CORONAVIRUS CLOTS CORONARIES: ST ELEVATION MYOCARDIAL INFARCTION IN A YOUNG MALE WITH CORONAVIRUS DISEASE 2019

ABSTRACT

SESSION TITLE Medical Student/Resident Critical Care Posters SESSION TYPE Med Student/Res Case Rep Postr PRESENTED ON October 18-21, 2020 INTRODUCTION: The coronavirus disease 2019 (COVID-19) is characterized by flu-like symptoms or complications related to pneumonia and acute respiratory distress syndrome. Later in the disease course, clinically significant thrombotic events, both venous and arterial, are being recognized. Our case describes ST elevation myocardial infarction (STEMI) as a complication of COVID-19. CASE PRESENTATION A 38-year-old male with no medical history and non-smoker presented with 10 days of fever, cough, malaise, myalgia, and exertional dyspnea. He denied chest pain. He had completed a five-day course of azithromycin and steroids. No personal or family history of clotting disorders or heart disease. Exam revealed oxygen saturation of 89% on room air with bilateral crepitations. Chest x-ray showed bilateral patchy parenchymal airspace disease. Electrocardiogram (EKG) showed sinus tachycardia without ischemic changes. Labs showed C-reactive protein 179 mg/L and D-dimer 0.64 ug/mL. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction assay was positive. He was started on ceftriaxone, doxycycline, hydroxychloroquine, enoxaparin, and methylprednisolone. After 5 days, he was discharged on prophylactic apixaban. He returned 1 day later with substernal chest pain. EKG showed ST elevation in the inferior leads. Troponin T was 3.74 ng/mL, D-dimer 0.75 ug/mL, and coagulation profile was normal. Emergent coronary angiography revealed 100% occlusion of mid-right coronary artery and right posterolateral branch requiring extensive thrombectomy and placement of drug eluting stents. He was started on aspirin, ticagrelor, eptifibatide, high intensity statin, and metoprolol. Echocardiography revealed severe basal to mid- inferior and posterior wall hypokinesis with left ventricular ejection fraction of 40%. He was discharged on ticagrelor, apixaban, atorvastatin and metoprolol. Anti-phospholipid antibody panel testing results returned normal. DISCUSSION: It is becoming increasingly evident that SARS-CoV-2 predisposes to venous thromboembolism, but arterial thromboembolism, especially manifest as acute STEMI, is rare. A recent Dutch study of 184 ICU patients with COVID-19 demonstrated confirmed arterial thrombotic events in 3.7%.(1) The pro-coagulant pattern is characterized by increased clot strength, elevated platelet and fibrinogen contribution to clot strength, elevated D-dimer levels, and hyperfibrinogenemia.(2) In a recent case series, 67% of patients with COVID-19 undergoing coronary angiography for STEMI had obstructive coronary artery disease (CAD) with 83% requiring PTCA (3). Interestingly, none of these patients had a known prior history of CAD. CONCLUSIONS: Further discussion regarding prophylactic anti-platelet and anti-coagulation strategies in patients with COVID-19 and studies to identify risk factors for thrombotic disease is warranted. Reference #1 Kloka, F A, Kruipb M J H A, van der Meerc N J M, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research. 2020. doi10.1016/j.thromres.2020.04.013 Reference #2 Ranucci, M, Ballotta, A, Di Dedda, U, et al. The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome. Journal of Thrombosis and Haemostasis. April 2020. doi10.1111/jth.14854 Reference #3 Bangalore, S, Sharma, A, Slotwiner, A, et al. ST-Segment Elevation in Patients with Covid-19 — A Case Series. NEJM. April 17, 2020. doi 10.1056/NEJMc2009020 DISCLOSURES No relevant relationships by Juliann Allen, source=Web Response No relevant relationships by Aalap Chokshi, source=Web Response No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Rani Sittol, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response