COVID-19-associated myocardial infarction
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 Haddadi, M.D.[2]
Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Wuhan coronavirus, myocardial infarction, MI, Acute coronary syndrome, ACS
Overview
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[1]. 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
- 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)
In regards to COVID-19, most of the MIs are type 2 indicating the causes to be the primary infection, hemodynamic disturbance, or respiratory deterioration.
Historical Perspective
- COVID-19 (SARS-CoV-2) outbreak initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.[2]
- 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.[3]
- "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[4]
- On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of STEMI Care Before and After COVID-19 Outbreak[5]
- On March 31, 2020, Kang discussed underlying diseases such as cardiovascular disease as a risk factor developing a serious and severe COVID-19.[6]
- 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[7]
Classification
Myocardial infarction may be classified according to two sub-types:
- Non ST Elevation Myocardial Infarction (NSTEMI)
- ST Elevation Myocardial Infarction (STEMI)
Pathophysiology
The mechanism of COVID-19 myocardial infarction is not fully understood and is likely multi-factorial.
- Two potential mechanisms for myocardial infarction in the setting of COVID-19 infection include:[8]
- Plaque rupture in the setting of the inflammatory condition/shear stress caused by the virus
- Exacerbation of pre-existing coronary artery disease
- The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, and direct myocardial suppression. For hypercoagulable state in COVID-19, click here
- Increased inflammatory response may also lead to endothelial dysfunction causing the formation of microthrombi.[9]
- 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 leads to microvascular impairment.[10]
- The above video shows plaque rupture or disruption of an atherosclerotic plaque in the mid left anterior descending artery (LAD) .
- To view Non-ST-elevation myocardial infarction pathophysiology click here
- To view ST-elevation myocardial infarction pathophysiology click here
Pathological changes:
- In cardiac tissue: observations range from minimal change to interstitial inflammatory infiltration and myocyte necrosis
- In the vasculature: findings include micro-thrombosis and vascular inflammation[11]
Causes
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
Most of the MIs associated with COVID-19 are type 2 indicating the cause to be the primary infection, hemodynamic disturbance, or respiratory deterioration.[12] [13][9]
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 data on the incidence of myocardial infarction in the setting of COVID-19 infection is limited.
- Hospitalized patients with COVID-19 and Cardiovascular disease seem to be more prevalent in both the USA and China. [11]
- Studies have shown a reduction of incidence and hospitalization of acute MI during COVID-19 Pandemic.[14][15][16][17]
- 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. [14]
Based on incidence rate of hospitalization among adults with STEMI and non-STEMI in the Kaiser Permanente system before and after the first reported death from COVID-19 in Northern California on March 4, 2020:
- The incidence rate (IR) of MI increases with age:
- The IR between Jan 1-Mar 3 2020 for patients Age <65 with AMI was 1.5 which decreased to 1 during Apr 8-14 2020
- The IR between Jan 1-Mar 3 2020 for patients Age >65 with AMI was 12.9 which decreased to 6 during Apr 8-14 2020
- Males are more commonly affected by [MI] than females:
- The IR between Jan 1-Mar 3 2020 among male patients was 5.1 which decreased to 2.9 during Apr 8-14 2020
- The IR between Jan 1-Mar 3 2020 among female patients was 3.1 which decreased to 1.5 during Apr 8-14 2020[18]
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 admission, which was found to be as long as 318 minutes. This is important because COVID-19 can be the cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.[19][20]
- Potential etiologies for the reduction in STEMI PPCI activations:
- Avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
- STEMI misdiagnosis
- Increased use of pharmacological reperfusion due to COVID-19
It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.[15][12]
Risk Factors
Common risk factors in the development of acute coronary syndrome including STEMI and non-STEMI are listed below:[21]
- Age (men >45 and women >55)
- Diabetes mellitus
- Hypercholesterolemia
- Hypertension
- Smoking
- Obesity
- 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
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.[20]
Natural History, Complications and Prognosis
- Myocardial infarction in the setting of COVID-19 may be the first clinical manifestation of the disease. [22]
- In a study done among 28 patients with COVID-19, STEMI was the first presentation of the COVID-19 infection in 24 cases.
- Typical chest pain in the presence/absence of dyspnea was the most common symptom. Dyspnea without chest pain was the second common symptoms among the cases.
- 11 out of 28 (39.3%) patients died during their hospitalization course.
- 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.[23]
Diagnosis
Diagnostic Study of Choice
- 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
- 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).[12]
- For ST-elevation myocardial infarction diagnostic criteria please click here
- Considering the diagnostic criteria, it is not difficult to differentiate STEMI from other causes of chest pain or equivalent anginal symptoms. However, during COVID-19 pandemic other causes of COVID-19-associated myocardial injury such as COVID-19-associated stress cardiomyopathy or COVID-19-associated myocarditis should be the top of the differential diagnosis list.
- EKG criteria are not specific and may also be present in other COVID-19-associated myocardial injury conditions associated with COVID-19.
- Although elevated troponin is also a non-specific finding, for patients with a high troponin level and suspected STEMI, echocardiography is not generally performed due to the emergent need for angiography.
- For critically ill patients due to COVID-19, the decision to perform angiography or reperfusion should be done on a case by case basis.[13]
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:[24]
- Substernal chest pain
- Occurs at rest or exertion
- Radiation to neck, jaw, left shoulder and left arm
- Aggravated by physical activity and emotional stress
- Relieved by rest, nitroglycerin or both
- Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
- Dyspnea
- Diaphoresis
- Nausea and vomiting
- Fatigue
- Syncope[24]
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
Elevated cardiac Troponin levels have been detected in 10%-30% 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. [25]
- 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
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:[22]
- Localized wall motion abnormalities
- Diffuse hypokinesia
- Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.
- For COVID-19 echocardiography please click here
- For non-STEMI Echocardiography please click here
- For STEMI Echocardiography please click here
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.[22]
- For non-STEMI coronary angiography please click here
- For STEMI coronary angiography please click here
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.[11] [26]
- Treatment of STEMI and COVID-19:
- The specific protocols for the treatment are 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.[19]
- 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 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.[9]
Primary Prevention
- 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.[9]
- For Risk factors associated with COVID-19 please click here
Secondary Prevention
- 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
References
- ↑ "Cardiac injury associated with severe disease or ICU admission and death in hospitalized patients with COVID-19: a meta-analysis and systematic review | Critical Care | Full Text".
- ↑ Meng X, Deng Y, Dai Z, Meng Z (June 2020). "COVID-19 and anosmia: A review based on up-to-date knowledge". Am J Otolaryngol. 41 (5): 102581. doi:10.1016/j.amjoto.2020.102581. PMC 7265845 Check
|pmc=value (help). PMID 32563019 Check|pmid=value (help). - ↑ Zeng, Jie; Huang, Jianxin; Pan, Lingai (2020). "How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital". Intensive Care Medicine. 46 (6): 1111–1113. doi:10.1007/s00134-020-05993-9. ISSN 0342-4642.
- ↑ Ardati, Amer K.; Mena Lora, Alfredo J. (2020). "Be Prepared". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006661. ISSN 1941-7713.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Bansal, Manish (2020). "Cardiovascular disease and COVID-19". Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 14 (3): 247–250. doi:10.1016/j.dsx.2020.03.013. ISSN 1871-4021.
- ↑ 9.0 9.1 9.2 9.3 Montone, Rocco A; Iannaccone, Giulia; Meucci, Maria Chiara; Gurgoglione, Filippo; Niccoli, Giampaolo (2020). "Myocardial and Microvascular Injury Due to Coronavirus Disease 2019". European Cardiology Review. 15. doi:10.15420/ecr.2020.22. ISSN 1758-3764.
- ↑ Xiong, Chenglong; Feng, Yi; Chen, Mingquan; Li, Xiangjie; Chen, Liang (2020). "The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2". Cardiovascular Research. 116 (6): 1097–1100. doi:10.1093/cvr/cvaa078. ISSN 0008-6363.
- ↑ 11.0 11.1 11.2 Kang Y, Chen T, Mui D, Ferrari V, Jagasia D, Scherrer-Crosbie M; et al. (2020). "Cardiovascular manifestations and treatment considerations in covid-19". Heart. doi:10.1136/heartjnl-2020-317056. PMC 7211105 Check
|pmc=value (help). PMID 32354800 Check|pmid=value (help). - ↑ 12.0 12.1 12.2 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA; et al. (2018). "Fourth Universal Definition of Myocardial Infarction (2018)". J Am Coll Cardiol. 72 (18): 2231–2264. doi:10.1016/j.jacc.2018.08.1038. PMID 30153967.
- ↑ 13.0 13.1 Template:Cite website
- ↑ 14.0 14.1 De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP; et al. (2020). "Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era". Eur Heart J. 41 (22): 2083–2088. doi:10.1093/eurheartj/ehaa409. PMC 7239145 Check
|pmc=value (help). PMID 32412631 Check|pmid=value (help). - ↑ 15.0 15.1 Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA; et al. (2020). "Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic". J Am Coll Cardiol. 75 (22): 2871–2872. doi:10.1016/j.jacc.2020.04.011. PMC 7151384 Check
|pmc=value (help). PMID 32283124 Check|pmid=value (help). - ↑ Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH; et al. (2020). "The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction". N Engl J Med. doi:10.1056/NEJMc2015630. PMID 32427432 Check
|pmid=value (help). - ↑ De Filippo O, D'Ascenzo F, Angelini F, Bocchino PP, Conrotto F, Saglietto A; et al. (2020). "Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy". N Engl J Med. doi:10.1056/NEJMc2009166. PMC 7224608 Check
|pmc=value (help). PMID 32343497 Check|pmid=value (help). - ↑ Solomon, Matthew D.; McNulty, Edward J.; Rana, Jamal S.; Leong, Thomas K.; Lee, Catherine; Sung, Sue-Hee; Ambrosy, Andrew P.; Sidney, Stephen; Go, Alan S. (2020). "The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction". New England Journal of Medicine. doi:10.1056/NEJMc2015630. ISSN 0028-4793.
- ↑ 19.0 19.1 Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC; et al. (2020). "As the COVID-19 pandemic drags on, where have all the STEMIs gone?". Int J Cardiol Heart Vasc. 29: 100550. doi:10.1016/j.ijcha.2020.100550. PMC 7261452 Check
|pmc=value (help). PMID 32550258 Check|pmid=value (help). - ↑ 20.0 20.1 Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check
|pmc=value (help). PMID 32219356 Check|pmid=value (help). - ↑ Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J (1988). "Insights into the pathogenesis of acute ischemic syndromes". Circulation. 77 (6): 1213–20. PMID 3286036.
- ↑ 22.0 22.1 22.2 Stefanini, Giulio G.; Montorfano, Matteo; Trabattoni, Daniela; Andreini, Daniele; Ferrante, Giuseppe; Ancona, Marco; Metra, Marco; Curello, Salvatore; Maffeo, Diego; Pero, Gaetano; Cacucci, Michele; Assanelli, Emilio; Bellini, Barbara; Russo, Filippo; Ielasi, Alfonso; Tespili, Maurizio; Danzi, Gian Battista; Vandoni, Pietro; Bollati, Mario; Barbieri, Lucia; Oreglia, Jacopo; Lettieri, Corrado; Cremonesi, Alberto; Carugo, Stefano; Reimers, Bernhard; Condorelli, Gianluigi; Chieffo, Alaide (2020). "ST-Elevation Myocardial Infarction in Patients With COVID-19". Circulation. 141 (25): 2113–2116. doi:10.1161/CIRCULATIONAHA.120.047525. ISSN 0009-7322.
- ↑ Nasiri, Mohammad Javad; Haddadi, Sara; Tahvildari, Azin; Farsi, Yeganeh; Arbabi, Mahta; Hasanzadeh, Saba; Jamshidi, Parnian; Murthi, Mukunthan; Mirsaeidi, Mehdi (2020). doi:10.1101/2020.03.24.20042903. Missing or empty
|title=(help) - ↑ 24.0 24.1 Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
- ↑ Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z; et al. (2020). "Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study". Lancet. 395 (10229): 1054–1062. doi:10.1016/S0140-6736(20)30566-3. PMC 7270627 Check
|pmc=value (help). PMID 32171076 Check|pmid=value (help). - ↑ Szerlip M, Anwaruddin S, Aronow HD, Cohen MG, Daniels MJ, Dehghani P; et al. (2020). "Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates". Catheter Cardiovasc Interv. doi:10.1002/ccd.28887. PMID 32212409 Check
|pmid=value (help).