ST Elevation in a COVID-19 Positive Patient

Patient

• 83 years old
• Male
• diabetes
• HTA
• COPD

Treatment

• Tiotropium
• beclomethasone formoterol,
• Valsartan 60 1 cp
• lercadipine 20
• nebivolol 1/2 x 2
• repaglinide
• metformine
• acenocumarol

History

• Fever from 10 days, treated with paracetamol
• Cough from 7 days, treated with unknown ATB
• Acute onset of dyspnea

Physical Examination

• Tachypneic, tachycardic.
• BP 160/100mmHg, HR 114bpm, SO2 92% R15L, RR30
• ABG in reservoir 15L 40%: pH 7,39, pCO2 27, pO2 126, HCO3 19
• P/F 137

ECG

SR, diffuse abnormalities of lateral and inferior repolarization

Lung Ultrasound

B diffuse lines

CT Scan

Centrilobular emphysema

Patchy ground-glass opacities

HRCT showing severe centrilobular emphysema, prevalent in the upper lobes, associated with patchy ground-glass opacities mostly peripherally distributed.

Laboratory Exam

• WBC 8.41 x10^3/µl L 0,52 x10^3 (NR 1,5-4)
• CRP 20 (normal range 0 - 0.5)
• LDH 587 U/L
• CPK 508 U/L
• GOT 58 U/L
• TnI 600 (<31ng/L)
• Swab for COVID-19+ (24h)

Treatment

• Admitted to COVID-19 ward
• Hydroxychloroquine 200mg x 2 for 7 days
• Azithromycin 500mg od for 5 days
• Darunavir-cobicistat 800mg/150mg od
• Methylprednisolone 20mg bd
• Phytomenadione 1fl (INR 9,5)
• Bisoprolol 2,5mg

ECG

After seven days of acute chest pain

Inferior STEMI

Coronary Angiography

Moderate CX stenosis - Not performed FFR

Severe stenosis of RCA with diffuse thrombus

PTCA on RCA

Echocardiography

Inferior and posterior mediobasal hypokinesis

Lab

• TnI 7700 ng/ml (URL < 31ng/L).
• Improvement of cardiorespiratory conditions

Take-Home Messages

• Diagnosis: thrombotic occlusion of RCA
• COVID-19 is a pro-thrombotic condition (high d-dimer, High fibrinogen)
• Always perform ECG when chest pain
• Cath Lab staff need PPE for STEMI COVID+ cases
• Organise monitored beds for COVID positive and negative patients
• Choose the right drug  – check interactions with darunavir or lopinavir here