Discussion:
Cardiac injury caused by COVID-19 infection has been observed in early
studies with a significantly increased risk of mortality. (2-3, 21)
Increased risk of MI in the setting of a hypercoagulable state such as
COVID-19, has been well documented in many cases. (4, 5) A possible
pathophysiology has been reported by Esmail et al where COVID-19 causes
a significant inflammatory reaction that manifest in the alveoli. The
activation of epithelial cells, monocytes, and macrophages is caused by
the release of inflammatory cytokines. Direct ACE2 receptor infection
causes endothelial activation and dysfunction, TF expression, platelet
activation, and elevated levels of vWF and FVIII, all of which
contribute to thrombin production and fibrin clot formation. (6)
Specifically, cases have reported evidence for STEMI in the context of
COVID-19. (7) When comparing non-COVID vs COVID STEMI patients, there is
an increase in stent thrombosis and cardiogenic shock development after
PCI in COVID patients. (8)
Currently, there are no published case reports in the context of
COVID-19 resulting in STEMI with simultaneous cardiogenic shock leading
to acute heart failure requiring LVAD.
Majority of the previous CAD cases have been found in males, whereas our
report presents a female patient, suggesting sex may not be as
significant of a risk factor for developing STEMI, as previously
reported. (3,4) The cardiac risk factors in our patient were
hypertension and hyperlipidemia, which are known risk factors for
developing ACS; a similar trend has been observed in previously
published reports (9). The patient in our study presented with VF, AKI,
CS, and CHB; similar findings have been observed in previously published
COVID-19 reports (1,4,10-12). Heart failure (HF) is most prevalent,
accounting for 20% of outcomes among STEMI patients during the
pandemic; these findings support our case of developing HF during
hospitalization. (13) HF requiring LVAD implantation in a COVID
non-STEMI patient has been reported, with a proposed algorithm for
elective and urgent implantation based on coagulation and inflammatory
markers (14). In our case, given the increased inflammatory burden and
cardiac risk factors, it is important to approach with a higher index of
suspicion of the common complications of STEMI.
These complications are life-threatening and require immediate
management and interventions, as in our case where the patient first
required PCI with LAD stent placement subsequently placed on ECMO. After
further complications, the patient underwent AICD implantation and
ultimately after worsening HF required LVAD. Similar findings and
management for STEMI patients have been reported (15). Recent reports
show cardiovascular complications of stent thrombosis and cardiogenic
shock development after PCI in COVID-19 patients with STEMI in
comparison to non-COVID 19 patients (16). One large multicenter study
found that LVAD implantation is an effective management strategy and
should be considered early for patients with myocardial infarction and
low output states who do not respond to medical therapy. (17) Medical
teams must be cognizant of these adverse events to efficiently identify
and implement guidelines issued by European society of Cardiology (ESC)
and American Heart Association (AHA), And American College of Cardiology
(ACC) for appropriate management to reduce mortality (18-20).