Virus World

The relationship between coronavirus disease 2019 (COVID-19) and myocardial injury was established at the onset of the COVID-19 pandemic. An increase in the incidence of out-of-hospital cardiac arrest was also observed. This case report aims to point to the prothrombotic and proinflammatory nature of coronavirus infection, leading to simultaneous coronary vessel thrombosis and subsequently to out-of-hospital cardiac arrest. During the COVID-19 pandemic, a 46-year-old male patient with no comorbidities suffered out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation as the first recorded rhythm. The applied cardiopulmonary resuscitation (CPR) measures initiated by bystanders and continued by emergency medical service (EMS) resulted in the return of spontaneous circulation. The stabilized patient was transferred to the tertiary university center.

Electrocardiogram (ECG) revealed “lambda-like” ST-segment elevation in DI and aVL leads, necessitating an immediate coronary angiography, which demonstrated simultaneous occlusion of the left anterior descending (LAD) and right coronary artery (RCA). Primary percutaneous coronary intervention (PCI) with the implantation of one drug-eluting stent (DES) in LAD and two DES in RCA was done. Due to the presence of cardiogenic shock (SCAI C), an intra-aortic balloon pump (IABP) was implanted during the procedure, and due to the comatose state and shockable cardiac arrest, targeted temperature management was initiated. The baseline chest X-ray revealed bilateral interstitial infiltrates, followed by increased proinflammatory markers and a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) demasking underlying COVID-19-related pneumonia.

Within the following 48 h, the patient was hemodynamically stable, which enabled weaning from IABP and vasopressor discontinuation. However, due to the worsening of COVID-19 pneumonia, prolonged mechanical ventilation, together with antibiotics and other supportive measures, was needed. The applied therapy resulted in clinical improvement, and the patient was extubated and finally discharged on Day 26, with no neurological sequelae and with mildly reduced left ventricle ejection fraction.

Published in MDPI (Dec. 25, 2023):

https://doi.org/10.3390/medicina60010039

In a single-center experience, no patients hospitalized with COVID-19 who developed cardiac arrest survived to discharge after receiving CPR, researchers found.“ These outcomes warrant further investigation into the risks and benefits of performing prolonged CPR in this subset of patients, especially because the resuscitation process generates aerosols that may place health care personnel at a higher risk of contracting the virus,” Shrinjaya B. Thapa, MD, internist at William Beaumont Hospital in Royal Oak, Michigan, and colleagues wrote.  In this single-center study, researchers analyzed data from 1,309 patients with COVID-19 admitted to the hospital between March 15 and April 3. These data were used to identify patients who underwent CPR for cardiac arrest. Primary outcomes included the initial cardiac arrest rhythm, overall survival to discharge and time to return of spontaneous circulation.

Among the cohort, 4.6% (n = 60) had in-hospital cardiac arrest and underwent CPR. The sample size was reduced to 54 patients (mean age, 62 years; 61% men; 67% Black) after some lacked CPR documentation. The time to cardiac arrest from admission was a median of 8 days. The median duration of CPR was 10 minutes. None of the patients who received CPR survived to discharge (95% CI, 0-6.6). The initial rhythm was nonshockable in 96.3% of patients, 14.8% had asystole and 81.5% had pulseless electrical activity. Although no patients developed ventricular fibrillation, 3.7% of patients had pulseless ventricular tachycardia. More than half of patients (53.7%) achieved return of spontaneous circulation during a median time of 8 minutes. Of these patients, 51.7% changed their code status to do not resuscitate and 48.3% were recoded, underwent further CPR and died. “The high mortality following CPR is likely multifactorial,” Thapa and colleagues wrote. “Given that most of the patients in this study developed a nonshockable rhythm, the outcome was likely to be poor. Additionally, at the time of cardiac arrest, many patients were either receiving mechanical ventilation, kidney replacement therapy or vasopressor support, all factors previously shown to be associated with a poor outcome following [in-hospital cardiac arrest].”

In a related editorial, Matthew E. Modes, MD, MPP, MS, fellow in the division of pulmonary, critical care and sleep medicine at University of Washington in Seattle, and colleagues wrote: “These small case series reporting hospital survival after in-hospital cardiac arrest among patients with COVID-19 must be interpreted with caution, as only one or two additional survivors would make important differences in the observed estimates. Outcomes in the setting of COVID-19 may not actually differ from pre-COVID-19 outcomes of in-hospital cardiac arrest for patients with nonshockable rhythms, for whom hospital survival is often less than 15%. Nonetheless, this article represents important early evidence suggesting outcomes for in-hospital cardiac arrest in patients with COVID-19 pneumonia are likely poor, particularly among patients with respiratory failure. Improving outcomes for patients with severe illness with COVID-19 and in-hospital cardiac arrest will be challenging, as few of the likely drivers of poor outcomes (eg, nonshockable rhythms, respiratory etiologies of arrest and underlying critical illness) are modifiable.”

Original study published in JAMA (Sept. 28, 2020):

https://doi.org/10.1001/jamainternmed.2020.4779