-day history of worsening dyspnea. He had vague chest pain that resolved on the day before presentation. Vital signs at presentation showed a blood pressure 147/79 mm Hg, a heart rate of 113 beats/min, a respiratory rate of 30 breaths/min, a temperature of 36.1°C, and oxygen saturation of 78% on room air that improved to 95% on 15 L/min by nonrebreather mask. An ECG demonstrated >2 mm ST segment elevations in the lateral leads with inferior ST segment depressions (Figure 3); no previous ECG was available for comparison. CXR showed bibasilar interstitial airspace opacities; point-of-care cardiac ultrasound showed normal right and left ventricular systolic function by visual estimation and no regional wall motion abnormalities. Interventional cardiology was consulted and recommended emergent cardiac catheterization, which the patient initially declined. Laboratory testing revealed a blood glucose of 518 mg/dL and anion gap of 34 consistent with diabetic ketoacidosis, creatinine of 1.43 mg/dL, high-sensitivity troponin 6853 ng/L, D-dimer >35.2 mg/L, fibrinogen 646 mg/dL, and ferritin 996.1 ng/mL. Computed tomography pulmonary angiography was negative for pulmonary embolism. The patient ultimately agreed to cardiac catherization and was given 5000 units of heparin and 325 mg oral aspirin. He was intubated and taken to the CCL where angiography revealed 35% stenosis of the distal left main artery, 20% stenosis of the mid-LAD, 60% stenosis of the proximal first obtuse marginal artery, and 90% stenosis of the proximal posterior descending artery; no intervention was performed. His COVID-19 polymerase chain reaction nasal swab was positive; he received methylprednisolone, remdesivir, azithromycin, and ceftriaxone for pneumonia, enoxaparin 100 mg twice daily, and 81 mg daily aspirin. He stabilized with medical management in the intensive care unit. He was extubated on hospital day 6 and found to have a new left-sided facial droop. His symptoms resolved and neuroimaging did not show any findings of cerebral ischemia, leading to a diagnosis of transient ischemic attack. He was transferred out of the intensive care unit on day 7, requiring oxygen by nonrebreather mask to maintain his oxygen saturation >90%. In-hospital comprehensive echocardiography was not performed because of concerns over the spread of COVID-19 infection. On hospital day 14, while awaiting discharge to a skilled nursing facility, he suffered a cardiac arrest and died.