COVID-19 and ST elevations-keep an open mind: a case report
Michael R Kendall1, Sridhar M Reddy1, Laura E Meinke1
1Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
Insights
Pulmonary embolism (PE) can cause ST elevations mimicking heart attacks in COVID-19 patients. Prompt diagnosis and treatment of PE are crucial, especially in younger individuals without traditional cardiac risk factors.
Area of Science:
- Cardiology
- Infectious Diseases
- Pulmonology
Background:
- Coronavirus disease 2019 (COVID-19) is linked to cardiovascular issues like myocardial injury and thromboembolism.
- Pulmonary embolism (PE) can manifest as ST elevations, mimicking myocardial infarction due to right ventricular strain.
Purpose of the Study:
- To highlight the association between COVID-19, pulmonary embolism, and ST-elevation myocardial infarction (STEMI)-like presentations.
- To emphasize the importance of considering PE in COVID-19 patients presenting with ST elevations.
Main Methods:
- Case report of a 48-year-old female with type 2 diabetes and hypertension presenting with COVID-19 symptoms.
- Clinical presentation included respiratory failure, hypoxia, hypotension, and new ST elevations on ECG.
- Diagnostic workup included echocardiography revealing right ventricular dilation and McConnell's sign.
Main Results:
- The patient experienced ST elevations on ECG, indicative of potential myocardial infarction.
- Echocardiography showed moderate right ventricular dilation and McConnell's sign, suggesting acute PE.
- Treatment with tenecteplase led to complete resolution of ST elevations and improved oxygenation.
Conclusions:
- Pulmonary embolism should be considered in the differential diagnosis for ST elevations in COVID-19 patients.
- This is particularly important in younger patients with minimal coronary artery disease risk factors.
- Early recognition and management of PE can prevent adverse cardiovascular outcomes in COVID-19.
Background:
Coronavirus disease 2019 (COVID-19) has been associated with a range of cardiovascular manifestations, including myocardial injury and thrombo-embolism. Pulmonary embolism (PE) causing anteroseptal/anterior ST elevations that mimic myocardial infarction have previously been described. This phenomenon is thought to be related to right ventricular injury from large emboli.
Case Summary:
A 48-year-old woman with history of type 2 diabetes mellitus and hypertension presented to her local hospital with fever, cough, nausea, and dyspnoea. A test for SARS-CoV-2 was taken, and she was discharged with instructions to self-quarantine. She was subsequently notified of a positive SARS-CoV-2 result. Three days later, she re-presented with worsening dyspnoea and respiratory failure requiring intubation. On hospital Day 6, she became acutely hypoxic and hypotensive. Telemetry was noted to have ST changes, prompting ECG that revealed sinus tachycardia with prominent new ST elevations in her precordial leads. Transthoracic echocardiogram showed normal left ventricular function; however, the right ventricle was moderately dilated with positive McConnell's sign. Due to her unstable clinical state and high suspicion for PE, she was treated with tenecteplase 50 mg i.v. with complete resolution of her ST elevations and improved oxygenation.
Discussion:
Given the high rates of thrombo-embolic events in COVID-19 patients, PE should be in the differential diagnosis of ST elevation, particularly in younger patients with few risk factors for coronary artery disease.
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