Stress-Induced Cardiomyopathy Masquerading as Acute ST-Segment Elevation Myocardial Infarction.

Myocardial stress can lead to a myriad of cardiovascular complications, and stress-induced cardiomyopathy is the predominant manifestation. Exogenous or endogenous hormonal excess, sepsis, tachycardia, and physical or emotional trauma can lead to neurohormonal and catecholaminergic surges. Stress-induced cardiomyopathy often presents with chest pain, ischemic-like ECG changes, troponin elevation, and wall motion abnormalities in echocardiography. It is a diagnosis of exclusion, and coronary artery disease needs to be ruled out by a normal angiogram as per guidelines. It presents predominantly in postmenopausal women and presentation is similar to acute coronary syndrome (ACS) due to plaque rupture. We report a case of a 72-year-old female who presented to the emergency room with severe anginal chest pain without any preceding stress. ECG showed lateral leads ST-elevation and serial serum troponins were elevated. Emergent cardiac catheterization showed insignificant coronary artery disease. Left ventriculogram and echocardiogram showed a moderately reduced left ventricular systolic function with akinetic-hypokinetic mid to distal myocardial segments and normal basal contraction suggestive of stress-induced cardiomyopathy.

COVID-19 Vaccine-Induced Acute Perimyocarditis: A Case Report.

Perimyocarditis is the inflammation of the pericardium along with the myocardium. Presentation is similar to acute pericarditis, but it is associated with myocardial damage, leading to an elevation in serum troponin and a left ventricular dysfunction (manifested as an ejection fraction of less than 55 percent). Perimyocarditis is mostly managed like acute myocarditis. Etiology is generally idiopathic and likely secondary to viral infections. Cases of vaccine-associated myocarditis have been infrequently reported in past, most recently with the COVID-19 mRNA vaccine. We present a rare case of a young healthy adolescent male who developed perimyocarditis after the first booster dose of the COVID-19 mRNA vaccine.

Unresolved Heart Block in Lyme Carditis: A Case Report.

A man in his thirties presented to the emergency department with a one-day history of syncopal episodes. He was found to have complete heart block and had multiple long and symptomatic pauses in telemetry while in the hospital. The longest pause was measured at 30 seconds. He had frequent occupational exposure to ticks and was found to have positive immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies for Lyme disease. He was immediately started on IV (intravenous) ceftriaxone and isoproterenol infusion for inotropy in anticipation of recovery of atrioventricular (AV) conduction with IV antibiotics. Rapid response was called for multiple symptomatic pauses overnight, the longest one lasting 30 seconds. The patient was taken for urgent temporary transvenous pacemaker placement in the morning. AV conduction failed to improve with IV antibiotics. A permanent pacemaker was placed on day four of hospitalization as his complete heart block failed to resolve with IV antibiotics and the patient could not be weaned from temporary pacemaker support. A complete heart block is a rare manifestation of Lyme disease and warrants a high index of suspicion when a patient in an endemic area presents with this condition. A majority of patients recover with IV antibiotics, although some patients may need to be put on temporary pacemaker support in the interim. On rare occasions, a permanent pacemaker is necessary. Atrioventricular conduction may fail to improve with IV antibiotics, and these patients may need early pacemaker support with a transvenous pacemaker in addition to IV ceftriaxone followed by permanent pacemaker placement. Our patient presented with recurrent Lyme disease and had a complete heart block on presentation, which failed to improve with IV antibiotics and required temporary transvenous pacemaker support followed by permanent pacemaker placement.

A Left Atrial Myxoma Masquerading As Acute Coronary Syndrome.

Acute coronary syndrome is caused by a rupture of atherosclerotic plaque with superimposed thrombus formation. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) occurs when occlusion of the epicardial coronary artery by a thrombus causes partial thickness myocardial ischemia and an ischemic cascade downstream. Cardiac masses are known to produce symptoms predominantly by local obstruction or systemic embolism. Coronary artery tumor embolism causing acute coronary syndrome is a rare presentation of cardiac mass. We report NSTE-ACS as the initial presentation of the left atrial myxoma in a 62-year-old woman. She presented to the emergency department with acute onset severe anginal chest pain, diaphoresis, and dizziness. Her serial electrocardiograms (ECGs) were normal, and serial troponins were elevated, consistent with non-ST-segment elevation acute coronary syndrome. Cardiac catheterization revealed insignificant coronary artery disease, and transthoracic and transesophageal echocardiograms showed a left atrial mass attached to the interatrial septum consistent with myxoma. The patient underwent surgical excision, and histopathology was consistent with myxoma. Her symptoms subsided after surgery. Primary cardiac tumors are very uncommon and can present with myriad symptoms, from tumor embolism, local cardiac effects, to constitutional symptoms. Although embolism to other organs has been reported, left atrial myxoma presenting as an acute coronary syndrome is very uncommon.

A Non-atherosclerotic Heart Tears Apart: A Case of Spontaneous Coronary Artery Dissection in a Healthy Postmenopausal Woman.

Due to limited understanding and knowledge of spontaneous coronary artery dissection (SCAD), it is typically believed to affect young peripartum women. We present a case of a post-menopausal older woman who suffered an acute non-ST segment elevation myocardial infarction (NSTEMI), secondary to a SCAD of the right posterior descending artery (PDA), after strenuous exercise. As the patient was hemodynamically stable and without signs of ongoing ischemia, she was managed conservatively. SCAD should be in differentials for patients presenting with acute coronary syndrome (ACS) who have no or few cardiovascular atherosclerotic risk factors. SCAD can be missed due to low suspicion of ACS in young and healthy patients. ACS from SCAD is often misdiagnosed and/or mismanaged as atherosclerotic ACS. Increasing awareness about this condition can lead to earlier diagnosis and prevention of sudden cardiac deaths. As most cases of SCAD can be managed conservatively, differentiating it from atherosclerotic ACS can reduce unnecessary reperfusion procedures and complications thereof.

Invasive Lipoma of the Interventricular Septum, a Rare Benign Cardiac Mass With Atypical Presentation and Management.

Lipoma of the interventricular septum involving the tricuspid valve is a rare entity. A 50-year-old woman presented with exertional dyspnea. She was found to have a large right interventricular septal mass in the initial transthoracic echocardiography. This mass was further investigated by transesophageal echocardiography, cardiac gated CT, and cardiac magnetic resonance imaging. It was found to be lipomatous and embedded into the septal leaflet of the tricuspid valve. The diagnosis was confirmed by biopsy. Surgical exploration revealed that the mass was deeply embedded in the interventricular septum and septal leaflet of the tricuspid valve. The mass was resected along with sections of the interventricular septum and tricuspid valve. She underwent bioprosthetic tricuspid valve placement and patch reconstruction of the interventricular septum. We also searched case reports from MEDLINE and studied pathological and epidemiological characteristics of the published cases of cardiac masses in the past year. Cardiac lipoma although a benign tumor can cause serious hemodynamic complications. Initial transthoracic echocardiography followed by multimodality imaging is the cornerstone of the diagnosis.

Traumatic aortic root rupture leading to acute aortic regurgitation and acute type A aortic dissection.

A 17-year-old male sustained a blunt thoracic trauma after he had a dirt bike accident. He was admitted for the management of multiple fractures, was hemodynamically stable, and presented without any cardiac symptoms. The patient underwent transthoracic echocardiography and CT angiogram of the thorax as the workup of possible cardiac injury as he had a new aortic regurgitation murmur, troponin rise, and a new RBBB. Imaging showed aortic root rupture, type A aortic dissection involving aortic root and proximal ascending aorta, and acute severe aortic regurgitation, not typically seen with blunt thoracic trauma. The patient was immediately taken to the operating room, underwent a surgical aortic valve and root replacement with the Bentall procedure, and had a good outcome.

Anomalous origin of the left coronary artery from pulmonary artery misdiagnosed as postpartum cardiomyopathy.

A 30-year-old woman with a history of presumed postpartum cardiomyopathy presented to her primary care physician's office with crescendo angina and shortness of breath. She was found to be in supraventricular tachycardia, managed with the Valsalva maneuver, and was discharged home without any further workup. She again presented with exertional symptoms. Her electrocardiogram revealed abnormal T waves and her stress test was strongly positive. Cardiac catheterization revealed an absent left coronary ostium and a dilated right coronary artery, with large collaterals supplying the left coronary system; coronary computerized tomography revealed the anomalous origin of the left main coronary artery arising from the posterolateral aspect of the pulmonary artery, highly suggestive of the anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) anomaly (Bland-White-Garland anomaly).