COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

ABSTRACT

Clinical Information Patient Initials or Identifier Number JS Relevant Clinical History and Physical Exam A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s) SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023