Impact of SARS-CoV-2 On St-Elevation Myocardial Infarction (STEMI)

Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV 2) pandemic originated from Wuhan, China, in December 2019 and rapidly spread throughout the globe [1]. Currently, SARS-CoV 2 has resulted in an enormous number of deaths worldwide [2,3]. Based on the WHO report on 28 April 2020, almost 3 million confirmed cases of COVID-19 have been identified, and nearly 7% of them have died due to disease and its complications [4]. Regarding the catastrophic impact of COVID-19 on human well-being, investigation of its manifestations, complications, and appropriate treatment has become the most concerning issue in the World Health Organization recently.


Introduction
Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV 2) pandemic originated from Wuhan, China, in December 2019 and rapidly spread throughout the globe [1]. Currently, SARS-CoV 2 has resulted in an enormous number of deaths worldwide [2,3]. Based on the WHO report on 28 April 2020, almost 3 million confirmed cases of COVID-19 have been identified, and nearly 7% of them have died due to disease and its complications [4]. Regarding the catastrophic impact of COVID-19 on human well-being, investigation of its manifestations, complications, and appropriate treatment has become the most concerning issue in the World Health Organization recently.
Patients suffering from COVID-19 are mostly presented with respiratory involvement, fever, and myalgia; Generally, respiratory involvement and general condition exacerbate and eventually leads to pneumonia and, in severe cases, results in Acute Respiratory Distress Syndrome (ARDS) or shock. The most common manifestations revealed in COVID-19 patients are fever, cough, and malaise [11]. Compared to respiratory involvement,  Various cardiac manifestation has been reported in COVID-19 patients consisting of cardiogenic shock, Acute myocardial damage, ST-elevation Myocardial Injury, Viral Myocarditis, Arrhythmiainduced cardiomyopathy, and venous thrombosis [12][13][14]. A caseseries in Washington D.C. revealed that 33% of COVID-19 patients in the Intensive Care Unit have experience cardiomyopathy [15].
Besides, there were reports of cardiac Tamponade and Takotsubo cardiomyopathy secondary to COVID-19 [16]. The physiopathology behind the cardiac damage in COVID-19 is not still clear; however, scientists believe that Plaque rupture, Cytokine storm, inflammatory damage, hypoxic damage, coronary spasm, micro thrombus, and direct endothelial damage probably play important roles [17].
Cardiac symptoms in COVID-19 patients could be found in ECG, while no other findings are presented. In this regard, a 66-yearold Chinese woman with "temporary S1Q3T3 morphology" and secondary "reversible nearly complete A.V. block" without any remarkable past medical history has been reported. Furthermore, many cases of COVID-19 patients with ST-elevation have been registered. ST-elevation Myocardial Infarction is one of the most important causes of death due to cardiovascular involvement.
Generally, patients with NSTEMI have a better prognosis than STEMI [18].

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The first COVID-19 patient with simultaneous STEMI was a 31-year-old female with remarkable past medical history comprising of COPD, Coronary artery disease, Pulmonary Hypertension, Diabetes, and CVA. She denied any history of fever, sore throat, and G.I. discomfort. In basic ECG on admission, STelevation in Leads 2, 3, and AVF with reciprocal changes in V1 and V2 were demonstrated, which is determinant of Acute Inferior Wall STEMI. She underwent Coronary revascularization and successfully cured [19].
Another surprising report about the cardiac manifestation of ST-elevation, and Sinus tachycardia were discovered. Following angiography exposed non-obstructive CAD [14].
In a case-series study through the COVID-19 outbreak in the United States, 18 cases with ST-elevation were reported. Ten of them were hospitalized with ST-elevation on admission, while eight others developed ST-elevation during the hospitalization.
18% of patients had a history of CAD who had a poor prognosis and different manifestations compared to others. Coronary angiography proceeded for 50% of cases. 66% of angiography results indicated coronary obstruction. Thirteen patients died due to cardiac complications [20].
Various Guidelines have evolved for approaching to COVID-19 patients with Acute Myocardial Damage [8,15,21,22]. As a result of the presence of numerous differential diagnoses for ST-elevation, including viral myocarditis, the determination of appropriate treatment has remained a challenge; Nonetheless, primary PCI is the standard treatment in STEMI patients. Fibrinolysis-based strategies are the substitutive treatment in the absence of PCI equipment [23]. Further studies are needed to investigate the effect of COVID-19 on Cardiovascular function. We suggest physicians be thoroughly informed of atypical findings of COVID-19, early diagnosis, and treatment approaches.