ABC | Volume 114, Nº6, June 2020

Case Report COVID-19 and Acute Coronary Events – Collateral Damage. A Case Report. Luiz Eduardo Fonteles Ritt, 1, 2 M ateus S. Viana, 1, 2 Gustavo Freitas Feitosa, 1 Adriano Martins de Oliveira, 1 Fabio Solano Souza, 1 Eduardo Sahade Darzé 1,2 Hospital Cardio Pulmonar, 1 Salvador, BA - Brazil Escola Bahiana de Medicina e Saúde Pública, 2 Salvador, BA - Brazil “On account of your fear, Sancho, you do not see or hear things correctly — said Don Quixote —, because one of the effects of fear is that it disturbs the senses and makes things seem not what they are.” Miguel de Cervantes, Don Quixote A 49-year-old male patient, with dyslipidemia, 8-year- history of hypertension, and family history of coronary artery disease (His father had had an infarction at 60 years of age), had been using olmesartan 40 mg and rosuvastatin 10 mg daily until 10 days before being admitted to the hospital, having suspended use of olmesartan due to concern that the medication would facilitate SARS-CoV-2 infection. On the morning of April 2, 2020, the patient had intense retrosternal chest discomfort and feeling of dyspnea. These symptoms were triggered by the slightest effort; they ceased while resting and recurred with decreasing intensity throughout the day. Concerned with the possibility of SARS-CoV-2 infection, he self-isolated, monitored his temperature, and self-administered paracetamol. He did not record a fever. The following day, chest pain recurred, radiating to his shoulders, in association with sweating and dyspnea. Due to the sweating, he became even more worried about the possibility of SARS-CoV-2, and he called an infectologist who instructed him to seek emergency medical care if the symptoms persisted or recurred. Throughout the day, the patient remained isolated and self-monitored his temperature. He reported that “only the possibility of coronavirus went through his mind.” On the morning of April 4, when the pain worsened, and the sweating was more intense, the patient decided to seek emergency medical care. The case was screened as possible acute coronary syndrome (ACS), but the patient refused to undergo tests, because he did not wish to remain in the sector where there were other patients, and he left against medical advice. On his way home, symptoms intensified, namely more profuse sweating and dyspnea; the patient changed course and came to our hospital, where he presented with sinus tachycardia (HR 108 bpm), SBP 176 mmHg, O2 saturation 98%, and temperature 36.4ºC. Electrocardiogram revealed ST segment elevation in V5, V6, D1, and AVL (Figure 1), indicating acute myocardial infarction with ST elevation (STEMI). The patient underwent coronary cineangiography and primary angioplasty in the middle third of the anterior descending artery, with a door-to-balloon time of 57 minutes (Figure 2). Echocardiogram showed mild systolic dysfunction, due to akinesia of the entire apical region and the middle segment of the anterior wall; ejection fraction was 45%, using the Simpson Method. Peak high sensitivity troponin I was 21,424 ng/L. The patient progressed without complications and was discharged after 3 days of hospitalization. Figure 3 shows the timeline of events up to diagnosis of acute STEMI. Discussion Considering the SARS-CoV-2 pandemic, quarantine periods have been declared in several cities in Brazil and worldwide, and people have been instructed to maintain social distancing in order to contain the rapid spread of the virus. Taken to the extreme, fear of becoming infected may result in typical symptoms of ACS being neglected or erroneously attributed to other less probable causes, delaying treatment and imposing avoidable risks to patients’ lives. We report a typical case of ACS in a patient with risk factors for atherosclerotic disease, who, driven by panic related to COVID-19, was unable to recognize the nature of his symptoms, thus delaying his trip to the emergency room until the moment that chest pain became unbearable. Furthermore, also due to concerns related to SARS-CoV-2 infection, the patient suspended use of angiotensin receptor blocker (ARB). In spite of a door-to-balloon time of 57 minutes, as a result of prolonged ischemia time, the patient developed left ventricular systolic dysfunction, albeit asymptomatic. Delayed recognition and medical care in acute myocardial infarction Acute myocardial infarction (AMI) is the most lethal medical emergency worldwide, with an incidence of 43 – 144 per 100,000 people/year and a hospital mortality of 4% – 12%. 1 Primary angioplasty, especially when instituted within the first 12 hours after onset of symptoms, is considered the gold standard treatment. 1,2 Door-to-balloon time is an indicator of treatment quality in the context of AMI. It is equally important to minimize the time between onset of symptoms and arrival at a hospital. While time of Mailing Address: Luiz Eduardo Fonteles Ritt • Hospital Cardio Pulmonar - Centro de Estudos Clínicos – Av. Anita Garibaldi, 2199. Postal Code 40170-130, Ondina, Salvador, BA – Brazil E-mail: luizritt@hotmail.com, lefr@cardiol.br Manuscript received April 14, 2020, revised manuscript April 15, 2020, accepted April 29, 2020 Keywords ST Myocardial Infarction; Coronavirus; Pandemics; Panic; Fear; Cineangiography; Echocardiography/methods; Risk Factors. DOI: https://doi.org/10.36660/abc.20200329 1072