To the Editor:
Myocardial injury with ST-segment elevation has been observed in patients with coronavirus disease 2019 (Covid-19). Here, we describe our experience in the initial month of the Covid-19 outbreak in New York City.
Patients with confirmed Covid-19 who had ST-segment elevation on electrocardiography were included in the study from six New York hospitals. Patients with Covid-19 who had nonobstructive disease on coronary angiography or had normal wall motion on echocardiography in the absence of angiography were presumed to have noncoronary myocardial injury.
Table 1.
Table 1. Characteristics of 18 Patients with Covid-19 with ST-Segment Elevation on Electrocardiography.
We identified 18 patients with Covid-19 who had ST-segment elevation indicating potential acute myocardial infarction (Fig. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The median age of the patients was 63 years, 83% were men, and 33% had chest pain around the time of ST-segment elevation (Table 1). A total of 10 patients (56%) had ST-segment elevation at the time of presentation, and the other 8 patients had development of ST-segment elevation during hospitalization (median, 6 days) (Fig. S2A).
Of 14 patients (78%) with focal ST-segment elevation, 5 (36%) had a normal left ventricular ejection fraction, of whom 1 (20%) had a regional wall-motion abnormality; 8 patients (57%) had a reduced left ventricular ejection fraction, of whom 5 (62%) had regional wall-motion abnormalities. (One patient did not have an echocardiogram.) Of the 4 patients (22% of the overall population) with diffuse ST-segment elevation, 3 (75%) had a normal left ventricular ejection fraction and normal wall motion; 1 patient had a left ventricular ejection fraction of 10% with global hypokinesis.
A total of 9 patients (50%) underwent coronary angiography; 6 of these patients (67%) had obstructive disease, and 5 (56%) underwent percutaneous coronary intervention (1 after the administration of fibrinolytic agents) (Fig. S3). The relationship among electrocardiographic, echocardiographic, and angiographic findings are summarized in Figure S4. The 8 patients (44%) who received a clinical diagnosis of myocardial infarction had higher median peak troponin and d-dimer levels than the 10 patients (56%) with noncoronary myocardial injury (Fig. S2B and S2C). A total of 13 patients (72%) died in the hospital (4 patients with myocardial infarction and 9 with noncoronary myocardial injury).
In this series of patients with Covid-19 who had ST-segment elevation, there was variability in presentation, a high prevalence of nonobstructive disease, and a poor prognosis. Half the patients underwent coronary angiography, of whom two thirds had obstructive disease. Of note, all 18 patients had elevated d-dimer levels. In contrast, in a previous study involving patients who presented with ST-segment elevation myocardial infarction, 64% had normal d-dimer levels.1 Myocardial injury in patients with Covid-19 could be due to plaque rupture, cytokine storm, hypoxic injury, coronary spasm, microthrombi, or direct endothelial or vascular injury.2 Myocardial interstitial edema has been shown on magnetic resonance imaging in such patients.3
Sripal Bangalore, M.D., M.H.A.
Atul Sharma, M.D.
Alexander Slotwiner, M.D.
New York University Grossman School of Medicine, New York, NY
[email protected]
Leonid Yatskar, M.D.
New York City Health and Hospitals–Elmhurst, New York, NY
Rafael Harari, M.D.
New York University Grossman School of Medicine, New York, NY
Binita Shah, M.D.
VA New York Harbor Healthcare System, New York, NY
Homam Ibrahim, M.D.
New York University Grossman School of Medicine, New York, NY
Gary H. Friedman, M.D.
St. Francis Hospital, Roslyn, NY
Craig Thompson, M.D.
New York University Grossman School of Medicine, New York, NY
Carlos L. Alviar, M.D.
New York City Health and Hospitals–Bellevue, New York, NY
Hal L. Chadow, M.D.
Brookdale University Hospital and Medical Center, New York, NY
Glenn I. Fishman, M.D.
Harmony R. Reynolds, M.D.
New York University Grossman School of Medicine, New York, NY
Norma Keller, M.D.
New York City Health and Hospitals–Bellevue, New York, NY
Judith S. Hochman, M.D.
New York University Grossman School of Medicine, New York, NY
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on April 17, 2020, at NEJM.org.
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1. Choi S, Jang WJ, Song YB, et al. D-dimer levels predict myocardial injury in ST-segment elevation myocardial infarction: a cardiac magnetic resonance imaging study. PLoS One 2016;11(8):e0160955-e0160955.
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2. Tavazzi G, Pellegrini C, Maurelli M, et al. Myocardial localization of coronavirus in COVID-19 cardiogenic shock. Eur J Heart Fail 2020 April 10 (Epub ahead of print).
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3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020 March 27 (Epub ahead of print).
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