Our patient is a 72-year-old woman with a past medical history of diabetes mellitus and stage 3b chronic kidney disease who was brought by ambulance to the emergency department with altered mental status. According to the family, the patient was independent in activities of daily living before this admission. A physical examination on admission showed disorientation, dehydration, wheezing, and tachycardia. Notable labs for the introduction can be found in the table below (Table 1). The patient was found to be positive for COVID-19 with bilateral pneumonia and ground-glass opacities seen on chest X-ray (Figure 1) and computed tomography (CT) of the chest (Figure 2). The patient was also in septic shock with tachycardia, tachypnea, leukocytosis, and elevated lactate. Computed tomography of the head was negative for any acute disease. Urine toxicology was also negative. Her electrocardiogram (ECG) on admission showed new-onset atrial fibrillation with a rapid ventricular response (Figure 3). he had no known prior history of atrial fibrillation. On admission, high-sensitivity troponins were elevated to more than 20,000 nanograms per liter, but no ST deviations or T-wave abnormalities suggestive of acute ischemia were seen on the ECG. Laboratory test Normal range Results white blood cells 4,500 – 11,000 cells per microsphere 13,500 cells per microsphere hemoglobin 11.0 – 15.0 grams per right bundle 17.4 grams per deciliter hematocrit 35 – 46 % 52.4 per microsphere 111,000 platelets per microsphere blood urea nitrogen 20 – 9.8 .1 milligrams per deciliter 104.1 milligrams per deciliter creatinine 0.57 – 1.11 milligrams per deciliter 3.19 milligrams per deciliter estimated glomerular filtration rate > = 90.0 millimeters per minute per minute per 1.73 square meters 14.2 millimeters per minute per 1.73 square meters Potassium 3.5 – 5.1 milligrams per liter 4.2 milligrams per liter Phosphorus 2.3 – 4.7 milligrams per deciliter 4.0 milligrams per deciliter Magnesium 1.6 – 2.6 milligrams per deciliter 3.3 milligrams per deciliter 3.3 milligrams per deciliter 3.3 milligrams per deciliter nanograms per milliliter d-dimer units Pro Thrombin Time 9.8 – 13.4 seconds 15.5 seconds International Normalized Ratio 0.85 – 1.15 Ratio 1.27 Partial Thromboplastin Ratio 24.9 – 35.9 seconds 29.9 seconds Thyroid Hormone 0.465 – 4.680 micro -international units per milliliter 0.926 micro -ancient onits thyroxine per deciliter 1.19 nanograms per deciliter Brain natriuretic peptide 10.0 – 100.0 picograms per milliliter 365.2 picograms per milliliter Table 1: Patient laboratory findings on admission Figure 1: Chest X-ray on admission Chest x-ray reveals diffuse bilateral air space opacities consistent with bilateral pneumonia. Figure 2: Chest CT on admission Multifocal integration with ground glass opacity is discernible. Figure 3: ECG on admission EKG reveals atrial fibrillation with a rapid ventricular response with a heart rate of 133 beats per minute. The patient was treated with drip cardizem, which was eventually changed to oral amiodarone and metoprolol. Serial ECGs showed sustained atrial fibrillation with controlled ventricular rate (Figure 4). The patient was medically managed for type 2 myocardial infarction. Cardiac catheterization and echocardiography could not be performed due to the patient’s unstable condition, but due to the patient’s rapidly falling troponin (Table 2) type 2 myocardial infarction is highly likely .On the third day, the patient became 80-85% desaturated and using accessory muscles for breathing and was thus intubated and placed on mechanical ventilation. The patient’s sputum culture also grew Klebsiella pneumoniae extended-spectrum beta-lactamase, which was treated with gentamicin. Dexamethasone was started for COVID-19 on admission. The patient’s neurologic examination and brainstem reflexes were normal, and there was improvement in the patient’s respiratory parameters on a spontaneous breathing test. Thus a trial of weaning from the ventilator was attempted but failed and finally a tracheostomy was performed on hospital day 21. Placement of a percutaneous endoscopic gastrostomy feeding tube was planned, but the patient coded and died on hospital day 23. Figure 4: ECG Post-Cardizem Drip The EKG shows atrial fibrillation with a controlled heart rate of 79 beats per minute. On Admission Time 8 Hours 16 Day 2 Day 7 High Sensitivity Troponin (Normal Range: 0.0 – 17.0 nanograms per liter) 20,334.6 nanograms per liter 21,049.0 nanograms per liter 21,250.0 nanograms per liter 21,250.0 nanograms 3 nograms per liter, 791 liters. Infection with the COVID-19 virus has been associated with adverse cardiovascular outcomes, including arrhythmias, myocarditis, and myocardial infarction. It has been associated with the development of new AF and a poor prognosis [3]. These effects may be attributed to the expression of angiotensin converting enzyme 2 (ACE-2) receptors in the myocardium [5]. Atrial fibrillation has been observed more strongly in patients with predisposing chronic cardiovascular diseases such as hypertension [2]. Other associated risk factors include diabetes, older age, heart failure, and kidney dysfunction [2, 6]. There are several factors that are thought to play a role in the development of new AF. These factors include involvement of ACE-2 receptors, inflammatory cytokine storm, electrolyte abnormalities, direct endothelial damage, and acid-base disturbances. [5, 7]. Additionally, a correlation has been observed between disease severity and the development of new AF [3]. There is an increased incidence of AFIB in patients with renal deterioration, thrombotic complications, hypoxia, need for intensive care, and longer hospital stays. The risk of new-onset AFIB has also been associated with an increased level of epicardial adipose tissue [8]. In this case, the patient developed an acute myocardial infarction with new-onset atrial fibrillation during acute COVID-19 infection. Our patient also had sepsis that could have caused or contributed to the development of AF. In a study based on the American Heart Association’s COVID-19 Cardiovascular Registry, the incidence of AFIB was 5.4% [3]. Among those with new-onset AFIB, the incidence of myocardial infarction was 9.8% while the incidence of myocardial infarction was 2.7% in COVID-19 patients without AFIB. An association was found between new-onset atrial fibrillation and major adverse cardiovascular events such as myocardial infarction. New-onset atrial fibrillation has been associated with worsening clinical outcomes in patients with COVID-19 [9]. It is a life-threatening complication associated with a twofold increase in mortality and a threefold increase in secondary outcomes. Secondary outcomes due to new AFIB include major adverse cardiovascular events such as cardiovascular death, myocardial infarction, new-onset heart failure, stroke, and cardiogenic shock. Other adverse outcomes include the need for intensive care, mechanical ventilation, vasoconstrictors, renal replacement therapy, and thromboembolic complications. New-onset AFIB has been associated with a higher incidence of embolic events [10]. Management of new-onset atrial fibrillation in patients with COVID-19 focuses on rhythm control [11]. The use of beta-blockers and non-dihydropyridine calcium channel blockers is the mainstay of long-term management after stabilization. In acutely decompensated patients, intravenous digoxin or amiodarone is used for rate control and stabilization [12]. Use of anticoagulation with warfarin, new oral anticoagulants, or low molecular weight heparin based on risk factors is indicated to reduce thromboembolic risk [13]. Here we present a case of new-onset atrial fibrillation and type 2 myocardial infarction in a patient who developed COVID-19 pneumonia. To our knowledge, this is the first case documenting both new-onset AF and acute myocardial infarction in a single patient with COVID-19 pneumonia. It is important to be on the lookout for cardiovascular complications such as atrial fibrillation and myocardial infarction in patients presenting with COVID-19.
