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Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

Educational Objective
To understand what are the cardiac complications associated with the emerging outbreak of coronavirus disease 2019 (COVID-19)?
1 Credit CME
Key Points

Question  What are the cardiac complications associated with the emerging outbreak of coronavirus disease 2019 (COVID-19)?

Findings  In this case report, an otherwise healthy 53-year-old patient developed acute myopericarditis with systolic dysfunction confirmed on cardiac magnetic resonance imaging a week after onset of fever and dry cough due to COVID-19. The patient was treated with inotropic support, antiviral drugs, corticosteroids, and chloroquine, with progressive stabilization of the clinical course.

Meaning  The emerging outbreak of COVID-19 can be associated with cardiac involvement, even after the resolution of the upper respiratory tract infection.

Abstract

Importance  Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objective  To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms.

Design, Setting, and Participant  This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course.

Exposure  Cardiac involvement with COVID-19.

Main Outcomes and Measures  Detection of cardiac involvement with an increase in levels of N-terminal pro–brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging.

Results  An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase–polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization.

Conclusions and Relevance  This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.

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Article Information

Accepted for Publication: March 13, 2020.

Corresponding Author: Marco Metra, MD, Institute of Cardiology, c/o Spedali Civili, Piazzale Spedali Civili 1, Brescia BS 25123, Italy (metramarco@libero.it).

Published Online: March 27, 2020. doi:10.1001/jamacardio.2020.1096

Author Contributions: Drs Inciardi and Metra had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Inciardi, Lupi, Zaccone, Italia, Raffo, Tomasoni, Cani, Maroldi, Sinagra, Lombardi, Metra.

Acquisition, analysis, or interpretation of data: Inciardi, Lupi, Zaccone, Raffo, Cerini, Farina, Gavazzi, Adamo, Ammirati, Metra.

Drafting of the manuscript: Inciardi, Lupi, Zaccone, Italia, Raffo, Tomasoni, Cani, Farina, Metra.

Critical revision of the manuscript for important intellectual content: Inciardi, Lupi, Cerini, Gavazzi, Maroldi, Adamo, Ammirati, Sinagra, Lombardi, Metra.

Administrative, technical, or material support: Lupi, Cerini, Metra.

Study supervision: Inciardi, Lupi, Farina, Maroldi, Adamo, Ammirati, Sinagra, Metra.

Conflict of Interest Disclosures: Dr Farina has received personal fees from Bayer and Bracco Group. Dr Metra has received personal fees from Abbott Vascular, Amgen, Bayer, Edwards Therapeutics, and Vifor Pharma. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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