Acute Coronary Syndrome and COVID-19: A Case Report of Refractory Hypercoagulability

Novel coronavirus disease 2019 (COVID-19) is known to cause severe bilateral pneumonia and acute respiratory distress syndrome (ARDS), leading to difficulty breathing requiring mechanical ventilation and ICU management. In many patients, it has been found to cause severe hypercoagulability. We present a case of COVID-19 positive patient who developed myocardial infarction (MI) despite being on multiple anticoagulants. A 51-year-old, Middle-Eastern male diabetic patient presented to the emergency room with complaints of sudden onset left leg pain, paresthesias, and swelling for one day. On physical examination, the left leg was cool to touch from forefoot to mid-calf, with noticeable mottling over the forefoot and a nonpalpable dorsalis pedis. The patient was started on therapeutic enoxaparin and diltiazem in ED. Chest X-ray showed bilateral pulmonary infiltrates beginning peripherally and COVID-19 pneumonitis. The patient underwent a mechanical thrombectomy and was loaded with aspirin/clopidogrel, heparin drip, and enoxaparin. Despite being on triple anticoagulation, the patient had new-onset STEMI and elevated troponin levels. On angiography, the patient was found to have occluded mid-left anterior descending, most likely from acute on chronic thrombosis related to the patient's COVID-19 status. As flow could not be re-established, the patient was kept on long-term protective anticoagulation-triple therapy (an oral anticoagulant and dual antiplatelet therapy) and received pulmonary care for COVID-19 infection. The patient was discharged on long-term triple anticoagulation and COVID-19 precautions with scheduled retesting and follow-up.