Case 2:
A 70-year old healthy Hispanic woman with past medical history
significant only for hypertension, presented with new-onset severe
retrosternal chest discomfort, that was worse with activity, associated
with diaphoresis and shortness of breath, symptoms started about 24
hours prior to presentation. She was seen at her cardiologist’s office,
her EKG showed new deep T wave inversions in the precordial leads and
subtle ST elevation in the inferior leads (Figure 3). She was sent to
the emergency department from the office, her echocardiogram showed
severe hypokinesis of the antero-apical wall, confirming anterior
myocardial infarction. She tested negative for SARS-CoV-2 and was
emergently taken to the cardiac catheterization lab for further
evaluation.
Coronary angiography revealed only mild calcification and
non-obstructive disease in the coronary arteries with a right dominant
circulation (Figure 4). Myocardial bridge was noted in the proximal-mid
left anterior descending artery (Figure 4). Further, left ventricular
end-diastolic pressure was elevated at 22 mm Hg and left
ventriculography showed a severely depressed left ventricular ejection
fraction of 30% with antero-apical and infero-apical wall akinesis
(Figure 4 and Supplementary videos 1 and 2). Overall, her clinical
presentation was hence consistent with Takotsubo cardiomyopathy. She was
started on medical therapy with beta-blockers, anxiolytics, and
discharged home with close cardiology follow-up.
In retrospect, during our interaction with the patient, she endorsed
significant stress during the past few weeks, due to ongoing health
issues. She had noticed a gradual decline in her visual acuity, however,
due to the ongoing pandemic and outpatient appointment restrictions due
to that, she was not able to schedule an ophthalmology appointment,
despite repeated attempts, further adding to her stress.