Unusual presentation of acute coronary syndrome in a patient with SARS-CoV-2 infection

A 62-year-old woman with hypertension and chronic ischaemic heart disease was referred to the hospital for asthenia and self-limiting episodes of chest pain. ECG showed no evidence of acute ischaemia (Figure 1). High sensitivity troponin T and C-reactive protein were elevated. Chest X-ray showed a subtle consolidation on the left lung base (Figure 2). Baseline chest scan confirmed an opacity on the left lung (yellow arrow) and ruled out pulmonary embolism (Figure 3). Nasopharyngeal swab was positive for SARS-CoV-2. Due to the persistence of chest pain, coronary angiography was requested. Coronary angiography showed a focal and moderate stenosis (white arrow) in the proximal right coronary artery (Figure 4B; Supplementary material, Video 1), that was not present in the previous coronary angiography 2 years previously (Figure 4A; Supplementary material, Video 2). Optical coherence tomography showed a plaque with a crescent-shaped low-signal region (*) with heterogeneous content adjacent to the calcification (**) that suggested intraplaque haemorrhage (Figure 5A and B; Supplementary material, Video 3). There was no disruption of the intima or thrombus. Intraplaque haemorrhage is described as an unstable plaque mechanism, so it was decided to implant a drug-eluting stent. The patient evolved well without new episodes of chest pain and a benign course of COVID-19 disease. The systemic inflammatory response of SARS-CoV-2 infection could trigger a focal inflammatory response in the coronary wall and be responsible for the instability of an atherosclerotic plaque. We showed the first direct evidence of complicated atherosclerotic plaque in a COVID-19 patient, undergoing optical coherence tomography characterization.

Supplementary material

Supplementary material is available online at European Heart Journal – Cardiovascular Imaging.