“Quadruple Rule-Out” With Computed Tomography in a COVID-19 Patient With Equivocal Acute Coronary Syndrome Presentation

A 59-year-old man from an endemic area for coronavirus disease-2019 (COVID-19) in northern Italy presented to the hospital with dyspnea and chest pain. On physical examination, his temperature was 36.9°C and electrocardiogram showed ST-segment elevation in leads V₂ to V₃. The blood tests showed leukopenia (3,800 cells/μl) and troponin I increase (140 ng/l). Chest X-ray showed no pathological findings. Because of the COVID-19 emergency, a large-scale hub-and-spoke model was developed in the Lombardy region to select dedicated cardiology centers for management of acute coronary syndromes (ACS) to support other general hospitals that were converted to treat only patients with COVID-19 (1). In agreement with this model, the patient received a nasopharyngeal swab that tested positive for SARS-CoV-2 and subsequently underwent invasive coronary angiography (ICA) in a dedicated catheterization laboratory. ICA demonstrated normal coronary arteries with a diagnosis of myocardial injury with nonobstructive coronary artery disease. Although cardiac magnetic resonance (CMR) was considered for further evaluation, it was not performed because of equipment and room cleaning and disinfection issues. The day after admission, to evaluate for lung infection, pulmonary embolism, and myocardial injury, as suspected by biomarker elevation, a modified scan protocol including a nonenhanced acquisition followed by electrocardiogram-triggered contrast-enhanced computed tomography (CT) with delayed acquisition was performed. The pre-contrast CT showed scattered patchy ground-glass opacities in the peripheral area of the lungs (Figures 1A to 1C ), while the contrast-enhanced scan confirmed the absence of both pulmonary embolism and coronary artery disease (Figures 1D to 1G). Finally, the delayed post-contrast scan showed a large subepicardial area of hyperdensity in the basal-mid inferolateral wall of the left ventricle (Figures 1H and 1I), suggesting the presence of myocarditis in addition to early-stage interstitial pneumonia. The patient was medically treated with a progressive clinical improvement.

Figure 1.

Modified Scan Protocol to Evaluate for Lung Infection, Pulmonary Embolism, and Myocardial Injury

Pre-contrast computed tomography showing scattered patchy ground-glass opacities in the peripheral areas of both lungs with associated consolidation (A to C, with red boxes magnifying lung abnormalities). Coronary computed tomography angiography showing absence of coronary artery disease in the left anterior descending artery (D), left circumflex (E), marginal branch (F), and right coronary artery (G). Delayed postcontrast scan showing a large subepicardial area of hyperdensity in the basal-mid inferolateral wall of the left ventricle (H and I, blue arrows) suggesting the presence of myocarditis.

The Lombardy region in northern Italy is one of the areas with the highest number of patients with COVID-19. Comparing the period between February 15 and March 20, 2020, with the same period last year, we observed a significant increase of ACS with no obstructive coronary artery disease (27% vs. 4%; p < 0.01). Recent reports suggest that acute cardiac injury is present in approximately 7% of patients with COVID-19 and may be related to myocarditis. Although CMR is known to be highly effective in identifying the underlying diagnosis beyond myocardial infarction with nonobstructive coronary arteries, some concerns related to equipment and room disinfection should be considered in patients with COVID-19. Recently, cardiac CT (CCT) has shown the ability to detect myocardial damage (2,3) through late iodine-enhanced scans. A lesson from this case is that in these patients with equivocal ACS presentation who are hemodynamically stable, CCT could be considered to rule out coronary artery disease as an alternative to ICA. Moreover, additional information to rule out interstitial pneumonia, pulmonary embolism, and myocarditis could be obtained with dedicated protocol acquisition in a new concept of “quadruple rule out.” However, the potential renal injury related to the higher amount of contrast agent required should be carefully evaluated on a case-by-case basis. To the best of our knowledge, this is the first report showing the use of CCT as part of a comprehensive cardiopulmonary assessment during the COVID-19 pandemic, thus, potentially minimizing exposure to healthcare providers and personal protective equipment utilization.