This is the sixth installment of our 8-part series on cardiovascular complications in patients with COVID-19. In this installment, we will discuss cardiogenic shock in patients with COVID-19.

A 59-year-old man who tested positive for COVID-19 presents to the emergency department with shortness of breath, hypotension, tachycardia, and oliguria. Symptoms of cough, fever, fatigue, and mild shortness of breath started 10 days prior. He initially self-treated at home with over-the-counter medications but his shortness of breath worsened over the past few days prompting him to seek medical care.

On initial presentation, his oxygen saturation is 66% on room air and peripheral mid- and lower-lung consolidation/infiltrates are found on chest radiographs. Results of serologic analysis and arterial blood gas test after initiation of supplementation oxygen via high-flow nasal cannula with 100% FiO2 at 40 L/min flow are shown in Table 1. Twelve lead electrocardiogram (ECG) showed sinus tachycardia with ST elevation in leads V1 and V2 and no reciprocal changes.

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Table 1. Laboratory Rest Results

Arterial blood gases test         
Pao2, mm hg79.6
Paco2, mm hg25.9
Base excess/deficit-13.1
Sao2, %92.4
Serologic analysis 
BUN, mg/dL38
Creatinine, mg/dL1.31
Alkaline phosphatase, IU/L210
Albumin, g/dL2.9
AST, U/L130
LDH, U/L534
Glucose, mg/dL534
Troponin, ng/dL0.62
Triglycerides, mg/dL744
HDL, mg/dL16 dL
LDL, mg/dL>400
ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; HDL, high-density lipoprotein; LDH, lactate dehydrogenase; LDL, low-density lipoprotein; Sao2, arterial oxygen saturation

Significant Medical History

Past medical history is significant for diabetes, hypertension, and hyperlipidemia. Medication management for his chronic health problems includes metformin and glipizide.

Physical Examination

The patient is a middle-aged man with obesity who is in moderate distress with labored respirations at a rate of 32 breaths per minute. Room air oxygen saturation is 66% but is increased to 92% after initiation of high-flow nasal cannula with a fraction of inspired oxygen (FIO2) of 100% and flow rate of 40 L/min. Crackles are heard bilaterally in the lungs both anteriorly and posteriorly. Heart rhythm is regular with a rate of 126 beats per minute and blood pressure is 86/42 mm Hg with cool extremities. The patient complains of chest pain but denies palpitations or gastrointestinal complaints. Glasgow Coma Scale score is 15/15.

Diagnosis and Treatment

Initial diagnosis is COVID-19, cardiogenic shock, adult respiratory distress syndrome, hyperglycemia, metabolic acidosis, and acute renal insufficiency. The patient is placed on supplemental oxygen via high-flow nasal cannula for hypoxia. A vasopressor infusion of norepinephrine is started for hypotension. Insulin, dexamethasone, and enoxaparin are initiated for hyperglycemia, inflammatory response, and venous thromboembolism prophylaxis, respectively. Because of his elevated cardiac troponin, 12-lead ECG with ST-segment elevation, and chest pain, an emergent cardiac catherization with percutaneous intervention and ventriculogram are performed.

The patient is found to have triple-vessel disease. Left ventriculography reveals the left ventricle to be moderately dilated with a large anteroapical microinfarction with very poor overall systolic function. Left ventricular ejection fraction is estimated to be 10% to 15%. Balloon dilations of proximal and proximal-mid LAD lesions are performed but the patient experiences episodes of hypotension, hypoxia, and bradycardia. At the end of the procedure, he develops severe bradycardia and then pulseless electrical activity (PEA) cardiac arrest. Extensive CPR is performed but resuscitation is unsuccessful and the patient is pronounced dead.