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Just a simple inferior myocardial infarction

A 53-year-old male with negative medical history and absence of cardiovascular risk factors was found positive for SARS-CoV2 infection on 9 December 2020. During the quarantine, on 12 December 2020, he suffered a sudden onset of oppressive chest pain with dyspnoea. The ECG performed by Emergency Medical Service showed inferior ST-elevation myocardial infarction. The emergency coronary angiography showed long endoluminal thrombosis due to a complicated atherosclerotic plaque in the third tract of the right coronary artery (confirmed by IVUS). Thrombus aspiration and implantation of a medicated stent were performed with an excellent final result (Fig. 1). Tirofiban intravenous bolus was administrated followed by Prasugrel loading. The ECG after the procedure showed marked sinus tachycardia (over 130 bpm) with persistence of ST-elevation in the inferior leads. The following day the molecular swab for SARS-CoV2 was negative but the patient remained sweaty, dyspnoic with desaturation despite high flow oxygen, tachycardic and with low systolic pressure. On cardiac ultrasound, the right ventricle was dilated and strongly dysfunctional. Pulmonary pressure was 40mmHg with dilated and fixed inferior vena cava. D-dimer was 17071 ng/mL. A Chest Computer Tomography confirmed the diagnostic suspicion of pulmonary embolism by documenting gross cardio-embolic defects affecting the right and left main pulmonary artery that extend to the peripheral branches assigned to all lobes (Fig. 2). The chest CT also showed typical aspects of SARS-CoV2 related pneumonia and a small area of infarcted lung parenchyma (Fig. 3). The patient was therefore treated with anticoagulant therapy with full dose of low molecular weight heparin and antibiotic therapy. The subsequent hospitalization proceeded on a regular basis, with a progressive reduction of the oxygen and progressive recovery of the biventricular pump function. The patient also underwent a venous ultrasound of the lower limbs which documented thrombosis of the right sural vein and a transoesophageal echocardiography which excluded the presence of patent foramen ovale. At discharge, anticoagulant therapy with Apixaban 5mg x 2 and single anti-aggregation therapy with Prasugrel 10 mg for 12 months was set. (Table Presented).