In the midst of current pandemic individuals with all sorts of medical ailments are afraid to venture into health-care settings and risk contracting Coronavirus disease 2019 (COVID-19). Irrespective of the inherent thromboembolic risks associated with COVID-19, this puts patients at high risk of cardiac complication

Ahmad, Asrar

Boigon, Margot I.

Chadi Alraies, M.

Haas, Donald C.

Saeed, Rehan

Sattar, Yasar

Ullah, Waqas

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Abington Jefferson Health Papers Abington Jefferson Health 5-31-2020 As the COVID-19 pandemic drags on, where have all the STEMIs gone? Waqas Ullah Abington Jefferson Health Yasar Sattar Icahn School of Medicine at Mount Sinai Elmhurst Hospital Rehan Saeed Abington Jefferson Health Asrar Ahmad Abington Jefferson Health Margot I. Boigon Abington Jefferson Health See next page for additional authors Follow this and additional works at: https://jdc.jefferson.edu/abingtonfp  Part of the Cardiology Commons, and the Infectious Disease Commons Let us know how access to this document benefits you Recommended Citation Ullah, Waqas; Sattar, Yasar; Saeed, Rehan; Ahmad, Asrar; Boigon, Margot I.; Haas, Donald C.; and Chadi Alraies, M., "As the COVID-19 pandemic drags on, where have all the STEMIs gone?" (2020). Abington Jefferson Health Papers. Paper 22. https://jdc.jefferson.edu/abingtonfp/22 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Abington Jefferson Health Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Authors Waqas Ullah, Yasar Sattar, Rehan Saeed, Asrar Ahmad, Margot I. Boigon, Donald C. Haas, and M. Chadi Alraies This letter to the editor is available at Jefferson Digital Commons: https://jdc.jefferson.edu/abingtonfp/22 As the COVID-19 pandemic drags on, wherehave all the STEMIs gone?To the Editor,In the midst of current pandemic individuals with all sorts ofmedical ailments are afraid to venture into health-care settingsand risk contracting Coronavirus disease 2019 (COVID-19). Irre-spective of the inherent thromboembolic risks associated withCOVID-19, this puts patients at high risk of cardiac complications.A 36-year-old male was brought to the emergency department(ED) after being found unresponsive at home. History was limited,given his condition. He was last seen normal over 15 h ago. He hadno significant past or family medical history. He denied any use ofalcohol or smoking. In the ED, he was febrile (101.2F) andhypotensive 78/59 mm Hg. His oxygen saturation (SaO2) was78%. Laboratory investigations revealed leukocytosis (16,760/uL),elevated d-dimer of 48,648 ng/mL (normal < 0.50 ng/ml) andserum troponin-T (TnT) of 1.86 ng/L, which peaked to 44.4 ng/L(normal < 0.10 ng/L). Electrocardiogram revealed ST-segment ele-vation in the anteroseptal leads (V2-V4). (Fig. 1) Transthoracicechocardiography (TTE) showed extensive septal, anterior and api-cal akinesia with an apical left ventricular (LV) thrombus and areduced ejection fraction of 35%. (Fig. 2) He was intubated forhypoxia and was started on norepinephrine infusion for hypoten-sion. His chest x-ray and computed tomography showedmultifocalinfiltrates. He received aspirin, clopidogrel, atorvastatin and aheparin infusion for a presumed subacute ST-segment elevationmyocardial infarction (STEMI). The following day his nasal swabtest for real-time polymerase chain reaction (RT-PCR) returnedpositive for acute respiratory syndrome coronavirus-2 (SARS-CoV-2). He was treated with an 80 mg single dose of tocilizumaband hydroxychloroquine 400 mg twice a day on the first day fol-lowed by 200 mg twice a day for the next 4 days. Post-extubation,he revealed that he had been having substernal chest pain forhttps://doi.org/10.1016/j.ijcha.2020.1005502352-9067/ 2020 The Authors. Published by Elsevier B.V.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Fig. 1. EKG showing ST-elevation in leads v2-v4 indicating anteroseptal wall myocardial infarction.Fig. 2. TEE, apical view showing an apical thrombus (arrow).IJC Heart & Vasculature 29 (2020) 100550Contents lists available at ScienceDirectIJC Heart & Vasculaturejournal homepage: www.journals .e lsevier .com/i jc -heart -and-vasculatureseveral hours before losing consciousness but had not sought careearlier due to fear of getting COVID-19 in the hospital. He refusedfurther workup and was discharged home with a plan to continueaspirin, clopidogrel, atorvastatin in addition to carvedilol andlisinopril post-discharge. A week later, he had an elective left-sidedangiography demonstrating a 99% occlusion of the left anteriordescending artery (LAD), a drug-eluting stent was deployed withan adequate restoration of blood flow. (Fig. 3) He was advised tobe compliant with his medications and subsequent cardiology fol-low-ups.The novel Coronavirus Disease 2019 (COVID-19) is a genera-tion-defining global pandemic; the scale, scope and pace of whichis unprecedented. Despite the high rate of cardiovascular compli-cations, contemporary reports show that COVID-19 concerns haveprompted patients to delay seeking emergent care, reducing thenumber of STEMI cases.[1,2] This is presumptively being attributedto patients being reluctant to go to the hospital even in dire cir-cumstances and possibly underdiagnosis in overwhelmed ED’s,the former being the case in our patient. [1]Recently, a United States (US) model from 9 major centersobserved a 38% drop in total STEMI activations.[3] This is similarto a 40% reduction noted in Spain.[4] The early Hong Kong experi-ence demonstrated a significant delay in the time of symptomonset to the first medical encounter by about 318 min.[2] Thesefindings are particularly concerning given that COVID-19 itselfcan be a cause of STEMI due to microthrombi, cytokine storm,coronary spasm, or direct endothelial injury, furthermore acutecoronary syndrome occurring in COVID-19 patients has been asso-ciated with a worse prognosis. [5,6] Reluctance to visit a hospitaldue to fear of morbidity related to COVID-19 only adds to timedelays in managing STEMI due to increased precautionary mea-sures and accessory testing in the ED, delayed triaging, short staff-ing and slow activation of cardiac catheterization labs, puttingpatients at risk of worse clinical outcomes.[2]The specific treatment protocols for STEMI patients withCOVID-19 have been evolving. Early recommendations from theWuhan experience included intravenous thrombolysis as first-linetherapy for STEMI patients with confirmed COVID-19 given thatmost hospitals do not have protected cardiac catheterization labsand coronary care units for respiratory borne illnesses.[7] Morerecently, the Society of Cardiovascular Angiography and Interven-tion (SCAI) recommendations favored continuation of the currentstandard of care (percutaneous intervention) in COVID-19 patients,though recognize that this may change if hospital systems becomefurther overwhelmed.[8]In our case, the collision between COVID-19 induced STEMI anda reluctance to seek urgent care led to catastrophic complications.The reduced ejection fraction, cardiogenic shock and the earlydevelopment of an LV thrombus seen in this case can be attributedto not only the late presentation but perhaps also a consequence ofCOVID-19 specific hypercoagulable state. Elevated D-dimer, raisedtroponin levels and EKG abnormalities prompted a high suspicionfor ACS even in a hitherto healthy person with no conventional car-diovascular risk factors.While remarkable public health efforts are ongoing, we advo-cate for increased public awareness of cardiovascular complica-tions of COVID-19 and the need to seek early medical attention.Disclosure: NoneIndustrial Relationship/Financial Disclosure: NoneAppendix A. Supplementary dataSupplementary data to this article can be found online athttps://doi.org/10.1016/j.ijcha.2020.100550.References[1] Oriol Rodríguez-Leor, Belén Cid-Álvarez, Soledad Ojeda, Javier Martín-Moreiras,José Ramón Rumoroso, Ramón López-Palop, Ana Serrador, Ángel Cequier, RafaelRomaguera, Ignacio Cruz, Armando Pérez de Prado, Raúl Moreno, Impacto de lapandemia de COVID-19 sobre la actividad asistencial en cardiologíaintervencionista en España, RECIC (2020), https://doi.org/10.24875/RECIC.M20000120.[2] Tam CF, Cheung KS, Lam S, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in HongKong, China. Circ Cardiovasc Qual Outcomes. 2020 Mar 17:Circoutcomes120006631.[3] Crystal Phend: Medpagetoday. 2020 April 11: https://www.medpagetoday.com/infectiousdisease/covid19/85922[4] S. Garcia, M.S. Albaghdadi, P.M. Meraj, C. Schmidt, R. Garberich, F.A. Jaffer, S.Dixon, J.J. Rade, M. Tannenbaum, J. Chambers, P.P. Huang, Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the UnitedStates during COVID-19 Pandemic, Journal of the American College ofCardiology. (2020).[5] ST-Segment Elevation in Patients with Covid-19 — A Case Series, NEJM, April 17,2020, DOI: 10.1056/NEJMc2009020[6] G.G. Stefanini, M. Montorfano, D. Trabattoni, et al, ST-Elevation MyocardialInfarction in Patients with COVID-19: Clinical and Angiographic Outcomes,Circulation (2020 Apr 30).[7] J. Zeng, J. Huang, L. Pan, How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital, Intensive caremedicine. 11 (2020 Mar) 1–3.[8] M. Szerlip, S. Anwaruddin, H.D. Aronow, M.G. Cohen, M.J. Daniels, P. Dehghani,D.E. Drachman, S. Elmariah, D.N. Feldman, S. Garcia, J. Giri, Considerations forcardiac catheterization laboratory procedures during the COVID-19 pandemic,Catheter Cardiovasc Interv (2020).Fig. 3. A. Angiography demonstrating left anterior descending artery occlusion (arrow), B. with an adequate restoration of blood flow post-stenting.2 / IJC Heart & Vasculature 29 (2020) 100550Waqas Ullah a,⇑Yasar Sattar bRehan Saeed aAsrar Ahmad aMargot I. Boigon aDonald C. Haas aM. Chadi Alraies caAbington Hospital-Jefferson Health, Abington, USAb Icahn School of Medicine at Mount Sinai- Elmhurst Hospital, NY, USAcDetroit Medical Center, MI, USA⇑ Corresponding author at: 1200 Old York Road, Abington, PA, USA.E-mail addresses: Waqasullah.dr@gmail.com (W. Ullah), mdyasar-sattar@gmail.com (Y. Sattar), alraies@hotmail.com (M.C. Alraies)Received 13 May 2020Received in revised form 25 May 2020Accepted 27 May 2020Available online 31 May 2020/ IJC Heart & Vasculature 29 (2020) 100550 3

As the COVID-19 pandemic drags on, where have all the STEMIs gone?

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As the COVID-19 pandemic drags on, where have all the STEMIs gone?

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