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Myocardial infarction presenting with Cardiac arrest in post covid patient

Some weeks back, a male 37 years old, with no co-morbidities presented with burning chest pain and syncope at around midnight to another nearby hospital. ECG is suggestive of STEIWMI with CHB. His Heart Rate – was 35b/min, BP- was 70/30 mhg & patient was in cardiogenic shock. The same patient was then shifted to our hospital for further management. On arrival at our hospital, he had no recordable pulse and BP i.e. Pulseless electrical activity. CPR was started, Supported with Inotropes, and given Injections of Atropine and Injection Adrenaline. He was intubated and put on ventilator support, simultaneously loaded with Antiplatelets T.Dispirin 325mg, T.Brilinta 180mg, T.Rosuvastatin 40mg, and Injection Heparin 5000U i.v.stat. Attendees were undecided on primary Angioplasty, so he was started on thrombolysis with Injection Streptokinase 1.5 million units i.v. Infusion. CPR continued for nearly 40 minutes and received DC Cardioversion multiple times for VT/VF. Patient heart rate improved to 60b/min & BP-80/40mhg, still in cardiogenic shock. Patient attendees agreed to primary angioplasty with high-risk consent.

After prolonged CPR for nearly 40 minutes with unknown neurological status, the patient was shifted to the Cath lab. Thrombolysis was stopped and a coronary angiogram is done from Rt. A femoral artery with Temporary pacing support showed Rt. Dominant single vessel disease in Proximal RCA with 80-90% thrombus-containing stenosis. Did primary angioplasty to Proximal RCA with DES 3.5 *32mm with TIMI 3 flow. ECG reverted to sinus rhythm, BP improved and Inotropes stopped. He was shifted to ICU in stable condition.

Course in ICU: After some hours post angioplasty patient developed hypotension noted to RVMI with inferior wall hypokinesia with EF – 35%. Managed with i.v. fluids & inotropes. Neurologist consultation was sought to assess his neurological status, and EEG was normal. The patient improved hemodynamically over 24 hours and was extubated on day 2 after regaining consciousness, and was off inotropes by 48-72 hours. Retrospectively, we noted the patient was Covid positive with mild symptoms two months back with no sequelae. Had some protective IgG antibodies ((-21.19(>1reactive)). Discharged on day 6 with dual antiplatelet therapy.

Follow up:

Follow-up after a week showed improvement in his left ventricle & RV function. The patient was asymptomatic with dual antiplatelet. Follow up at 1-month post-procedure, the patient was asymptomatic and Echo showed completely recovered LV function.

Conclusions:

Acute Myocardial Infarction in young patients is becoming quite common these days even with no comorbidities. Smoking, a sedentary lifestyle, and mental stress are more common in this subset of patients. Pharmaco-invasive therapy (as in this patient who was undecided on primary angioplasty) may help certain patients to open up the infarct-related artery. In this patient, Acute MI could also have been a complication of Covid as we have noted patients developing MI, Stroke, and other complications as Covid sequelae. Therefore postCovid, patients should at least be on antiplatelet or anticoagulation depending on Covid severity. Patients should also avoid smoking and develop healthy lifestyle habits like yoga and meditation.

Dr. Naveen A.J

Head of Cardiology Department

Suguna Hospital, Bangalore