COVID-19, Known to Spark Heart Problems, Can Also Mimic STEMI

By Gene Emery

April 29, 2020

(Reuters Health) - Doctors are warning that COVID-19 can create false signs of an ST-elevation myocardial infarction (STEMI) and are urging physicians to look beyond an electrocardiogram reading before committing to an intervention.

"The days of reflexively activating the STEMI team for immediate primary PCI have to be modified as we work through the challenges of STEMI mimics and delays in time-to-treatment," three doctors warn in an editorial in the Journal of the American College of Cardiology: Case Reports.

The phenomenon further complicates treatment for COVID-19, which can attack the heart, spark strokes, damage the kidneys and effectively destroy the lungs.

The editorial was prompted by the case of a 29-year-old morbidly obese man who tested positive for COVID-19, developed rapidly-progressing acute respiratory distress syndrome and, while mechanically ventilated, showed ST segment elevations on his electrocardiogram.

Serial cardiac troponin I levels were normal, however, and transthoracic echocardiography didn't reveal a problem.

"In the pre-COVID-19 era, this patient probably would have undergone emergent diagnostic coronary angiography and would not have been the subject of a case report. Not now. We live in the COVID-19 era and how we approach STEMI has changed for the immediate future," said the editorial's authors, led by Dr. Mladen Vidovich of the Jesse Brown VA Medical Center in Chicago.

Dr. Catalin Loghin of the University of Texas Health Science Center at Houston, the lead author on the case study of the 29-year-old man, told Reuters Health that the troponin levels were enough to convince him that the patient didn't need a trip to the cath lab.

The physicians noted the man's age, the fact that he didn't have a family history of cardiovascular disease, the absence of coronary calcification on his chest CT, the absence of wall motion abnormalities on his echocardiogram, the fact that he had a normal left ventricular ejection fraction, and a negative myoglobin test.

"It illustrates that not everything that's ST elevation means an acute MI," said Dr. Loghin, a professor of cardiovascular medicine with McGovern Medical School at UTHealth. "It also means we can tone down and can accomplish a lot without using anything very complex and very expensive. It's a case of less is more."

"We need to be on the same page and follow the same standard criteria when we classify COVID-related complications," he said.

"We are learning that ST-elevation in the COVID-19 era may represent STEMI mimics," the Vidovich team said in their editorial.

Not only does angiography pose the added risk of spreading COVID-19 to staff and equipment, they said, but doctors "should think twice before administering intravenous contrast medium in these patients" because they already face a higher risk of acute kidney injury.

Instead, and because it's harder to schedule PCI in hospitals overwhelmed by COVID cases, doctors may want to consider fibrinolytic therapy once STEMI mimics have been excluded, they said, although "at PCI-capable hospitals with adequate staffing, primary PCI is still preferred."

Meanwhile, the journal is also publishing the case report of a 56-year-old's heart attack that went undiagnosed because of his suspected COVID-19 infection.

The long-time smoker initially reported fatigue, fever, muscle aches, shortness of breath and cough associated with a dull chest pain. "On further questioning, he also mentioned similar episodes of chest pain in the past, with exertion" to his primary doctor during a virtual visit, according to a report by Drs. Rayan Yousefzai and Arvind Bhimaraj of the Houston Methodist DeBakey Heart and Vascular Center.

The patient called 911 three days later when his symptoms worsened. At the hospital, he was in respiratory distress, a chest X-ray showed diffuse patchy airspace opacities through his lungs, and he was eventually intubated. An ECG showed a left bundle branch block not present on an ECG done two months earlier. His troponin level was 56.82 ng/ml, which was considered to be due to myocarditis, and his B-type natriuretic peptide was 2493 pg/ml.

But his COVID-19 PCR test came up negative. Twice.

He ended up in the ICU with an implanted heart pump, where further treatment was to be weighed.

"In the COVID-19 era, the diagnosis was diverted towards COVID-19, and STEMI was missed," Dr. Yousefzai and Bhimaraj said. "COVID-19 patients can present with cardiovascular manifestations. We have to be vigilant in diagnosing COVID-19 patients; however, we should not forget about the common diagnosis."

"Fear should not deter us from recognizing common pathologies," they said.

SOURCES: https://bit.ly/2YeKKVC, https://bit.ly/3eYvouz, and https://bit.ly/2xYgyDN; Journal of the American College of Cardiology: Case Reports, online April 27, 2020.

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