A 68-year-old male presented to the hospital for chest pain and shortness of breath (SOB). His medical history includes hypertension, type 2 diabetes mellitus, and hyperlipidemia. He is an active smoker, smoking 1 pack per day for the last 45 years. Family history is significant for a father with hypertension and coronary artery disease (CAD) in his 60s and mother with hypertension and diabetes mellitus.
The patient reports a 3-day history of worsening substernal chest pain radiating to the left shoulder. Pain was initially 4/10 in intensity, which later increased to 9/10. Chest pain was nonexertional and associated with SOB, nausea, and diaphoresis. No history of similar complaints in the past. One week prior to presentation, the patient reported low-grade fever, weakness, and loss of sense of taste. He was tested for COVID-19, which came back positive. Given the mild symptoms, he was advised to self-isolate at home and was prescribed azithromycin 500 mg for 5 days. He was advised to monitor his temperature at home and to seek medical attention if his symptoms persist or worsen. His symptoms improved except for loss of sense of taste.
En route to the hospital the patient received aspirin 320 mg orally by emergency medical services (EMS). In the emergency room he was tachycardic (heart rate [HR] 116 beats/min), blood pressure (BP) 168/95 mmHg, temperature 98.5°F, and oxygen saturation of 96% on room air. Electrocardiogram (ECG) showed ST elevation in the inferior leads with reciprocal changes in the anterolateral leads. He underwent coronary angiography with percutaneous coronary intervention (PCI) and drug-eluting stents placed in the right coronary artery. He was moved to the cardiac care unit and COVID testing was performed, which came back negative. COVID antibodies were positive. Transthoracic echocardiogram showed ejection fraction (EF) of 55%, grade 2 diastolic dysfunction, akinesia of the inferior wall, and pulmonary artery pressure of 48 mmHg. Laboratory data revealed elevated inflammatory marker, peaked cardiac troponin of 820 (normal <5), and pro-brain natriuretic peptide (BNP) of 1200 ng/L. The patient had an uncomplicated hospital stay and was discharged after 4 days.
According to a survey from China, 10%-25% of cases of COVID-19 infection had underlying CAD. It is associated with an extremely high mortality rate in CAD patients. In a hospital-wide observational study in the United Kingdom, hospital admissions for ACS have gone down by 40% (compared with 2019) from January to April 2020, and were partially recovered in May. Similarly, the rate of PCI declined by 21% in patients with ST elevation myocardial infarction (STEMI) partly because of fear of contracting COVID-19 infection in the hospital along with loss of healthcare benefits. Pain perception is also altered due to COVID–related neurologic involvement.
COVID-19 can create an inflammatory milieu, which can trigger thrombotic events such as ACS. ...