Research in Cardiovascular Medicine

CASE REPORT
Year
: 2021  |  Volume : 10  |  Issue : 1  |  Page : 20--22

Late stent thrombosis and acute ST-elevation myocardial infarction in a case affected with COVID-19: A rare manifestation


Rahimeh Eskandarian1, Zahra Alizadeh Sani2, Mohaddeseh Behjati3, Roohallah Alizadehsani4, Afshin Shoeibi5, Kourosh Kakhi6, Abbas Khosravi4, Saeid Nahavandi4, Sheikh Mohammed Shariful Islam7,  
1 Internal Medicine Research Center, Semnan University of Medical Sciences, Semnan, Iran
2 Rajaie Cardiovascular Medical and Research Center; Omid Hospital, Iran University of Medical Sciences, Tehran, Iran
3 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
4 Institute for Intelligent Systems Research and Innovation, Deakin University, Geelong, Australia
5 Faculty of Electrical Engineering, Biomedical Data Acquisition Lab, K. N. Toosi University of Technology, Tehran; Department of Computer Engineering, Ferdowsi University of Mashhad, Mashhad, Iran
6 Department of Data Science & AI, Monash University, Melbourne, VIC, Australia
7 Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC; Cardiovascular Division, The George Institute for Global Health, Newtown; Sydney Medical School, University of Sydney, Sydney, NSW, Australia

Correspondence Address:
Dr. Roohallah Alizadehsani
Institute for Intelligent Systems Research and Innovation, Deakin University, Geelong, VIC 3216
Australia

Abstract

A 65-year-old male was introduced with a history of percutaneous coronary intervention 2 years ago who received Aspirin and Plavix. He was referred for coronary angiography after receiving thrombolytic therapy for ST-elevation myocardial infarction in precordial leads. On admission, he had dyspnea with low oxygen saturation, leukocytosis, lymphopenia, elevated C-reactive protein, and cardiac troponin levels. Transthoracic echocardiography demonstrated left ventricular ejection fraction (LVEF) of 25% and pulmonary artery pressure of 45 mmHg. A small thrombus at the site of the previously deployed stent was noticeable at coronary angiography. The chest computed tomography depicted significant involvement of the lungs manifested by peripheral ground-glass opacifications. A positive polymerase chain reaction confirmed coronavirus infection. He was oxygen dependent for 1 week. Gradually, his respiratory distress improved and his LVEF reached to 30% after discharge.



How to cite this article:
Eskandarian R, Sani ZA, Behjati M, Alizadehsani R, Shoeibi A, Kakhi K, Khosravi A, Nahavandi S, Shariful Islam SM. Late stent thrombosis and acute ST-elevation myocardial infarction in a case affected with COVID-19: A rare manifestation.Res Cardiovasc Med 2021;10:20-22


How to cite this URL:
Eskandarian R, Sani ZA, Behjati M, Alizadehsani R, Shoeibi A, Kakhi K, Khosravi A, Nahavandi S, Shariful Islam SM. Late stent thrombosis and acute ST-elevation myocardial infarction in a case affected with COVID-19: A rare manifestation. Res Cardiovasc Med [serial online] 2021 [cited 2022 Dec 9 ];10:20-22
Available from: https://www.rcvmonline.com/text.asp?2021/10/1/20/319788


Full Text



 Introduction



Stent thrombosis is a severe complication of percutaneous coronary intervention (PCI) that presents by ST-elevation myocardial infarction (STEMI) with a high mortality rate.[1] Coronavirus disease-2019 (COVID-19) predisposes patients to thrombotic events.[2] As a result of this, we report a case of stent thrombosis in a situation with COVID-19.

 Case Report



Our case was a 65-year-old male with a history of PCI on his left anterior descending artery 2 years ago. He has received Aspirin and clopidogrel after PCI. Due to severe chest pain, he was admitted to the emergency department with a diagnosis of STEMI in precordial leads [Figure 1]. He was referred to our center for coronary angiography after receiving thrombolytic therapy due to ongoing chest pain within <24 h. On admission, his oxygen saturation was about 82% detected by a pulse oximeter, and he had dyspnea. Lad data showed leukocytosis, lymphopenia, elevated C-reactive protein, and cardiac troponin levels. Transthoracic echocardiography (TTE) demonstrated left ventricular ejection fraction (LVEF) of 25% and pulmonary artery pressure (PAP) of 45 mmHg that were significantly changed compared with his previously available TTE with LVEF of 55% and PAP of 35 mmHg (before). Coronary angiography was performed under full personal protection equipment that showed a diminutive and the patent right coronary artery. A small thrombus at the site of the previously deployed stent with length of 28 mm was noticeable [Figure 2]. Treatment of acute coronary syndrome (ACS) due to late stent thrombosis and acute heart failure was initiated. His chest computed tomography depicted significant involvement of more than 50% of lungs manifested by peripheral ground-glass opacifications [Figure 3]. A positive polymerase chain reaction confirmed coronavirus infection. He was oxygen dependent for 1 week. Gradually, his respiratory distress improved and his LVEF reached to 30% after discharge.{Figure 1}{Figure 2}{Figure 3}

 Discussion



During COVID-19 pandemic era, patients with coronary stents might be at increased risk of stent thrombosis as a result of a higher tendency to thrombosis due to underlying systemic inflammation.[3] Previous studies have suggested an association between cytokine storm due to COVID-19 and hypercoagulability and thrombosis.[4] Preexisting cardiovascular disease is a predisposing factor for COVID-19 infection with a worse prognosis with high mortality.[5]

COVID-19 has mainly affected the respiratory tract but an immune reaction, or “cytokine storm,” with a dramatic systemic impact observed in a late. COVID-19 prognosis can be worsened by underlying cardiovascular diseases, or acute cardiovascular events may occurred by COVID-19 even if there was not a reasonable history which includes thrombotic manifestations as local (i.e., pulmonary) or systemic Disseminated intravascular coagulation (DIC) forms, QT interval prolongation. Finally, in the lack of evidence regarding the postulated harmful effect of angiotensin-II-receptor antagonists in terms of SARS-CoV-2 virulence, these drugs should be continued.[6]

In addition to the possible impact of Covid-19 on the cardiovascular system, the pandemic has independently created a perfect storm for the health across the globe. It is important to be aware of the physical, emotional, and clinical consequences of these issues.[7]

Our case hints a point toward this hypothesis. Our case received antiplatelet therapy and we did not have the feasibility to check the patient for increased risk of resistance to antiplatelet induced by COVID-19. However, one of our speculations is that COVID-19 may strengthen the rate of stent thrombosis by producing Plavix resistance. This could be explained based on systemic inflammation but needs further investigation.

Antuña et al. presented a case of late coronary stent thrombosis in a COVID-19 case.[8] Hinterseer et al. reported a case of acute myocardial infarction due to stent thrombosis in an asymptomatic COVID-19 case.[9] Prieto-Lobato A. et al. reported a case series of four patients presenting with stent thrombosis during COVID-19 pandemic.[3] On the other hand, Hamadeh et al. reported a high rate of stent thrombosis in their retrospective multicenter study.[10] Since stent thrombosis and its consequences may occur in COVID-19, emergency coronary angiography should be considered with more attention in infected patients with coronavirus. This also indicates to need for adapted guidelines related to the treatment of ACS in patients with COVID-19. Finally, stent thrombosis could be added to the list of thrombotic events induced by COVID-19.

 Conclusions



Stent thrombosis could be considered as a thrombotic event related to COVID-19. Emergency coronary angiography is therefore essential in COVID-19 cases with acute myocardial infarction.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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