key: cord-0934891-79g5f02t
authors: Manzur-Sandoval, Daniel; Carmona-Levario, Patricia; García-Cruz, Edgar
title: Giant inverted T waves in a patient with COVID-19 infection.
date: 2020-08-04
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.07.037
sha: c8dda9e24355932c628d790cc2c2eaa91b893c2b
doc_id: 934891
cord_uid: 79g5f02t

Abstract. The differential diagnosis of giant inverted T waves in the ECG includes, among others, Takotsubo syndrome (TTS). In a critically ill patient with acute hemodynamic or respiratory deterioration, a stress-related cardiomyopathy syndrome needs to be ruled out. In COVID-19 infection the main physiopathological mechanisms include systemic inflammatory response syndrome and thrombosis, which can condition cardiovascular complications. We present the case of a patient with COVID-19 infection who developed acute hemodynamic and respiratory collapse associated with giant inverted T waves in the ECG and regional wall motion abnormalities in the transthoracic echocardiogram. The resolution of these alterations after medical management supports the diagnosis of TTS caused by COVID-19 infection; to date, few cases of this association have been reported.

The differential diagnosis of giant inverted T waves in the ECG includes, among others, Takotsubo syndrome (TTS). In a critically ill patient with acute hemodynamic or respiratory deterioration, a stress-related cardiomyopathy syndrome needs to be ruled out. In COVID-19 infection the main physiopathological mechanisms include systemic inflammatory response syndrome and thrombosis, which can condition cardiovascular complications. We present the case of a patient with COVID-19 infection who developed acute hemodynamic and respiratory collapse associated with giant inverted T waves in the ECG and regional wall motion abnormalities in the transthoracic echocardiogram. The resolution of these alterations after medical management supports the diagnosis of TTS caused by COVID-19 infection; to date, few cases of this association have been reported.

J o u r n a l P r e -p r o o f

A 54-year-old female with a past history of type 2 diabetes and hypertension was admitted with dry cough and 3-day fever. She was dyspneic with SaO 2 82%, heart rate (HR) 75 b.p.m. and blood pressure (BP) 100/60 mmHg. Diffuse pulmonary rales were found. Laboratories reported lymphopenia (total lymphocytes 900 per microliter), ferritine 717.5 ng/mL (23.9-336.2 ng/mL), albumine 3.3 g/dL (3.5-5 g/dL), D-dimer 1.6 µg/ml (0-0.24 µg/ml) and reactive C protein 33.2 mg/L (1-3 mg/L). Chest X ray showed bilateral diffuse intersticial inflitrates. The initial management included oxygen with a non-rebreathing mask at 10 L/min flow and thromboprophylaxis with enoxaparin. A real-time reverse transcription-polymerase chain reaction (RT-PCR) for detection of SARS-CoV-2 RNA was positive, so antiviral therapy (lopinavir/ritonavir 400 mg/100 mg bid) was added. On his 4th day of evolution she developed acute chest pain, hypotension and pulmonary edema.

The new laboratories reported high-sensitivity cardiac troponin (hs-cTn) 692 ng/L (8-18 ng/L), creatine kinase-MB (CKMB) 11.78 ng/dL (0.06-6.3 ng/dL) and NT-proBNP 9000 pg/mL (15-125 pg/mL). A 12-lead ECG was performed ( Figure 1 ).

What is your most likely diagnosis?

In figure 1 , the ECG shows HR 75, PR interval 160 mseg, QRS 100 mseg, and QTc interval prolongation (6 points); patients with a score of ≥50 are diagnosed as TTS in nearly 95% of cases (5) . The patient had an adequate evolution; tracheostomy was performed after 14 days of invasive mechanical ventilation and she was weaned from the ventilator. Priorizing intra-hospital security policies during pandemic to limit staff exposure and due to the TTE initial abnormalities and its reversal after medical management (along with T-waves J o u r n a l P r e -p r o o f normalization) we considered TTS as the final diagnosis without the need for coronary anatomy imaging (3).

• In a critically ill patient with new giant inverted T waves on the ECG and sudden hemodynamic instability, TTS need to be considered.

• Differential diagnosis of giant inverted T waves should also include pulmonary embolism and acute myocardial infarction, among others.

• Improvement of the electrocardiographic and echocardiographic abnormalities over time is typical in patients with TTS. 

Giant Inverted T waves in the emergency department: case report and review of differential diagnoses

ECG Criteria to Differentiate Between Takotsubo (Stress) Cardiomyopathy and Myocardial Infarction

International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome and Management

Takotsubo Syndrome in the Setting of COVID-19. JACC: Case Reports

A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry

We thank the INC Critical Care Ultrasonography Working Group.