IJCS | Volume 33, Nº4, July and August 2020

434 The second case refers to a patient with AMI, probably triggered by a flu-like syndrome, in the context of COVID-19 pandemic. Not only can viral infections trigger cardiac events, they can also decompensate cardiac status. The known mechanisms involvedarevasoconstriction, endothelial inflammation, platelet dysfunction and thrombogenicity. An increased systemic inflammatory status can raise the incidence of arrhythmias and myocarditis, destabilizing coronary plaques and leading to coronary events. In this context, there is a higher incidence of coronary events during infections. 14,15 This case showed an AMI with atypical clinical manifestations during a COVID-19 infection. The non-specific case of fever and myalgia, evolving after a few days into dyspnea, is typically described in severe presentations of COVID-19. Even though the patient’s admission interview was brief, since he presented with respiratory failure, the absence of chest pain delayed essential specific cardiac procedures. Although the ECG was not performed immediately, as recommended, it was used to guide the treatment. The need for a differential diagnosis with an adrenergic cardiomyopathy (Takotsubo Syndrome) 16 made coronary angiography essential for defining the diagnosis, since Takotsubo cardiomyopathy can mimic AMI and is associated with COVID-19. As indicated by institutional protocols during pandemic, confirmed or suspected cases should be treated after all precautions and safe procedures have been taken, during transportation and inside the CCL, sometimes leading to prolonged reperfusion. Efforts have to be made to reduce reperfusion times in ST-elevation AMI during the COVID-19 pandemic. 9 Case 3 reports the unfavorable outcome of a patient with a typical flu-like presentation and COVID-19 confirmation that may have triggered a cardiovascular manifestation. The association with a cardiovascular disease contributed to clinical worsening. Despite early invasive measures, such as orotracheal intubation and administration of antiretrovirals, antibiotics and anticoagulants, the clinical presentation of STEMI posed a major challenge to the medical team. The differential diagnoses were myopericarditis, acute myocardial infarction, stress myocarditis and vasospasm. Even though this was a young patient, with no cardiovascular risk, it was not possible to rule out an AMI and, in this context, the indication of a TTE before the angiography was fundamental for the diagnosis of a stress cardiomyopathy. This decision, considering the significant alterations in the ECG, would not be the same outside the COVID-19 pandemic. This case also reinforces the exacerbated inflammatory and thrombotic reactions caused by the association between SARS- CoV-2 and cardiovascular complications. D-dimer elevation over 80.000 and interleukin 100 times over the normal values are clear parameters of this alteration that can lead to thrombotic events with AMI and/ or inflammatory presentations, such as myocarditis, which hinders the diagnostic elucidation of cases and promotes changes in diagnosis and treatment protocols. Conclusion COVID-19 is a global pandemic that in association with cardiovascular disease can lead to high morbidity and mortality rates. SARS-CoV-2 infection can trigger decompensation of coronary-artery plaques, leading to STEMI. Clinical presentation, ECG changes and elevated cardiac biomarkers can mimic AMI, but without obstructive coronary artery disease. Patients with COVID-19 and STEMI may require a long period of hospital stay, demanding multidisciplinary efforts to overcome critical clinical conditions. Learning objectives: 1 -Association between SARS-CoV-2 and STEMI can lead to high morbidity and mortality rates. 2 -COVID-19 can mimic AMI in clinical presentation and complementary exams in the absence of CAD. 3 -The use of personal protective equipment (PPE) by healthcare professionals is crucial to avoid system collapse. 4 -Cardiovascular disease clinical presentation in patients with COVID-19 is variable. Author Contributions Conception and design of the research: Esteves V, deLuca F, Zukowski CN, Feldman A. Acquisition of data:Arruda G, CamilettiA, Bandeira B. Critical revision of the manuscript for intellectual content: Souza OF. Potential Conflict of Interest No potential conflict of interest relevant to this rticle was reported. Esteves et al. Covid-19 and STEMI Int J Cardiovasc Sci. 2020; 33(4):429-435 Case Report