COVID-19-associated myocardial infarction
COVID-19-associated myocardial infarction On the Web
American Roentgen Ray Society Images of COVID-19-associated myocardial infarction
COVID-19 patients with cardiovascular comorbidities have higher mortality. According to a recent systematic review and meta-analysis,acute cardiac injury with troponin levels greater than 28 pg/ml was detected in 12.4% of confirmed COVID-19 patients. Acute Myocardial Infarction is defined as an acute myocardial injury with clinical evidence of acute myocardial ischemia plus rise and/or fall of cardiac troponin values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of myocardial ischemia including new ischemic ECG changes, development of pathological Q waves, imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology. Identification of a coronary thrombus by angiography or autopsy (not for type 2 or 3 MI).
- COVID-19 (SARS-CoV-2) outbreak initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.
- On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.
- Even before the pandemic declaration, concerns about the management of Acute Myocardial Infarction in COVID-19 era started to rise and on March 11, 2020, Zeng et al addressed this issue by introducing Protocols From Sichuan Provincial People's Hospital for Acute MI diagnosis and treatment protocol adjustment during COVID-19.
- "Be Prepared" is the title of a paper published on March 15, 2020, discussing the longer time from symptom onset to first medical contact in STEMI patients due to the COVID-19 outbreak.The call for maximizing acute care resources, maintaining access to services while limiting nosocomial COVID-19 infection was one of the earliest in regards to COVID-19-associated myocardial infarction
- On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of STEMI Care Before and After COVID-19 Outbreak
- On March 31, 2020, Kang discussed underlying diseases such as cardiovascular disease as a risk factor developing a serious and severe COVID-19.
- On June 9, 2020, Fried et al. discussed 4 cases showing a variety of cardiovascular presentations of COVID-19 and one of the uncertainties as whether or not the staff should proceed to coronary angiography in response to ECG changes and positive troponin
Myocardial infarction may be classified according to two subtypes:
ST-Elevation Myocardial Infarction (STEMI) and COVID-19:
A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.
- Potential etiologies for the reduction in STEMI PPCI activations:
The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.
- The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression. For hypercoagulable state in COVID-19, click here
- increased inflammatory response may also lead to endothelial dysfunction causing the microthrombi formation.
- ACE-2 is the receptor of SARS-CoV 2 which is highly expressed on cardiac pericytes. Therefore it can be speculated that the pericyte damage by the virus results in endothelial cell damage which at the end leads to microvascular impairment.
- This video shows plaque rupture or disruption of the atherosclerotic plaque in the mid left anterior descending artery (LAD) .
- In the level of cardiac tissue: findings include a range of minimal change to interstitial inflammatory infiltration and myocyte necrosis
- In the level of vasculature: micro-thrombosis and vascular inflammation
According to the Fourth Universal Definition of MI, there are two clinical classifications of the disease based on the causes:
- Type 1: MI caused by acute atherothrombotic CAD precipitated by atherosclerotic plaque disruption (rupture or erosion).
- Type 2: MI due to a mismatch between oxygen demand and supply, possible causes are hypotension due to septic state and hypoxemia due to respiratory failure
Differentiating Myocardial infarction from other Diseases
Epidemiology and Demographics
- Hospitalized patients with COVID-19 and Cardiovascular disease seem to be more prevalent in both the USA and China. 
- Studies have shown reduction of incidence and hospitalization of acute MI during COVID-19 Pandemic.
- A study in Italy showed up to a 49.4 percent reduction in admissions for acute MI to coronary care units from March 12th to 19th in 2020 compared to the equivalent time in 2019. 
- Age (men >45 and women >55)
- Diabetes mellitus
- Lack of physical activity
- Family history of heart disease
- History of HTN, DM and pre-eclampsia during pregnancy
For Risk factors associated with COVID-19 please click here
Due to the higher mortality of patients with COVID-19 and cardiovascular comorbidities, it advisable to triage patients with COVID-19 based on their underlying CVD for a more aggressive treatment plan.
Natural History, Complications and Prognosis
In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.
- Based on the Troponin level The mortality during hospitalization was shown to be as below:
History and Symptoms
- Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
- Nausea and vomiting
- For non-ST elevation myocardial infarction physical examination please click here
- For STEMI physical examination please click here
Elevated cardiac Troponin levels has been detected in 10-30 percent of COVID-19 patients and studies have shown an association between mortality and higher troponin in COVID-19. However, the clinical value of troponin to assess suspected ACS based on clinical presentation has not been established. 
- For COVID-19 laboratory findings please click here
- For non ST elevation myocardial infarction biomarkers please click here
- For ST elevation myocardial infarction laboratory findings please click here
- For non-ST-elevation myocardial infarction electrocardiogram please click here
- For ST-elevation myocardial infarction electrocardiogram please click here
- For COVID-19 electrocardiogram findings please click here
- For X-ray findings in COVID-19 please click here
- For X-ray findings in Myocardial Infarction please click here
- For COVID-19 echocardiography please click here
- For non-STEMI Echocardiography please click here
- For STEMI Echocardiography please click here
There are no specific CT scan findings related to COVID-19-associated myocardial infarction.
There are no MRI findings related to COVID-19-associated myocardial infarction.
- For non-STEMI coronary angiography please click here
- For STEMI coronary angiography please click here
- Treatment of STEMI & COVID-19:
- The specific protocols for the treatment have been evolving. Early recommendations showed intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.
- According to the latest European Society of Cardiology (ESC) guidance for the management of cardiac complications related to COVID-19, if STEMI is diagnosed timely primary percutaneous intervention should be performed as stated by current ESC guidelines, irrespective of COVID-19 diagnosis. Fibrinolysis should be the first treatment choice when percutaneous intervention is not feasible within 12 hours of symptom onset.
- Treatment of non-ST-STEMI, should be based on risk stratification:
- high-risk cases: immediate invasive strategy, SARS-CoV-2 testing should be delayed.
- intermediate/low-risk cases: non-invasive strategies such as coronary CT-angiography with regular follow-ups should be the treatment of choice.
- There are no available vaccines against COVID-19 and studies are going on for finding an effective vaccine.
- Other primary prevention strategies include measures to reduce the occurrence of myocardial injury among COVID-19 patients. Recent studies have suggested the use of medications improving microcirculation, especially for the high-risk group such as males, smokers, diabetic patients, and patients with established cardiovascular disease comorbidities.
- For Risk factors associated with COVID-19 please click here
- There are no established measures for the secondary prevention of COVID-19-associated myocardial infarction.
- For ST-elevation myocardial infarction secondary prevention please click here
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