ST-Segment Elevation in Patients with Covid-19 — A Case Series

Key Points: ST-Segment Elevation in Patients with COVID-19 — A Case Series

Sripal Bangalore, M.D., M.H.A. Atul Sharma, M.D.
Alexander Slotwiner, M.D. New York University Grossman School of Medicine New York, NY

Report of patients with documented COVID – 19 from 6 New York Hospitals with ST-elevation on ECG.

  • Non-coronary related myocardial injury was defined by a non-obstructive coronary angiogram or in patients not undergoing coronary angiography having no wall motion abnormalities via echocardiography.
  • Patient Population – Patients – 18; Mean age – 63 years; Men-83%
  • ST-Elevation on admission – 10 ((56%), In Hospital – 8 (44%, median 6-days post-admission); Only 33% had chest pain at the time of ST-Elevation.
  • Focal ST-segment elevation was present in 14 patients (78%) – 5 (36%) with normal LVEF despite regional wall motion abnormality in 1 (20%); 8 patients (57%) had a reduced LVEF – regional wall motion abnormalities were present in 5 (62%). (one patient had no echocardiogram);
  • Diffuse ST-segment elevation was present in 4 (22%) patients; Normal LVEF with normal wall motion – 3 (75%) patients; LVEF was 10% in one patient with global hypokinesis with an LVEF of 10%.
  • Coronary Angiography was performed in 9 (50%) patients; Coronary Obstruction was identified in 6 patients (67%) with PCI in 5 (56%) patients.
  • Clinical Diagnosis of Myocardial Infarction – 8 (44%) of patients had higher median peak troponin levels and d-dimer levels than the 10 patients (56%) with myocardial injury unassociated with coronary artery disease.
  • Hospital Mortality was 72% (13 of 18 patients) – 4 with diagnosed, traditional myocardial infarction, 9 with non-coronary myocardial injury.
  • The etiologies of Myocardial Infarction versus diffuse Myocardial Injury remain unknown and are likely multifactorial given that the presentations were very diverse); Proposed mechanisms include ruptured coronary plaque, hypoxic injury, coronary spasm, microthrombi, direct endothelial and/or cytokine storm.
  • Of note, all 18 patients had elevated d-dimer values which have been observed in other COVID – 19 Reports.
  • In summary, patients with ST-segment Elevation are high risk despite divergent etiologies which can be coronary occlusion or diffuse myocardial injury. Management remains challenging, but invasive diagnosis may be frequently required to understand and potentially treat the underlying process.