Case 1:
An 85-year old Hispanic woman with past medical history significant for hypertension, pre-diabetes, chronic kidney disease, hyperlipidemia, presented to the hospital with acute onset chest pain, that started 2 hours prior to presentation. The pain was described as a diffuse pressure like sensation, radiating to her jaw and back, was waxing and waning in severity, but never fully resolved. She denied any associated nausea, vomiting, leg swelling, dizziness, syncope or shortness of breath. She did report increased palpitations in the last 2-3 weeks, but were not associated with her chest pain. She denied any antecedent fevers, chills, myalgias, sick contacts or recent travel.
Chest pain had intensified about an hour prior to arrival, when she called emergency medical services. ST-segment Elevation Myocardial Infarction (STEMI) alert was called in field for possible lateral wall ST segment changes. On arrival to the emergency department, our patient was afebrile with temperature of 36.9 degrees Celsius, tachycardic to 120 beats per minute, her blood pressure was 108/45 mm Hg (with no significant difference between right and left arm), she was mildly tachypneic at 15 breaths per minute, and oxygen saturation was 95 percent on room air. Physical exam was remarkable for an elderly, anxious, ill-appearing, frail woman, who was tachycardic, with normal pulses, normal cardiac exam with no significant murmur or rub on auscultation, lungs were clear to auscultation.
Electrocardiogram (EKG) on arrival (Figure 1), showed sinus tachycardia with inferior Q waves, poor R wave progression and non-specific ST-segment changes. She was loaded with aspirin 325 mg and clopidogrel 600 mg given concern for acute coronary syndrome, STEMI alert was canceled with plan for invasive assessment pending nasopharyngeal antigen testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Initial labs showed a normal leukocyte count of 7700 cells/uL with a normal differential, normocytic anemia with hemoglobin of 10 g/dL with a normal platelet count of 207,000 cells/uL, chemistry was notable for elevated creatinine to 1.57 mg/dL (with estimated glomerular filtration rate of 30 mL/min/1.73m2) and mildly elevated urea nitrogen at 28 mg/dL, electrolytes; while coagulation parameters and liver function tests were within normal limits. Cardiac biomarkers were elevated; initial troponin T was elevated at 1.31 mg/mL (reference range 0-0.06) and NT-proBNP was elevated at 3,397 pg/mL (reference range 0-450). Test was SARS-CoV-2 was negative and patient was taken for urgent coronary angiography. Coronary angiogram was negative for any significant obstructive coronary artery disease, left ventriculogram showed an ejection fraction of 45-50%, with severe hypokinesis of the apical segments with apical ballooning and basal hyperkinesis, changes consistent with classical Takotsubo cardiomyopathy (Figure 2).
On further questioning, our patient endorsed being in extreme emotional distress because of COVID social isolation, and her anxiety was further exacerbated by the recent political demonstrations/riots for racial justice. She was monitored in our coronary care unit for 48 hours, was started on beta-blockers, anxiolytics and afterload reduction with good effect. No significant arrhythmias were noted and she continued to be hemodynamically stable. Psychology was consulted for psychosocial assessment and coping skills were taught and information on community resources was provided. She was subsequently discharged home with close cardiology follow-up.