CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 AFRICA 331 intensive care unit, where he required continued dobutamine and adrenaline infusions. Echocardiography revealed a non-dilated left ventricle with a mildly impaired systolic function (40–45%), with an akinetic infero-postero-lateral wall and mild reduction in right ventricular function but no other mechanical complications. Despite continued support, the patient developed worsening shock and pulmonary oedema, with subsequent demise on the same day. Discussion Since the first reported case of COVID-19 in December 2019, there has been in excess of 470 million cases and 6.1 million fatalities. A hypercoagulable state has emerged as a prominent feature and is associated with high mortality rates.1 A recent review of a nationwide registry across 42 STEMI care networks reported a significant increase in ST in individuals with STEMI and COVID19 compared to non-infected individuals (3.3 vs 0.8%, p < 0.001).2 During infection, the interplay between coagulation/ antifibrinolysis versus anticoagulation/fibrinolysis is tipped in favour of thrombosis. The inflammatory response induces a prothrombotic milieu with activation of neutrophils and platelets and the production of ultra-large von Willebrand factor (VWF) multimers. Furthermore, hypoxia-inducible transcription factors promote the expression of plasminogen activator inhibitor-1 (PAI-1) and tissue factor.3 Another avenue by which hypercoagulability is induced is through down-regulation of angiotensin-converting enzyme 2 (ACE2) receptors during COVID-19. This results in increased levels of angiotensin II and PAI-I levels, which inhibit fibrinolysis.4 Fig. 3. A: RAO caudal projection of the LCA at the time of stent thrombosis. B: LAO projection of the RCA at the time of stent thrombosis. C: LAO caudal projection of the LCA after salvage attempts. D: LAO projection of the RCA injection after salvage attempts. RAO: right anterior oblique artery; LCA: left coronary artery; LAO: left anterior oblique artery; RCA: right coronary artery. A C B D
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