CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT POSITIVE FOR COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare cardiac phenomenon associated with autoimmune and inflammatory conditions seen often in young women with few conventional atherosclerotic risk factors. The presentation is indistinguishable from acute coronary syndrome and can lead to acute myocardial infarction, arrhythmias, and sudden death. We share a thought-provoking case of SCAD in a COVID-19 positive patient. CASE PRESENTATION: 51-year-old physically fit female with BMI of 22.46kg/m2, non-diabetic with recent unremarkable lipid panel and history of anxiety, postpartum cardiomyopathy 15 years prior with recovered ejection fraction presented with complaints of midsternal chest pain at rest, 9/10 intensity, radiating to the right shoulder associated with dyspnea, lasting for 3 hours until relieved by nitroglycerine patch. Initial workup revealed troponin of 3.08 and EKG consistent with acute ischemic changes without STEMI. She was incidentally found positive for SARS-CoV-2. Echocardiogram showed dyskinetic apex with normal ejection fraction. The following day, while she was on aspirin and heparin drip, she developed chest discomfort with EKG revealing dynamic T wave inversions and troponin trending up to 14.79. The patient was taken for an emergent cardiac catheterization which revealed patent coronaries with concern for distal left anterior descending artery dissection. Subsequently, the patient was continued on a heparin drip with an improvement of her symptoms. Troponin declined to 7.97 with no other COVID-19 related concerns. She was deemed medically stable and discharged home after completing her isolation. Furthermore, she underwent a cardiac and coronary artery CT angiogram 2 weeks later, showing patent coronaries and a calcium score of 0 and no findings of coronary artery disease. DISCUSSION: SCAD is an emergent condition closely associated with inflammatory conditions, systemic arteriopathy, emotional stress triggers, fibromuscular dysplasia, and pregnancy. It is not iatrogenic, traumatic or associated with atherosclerosis. The mainstay of detection of SCAD is coronary angiography. In our patient, since it was a distal LAD disease, the echo findings of dyskinetic apex helped established the diagnosis of SCAD. Management is mainly supportive usually carrying a good prognosis. In our case report, the connecting factor to SCAD was the presence of SARS-CoV-2. Our patient was without traditional risk factors for coronary artery disease, which reinforced the likelihood of SCAD instead of acute coronary syndrome. CONCLUSIONS: Thus, as the manifestations, complications, and sequelae of COVID-19 continue to emerge, we believe SCAD needs to remain a top differential in COVID -19 positive patients presenting with symptoms of the acute coronary syndrome. To better elucidate the pathophysiology of SCAD in SARS-CoV-2 patients, we encourage further vigilance of this phenomenon. Reference #1: Hayes, S. N. et al (2018, February 22). Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association. Circulation. Retrieved April 1, 2022, from https://www.ahajournals.org/doi/10.1161/cir.0000000000000564 Reference #2: Ahmed, T., Jeudy, J., & Srivastava, M. C. (2020). Imaging modalities to delineate sequelae of spontaneous coronary artery dissection managed with percutaneous coronary intervention. Cureus. https://doi.org/10.7759/cureus.7591 DISCLOSURES: No relevant relationships by Hareesh Lal No relevant relationships by Jennaire Lewars No relevant relationships by Avani Mohta

Coronary Vasospasm in a Pediatric Patient with Myopericardit is After COVID-19 Vaccine

Introduction: The COVID-19 vaccine was approved for use in adolescents ages 12-17 on May 10, 2021. There have since been case reports of myocarditis shortly after the COVID-19 vaccine, mostly in adolescent males. Among these cases, coronary vasospasm has not been described. Case Description: A 16 year old previously healthy male presented with two days of chest pain and subjective fevers three days after receiving the second dose of the Pfizer COVID-19 vaccine. High-sensitivity troponin I was 10,819 ng/L (reference range: 3-57), and ECG showed mild diffuse ST segment elevations (Image 1). He was admitted for suspected myopericarditis and treated with ketorolac, prednisone, and IVIG. Shortly after admission, he experienced sudden crushing, substernal chest pain. An ECG obtained during the episode showed striking ST segment elevation in the inferolateral leads (Image 2). He was started on a nitroglycerin drip, supplemental oxygen, low dose aspirin and received 3 doses of morphine. The acute chest pain responded rapidly to these measures, and the nitroglycerin drip was stopped after 24 hours without recurrence of symptoms. An echocardiogram was normal. Cardiac MRI showed subepicardial enhancement without evidence of acute infarction. He was discharged on hospital day #4, chest pain free for 24 hours with downtrending troponin. Discussion: Our patient's initial presentation of chest pain with elevated troponin and mild diffuse ST segment elevation is consistent with myopericarditis, similar to described cases occurring after the COVID-19 vaccine. During an acute, more severe, episode of chest pain, there was further localized ST segment elevation consistent with myocardial ischemia. Serial ECGs demonstrated improvement as the chest pain resolved, suggesting acute coronary artery vasospasm. Intravenous nitroglycerin, the mainstay of treatment for coronary vasospasm, was therapeutic with no recurrence of chest pain. Interestingly, our patient's acute inferolateral ST segment elevations during the episode of severe chest pain correlated with the distribution of myocardial enhancement noted on cardiac MRI, implicating subepicardial myocarditis as the likely cause. This complication has been reported in adults with viral myocarditis. Conclusion: This case highlights the importance of recognizing coronary vasospasm as a potential complication of COVID vaccine-induced myopericarditis.

DISSECTING COVID-19 - A RARE CASE OF SPONTANEOUS CORONARY ARTERY DISSECTION IN THE SETTING OF RECENT COVID-19 INFECTION

CASE: A 67 year old woman with no known cardiac history presented after acute onset chest pain while watching TV. The pain was described as a burning, substernal pain associated with shortness of breath and nausea. She had no prior history of similar chest pain and was recently exercising with no complaints. Her pain was not relieved by Tums, so she presented to the ED. A COVID-PCR test was positive on admission, however the patient stated she had the infection three weeks prior to presentation and was asymptomatic. She was given sublingual nitroglycerin which improved her pain. Vital signs and physical exam were unremarkable. Electrocardiogram demonstrated ST elevations in leads V3 and V4 with an initial troponin of 0.1 ng/ml (reference range <0.80 ng/ml). She subsequently was loaded with aspirin, a heparin bolus, and was taken to the cath lab. There, she was found to have a distal LAD spontaneous coronary artery dissection and underwent POBA with restoration of vessel flow. IMPACT/DISCUSSION: Spontaneous coronary artery dissection (SCAD) is a condition predominantly seen in women without conventional risks for coronary disease and an often missed cause of non-atherosclerotic ACS. Most often, patients present with typical chest pain and dynamic ECG changes. Diagnosis of SCAD is made during coronary angiogram, at times with the aid of intravascular ultrasound or OCT. Often, these patients will have associated conditions such as fibromuscular dysplasia, pregnancy/postpartum status, or connective tissue diseases. We describe a unique case of a patient without any cardiac risk factors presenting with SCAD after the resolution of an asymptomatic COVID-19 infection. Cardiac complications of COVID-19 have been extensively described, from myocarditis, myocardial infarction, heart failure, and arrhythmias. However, published literature on the association between COVID-19 and SCAD is sparse, with a few case reports reporting a possible connection. Among these, the majority of patients were acutely symptomatic with COVID-19 and subsequently developed angina during the hospitalization. There was one similar case describing a patient developing SCAD after the resolution of a COVID infection 3 months prior to presentation. However, this patient had factors which could have contributed to the SCAD. SCAD is associated with inflammatory diseases that lead to vessel wall weakness. COVID-19 induces a marked inflammatory and immune response during infection, which has been found to cause endothelial and smooth muscle damage. It is possible the inflammatory response from the infection could promote fragility of coronary vessels and lead to dissection. CONCLUSION: As the relationship between SCAD and COVID-19 continues to be explored, providers must be mindful of the potential cardiac manifestations of the virus. An index of suspicion for SCAD should be maintained in patients with COVID-19 or a history of COVID-19 presenting with acute myocardial infarction with few or no atherosclerotic risk factors.

Role of Dexmedetomidine in Perioperative Management of Pheochromocytoma

The prevalence of Pheochromocytoma in pat ient with hypertension is 0.1 -0.6%. These types of tumours are known for unpredictable perioperative course and hemodynamic instability. Various different drugs and anaesthesia techniques can be used to tackle these situations. Dexmedetomidine is emerged as newer agent with better hemodynamic stability, reducing requirement of other anaesthesia drugs, blunting of sympathoadrenal response in resection of Pheochromocytoma. We report four cases operated between January 2021 to June 2021.Preoperative preparation was done with α and β blockade. Dexmedetomidine was used during induction as 1 mcg/kg over 10 mins followed by 0.7mcg/kg/hr intraoperatively. Combination of Dexmedetomidine, Fentanyl, NTG, Isoflurane and Epidural analgesia was used. IF needed boluses of Esmolol and Labetalol were used during tumor manipulation. All the patients had an uneventful perioperative course. Dexmedetomidine with pre-operative α and β blockade reduce the need of other drugs intraoperatively and can be used as anaesthetic adjunct to maintain steady hemodynamic.

CAUGHT IN THE ACT: MINOCA IN A PATIENT WITH SEVERE CORONARY VASOSPASM

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and diagnostically challenging entity. Case: A 62-year-old female with recent COVID19 infection presented with chest pain. She was discharged just one week prior for NSTEMI, with mild non-obstructive CAD by left heart catheterization (LHC) and a normal transthoracic echocardiogram. This admission, Initial Troponin I peaked at 0.87 ng/mL and ECG without ischemic changes. Cardiac MRI (CMR) showed no myocarditis/pericarditis but moderate-severely hypokinetic apical cap, distal inferior and septal walls, with a small focus of subendocardial scar/infarction involving the distal septum (Fig.1A,B,C). LHC showed severe vasospasm in the right coronary artery and left anterior descending artery (Fig. 1D,E), which resolved after intracoronary nitroglycerin (Fig. 1F). With initiation of isosorbide mononitrate to manage coronary vasospasm, the patient’s symptoms improved. At 6-month follow-up, patient was doing well with no repeat hospitalizations. Decision-making: Even though initial workup did not identify a clear etiology, CMR was pivotal in prompting further evaluation that revealed severe coronary vasospasm. Given the transient nature of vasospasm, it is likely this had resolved prior to her initial LHC, but was caught on repeat imaging. Conclusion: CMR is a key diagnostic tool in preliminary investigation of MINOCA when a clear cause is not found, and can alter next steps in management. [Formula presented]