The Coronavirus Double Threat: A Rare Presentation of Chest Pain in a Young Female

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) led to global coronavirus disease 2019 (COVID-19) pandemic. The virus affects the respiratory system predominantly and has resulted in multiorgan complications. Myocarditis, acute coronary syndrome (ACS), cardiogenic shock, and sudden cardiac death were common cardiac manifestations of COVID-19. Spontaneous coronary artery dissection (SCAD) is a rare form of coronary artery disease that is previously reported in patients with COVID-19. SCAD usually occurs in a middle-aged woman with few or without any cardiovascular risk factors. The gold standard for its diagnosis is coronary angiography. The SCAD treatment recommendations depend on the hemodynamic status: conservative therapy in hemodynamically stable SCAD patients and urgent revascularization in hemodynamically unstable SCAD patients. The exact pathophysiology of COVID-19 associated with SCAD is unknown. It is considered a combination of systemic inflammatory response and localized vascular inflammation. The case reported is of COVID-19-associated SCAD in a patient with no history of cardiovascular disease later complicated by the transient ischemic attack (TIA) and left ventricular (LV) thrombus.

Spontaneous Coronary Artery Dissection and COVID-19: A Review of the Literature

“…Most patients also had symptoms related to SARS-CoV-2 infection such as fever, dyspnea, and cough, which are not characteristic of acute coronary events. Of note is the fact that most patients with SCAD (n = 9) experienced mild symptoms related to COVID-19 [ 26 , 29 , 30 , 32 , 33 , 34 , 35 , 36 , 37 ], five of them faced more severe manifestations [ 28 , 31 , 38 , 39 , 40 ], and only two demonstrated no symptoms [ 41 , 42 ].…”

“…Specifically, eight out of twelve patients were diagnosed with non-ST-segment-elevation myocardial infarction (NSTEMI) [ 28 , 31 , 32 , 34 , 35 , 36 , 39 , 42 ], while the other seven patients had ST-elevation myocardial infarction (STEMI) [ 26 , 29 , 33 , 37 , 38 , 40 , 41 ]. In the majority of patients (10 out of the 12 cases), the vessel involved was the left anterior descending coronary artery [ 28 , 31 , 33 , 34 , 35 , 37 , 38 , 40 , 41 , 42 ]; the right coronary artery was affected in two patients [ 29 , 32 ], the circumflex in four patients [ 30 , 36 , 38 , 40 ], and the ramus intermedius in one patient [ 31 ]. Among these, two patients had multivessel dissection [ 26 , 38 ].…”

“…Among these, two patients had multivessel dissection [ 26 , 38 ]. According to the data presented, nine of the sixteen cases of SCAD occurred in the immediate acute phase of the SARS-CoV-2 viral infection [ 29 , 32 , 34 , 35 , 37 , 39 , 40 , 41 , 42 ], while the other seven cases occurred in the post-acute phase (>14 days after the infection) [ 26 , 28 , 30 , 31 , 33 , 36 , 38 ]. A total of four patients underwent percutaneous coronary intervention (PCI) during their SCAD hospitalization [ 26 , 29 , 34 , 41 ], twelve patients were treated medically [ 28 , 30 , 31 , 32 , 33 , 35 , 36 , 37 , 38 , 39 , 40 , 42 ], and none of the patients underwent coronary artery bypass grafting (CABG).…”

“…Kireev et al administered DAPT and intravenous unfractionated heparin despite the presence of SCAD [ 26 ]. Pettinato et al [ 31 ] and Bashir et al [ 35 ] used ASA, clopidogrel with warfarin, and clopidogrel with warfarin, respectively, for an apical thrombus, with no reported adverse events. The optimal post-SCAD anticoagulation treatment remains unclear, emphasizing the need for future studies.…”

“…According to the data presented, nine of the sixteen cases of SCAD occurred in the immediate acute phase of the SARS-CoV-2 viral infection [29,32,34,35,37,[39][40][41][42], while the other seven cases occurred in the post-acute phase (>14 days after the infection) [26,28,30,31,33,36,38]. A total of four patients underwent percutaneous coronary intervention (PCI) during their SCAD hospitalization [26,29,34,41], twelve patients were treated medically [28,[30][31][32][33][35][36][37][38][39][40]42], and none of the patients underwent coronary artery bypass grafting (CABG). In addition to the documented instances of spontaneous coronary artery dissection (SCAD) with AMI following SARS-CoV-2 infection, there were also two cases of SCAD occurring after COVID-19, as reported by Mohammed et al [27].…”