Table 3.

Literature review of delayed presentations of STEMI with complications during COVID-19 pandemic

Author	Country	Publication month/year	Age/sex	Comorbidities	Clinical presentation	COVID-19 status	ECG/ cardiac enzymes	Multimodality imaging	Invasive findings	Management	Clinical course	Outcome
Moroni et al2	Italy	March/2020	64/M	Not reported	Left lower limb pain, cyanosis and paraesthesia for 10 days. CP and SOB for 10 days	NR	Q waves and STE in inferior leads	TTE: severe LV dilation, systolic dysfunction and apical thrombus. CTA: LAD occlusion, thromboembolic material in femoral arteries	Not performed	Emergent amputation of left lower limb	Cardiogenic shock necessitating inotropes and IABP	Recovered and discharged from ICU
Moroni et al2	Italy	March/2020	65/F	Not reported	Progressive SOB for 5 days, hypotension and respiratory distress. Episode of epigastric tightness few days earlier treated with antacids at home	NR	Q waves and STE anterior leads	CXR: acute pulmonary oedema. TTE: severe LV dysfunction, apical aneurysm, anteroseptal and anteroapical dyskinesia. CTA: critical LAD stenosis	Not performed	Intravenous diuretics, inotropic support and non-invasive ventilation	Not significant	Transferred to cardiology ward
Moroni et al2	Italy	March/2020	60/M	Not reported	Hypotension, diaphoresis, respiratory distress. Four-day history of crushing chest pain	NR	STE and Q waves in anterior leads	TTE: severe LV dysfunction with anteroseptal, anteroapical and lateral akinesia	LHC: CTO of proximal RCA and acute occlusion of proximal LAD	LHC: no-reflow phenomenon after stent implantation to LAD and ventricular fibrillation requiring defibrillation with I&V	ROSC, cardiogenic shock necessitating inotropes and mechanical support with Imeplla CP	Died after few days
Gadella et al19	Spain	April/2020	65/F	Dyslipidaemia, chronic hepatitis C, cervical cancer with surgical removal and active smoking	Typical CP for 24 hours, low grade fever and dry cough, and tachypnoea	+	Acute evolving anterior MI	CXR: bilateral patchy infiltrates. TTE: extensive LV wall motion abnormalities and severe systolic dysfunction	Urgent angiography and PCI deferred and considered elective after recovery from COVID-19	Aspirin, ticagrelor, empiric ceftriaxone and azithromycin, and hydroxychloroquine	Cardiogenic shock in 24 hours. New-onset holosystolic murmur and 13 mm apical VSR.	Patient managed conservatively and died the following day
Ullah et al20	USA	May/2020	36/M	No comorbidities	Unresponsive at home and last seen normal 15 hours ago	+	STE V2–V4. TnT elevated	TTE: extensive septal, anterior and apical akinesia with apical LV thrombus and EF of 35% (normal >55%). CXR and CT of the chest: multifocal infiltrates	LHC: 99% occlusion of LAD	DES in LAD, aspirin, clopidogrel, atorvastatin, carvedilol and lisinopril	Refused further work-up and discharged home	Not reported
Dash et al21	India	June/2020	59/F	HTN, DM, CAD with STEMI in March 2020	Dyspnoea for 2 days, tachycardia and hypoxia	NR	Left-axis deviation with Qs in anterior leads; TnT positive	Not reported	Not performed	Non-invasive ventilation, inotrope infusions, heparin, antiplatelets, lipid-lowering agents, antianginals and antibiotics	Gradual oliguria followed by anuria with severe metabolic acidosis and refractory hypotension	Cardiac arrest and died
Dash et al21	India	June/2020	58/F	DM and HTN	Anginal chest pain, dyspnoea and autonomic symptoms	NR	Qs complex in V1–V4. TnT +	CXR: cardiomegaly with bilateral alveolar opacities	Not performed	Oxygen, heparin, diuretics, antiplatelets, insulin and lipid-lowering agents	Responded well with symptom relief	Discharged from hospital
Dash et al21	India	June/2020	69/M	Not reported	Chest pain for more than 12 hours	NR	STE I, aVL with reciprocal ST depressions	Not performed	Ostial LAD 100% occlusion with poor retrograde filling from RCA	Repeated thrombosuction of LAD and DES to LAD	Managed on antiplatelets and inotropes, and developed refractory pulmonary oedema requiring I&V	Died after 12 hours
Mitevska et al22	North Macedonia	May/2020	47/M	HTN, DM II, smoking and increased body weight	Recurrent episodes of CP for 2 days prior to hospitalisation	–	Sinus tachycardia with STE in leads V2–V6, I, II, III and aVF. HsTnt 6385 ng/mL (normal <15 ng/mL)	TTE: akinesia of apex, anterior wall, mid-apical septal wall and global reduction in LV function with EF 35%	LHC: 99% stenosis of mid LAD, CTO of LCx and OM1, and 95% stenosis of RCA	DES to culprit lesion in mid LAD followed by another stage procedure with DES to proximal RCA on day 3 of hospitalisation	Angina relieved and STE resolution	Discharged on day 7 of hospitalisation and clinically stable
El Sakr and Marshall23	USA	June/2020	64/F	40-pack year history of tobacco use and mild COPD	CP and SOB for 1 day. Muscle and back aches for 5 days	–	STE in II, III, aVF, V3–V6 with reciprocal changes in I and aVL	TTE: inferior, inferoseptal, inferolateral and proximal-mid anteroseptal wall hypokinesis	LHC: occluded mid PCA, LVEDP 34 mm Hg (normal 19 mm Hg) and VSD. RHC: 73% sat on RV c/w step up and shunt, PCWP of 26 mm Hg (normal 12 mm Hg)	IABP support, rotational atherectomy and DES to RCA. Cardiac CT: VSD in basilar inferior septum with patch repair on day 4, mechanical support escalated to ECMO and Impella for cardiogenic shock	Postoperative bleeding requiring reoperation	Died
Joshi et al24	USA	June/2020	72/F	Dyslipidaemia and CAD with PCI in 2002	Substernal chest heaviness, light headedness and patient presentation 14 hours after persistent symptoms	NR	STE in inferior leads with Q waves reciprocal ST depressions and elevated TnT	CTA: insignificant	LHC: occlusion of mid RCA and ventriculogram showed VSR. RHC: O2 step up in RV and Qp:Qs 2.2:1	DES to mid RCA	Patient wished comfort measures	Died
Alsidawi et al25	USA	June/2020	67/F	CAD with prior LCx stent	CP, delayed seeking medical attention and presented after 14 hours	NR	Inferior STE with Q wave and elevated Tnt	TTE: EF 50% and hypokinesis of inferior and inferoseptal myocardium	LHC: dominant RCA totally occluded	Aspiration thrombectomy with symptom resolution	Discharged and presented with shock and new murmur 5 days later and found to have VSR	Complex VSD repair and ICU admission
Alsidawi et al25	USA	June/2020	62/F	HTN and MS	Chest pain for 4 days, dyspnoea and fever. Systolic thrill on examination	–	Anterior STE with Q waves	TTE: EF 35% with LAD WMA, apical VSR	RHC:Qp:Qs 1.5:1	Patient elected non-invasive management	Transitioned to hospice care	Not reported
Otero et al26	USA	July/2020	69/M	HTN, HD, DM II, tobacco use and aortic aneurysm	Exertional chest pain of unknown duration	–	Posterior STE	TTE: EF 25% and small circumferential pericardial effusion with visible thrombus	LHC: 100% occlusion of LCx and 90% occlusion of LAD. Unable to wore or balloon due to extensive thrombus burden	Initially received tenecteplase, aspirin and clopidogrel	Transferred to ICU on IABP. Medical management of STEMI. Avoidance of anticoagulation due to haemorrhagic pericardial effusion due to tenecteplase	Repeat TTE with resolution of pericardial effusion, staged PCI of LAD and discharged on day 19
The present report of patient 1	USA	2020	62/F	Cigarette smoking, hyperlipidaemia and obesity	Nausea, diarrhoea and chest pain for 2 weeks. SOB for 1 day.	–	Wide complex tachycardia. Elevated hsTnt and Tnt	TTE: severely reduced biventricular function	RHC: cardiogenic shock. LHC: total occlusion of RCA and 90% stenosis of LAD	Asystole during PCI and worsening cardiogenic shock with VA-ECMO support	Successful decannulation from VA-ECMO on day 7 and repeat TTE: LVEF 50%	Recovering on medical floor
The present report of patient 2	USA	2020	82/F	CAD, vascular disease, HTN, hyperlipidaemia and smoker	SOB and leg swelling for 2 days. New systolic murmur	–	STE V2–V6 with Q waves. Tnt elevated	TTE: LVEF 30% and muscular VSR	RHC: O2 step up in RV, Qp:Qs: 1:56. LHC: total occlusion of LAD, stenosis in LCx, RCA and muscular VSR	Antiplatelets, statin and anticoagulation	Progressive SOB on discharge and underwent percutaneous closure of VSR	Recovering well on medical floor

CAD, coronary artery disease; CP, chest pain; CXR, chest X-ray; DM, diabetes mellitus; EF, ejection fraction; HTN, hypertension; IABP, intra-aortic balloon pump; ICU, intensive care unit; I&V, intubation and ventilation; LAD, left anterior descending artery; LHC, left heart catheterisation; LV, left ventricle; PCI, percutaneous coronary intervention; RCA, right coronary artery; RHC, right heart catheterization; ROSC, return of spontaneous circulation; SOB, shortness of breath; STE, ST-segment elevations; STEMI, ST-segment elevation myocardial infarction; TnT, troponin T; TTE, transthoracic echocardiogram; VA-ECMO, venoarterial extracorporeal membrane oxygenation; VSD/R, ventricular septal defect/rupture.