In May of 2016, a 55-year-old male with history of hypertension, hyperlipidemia, and coronary artery disease (CAD) status after angioplasty of left anterior descending (LAD) artery 2 years ago presented to the emergency room (ER) with substernal chest pain. His cardiac enzymes were not elevated and electrocardiogram (EKG) showed normal sinus rhythm at a rate of 62 bpm with borderline AV conduction delay and right bundle branch block (RBBB) pattern (). The patient was only taking aspirin and had discontinued his statin due to muscle ache and metoprolol because of fatigue. His chest pain was relieved with sublingual nitroglycerin in the ER. In view of his significant history of CAD and typical anginal symptoms, patient underwent cardiac catheterization. It revealed 90 percent stenosis of the left mid circumflex coronary artery which was successfully stented with a drug-eluting stent. Right coronary artery (RCA) showed 50–60% stenosis while LAD showed patent stent. The patient recovered very well. After calculating the GRACE score, the patient was discharged on aspirin and ticagrelor as per the ACC guidelines. He was also prescribed rosuvastatin and metoprolol. Two months after PCI, the patient presented to his primary cardiologist due to worsening fatigue and intermittent dizziness. His metoprolol was stopped. In November, 2016, he was brought by emergency squad to the hospital due to worsening dizziness and diaphoresis at rest. He denied any h/o chest pain, palpitations, nausea, or loss of consciousness. The patient had stopped ticagrelor 1 day prior to this admission since he ran out of it. The patient requested a second opinion on this admission. On physical examination, his blood pressure was 126/66 mmHg and heart rate was regular at 42 beats per minute. The neck was supple with no carotid bruits and cardiac auscultation revealed 2/6 ejection systolic murmur in the left sternal border. Patient's EKG revealed second-degree type II atrioventricular (AV) block which was new (). His cardiac enzymes, thyroid stimulating hormone, serum potassium, and magnesium were within normal range. The patient did not receive ticagrelor further during the admission. Cardiac catheterization revealed RCA stenosis of 60–70% but no intervention was required as this was not the cause of the new onset heart block. We considered starting patient on oral theophylline on admission had the heart block not resolved within 24 hours. His second-degree heart block resolved 2 days after discontinuation of ticagrelor and his EKG showed sinus bradycardia (heart rate = 54 bpm) with borderline AV conduction delay with RBBB pattern () which was similar to his baseline EKG. Clopidogrel was started as an alternative P2Y12 platelet receptor inhibitor and aspirin was continued. He was discharged after an event monitor was placed.
A 55-year-old female presented to the hospital after an episode of syncope at home. Her past medical history included Hashimoto’s thyroiditis and hypertension, and both were chronically stable on levothyroxine and an angiotensin receptor blocker. Her current condition had started about seven days prior to the presentation when the patient had developed a dry cough and nasal congestion. She had decided to get tested for SARS-CoV-2 because of her close contact with family members who were positive for SARS-CoV-2 infection. She had turned out to be positive for SARS-CoV-2 infection as well. She had also developed symptoms of progressive episodes of diarrhea. On the day of the presentation, she had been sitting on the toilet seat having a bowel movement when she had suddenly felt her arms and legs becoming weak. She had passed out on the toilet seat and her husband had helped her off the toilet. She denied any head trauma, aura, palpitations, tongue bite, or confusion after the episode of syncope. She had been immediately brought to the hospital for her unwitnessed syncopal episode.\nOn presentation, her review of systems included subjective fever, shortness of breath on exertion, decreased oral intake, diarrhea, and nausea, but she denied any vomiting, chest pain, and abdominal pain.\nThe patient tested positive for SARS-CoV-2 on nasal swab again on admission to the hospital. The EKG on admission showed normal sinus rhythm. The vital signs in the emergency department were as follows - temperature: 98.8 °F, heart rate: 60 beats/minute, blood pressure: 106/56 mmHg, respiratory rate: 20 breaths/minute, and pulse oximetry: 93% on room air. She was admitted to the telemetry floor as a part of an evaluation of a suspected syncopal episode. The laboratory results upon admission were as follows - white cell count: 5,860 cell count/uL, hemoglobin: 13.3 g/dL, platelets: 1,36,000 cells/uL, and the complete metabolic panel was unremarkable except for a potassium level of 3.3 mmol/L and blood glucose of 141 mg/dL. The cardiac enzyme (troponin T) was <0.01 ng/ml. Orthostatic vitals on admission were also normal. The inflammatory markers at the time of admission are summarized in Table . The patient's chest X-ray is shown in Figure , and her baseline EKG is presented in Figure .\nOn the third day post-admission, a rapid response was called on her due to acute hypoxia and a brief syncopal episode while she was using the bathroom in the hospital. She was immediately transferred to the bed and evaluated at the bedside. Upon assessment, the patient had regained her consciousness and was oriented to time, place, and person. Her vitals at the time were as follows - heart rate: 62 beats/minute, blood pressure: 153/73 mmHg, but her oxygen saturation had dropped to 88% on the room air, and hence she was placed on a nasal cannula with 4 liters of oxygen per minute. On the telemonitor, she was found to have two consecutive episodes of asystole lasting approximately one minute, 20 seconds, and later one minute, 30 seconds (Figure ). She was immediately placed on pacer pads and upgraded to the intensive care unit for further evaluation.\nThe patient was evaluated by the cardio-electrophysiology team for the symptomatic asystole episodes. She was further investigated for thyroid function, cardiac enzymes, and echocardiogram, which were in the normal range. She successfully underwent dual chamber pacemaker placement. For hypoxia, she received remdesivir and steroid treatment as a part of COVID-19 pneumonia treatment. In the later part of the hospital stay, she remained stable and was subsequently discharged home with an outpatient follow-up with the pulmonologist and cardiologist.