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A 45-year-old African-American man with history of human immunodeficiency virus (HIV), hypertension, and hyperlipidemia was admitted to hospital with fever, dyspnea, and hypoxia. He was diagnosed with Covid-19 6 days prior and was discharged from the hospital 2 days prior to current admission. He now presented to the emergency room with substernal chest pressure of sudden onset which started 1 hour prior to his current presentation. Electrocardiogram showed an acute inferolateral ST-elevation myocardial infarction (STEMI) (Figure 1). Troponin was pending at the time of emergent catheterization.
The patient was taken emergently to the catheterization laboratory. A coronary angiogram was performed using a right common femoral artery access. The diagnostic coronary angiogram demonstrated a linear dissection of the mid right coronary artery (RCA) with possible intramural hematoma based on the angiogram (Figures 2-3 and Videos 1A-B, see below) and non-obstructive coronary artery disease (CAD) in the rest of the coronary arteries (Videos 2A-B, see below). There was Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow in the distal RCA. Due to the patient’s ongoing chest pain, we decided to proceed with primary percutaneous coronary intervention (PCI). Intracoronary imaging was not performed, because of the obvious coronary artery dissection noted on the coronary angiogram. The lesion was stented with a 4.5 x 30 mm drug-eluting stent and post dilated using a 5.0 x 20 mm non-compliant balloon at 24 atmospheres (Videos 3A-B, see below). The follow-up angiogram showed good results with TIMI-3 flow (Figure 4) and there were no complications. The patient’s chest pain resolved after PCI and he was discharged home 2 days later.
Infection with Covid-19 has been associated with spontaneous coronary artery dissection (SCAD),1,2 which is likely secondary to an inflammatory cascade provoked by Covid-19. Conservative management is usually preferred in SCAD with TIMI-3 flow due to the concern for progression of dissection with PCI. However, due to the ongoing severe chest pain, we decided to primarily stent the RCA. SCAD should be considered in the differential diagnosis of Covid-19 patients presenting with an acute coronary syndrome. Conservative versus invasive management options should be decided on a case-by-case basis.
1. Albiero R, Seresini G. Atherosclerotic spontaneous coronary artery dissection (A-SCAD) in a patient with COVID-19: case report and possible mechanisms. Eur Heart J Case Rep. 2020 May 12: ytaa133. doi:10.1093/ehjcr/ytaa133
2. Courand PY, Harbaoui B, Bonnet M, Lantelme P. Spontaneous coronary artery dissection in a patient with COVID-19. JACC Cardiovasc Interv. 2020;13(12):e107-e108. doi:10.1016/j.jcin.2020.04.006
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Hemang B. Panchal, MD, MPH, at firstname.lastname@example.org.
Video 1A and 1B. Right coronary artery angiogram showing dissection in the mid segment of the artery with intramural hematoma, as evident by linear haziness in the inner curvature side.
Video 2A and 2B. Angiogram of left-sided coronary arteries showing mild, non-obstructive coronary artery disease.
Video 3A and 3B. Angiogram of right coronary artery after stenting.