Introduction:

Two drug-eluting stents – 4.0 X 20 Synergy XD and 4.0 X 8 Synergy XD – were placed in the proximal LAD lesion. There was TIMI 2 flow before, and TIMI 3 flow after the intervention was performed on the proximal LAD. Mechanical thrombectomy with a CAT6 RX kit and balloon angioplasty was performed on the distal LAD lesion. TIMI 0 flow improved to TIMI 2 flow after the procedure [Figure 5]. Blood flow to other coronary artery branches was normal. The patient was subsequently admitted to the Coronary Care Unit, where he underwent a significant hypercoagulability workup.

Subsequent labs showed an elevated C-reactive protein (CRP) level of 6.7, an elevated serum lactate dehydrogenase (LDH) level of 566, an elevated triglyceride level of 250, an elevated total cholesterol level of 276, an elevated LDL (low-density lipoprotein) cholesterol level of 174, a normal HDL (high-density lipoprotein) cholesterol level of 51, a d-dimer level less than 150, ferritin 336, and a serum pro-brain natriuretic peptide (pro-BNP) level of 9. The Transthoracic Echocardiogram revealed a moderately reduced ejection fraction of 40%, along with a moderate decrease in the left ventricular systolic function of the apical inferior, lateral, and septal segments.

The patient was discharged home on 81 mg aspirin once daily, 75 mg Plavix once a day, sacubitril-valsartan 24-26 mg twice a day, Xarelto 20 mg once a day, atorvastatin 40 mg once a day, metoprolol succinate 50 mg once a day, and pantoprazole 40 mg once a day.

Discussion:

Acute ST-elevation myocardial infarction (STEMI) is a serious condition associated with high morbidity and mortality rates, which are influenced by patient characteristics. Older age, female sex, medical comorbidities, anterior MI, and underlying coronary artery disease are all associated with worse outcomes in these patients [7]. Recent evidence suggests that acute respiratory viral infections, including influenza, can act as triggers for acute STEMI, with influenza increasing the risk of morbidity and mortality [2,8] Therefore, it is plausible that COVID-19 infection and the subsequent systemic inflammatory response may have triggered the STEMI event in our patient.

The optimal management strategy for stable patients presenting with COVID-19 and concurrent STEMI poses a challenge. Fibrinolytic therapy has gained attention as a potential treatment option for this patient population [9]. In China, experts recommend fibrinolytic therapy over primary percutaneous coronary intervention (PCI) for stable STEMI patients with COVID-19 who present within 12 hours of symptom onset and have no contraindications for fibrinolytics [10] This recommendation is based on the need to carefully balance healthcare provider exposure and patient benefit [11] However, findings from a large case series of COVID-19 positive patients presenting with STEMI who were treated with PCI reported a higher rate of stent thrombosis (21%) than previously reported rates of early stent thrombosis (1%) [1,12]. This highlights the need to adapt STEMI management for COVID-19 patients and underscores the importance of monitoring thrombotic events in this population. Many questions remain unanswered about this select patient population, and further research is needed.

For COVID-19 negative patients presenting with STEMI, the current standard of care is PCI within 90 minutes of hospital presentation. Fibrinolytic therapy is recommended if there is an expected delay of more than 90 minutes to PCI [13,14]. The Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American Heart Association (AHA) recommend pursuing PCI in STEMI patients during the COVID-19 pandemic [15] An ongoing observational registry created under the guidance of these cardiology societies supports this recommendation, as PCI is feasible and remains the predominant reperfusion strategy for COVID-19 positive patients presenting with MI [16].

Conclusion:

The COVID-19 pandemic has posed a challenge to the management of STEMI patients. While PCI remains the standard of care for COVID-19 negative patients, fibrinolytic therapy has gained attention as a potential treatment option for stable COVID-19 positive patients. However, the risk of thrombotic events in this population underscores the importance of careful patient selection and monitoring. Further research is needed to guide the optimal management strategy for this select patient population.