Intracoronary Thrombus in a Patient with Elevated Lp(a) Levels and COVID-19

LEAD AUTHOR'S FINANCIAL DISCLOSURES: Nothing to disclose. STUDY FUNDING: None. BACKGROUND/SYNOPSIS: Lp(a) is elevated in 20% of the population and is associated with increased risk for myocardial infarctions and strokes. In patients with COVID-19, Lp(a) is upregulated as a response to the systemic inflammatory infection which can potentially increase the risk for atherothrombotic events. The following case presents the first report of a patient with elevated Lp(a) levels and COVID-19 who presented with an acute MI and evidence for intracoronary thrombus. OBJECTIVE/PURPOSE: 49-year-old male with past medical history of thoracic aortic aneurysm recently diagnosed with COVID-19 presented to ED with chest pain. EKG showed ST-segment elevation in the anterior leads with a 12.7 troponin score. Patient underwent emergent cardiac catheterization that showed 90% ulcerated thrombotic lesion in the proximal LAD. The thrombus was demonstrated by both angiography and IVUS. Thrombectomy, angioplasty, and stenting were performed. There was embolization of thrombus to the distal LAD. Echocardiogram revealed LVEF 55% with apical hypokinesis. He was started on DAPT, statin, and rivaroxaban due to the high risk of recurrent coronary thrombosis. His Lp(a) was 200 nmol/L. (Normal < 75 nmol/L). METHODS: N/A. RESULTS: Cases of patients with COVID-19 and elevated Lp(a) presenting with acute MI and intracoronary thrombus have yet to be reported. Elevated Lp(a) level is thought to increase the risk of cardiovascular events and venous thromboembolism through anti-fibrinolytic and pro- atherosclerotic properties. Acute, transient elevations in Lp(a) secondary to IL-6 production have been observed in inflammatory states, such as COVID-19 infections. A cohort study of 146 COVID-19 patients in the Netherlands observed a mean increase in Lp(a) of 16.9mg/dL from baseline over a course of 21 days during hospitalization In a retrospective study of patients admitted with COVID-19, 5.6% of 531 experienced arterial thrombosis, 9 of which suffered myocardial infarction. In patients similar to ours with COVID- 19 and elevated Lp(a), there may be elevated risk of similar events and providers should remain vigilant for potential complications. It is possible that acutely elevated Lp(a) levels contribute to arterial thrombotic events in the coronaries during COVID-19 infection. CONCLUSIONS: In patients presenting with COVID-19 and acute myocardial infarction, we recommend that clinicians measure Lp(a) level and evaluate for intracoronary thrombi to correlate our findings.