Presentation and outcome of myocardial infarction with non-obstructive coronary arteries in coronavirus disease 2019

Table 1 Case reports of myocardial infarction with non-obstructive coronary arteries in coronavirus disease 2019

Sl. No	Ref.	Age in yr	Sex	Presenting complaint	Comorbidities	Chest imaging	ECG	Cardiac troponins	Echocardiogram	Angiogram	Other investigations	Management	Outcome
1	[3]	47	M	Shortness of breath for 6 d, angina on day 2 of admittion	Hypertension	CT thorax: Diffuse bilateral infiltrates, ground glass opacities, crazy paving with thickened interlobular septa, and consolidation in lower lobes	Inferior STEMI	0.012 ng/mL (Ref range: < 0.0262 ng/mL)	Not reported	Emergency coronary angiography showed 30%-40% stenosis in the midportion of the left anterior descending artery. In addition to this, the left main coronary artery, left circumflex artery and right coronary artery were normal. ST segment elevation regressed in the ECG of the patient, who had no more ischemic cardiac symptoms after the intervention	CTPA did not reveal any evidence of pulmonary embolism. Cardiogoniometry (a non-invasive medical tool worked with spatiotemporal vectocardiographic advancement), was performed after 24 h of the pain, it revealed septal inferior myocardial ischemia	300 mg po acetylsalicylic acid, 180 mg po ticagrelor, and 4000 IU IV heparin	Discharged on the eleventh day of his hospitalization in a healthy state
2	[4]	48	F	Pain in her chest and left shoulder for 1 day	none	none	Inverted T-waves in II, III, aVF, V4, V5, and V6	Upward of 25000 pg/mL (Ref range: 0.0–51.4 pg/mL)	Hypokinesis in the apical inferior segment of the left ventricle	CTCA was performed to exclude a coronary origin for the complaints and for the laboratory and ECG abnormalities, which revealed no significant coronary obstruction	CMR showed features of myocardial oedema restricted to the mid-ventricular to apical territory of the right coronary artery (RCA). Based on subendocardial to partially transmural late gadolinium enhancement in the mid-ventricular to apical inferior wall, an acute myocardial infarction was diagnosed. Cardiac positron emission tomography–computed tomography showed evidence of reduced metabolic activity in the area affected by the infarction	Acetylsalicylic acid, prophylactic-dose low-molecular-weight heparin, and statin. Later dual anti-platelet therapy and an angiotensin-converting-enzyme inhibitor was started	Discharged. Follow-up echocardiography 2 d after discharge revealed a normal ejection fraction (58%) despite persistent inferior apical akinesia
3	[5]	86	M	Cough and shortness of breath which progressed to acute hypoxemic respiratory failure requiring intubation		Chest X-ray: bilateral infiltrates at the bases with no other abnormalities	3–4 mm ST-segment elevations in leads V2 and V3	4.82 ng/mL (Ref range: < 0.10 ng/mL	Ejection fraction of 50%–55%, no significant regional wall motion abnormalities, and no signs of cardiac tamponade	No significant coronary artery disease		Admitted to the intensive care unit, requiring mechanical ventilation and vasopressor support	Respiratory status worsened and he required increased oxygen and positive end-expiratory pressure, renal function worsened, as did lymphopenia and inflammatory biomarker abnormalities. Died on day 8
4	[6]	61	M	Shortness of breath, respiratory failure requiring intubation	Hypertension, diabetes mellitus		2 mm of antero-lateral ST-elevation without reciprocal depression	6283 ng/L (Ref range: < 40 ng/L)	Moderate left ventricular systolic dysfunction	No luminal stenosis or thrombosis, with preserved TIMI 3 flows in all coronary arteries	Left ventriculography: Mild apical hypokinesis	Loading dose of ticagrelor and IV heparin	On day 13, he was anuric and CVVH was started. Continued to worsen and died
5	[6]	59	F	Found minimally responsive on the ground. Intubated by paramedics	Hypertension, COPD	CT thorax: Bilateral lower lung lobe infiltrates and pulmonary oedema with moderate calcification in the mid-left anterior descending artery	ST-segment elevations in V1–V4 and reciprocal ST-depressions in leads II, III, and aVF	2390 ng/L	reduced left ventricular ejection fraction of 40% with antero-apical wall hypokinesis	Moderate diffuse atherosclerotic disease was observed in the left system with no significant luminal obstruction elsewhere		Not specified	Extubated on Day 3. Discharged home subsequently
6	[6]	69	F	acute onset chest tightness and dyspnea	Non-ischemic heart failure with reduced ejection. Implantable cardioverter-defibrillator was placed in 2004. Motor neurone disease, diagnosed 4 yr previously	Chest X-ray: Bilateral infiltrates	Left bundle branch block. On day 3 progressive dynamic concordant ST-elevation in V1–V2 and ST-depression in V3–V5	504 ng/L	Impaired left ventricular function which was similar to baseline	No obstructive atheroma or thrombus		Loading dose dual antiplatelets, therapeutic low molecular weight heparin, high-dose IV diuretics, and IV nitrates	The patient died on Day 7 of admission
7	[7]	51	M	Left sided chest pain, diaphoresis, syncope	Hypertension and hypercholesterolemia	Chest X-ray: Bilateral interstitial prominenceCT chest: perihilar ground glass opacities, thickening of interlobular septa, and minimal bilateral pleural effusions, interpreted as consistent with congestive heart failure	3.5 mm ST elevation in I and avL, 5 mm isolated ST elevation in lead V2, with deep reciprocal depressions in III, avF and avR	Not reported	Preserved left ventricular ejection fraction (LVEF) of 55% and anteroapical hypokinesis on ventriculography	Patent coronary arteries		Admitted to Cardiac Intensive Care Unit and started on supportive measures. Treated with lopinavir/ritonavir 400 mg/100 mg tablet every 12 h for 4 d and hydroxychloroquine 500 mg every 12 h, then hydroxychloroquine alone 400 mg daily	The patient recovered and was discharged home on day 26 on aspirin, statin and metoprolol
8	[8]	71	F	Chest-pain	Hypertension, past STEMI	Chest X-ray: No pulmonary opacities	ST-segment elevation in inferior leads, and ST depression, and inverted T waves in V1-3	Negative	Preserved left ventricular ejection fraction of 50% with inferior and septal hypokinesis	Non-obstructive coronary artery disease		Loading dose of ticagrelor and unfractionated heparin	Discharged

M: Male; F: Female; ECG: electrocardiogram; CT: Computed tomography; STEMI: ST-elevation myocardial infarction; CTPA: Computed tomographic pulmonary angiography; CTCA: Computed tomography coronary angiography; CMR: Cardiac Magnetic Resonance Imaging; TIMI: Thrombolysis in myocardial infarction; CVVH: Continuous veno-venous hemofiltration; COPD: Chronic Obstructive Pulmonary Disease.

Table 2 Studies that reported myocardial infarction with non-obstructive coronary arteries in coronavirus disease 2019

Sl. No	Ref.	Total number of patients with MINOCA (%)	Mean age	Male (%)	Comorbidities (%)	Smoking(%)	Prior MI (%)	LVEF	EKG (%)	Mortality (%)
1	[9]	11/28 (39.3)	69.27 ± 10.6	6 (54.5)	Diabetes mellitus: 1/11 (9.1), Hypertension: 9/11 (91.8), Dyslipidemia: 3/11 (27.3), Chronic kidney disease: 5/11 (45.4)	1/11 (9.1)	1/11 (9.1)	43 ± 12.7	ST elevation: 9/11 (81.81), New onset LBBB: 2/11 (18.2)	5/11 (45.4)
2	[10]	6/11 (54.5)	-	-	-	-	-		-	-
3	[11]	3/9 (33.3)	-	-	-	-	--	Low ejection fraction and RWMA in 2 patients (ECHO not done for third)	ST elevation: 3/3 (100)	2/3 (66)
4	[12]	1/19 (5.2)	-	-	-	-		-	-	-
5	[13]	5/29 (17.24)	-	-	-	-	-	-	-	-

MINOCA: Myocardial infarction with non-obstructive coronary arteries; MI: Myocardial infarction; LVEF: Left ventricular ejection fraction; EKG: Electrocardiogram; LBBB: Left bundle branch block: RWMA: Regional Wall Motion Abnormality: ECHO: Echocardiography.