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.