COVID-19-associated myocardial infarction

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Main article:COVID-19
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Sara Haddadi, M.D.[3]

Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Myocardial Infarction, MI, ST Elevation Myocardial Infarction, STEMI, Non ST Elevation Myocardial Infarction, NSTEMI

Overview

On March 11, 2020, the World Health Organization declared the COVID-19 outbreak as a pandemic. Coronavirus disease 2019 (COVID-19) has negative effect on patients with ST-segment elevation myocardial infarction (STEMI). STEMI can be the first manifestation of COVID-19. Reported case series addressed the significant reduction of STEMI presentation and cath lab activation rate during first wave of pandemic period. So, the number of out-of hospital cardiac arrest increased due to late presentation of STEMI in italy. Additionally, there was an increased incidence of acute thrombotic STEMI among patients undergoing coronary angiography suggestive of increased inflammation and platelet activation and direct viral interaction with ACE2 receptors. However, one-third of STEMI patients undergoing angiography had non-obstructive culprit lesion indicating of type2 myocardial infarction, myocarditis secondary to SARS-COV-2 infection, SARS-COV-2 related endothelial dysfunction, or cytokine storm. STEMI patients with confirmed COVID-19 presented with lower conventional risk factors and were more likely to present with deteriotated clinical status and higher killip class and progression to cardiogenic shock as well as higher mortality rate due to COVID-19 thrombogenicity and high thrombisis burden in coronary arteries.

Historical Perspective

  • COVID-19 (SARS-CoV-2) outbreak initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.[1]
  • 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.[2]
  • "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.[3]
  • On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of STEMI Care Before and After COVID-19 Outbreak[4]
  • On March 31, 2020, Kang discussed underlying diseases such as cardiovascular disease as a risk factor developing a serious and severe COVID-19.[5]
  • 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[6]

Classification

Myocardial infarction may be classified according to two sub-types:

Pathophysiology

The mechanism of COVID-19 myocardial infarction is not fully understood and is likely multi-factorial.

Pathological changes:

Causes

According to the Fourth Universal Definition of MI, there are two clinical classifications of the disease based on the causes:

Most of the MIs associated with COVID-19 are type 2 indicating the cause to be the primary infection, hemodynamic disturbance, or respiratory deterioration.[11] [8]

Differentiating Myocardial infarction from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • The exact incidence of STEMI associated COVID-19 is not fully understood yet. However, during the first wave of pandemic, the number of hospitalized STEMI patients decreased in comparison with the parallel year.[12][13][14][15]
    • A study in Italy showed up to a 49.4% reduction in admissions for acute MI to coronary care units from March 12th to 19th in 2020 compared to the equivalent time in 2019. [12]

Age

Gender

Race

Risk Factors

Common risk factors in the development of acute coronary syndrome including STEMI and non-STEMI are listed below:[17]

For Risk factors associated with COVID-19 please click here

Screening

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.[18]

Natural History, Complications and Prognosis

Age, sex Cardiovascular history Symptoms Laboratory findings Timing according to covid-19 infection Concomitant covid-19 complications Covid-19 severity Diagnosis Vessle Treatment Outcome
65 years, male Hypertension, diabetes mellitus New chest pain, shortness of breath High levels of troponin, CRP, D-dimer 7 days Sinus bradycardia, complete heart block, inferior STelevation Mild Inferior STEMI 100% RCA stenosis, moderate LAD stenosis, NO visible edge dissection in IVUS ASA, ticagrelor, heparin, eptifibatide , PCI of RCA, ballon angioplasty, thrombectomy, vasodilation, IABP Cardiogenic shock after PCI despite patency of stent or no evidence of edge dissection in IVUS, expired due to persistent microvascular thrombosis
74 years, female Hypertension, diabetes mellitus, hyperlipidemia Shortness of breath, fever, myalgia, hypoxic respiratory failure, new onset chest pain 5 days after admission High levels of troponin, CRP, ferritin, D-dimer 8 days Severe lung infiltration Antrolateral STEMI 100% distal LAD lesion, ASA, clopidogrel, enoxaparin, intubation, urgent catheterization, thrombectomy, PCI of LAD lesion, ballon angioplasty, stent placement, no achieved distal flow Expired due to sepsis and respiratory failure

Diagnosis

Diagnostic Study of Choice


History and Symptoms

There are no specific symptoms associated with COVID-19-associated-Myocardial infarction. Common symptoms in patients with acute MI is listed below:[27]

For non-ST elevation myocardial infarction history and symptoms please click here
For ST elevation myocardial infarction history and symptoms please click here

Physical Examination

  • For non-ST elevation myocardial infarction physical examination please click here
  • For STEMI physical examination please click here

Laboratory Findings

Electrocardiogram

There are no specific ECG findings associated with both COVID-19 and Myocardial infarction.

  • 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

X-ray

There are no specific X-ray findings associated with both COVID-19 and Myocardial infarction.

  • For X-ray findings in COVID-19 please click here
  • For X-ray findings in Myocardial Infarction please click here

Echocardiography

  • In a study done among 28 patients with COVID-19 with STEMI, the following echocardiographic findings were reported:[19]
    • Localized wall motion abnormalities
    • Diffuse hypokinesia  
    • Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.


CT scan

  • There are no specific CT scan findings related to COVID-19-associated myocardial infarction.

MRI

  • There are no MRI findings related to COVID-19-associated myocardial infarction.

Other Imaging Studies

Coronary Angiography

  • In one study done among patients with COVID-19 with STEMI, coronary angiography failed to reveal any culprit lesion in about 40% of the patients. However, in the remaining patients, coronary angiography was able to localize a lesion.[19]


Other Diagnostic Studies

  • There are no specific other diagnostic studies related to COVID-19-associated myocardial infarction.

Treatment

Medical Therapy

In patients with ACS and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.[10] [28]

  • Treatment of STEMI and COVID-19:
    • Intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.[29]
    • 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, 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 NSTEMI should be based on risk stratification:

Primary Prevention

Secondary Prevention

References

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  4. Tam, Chor-Cheung Frankie; Cheung, Kent-Shek; Lam, Simon; Wong, Anthony; Yung, Arthur; Sze, Michael; Lam, Yui-Ming; Chan, Carmen; Tsang, Tat-Chi; Tsui, Matthew; Tse, Hung-Fat; Siu, Chung-Wah (2020). "Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006631. ISSN 1941-7713.
  5. Kang, Yun-Jung (2020). "Mortality Rate of Infection With COVID-19 in Korea From the Perspective of Underlying Disease". Disaster Medicine and Public Health Preparedness: 1–3. doi:10.1017/dmp.2020.60. ISSN 1935-7893.
  6. Fried, Justin A.; Ramasubbu, Kumudha; Bhatt, Reema; Topkara, Veli K.; Clerkin, Kevin J.; Horn, Evelyn; Rabbani, LeRoy; Brodie, Daniel; Jain, Sneha S.; Kirtane, Ajay J.; Masoumi, Amirali; Takeda, Koji; Kumaraiah, Deepa; Burkhoff, Daniel; Leon, Martin; Schwartz, Allan; Uriel, Nir; Sayer, Gabriel (2020). "The Variety of Cardiovascular Presentations of COVID-19". Circulation. 141 (23): 1930–1936. doi:10.1161/CIRCULATIONAHA.120.047164. ISSN 0009-7322.
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