During the period studied 14 COVID-19 patients had a systemic arterial event, which represents an incidence of 1% in relation to the total number of hospitalized patients. Patient characteristics and outcome are summarized in Table 1. Vascular events occurred along the whole course of the disease but they tended to cluster during the second week. Their specific time distribution is depicted in Figure 1.
Three patients suffered an acute coronary syndrome (ACS), two with persistent ST-segment elevation. The first was a 66-year-old woman with mild pneumonia. An emergency coronary angiogram was performed, and an acute occlusion of the circumflex artery was stented with good outcome. The other patient was a 77-year-old male with very severe acute respiratory distress and poor life prognosis. Conservative management for an inferior infarction was opted for, with death occurring 8 days later from respiratory causes. The third patient was a 64-year-old male with severe respiratory distress on non-invasive mechanical ventilation who developed chest pain with transient ST elevation but no troponin elevation and was managed medically. Once his respiratory status resolved, a coronary angiography showed no significant coronary disease and the patient was successfully discharged. As a matter of comparison, in the same time period in 2019 four patients were treated in our hospital who developed an ACS whilst hospitalized for another reason.
Eight patients had an ischemic stroke (IS) or a transient ischemic attack (TIA). Most patients had multiple cardiovascular risk factors and comorbidities (Table 2). The first patient, a 77-year-old male with severe bilateral pneumonia, suffered a right carotid IS, treated with intravenous thrombolysis, presenting a new IS in the context of hemodynamic instability due to severe respiratory failure, with Rankin score of 5 at discharge. An 86-year-old male, with a history of TIA who was admitted due to severe bilateral pneumonia, presented an IS in the left carotid region and died within 24 hours. A 69-year-old male with severe pneumonia, a history of atrial fibrillation (AF) on acenocoumarol and IS with right carotid occlusion, presented a new right carotid IS in the context of hemodynamic instability, and recovered spontaneously. Two patients with non-severe pneumonia suffered a TIA and were managed conservatively. Two patients admitted with severe pneumonia, suffered an IS due to intracranial arterial occlusion and were treated conservatively. The last patient, a 66-year-old male with AF on edoxaban, active lung cancer and severe bilateral pneumonia, presented bilateral IS, culture-negative aortic valve endocarditis and subsequently died from respiratory decline. Patients with severe COVID criteria  were more likely to suffer IS than TIA and had worse Rankin scores at discharge.
During the same time period three patients developed an acute lower limb ischemic event. All cases presented necrosis of the toes, two of them with bilateral involvement, and another with extension to the forefoot. The first patient, a 74-year-old man admitted with severe bilateral pneumonia developed an infrapopliteal arterial occlusion, and subsequently died within two days due to her respiratory condition. A 71-year-old woman admitted with bilateral pulmonary embolism developed a bilateral infrapopliteal thrombotic event two days after admission and as of today she is still hospitalized. Finally, a 63-year-old diabetic man, while critically ill in the ICU with severe bilateral pneumonia, developed foot ischemia 7 days after admission. He was eventually discharged from the hospital but is scheduled for minor toe or transmetatarsal amputation. Due to their poor general condition all patients received only conservative treatment with full anticoagulation. Interestingly, the two patients that were awake and conscious showed no or minimal pain, with no sensory loss.