ECG Cases 8 Cardiovascular Emergencies During The COVID-19 Pandemic

In this ECG Cases blog we look at 6 patients who presented with cardiorespiratory symptoms, possibly from COVID

Written by Jesse McLaren; Peer Reviewed and edited by Anton Helman. April  2020

Six patients presented with cardio-respiratory symptoms, possibly COVID-19.

Patient 1: 50yo with sore throat and recent sick contact, woke up short of breath with throat tightness. RR 20, sat 95%, HR 105, BP 160/70

Patient 2: 70yo with two weeks dry cough, then SOB and syncope. RR 36, sat 96%, HR 110, BP 120/80

Patient 3: 40yo with one week SOB and chest tightness, treated as pneumonia, currently painfree. Old then new ECG. RR 16, sat 98%, HR 80, BP 140/80, afebrile

Patient 4: 65yo one week intermittent epigastric pain and SOB, currently in pain x 5 hours. RR18 sat 100%, HR 55, BP 120/70, afebrile. Old then new ECG

Patient 5: 30yo with five days of fever and cough, increasing SOB. RR 28, sat 93% on 4L, HR 100, BP 100/70, temp 39

Patient 6: 45yo one week fever and cough, increasing SOB. RR 22, sat 93% on 4L, HR 90, BP 110/70, temp 38.5. Old then new ECG

COVID-19 pandemic and cardiovascular emergencies

The COVID-19 pandemic poses a number of challenges for cardiovascular emergencies, and not only for COVID-19 patients. A review summarized this new and evolving field: “First, those with COVID-19 and preexisting cardiovascular disease (CVD) have an increased risk of severe disease and death. Second, infection has been associated with multiple direct and indirect cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias and venous thromboembolism. The response to COVID-19 can compromise the rapid triage of non-COVID-19 patients with cardiovascular conditions. Finally, the provision of cardiovascular care may place health care workers in a position of vulnerability as they become host or vectors of virus transmission.”[1]

Acute cardiac injury (defined as abnormal troponin level) occurs in up to 20% of patients hospitalized for COVID-19, and is a marker of poor prognosis.[2] COVID-19 can cause acute cardiac injury through multiple mechanisms: “early reports indicate that there are two patterns of myocardial injury with COVID-19. The rise in hs-cTnI tracks with other inflammatory biomarkers (D-dimer, ferritin, interleukin-6, LDH), raising the possibility that this reflects cytokine storm. In contrast, reports of patients presenting with predominantly cardiac symptoms suggests a different pattern, potentially viral myocarditis or stress cardiomyopathy”[3] COVID-19 cardiac complications include both STEMI mimics like myocarditis (diagnosed retrospectively after a normal angiogram) [4] and concerns that the inflammatory response could cause plaque rupture leading to acute coronary occlusion (which the newly created North American COVID-19 ST-Segment Elevation Myocardial Infarction Registry (NACMI) will help track).

Patients hospitalized with COVID-19 can develop pulmonary emboli[5], and the rate is especially high in critically ill patients in ICU [6]. But the incidence of patients presenting to the ED with both COVID-19 and PE is isolated to case reports. As a report on a patient presenting with pneumonia and hemoptysis, along with right-heart strain on the ECG, concluded: “An association between COVID-19 and PE creates a diagnostic challenge for emergency medicine clinicians given the overlap in symptoms between the two clinical entities. Elevated D-Dimer levels (>1.0 mg/dl) have been identified as a potential predictor of increased mortality, but are not specific to the diagnosis of VTE. Reliance on D-dimer as a screening tool should be discouraged in this patient population and may lead to over utilization of Computed Tomography Angiography (CTA)…In addition to clinical features like hemoptysis, signs of right heart strain on adjunctive bedside tests like EKG or point of care ultrasound maybe helpful for clinicians in identifying COVID-19 patients at risk for concurrent pulmonary embolism.”[7]

In addition, the scale of the pandemic appears to be impacting non-COVID cardiovascular emergencies. In a number of regions hit hard by the pandemic there’s been a paradoxical drop in the number of STEMI cases, raising the concern that patient fear of COVID-19 is leading to medical distancing; avoidance of hospitals could lead to early death or late presentations.[8] Early data from one hospital in Hong Kong found delays in STEMI patients seeking medical care, as well as delays in door-to-device times.[9] As an American College of Cardiology clinical bulletin warned, “classic symptoms and presentation of AMI may be overshadowed in the context of COVID-19, resulting in underdiagnosis.”[10] This is especially important in the ED, where patients present with undifferentiated symptoms and unknown COVID-19 status. Anchoring on a pandemic disease whose diagnosis is delayed and whose main treatment is supportive could lead to missing cardiovascular emergencies that can be quickly diagnosed at the bedside and for whom specific treatments exist, like PE and acute coronary occlusion. Finally, there are changing protocols around interventional cardiology, varying between and within countries over time (and some which reinforce the false dichotomy between STEMI and NSTEMI). The Canadian Association of Interventional Cardiology recommends decisions on PCI vs medical management be guided by diagnosis, clinical stability, likelihood of COVID-19 or known status, and resource restrictions.[11] Each centre may have a slightly different approach, which may change over time, and COVID-19 test results are helpful in planning non-urgent cases.

Back to the cases

Patient 1: myocarditis, COVID(-)

ECG/trop done because of 50yo with SOB out of proportion to mild URTI symptoms.

• HR/rhythm: sinus tach
• Electrical conduction: normal
• Axis: normal
• R-wave: normal progression
• Tension: no hypertrophy
• ST-T waves: convex ST segment with terminal T wave inversion V3-4

Trop 19,000 and referred to cardiology. Normal echo and cath, and myocarditis diagnosed by cardiac MRI. Discharge ECG: normal V2 placement, normalizing ST morphology V2-3.

Patient 2: pulmonary embolism, COVID(-)

ECG/POCUS done because elderly patient with SOB and syncope.

• HR/rhythm: sinus tach
• Electrical: prolong QT
• Axis: left
• R-wave: delayed progression
• Tension: no hypertrophy
• ST-T: S1Q3T3 with antero-inferior T wave inversion

ECG concerning for PE. POCUS parasternal short-axis view:

RV dilation with D-sign. Treated with IV heparin, CTPA showed saddle embolism and no COVID pneumonia, and admitted to ICU. COVID swab (-)

Patient 3: reperfusing acute coronary occlusion (STEMI+ OMI+), COVID (-)

ECG/trop done because CP/SOB NYD.

• HR/rhythm: NSR
• Electrical: normal conduction
• Axis: left
• R wave: loss of precordial R wave height
• Tension: no hypertrophy
• ST-T: antero-inferior convex ST segment elevation and T wave inversion

A week of symptoms, currently painfree and ECG reflecting spontaneous reperfusion. Trop 3000 and referred to cardiology. PCI with PPE precautions: wrap-around LAD (supplying anterior and inferior walls) with 70% occlusion (reflected by reperfusion T wave inversion). Trop peak at 5000. Discharge ECG: resolution of ST elevation with ongoing reperfusion T wave inversion:

Patient 4: acute coronary occlusion (STEMI- OMI+), COVID (-)

• HR/rhythm: sinus bradycardia
• Electrical: normal intervals
• Axis: normal
• R wave: normal
• Tension: no hypertrophy
• ST-T: doesn’t meet STEMI criteria but is diagnostic of infero-posterior Occlusion MI: inferior convex ST segments with mild elevation and reciprocal ST depression in AVL from inferior MI, and ST depression in V2 from posterior extension, terminal T wave inversion.

A week of intermittent symptoms from occlusion and spontaneous reperfusion (with T wave inversion) with ongoing symptoms. Cath lab activated: 100% proximal RCA occlusion. First trop 1500, peak 18,000. Discharge ECG: ST segment resolution, inferior reperfusion T wave inversion

Patient 5: pneumonia, likely COVID

Symptoms of pneumonia, ECG/trop done for SOB and hypoxia.

• HR/rhythm: sinus tach
• Electrical: normal
• Axis: right
• R-wave: normal
• Tension: no hypertrophy
• ST-T: TWI in III only.

Trop negative, CXR bilateral infiltrates, elevated neutrophil/lymphocyte ratio. Treated as pneumonia and admitted as r/o COVID. COVID swab negative. CTPA done for ongoing hypoxia: negative for PE but bilateral peripheral opacities consistent with COVID-19.

Patient 6: pneumonia, COVID(+)

Symptoms of pneumonia, ECG done for SOB and hypoxia.

• HR/rhythm: NSR
• Electrical: normal
• Axis: normal
• R-wave: normal
• Tension: LVH
• ST-T: old inferior TWI, no change from prior

Trop negative, CXR bilateral infiltrates, admitted as pneumonia r/o COVID. COVID swab positive.

Take home points for ECG Cases 8: Cardiovascular emergencies during the COVID-19 pandemic

1. For patients with cardiorespiratory symptoms, guard against anchoring by considering non-COVID emergencies first (especially without classic infectious symptoms), for which ECG/POCUS can be helpful (eg PE, acute coronary occlusion)
2. For sick COVID-19 patients, consider cardiovascular complications (eg arrhythmia, myocarditis, CHF)
3. For admitted ACS patients, COVID-19 testing helps cardiologists plan their interventions

References for ECG Cases 8: Cardiovascular emergencies during the COVID-19 pandemic

1. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. J Am Coll Cardiol. 2020 Mar 18
2. Shi S, Qin M, Shen B, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol. 2020 Mar 25
3. Clerkin K, Fried J, Raikhelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation 2020 Mar 21
4. Hu H, Ma F, Wei X, et al. Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin. Eur Heart J 2020 Mar 16
5. Chen J, Wang X, Zhang S, et al. Findings of acute pulmonary embolism in COVID-19 patients
6. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Lancet 2020 Mar 10
7. Casey K, Iteen A, Nicolini R, et al. COVID-19 pneumonia with hemoptysis: acute segmental pulmonary emboli associated with novel coronavirus infection. Am J of Emerg Med 2020 Apr 8
8. Shelley Wood. The mystery of the missing STEMIs during the COVID-19 pandemic. tctmd 2020 Apr 2
9. Tam CF, Cheung KS, Lam S, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong, China. Circ Cardiovasc Qual Outcomes. 2020 Mar 17
10. ACC clinical bulletin: COVID-19 clinical guidance for the cardiovascular care team. ACC 2020 Feb 7
11. Wood D, Sathananthan J, Gin K, et al. Precautions and procedures for coronary and structural cardiac interventions during the COVID-19 pandemic: guidance from Canadian Association of Interventional Cardiology. Can J Cardiol 2020 Mar 24