|Year : 2020 | Volume
| Issue : 2 | Page : 176-179
Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned
Mahidhar Jeedigunta, Javaid Ahmad, Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||25-Apr-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||27-Aug-2020|
Dr. Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
COVID-19 is an ongoing global pandemic caused by a betacoronavirus named SARS-CoV-2. Within few months after the first index case is identified in Wuhan city of China, it attained a global pandemic status due to its unique epidemiology and pathophysiology. It typically presents with signs and symptoms of viral pneumonia. Patients with cardiac disease are at increased risk of COVID disease and create a diagnostic dilemma in differentiating from respiratory illnesses for the cardiologists. Furthermore, ST-segment changes in electrocardiogram and troponin elevation which form a key diagnostic point in the diagnosis of acute coronary syndromes are frequently seen in COVID-19 patients. This is a matter of utmost concern as the diagnostic dilemma caused may lead to many patients who may not have epicardial coronary artery disease that may be taken up for invasive angiography. Moreover, the prejudice caused by the COVID-19 is leading to fewer admissions for acute coronary syndromes and fewer primary percutaneous transluminal coronary angioplasty leading to inappropriate management of deserving patients with genuine acute coronary syndromes. These patients form a very important chunk of population as on the one hand, they are more likely to spread the infection if they are improperly triaged, and on the other hand, they are less likely to receive proper guideline-directed treatment of cardiovascular syndromes increasing the mortality from primary cardiac pathology. The following case highlights the above-mentioned issues faced in triaging and treating a patient who presented a diagnostic dilemma. Our patient a 53-year-old lady who is a known case of chronic coronary syndrome with effort-induced angina on exertion for the last 4 months on medical management presented to the emergency department, after being rejected admission by three hospitals, with features of chest pain at rest 5 days prior to admission associated with dyspnea and nonproductive cough along with elevated troponin and ST elevation. She was initially diagnosed as acute coronary syndrome with acute heart failure and was taken up to the cardiology ward where a proper clinical examination suggesting right middle lobe localized crackles and chest X-ray findings prompted the suspicion of COVID-19, testing for which by a viral RNA-based test came as positive. This case illustrated the unique challenge posed by the COVID-19 for the cardiologist and the importance of clinical examination and a high index of suspicion needed along with prompt isolation of any suspected case. She was shifted to the COVID ward from where she was discharged after 5 weeks.
Keywords: Atypical presentation, coronary artery disease, COVID-19
|How to cite this article:|
Jeedigunta M, Ahmad J, Ramakrishnan S. Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned. J Pract Cardiovasc Sci 2020;6:176-9
|How to cite this URL:|
Jeedigunta M, Ahmad J, Ramakrishnan S. Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Sep 26];6:176-9. Available from: http://www.j-pcs.org/text.asp?2020/6/2/176/293531
| Introduction|| |
India reported its first case of COVID on January 30, whereas the first case was reported in New Delhi on March 2, 2020. Although a nationwide lockdown was effected, there had been a rise in the number of COVID cases, which was more rapid and evident in major cities of India like Mumbai, Delhi, Chennai, Pune, and Ahmedabad attributable to higher population density and difficulty of social distancing in such a situation.
| Case Report|| |
Our current case, a 53-year-old female, a resident of New Delhi, presented with the chief complaints of chest pain at rest of 5-day duration. In the background, she had a history of exertion-induced angina of New York Heart Association Class II for the last 5 months, for which she was on medical therapy with aspirin, statin, and long-acting nitrate from another local hospital. Her past electrocardiogram (ECG) done in December 2019 and in February 2020 showed a complete right bundle branch block (RBBB) pattern. She had presented with chest pain at rest for 5 days with an episode of vomiting. She had a history of cough and sore throat 3 days prior to admission which, initially, she did not disclose. There was no history of palpitations, syncope, presyncope, decreased urine output, or high-grade fever.
Initially, she contacted local private medical facilities and a tertiary care center for rest pain and was referred to our center for further management. She had complaints of dyspnea at rest of 12 h duration. She denied a history of fever, flu-like symptoms, and diarrhea in the emergency. Hence, it was not referred to the COVID screening zone and a cardiologist consultation was sought. In the emergency department, she was tachypneic at rest and her ECG [Figure 1]a, [Figure 1]b, [Figure 1]- showed RBBB with 1-mm ST elevation in V1 and V2 and <1 mm ST elevation in V3, with ST depression in leads II and lead III. The ST-segment deviations are new onset as compared to the earlier ECG. Her Troponin I was elevated 0.78 ng/mL (95% upper limit of norma (UL) of normal <0.02 ng/mL). Bedside echocardiography done in emergency was suggestive of reduced left ventricular systolic function with ejection fraction of 40% with regional wall motion abnormality involving the left anterior descending artery territory. She was provisionally diagnosed as a case of recent anterior wall ST-elevation myocardial infarction (STEMI) out of window period with acute heart failure (Killip Class III).
|Figure 1: (a) Baseline electrocardiogram of the patient. (b) Electrocardiogram at presentation. (c) Electrocardiogram at admission.|
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She was admitted in the cardiology ward in view of heart failure and chest pain. On evaluation, she was conscious, coherent, oriented, dyspneic, and had severe bouts of nonproductive cough. She was afebrile and had a heart rate of 84 bpm, blood pressure of 101/60 mm Hg, and respiratory rate of 28 breathes/min with the usage of accessory muscles of breathing. Her jugular venous pressure was normal. On examination of the respiratory system, she had coarse crackles in the right mammary and right interscapular areas with minimal coarse crackles in the left mammary areas. She had no crepitations in the basal regions of the lung. Her cardiac system examination as well as examination of the abdomen and nervous system was unremarkable. On repeated questioning in the ward, she revealed a history of rhinorrhea, sneezing, severe cough, sore throat, and mild undocumented fever of 3 days duration that she did not initially disclose. She denied any foreign travel or contact with a positive case of COVID-19. She also disclosed that few of her family members had similar complaints of upper respiratory tract infection.
We initiated antiplatelets aspirin 75 mg and clopidogrel 75 mg, sublingual sorbitrate 5 mg, and long-acting nitrate (isosorbide mononitrate 30 mg). She was already started on long-acting beta-blocker (metoprolol succinate 25 mg) and statins (tablet atorvastatin 40 mg) that was continued. She reported symptomatic relief of chest pain with the antianginal medications. Acute heart failure symptoms responded to diuretic therapy.
In view of the presence of crepitations predominantly in middle lobes rather than basal crepitations and the history, a clinical suspicion of viral pneumonia was kept, and chest X-ray [Figure 2] and complete blood count and renal function tests and serum electrolytes were requested. In view of ongoing COVID-19 pandemic, she was isolated in the ward, and adequate PPE and nursing precautions were taken. Her chest X-ray was suggestive of alveolar opacities in the right and left middle zones with perihilar predominance with no significant pulmonary venous hypertension. Her total leukocyte count was 6400 cells/cc. Her nasopharyngeal and oropharyngeal swab was sent for COVID-19 testing which turned out to be positive. She was shifted to the COVID isolation ward and was appropriately managed. She eventually recovered from the COVID pneumonia with conservative management. She had a stay of 5 weeks in the hospital and was discharged from hospital after three successive polymerase chain reaction tests for COVID turned out negative. As for her chest pain, she did not have any further chest pain in the hospital after the antianginal medications were optimized and is currently doing fine.
| Discussion|| |
Coronaviruses are a group of viruses belonging to Coronaviridae which are enveloped, positive sense single-stranded RNA viruses, named because of the typical shape of their peplomers resembling solar corona. The virus causing the current global pandemic COVID-19 is named as SARS-CoV-2, which is a betacoronavirus. This particular strain of the virus was first identified in the Wuhan city in the Hubei province of China at the end of 2019 and by February 2020 assumed the status of a global pandemic. This disease is characterized by high infectivity, low virulence, and its ability for transmission during the asymptomatic phase which led to it spreading rapidly beyond. The disease predominantly affects the respiratory system, manifesting itself as a spectrum ranging from mild flu to severe fulminate pneumonia.
While the common symptoms of COVID-19 that bring a patient to medical notice are a dry cough, fever, and difficulty breathing, there are as such no typical clinical features that reliably and accurately distinguish COVID-19 from other pneumonias, especially viral. Early studies reported from china showed that fever is the most common symptom being present in almost 99% of cases, followed by fatigue and nonproductive cough. Although not as common, anosmia and dysgeusia have also been reported in a sizeable majority of patients presenting with COVID-19. As the experience with the disease rapidly increased, atypical presentations and rare symptoms are being identified in increasing frequency, which included the absence of fever or very low-grade fever, headache, sore throat, rhinorrhea, and gastrointestinal symptoms.,,
In addition, considering host factors, there seem to be certain groups of patients who are at an enhanced risk of developing complications. Studies till date including a study which included 72,314 clinically detected and viral nucleic acid test positive cases of COVID-19 showed that people with advanced age and those who suffer from other medical comorbidities such as cardiovascular disease, diabetes, hypertension, chronic pulmonary diseases, cancer, and chronic kidney disease are deemed to be at an increased risk for complications from the disease.,,,,,,
Patients with preexisting cardiovascular disease form an important segment of disease for the two reasons. They form a segment of the population who are more vulnerable to contracting the disease as well as developing complications. In addition, these groups of patients form a special category where a lack of fast and reliable COVID-19 testing is acutely felt due to atypical cardiovascular manifestations of the infection causing diagnostic dilemma, especially with primary respiratory illnesses. In the era of increased reliance on the cardiac markers and imaging modalities, a sizeable portion of these patients may be misdiagnosed to be in acute coronary syndrome and may either receive inappropriate treatment or may expose the health-care personnel and fellow cardiac patients, who already are a vulnerable group, to the risk of infection in case they are not triaged to the special isolation facilities. This dilemma is particularly experienced in patients presenting with dyspnea and minimal and/or no fever, as in our index case, where triage becomes challenging. Hence, accurate and rapid identification of the segment of patients who present with atypical symptoms and with a prior history of ongoing coronary artery disease needs to be interpreted extremely cautiously not only to avoid further contamination and spread of infection in the wards but also to identify the patients suffering primarily with coronary syndromes who are potentially salvageable.
Speaking of the cardiac manifestations, the most common cardiac presentation of COVID-19 appears to be an acute myocardial injury with troponin elevation. A series of 52 critically ill patients in China with COVID-19 revealed the myocardial injury in 29% of patients, as evidenced by a rise in troponin.
Similarly, various other cardiac manifestations mentioned till date in the COVID-19 infection are acute myocardial infarction, acute heart failure, arrhythmias, and pericardial effusion., The cause of the acute myocardial injury is currently uncertain but is thought to be due to viral myocarditis (which may be the result of direct viral invasion and replication in cardiomyocytes), microvasculature-related damage, systemic cytokine-mediated injury, myocyte damage due to hypoxia, and stress-related cardiomyopathy., Many potential hypotheses have been suggested for this observed cardiotoxicity of the virus such as direct viral replication in the cardiomyocytes, high levels of cytokines, stress cardiomyopathy, and hypoxic injury, none of which currently fully explain the cardiac damage.
The prevalence of coronary artery disease among patients infected with COVID ranges from 4.2% to 25% from series reported predominantly from China. Currently, cardiologists are interested in COVID-19 patients who present with signs and symptoms suggestive of acute coronary syndromes, such as, elevated troponin levels and ECG changes of acute coronary syndromes. The current european society of cardiology (ESC) recommends Peking Union Medical College Hospital recommendations for the management of acute coronary syndromes in patients with proven or suspected COVID-19, according to which immediate thrombolysis is a favored approach in patients with acute STEMI. In patients in whom the probability of COVID-19 is low as certified by specialists in Infectious Diseases, the patient can be taken up for immediate intervention in addition to judicious use of computed tomography chest and viral nucleic acid testing.
There have been reports which described cases with presentation suggestive of acute myocardial injury with marked cardiac troponin elevation, ECG showing ST-segment elevation or depression, on whom angiography often revealed no obstructive epicardial coronary arteries or culprit lesions; based on these data, it can be inferred that myocardial injury in this dubious set of population is most likely not due to epicardial coronary artery thrombosis but may be likely due to the aforementioned factors such as direct viral toxicity on cardiomyocytes, systemic cytokine-mediated cardiotoxicity, stress-related cardiomyopathy, or cardiac injury due to microvascular thrombosis.
Our index case presented with chest pain and elevated troponin which drew the attention of attending physicians toward an acute coronary syndrome and coupled with a doubtful history of mild fever and absence of travel, the patient was thought to have a primary cardiac disease and was shifted to the cardiology ward. Hence, in view of a myriad of cardiac presentations in patients with COVID-19 along with the diagnostic uncertainty, it is a matter of utmost importance to adequately identify the patients presenting with atypical presentations of COVID-19 from those with primary cardiac manifestations. Clinical scores and rapid laboratory tests with acceptable sensitivity and specificity to exclude those with COVID-19 are pressing need of the hour.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The case report was cleared by ethical clearance committee of the institute AIIMS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]