Clinical Case 11—acute Multivessel Coronary Artery Thrombi: an Unusual Presentation of STEMI and Management Dilemma in a Young Patient with COVID-19

Abstract Mr DC is a fit and healthy 32-year-old gentleman who presented on day 13 of his mild COVID-19 illness with sudden onset central chest discomfort, diaphoresis and vomiting following exercise. He had no past medical history, no significant cardiovascular risk factors and a normal physical exam. ECG showed ST elevation in anterior and inferior leads. Mr DC underwent coronary angiogram which revealed a large semi-occlusive thrombus in the proximal LAD and moderate thrombus in the proximal RCA. There was no significant stenosis or plaque in any vessel. The diagnosis was therefore STEMI secondary to multivessel proximal coronary artery thrombi. We hypothesise that the patient's concurrent COVID-19 infection, hypercoagulable state post exercise and possible plaque rupture led to the development of these thrombi. This is a very unusual case and presented a management dilemma. We decided to manage him conservatively with therapeutic heparin, dual antiplatelet therapy, bisoprolol and high dose statin therapy. Following one week of conservative management, we performed a repeat coronary angiogram which showed complete resolution of all intracoronary thrombi and yielded an excellent angiographic result. The patient was discharged to complete 1 year of dual antiplatelet therapy and has done very well. Learning points include: risk factors and management options for coronary artery thrombosis, successful conservative management strategy, interval of repeat diagnostic imaging, coronary artery thrombosis associated with COVID-19 infection, the potential for mild clinical COVID-19 illness but significant cardiovascular complications, more research needed on anticoagulation and antiplatelet treatment of ACS in the context of COVID-19.