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ST-segment elevation on the EKG in COVID-19 patients was especially complex and had poor prognosis in a small case series from New York City hospitals.

Confirmed COVID-19 was complicated by ST-segment elevation indicating potential acute MI in 18 cases across six centers in the first month of the outbreak, reported Sripal Bangalore, MD, MHA, of New York University Grossman School of Medicine, and colleagues.

More than half of the cases in a research letter in the had nonobstructive disease. Clinical diagnosis was MI in eight patients and non-coronary myocardial injury (defined as nonobstructive disease on coronary angiography or normal wall motion on echocardiography) in 10.

Ultimately, mortality was very high, as 13 patients died during hospitalization: half of those with MI and 90% of those with non-coronary myocardial injury.

Clinical judgment is requisite to sort out what's happening for a given patient, commented J. Dawn Abbott, MD, of Warren Alpert Medical School at Brown University in Providence, Rhode Island.

The SARS-CoV-2 virus that causes COVID-19 can damage the heart via viremia or migration of infected macrophages from the lung. Myocarditis or myopericarditis (which can cause ST elevation) can stem from inflammation, cytokine storm, and potentially microvascular thrombosis, she noted.

On the other hand, patients could also have a true plaque-rupture STEMI while infected with COVID-19, she added.

It all has implications for how to manage these patients, Bangalore told MedPage Today.

"Before the COVID-19 era, people would agree that taking these patients to the cath lab and opening blockages, if done quickly, was the way to go. Since COVID, the discussion has turned to maybe using clot busters first," he said.

However, "in more than half of patients there is no obstructive blockage, so giving clot busters may not be helpful and may even increase risk of harm, including bleeding. The other issue is we're also noticing that the patients take longer to present. They prefer to stay at home and present later, so even if they did have a real clot causing the heart attack, the clot is not as easily treated by clot busters," he explained.

"When we see ST-elevation in COVID-positive patients, they are a lot more complex than we were dealing with in non-COVID data," Bangalore concluded. "A one-size approach may not work for these patients."

Presentation was variable. ST-segment elevation was seen at presentation for 10 people and developed during hospitalization for the other eight.

Of 14 people who had focal ST-segment elevation, five had normal ejection fraction (with one showing a regional wall-motion abnormality) and eight had reduced ejection fraction (with five showing regional wall-motion abnormalities). One patient had no echocardiogram.

The four patients with diffuse ST-segment elevation had normal ejection fraction and normal wall motion in three cases. One of the four had an ejection fraction of 10% with global hypokinesis.

All 18 patients had elevated d-dimer levels in the case series.

In the nine patients in whom suspicion of a true STEMI was high enough to warrant coronary angiography, obstructive disease was recorded for six, with five going on to receive percutaneous coronary intervention (one doing so after getting fibrinolytic therapy).

Less frequent coronary obstruction in COVID-19 was in line with the experience of Marco Valgimigli, MD, PhD, of Bern University Hospital in Switzerland.

"This may be explained by a virus-related myocardial injury, most likely due to a pro-thrombotic state as suggested by the fact that all STEMI patients in this series are characterized by high d-dimers. Hence, the decision to bring these patients in the cath lab or not is clearly more challenging and requires a patient-by-patient decision," he told MedPage Today.

"The differential diagnosis should always take the probability of obstructive versus nonobstructive coronary artery disease into account. In case of doubt, an immediate coronary angiogram is indicated," he suggested.

There are many patients with ST-segment elevation that have COVID pneumonia and are critically ill without a clinical syndrome consistent with acute coronary syndrome, according to Abbott.

At her institution, "if there is no persistent chest pain or reason to suspect coronary obstruction based on echo-identified wall motion in the expected coronary distribution, the patients are managed with antiplatelet and anti-thrombin therapy and cath is not performed," she said.

Patients in the New York case series were a median 63 years of age, and 83% were men. One in three had chest pain at the time of ST-segment elevation.

The report was limited by its retrospective nature and the rather small and selected patient population.

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