When COVID-19 delays the management of an urgent heart condi
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Some severe life-threatening conditions could be misdiagnosed during the current COVID-19 pandemic.

This is a 61-year-old patient, an active smoker at 20 pack-years, in full professional activity during the period of total confinement, has presented a presyncope in the morning around 09.50 am without chest pain, or loss of consciousness or fall with notion of chills a few hours earlier. She was transported by the firefighters at 10:30 am for the Montluçon Hospital Center. The patient was received around 11:40 am and referred to its sector hospital in accordance with the COVID-19 Plan from the Regional Health Agency for screening as suspected of coronavirus infection 19.

On arrival at the emergency room of this health facility, an electrocardiogram carried out revealed an apicolateral and inferior persistent ST segment elevation with mirror image on anterior area. Then, the patient has been transported to the initial center for emergency coronary angiography where she arrived at 3:30 pm. Coronary angiography was performed and revealed the presence of a thrombus in the distal anterior interventricular artery with the appearance of "stick insect," a thrombus on the dominant circumflex artery obstructing the second marginal with a "radish tail" aspect and a right network free from any atheromatous lesion.

Transthoracic cardiac ultrasound found good biventricular systolo-diastolic function with a left ventricular ejection fraction of 69%, no abnormalities in segmental and global kinetics of the left ventricle. Troponin I was 2465 pg/ml, Creatine phosphokinase at 1874 pg/ml, C-reactive protein 1.1 mg/L, leukocytes at 13,81.109/L. The medical treatment included glycoprotein IIb / IIIa inhibitor, double anti-aggregation platelet and anticoagulant (unfractionated heparin), beta-blocker (bisoprolol) on Day 1 hospitalization. Bisoprolol has been changed to ivabradine because the patient remained tachycardic with low blood pressure.

It was noted on the Day 3 electrocardiogram, presence of a Q wave of apicolateral and inferior necrosis with persistence of the elevation from the same territory. Treatment with acetylsalicylic acid, clopidogrel, ivabradine, and inhibitor of the proton pump was given as an exit treatment. Magnetic resonance imaging (MRI) was performed on an outpatient basis at one month and found: a sequelae of infero-latero-moderate, infero-septo-average, latero-apical, infero-apical, and septo-apical with thinning of the middle and apical walls measuring, respectively, 3mm and 4mm, a left ventricular ejection fraction of 47%.

Coronarography control with optical coherence tomography (OCT) performed two months later allowed to highlight a complete healing of the lesions. OCT does not highlighted the intimal breach.

Source: https://onlinelibrary.wiley.com/doi/10.1002/ccr3.4708?af=R
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