Title

Double Whammy: Near Simultaneous Development of Coronary Thrombosis and Pulmonary Emboli in a Patient with COVID-19

Authors

John-Henry L. Dean, MD, William T. Williams III, DO, Michael N. Moulton, DO, Mayank P. Patel, MD, Michael S. Cahill, MD, Bryan C. Ramsey, MD

Introduction

Thrombotic and embolic phenomena have been described in patients with both severe and non-severe forms of COVID-19. Here, we present the rare case of a patient with COVID-19 pneumonia that developed coronary thrombosis and pulmonary emboli in quick succession and the therapeutic challenges inherent in managing both conditions.

Case Presentation

A 42-year-old male with obstructive sleep apnea and mild intermittent asthma presented to the Emergency Department (ED) for evaluation of worsening dyspnea, cough, and chest tightness after testing positive for COVID-19 three days prior. He was found to be hypoxemic during the ED evaluation and given the association of venous thromboembolism (VTE) with COVID-19, a computed tomography (CT) chest angiogram was performed to assess for the presence of a pulmonary embolus. No large pulmonary embolus was identified, though the assessment was limited by suboptimal timing of the intravenous contrast. He was admitted to the hospital for acute hypoxemic respiratory failure secondary to severe COVID-19 pneumonia and started on intravenous dexamethasone and remdesivir. He was also administered enoxaparin for venous thromboembolism prophylaxis. On the night of hospital day 3, the patient developed acute-onset chest pain with dynamic inferior ST segment changes concerning for ST Elevation Myocardial Infarction (STEMI). He was taken urgently for cardiac catheterization and found to have a culprit thrombotic occlusion of the distal right posterolateral (RPL) coronary artery. He underwent successful percutaneous coronary intervention (PCI) with a drug eluting stent (DES) and was placed on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. The patient required a nitroglycerin drip for persistent chest pain following the intervention. During the morning of hospital day 4, the patient developed worsening hypoxemia in the context of continued chest pain and repeat CT chest angiogram was performed. This repeat assessment revealed right basal segmental pulmonary emboli (PE), and the patient was then transitioned to therapeutic anticoagulation with heparin in addition to DAPT. After tolerating heparin for 24 hours, he was transitioned to apixaban to continue “triple therapy” treatment of PE and acute coronary syndrome. Following a complete evaluation to exclude paradoxical embolization to the right coronary system, the patient was discharged to complete 2 weeks of triple therapy followed by discontinuation of aspirin.

Discussion

This case describes the unique circumstances of a patient that developed two distinct thrombo-embolic phenomena in the context of COVID-19 pneumonia. Pharmacologic management of concurrent pulmonary emboli and acute coronary syndromes generates multiple therapeutic dilemmas, particularly in the setting of COVID-19 infection. As the optimal dosing and route of administration of prophylactic anticoagulation continues to be investigated, this case emphasizes the importance of remaining vigilant for all types of thrombi and/or emboli in patients diagnosed with COVID-19.

References

1. Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. JAMA. 2020;324(8):799-801. doi:10.1001/jama.2020.13372 2. Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost. 2020;18(6):1421-1424. doi:10.1111/jth.14830 3. Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost. 2020;18(7):1559-1561. doi:10.1111/jth.14849 4. Ueki Y, Otsuka T, Windecker S, Räber L. ST-elevation myocardial infarction and pulmonary embolism in a patient with COVID-19 acute respiratory distress syndrome. European Heart Journal. 2020;41(22):2134-2134. doi:10.1093/eurheartj/ehaa399 5. Randhawa P, Singh PP, Guragai N, et al. Acute myocardial infraction and pulmonary embolism in a same patient with COVID -19: a rare association. Journal of Community Hospital Internal Medicine Perspectives. 2021;11(3):311-314. doi:10.1080/20009666.2021.1893506 6. Singh B, Kaur P, Ajdir N, Gupta S, Maroules M. Covid-19 Presenting as Acute Limb Ischemia. Cureus. 12(7):e9344. doi:10.7759/cureus.9344 7. Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020;18(5):1023-1026. doi:10.1111/jth.14810 8. Lax SF, Skok K, Zechner P, et al. Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome?: Results From a Prospective, Single-Center, Clinicopathologic Case Series. Ann Intern Med. 2020;173(5):350-361. doi:10.7326/M20-2566 9. Capaccione KM, Leb JS, D’souza B, Utukuri P, Salvatore MM. Acute myocardial infarction secondary to COVID-19 infection: A case report and review of the literature. Clin Imaging. 2021;72:178-182. doi:10.1016/j.clinimag.2020.11.030