ST-segment elevation was observed in patients presenting with novel coronavirus disease 2019 (COVID-19) in New York City hospitals. These cases were described in a correspondence published in the New England Journal of Medicine on April 17, 2020.
In this case series of 18 patients with confirmed COVID-19 (median age, 63 years; 83% men; 50% Hispanic), ST-segment elevation was observed on electrocardiography (ECG), suggesting acute myocardial infarction. Ten patients had ST-segment elevation at hospital presentation, while 8 patients displayed it later during hospitalization (median, 6 days). Of the 18 patients described in this case series, 10 had noncoronary myocardial injury (ie, normal wall motion on ECG or nonobstructive disease on coronary angiography), 9 of whom died in the hospital. The other 8 patients had myocardial infarction, 4 of whom died.
Cardiovascular risk factors in this series of patients included hypertension (65%), hypercholesterolemia (41%), diabetes (35%), and a history of coronary artery disease (18%). Around the time ST-segment elevation was observed, patients had symptoms including cough/shortness of breath/respiratory distress (83%), fever (72%), and chest pain (33%); 67% of patients were intubated, and 39% had cardiogenic shock.
On ECG, 78% of patients had focal ST segment elevations (50% with lateral elevation; 57% with low left ventricular ejection fraction). Of the 4 patients with diffuse ST segment elevation, 3 had normal left ventricular ejection fraction. All patients with myocardial infarction had lateral ST elevation. Normal ejection fraction was observed in 47% of all patients and in 70% of those with noncoronary myocardial injury, and 88% and 75% of patients with myocardial infarction had low ejection fraction and regional wall-motion abnormality, respectively. Obstructive coronary artery disease was detected on coronary angiography in all patients with myocardial infarction, and 83% of patients with myocardial infarction had percutaneous coronary intervention. Opacities were observed in both lungs of 78% of patients.
Patients with myocardial infarction vs noncoronary myocardial injury had higher peak troponin I (median: 91.0 vs 13.5 ng/mL, respectively) and D-dimer levels (1909 vs 858 ng/mL, respectively).
“Myocardial injury in patients with COVID-19 could be due to plaque rupture, cytokine storm, hypoxic injury, coronary spasm, microthrombi, or direct endothelial or vascular injury,” noted the study authors.
We interviewed the lead author of the report, Sripal Bangalore, MD, MHA, associate professor of medicine, director of research at the cardiac catheterization laboratory, and director of the Cardiovascular Outcomes Group in the Cardiovascular Clinical Research Center at New York University Langone Health in New York, NY.
All of the patients who survived had ST-elevation at presentation. Granted this is a small sample, could you speculate as to whether this phenomenon occurring early may have had an impact on the prognosis?
Dr Bangalore: Good observation. It is likely that the ones who had ST elevation on presentation and who survived had less severe COVID-related illness.
Of the treatments that were provided (eg, hydroxychloroquine, azithromycin) by you or your colleagues, were any thought to partly account for the recovery of patients for a particular type of presentation?
Dr Bangalore: We haven’t seen a major difference in medication therapy that accounted for recovery of the patients.
Would you have recommendations on the initial management of similar cases for your colleagues?
Dr Bangalore: The main recommendation is to consider a combination of symptoms, ECG changes and echocardiographic findings in an attempt to tease out noncoronary myocardial injury from ST-Elevation myocardial infarction.
Are there large-scale plans to conduct studies on this patient population? What design would you propose for such studies?
Dr Bangalore: We will continue to build on the registry to attempt to understand the drivers of prognosis in these patients.
Bangalore S, Sharma A, Slotwiner A, et al. ST-segment elevation in patients with Covid-19 – A case series [published online April 17, 2020]. N Engl J Med. 2020. doi:10.1056/NEJMc2009020