A 64-year-old male with a medical history of hypertension, diabetes mellitus and hyperlipidemia and a chronic smoker presented with complaints of chest pain which was sharp, continuous in nature and was aggravated by slight walking or lifting of heavy loads. The patient also had complaints of shortness of breath of Grade 4 according to the Medical Research Council (MRC) Dyspnoea Scale []. He had a body mass index (BMI) of 25.8 Kg/m2. The baseline HbA1c% value was 10.8 gm%. He underwent coronary angiography at the discretion of the concerned cardiologist. A diagnosis of Acute Coronary Syndrome (ACS) with Non-ST elevation Myocardial Infarction (NSTEMI) with an occlusion of 99% in the left circumflex artery (LCX) was made. Percutaneous Coronary Angioplasty (PTCA) was performed on the same day with the placement of one everolimus eluting coronary stent in the LCX.\nA loading dose of 180 mg of ticagrelor was given to the patient just before the PTCA was performed. A thrombolysis in myocardial infarction (TIMI) 3 flow was achieved post the procedure. Blood flow distal to the stent was achieved and the procedure was concluded successfully. The post procedural ejection fraction (EF) was 45%. Post procedural electrocardiogram (ECG) was also performed and it showed a QTc of 402 ms with atrial fibrillation and poor progression of the R wave in leads V4 and V5 (). He got discharged after 2 days with an advice of 180 mg ticagrelor, 75 mg aspirin, 20 mg atorvastatin, 25 mg metoprolol, 25 mg spironolactone, 10 mg furosemide and 1000 mg of metformin daily. He was advised to visit the out-patient department (OPD) of Cardiology after 2 months or the ED in case of any emergency.\nThe patient came to the OPD after 1.5 months with complaints of severe shortness of breath (MRC Dyspnoea Scale Grade 5) along with infrequent bouts of coughs. Vitals were measured and the blood pressure was 104/60 mm Hg, with the pulse being 68/min. On auscultation, no bronchopulmonary abnormality could be inferred. Bilateral clear breath sounds were obtained. A BMI of 24.6 Kg/m2 was recorded. In view of ticagrelor induced dyspnea, ticagrelor was discontinued and 75 mg clopidogrel once daily was started while rest of the medications were kept unchanged. An ECG was obtained and it showed a QTc of 468 ms (16.4% increase) with biphasic T wave in Lead III (). He was advised to visit the Cardiology OPD after 1 month or the ED in case of any emergency.\nThe patient came back after one month for follow-up. He had no complaints of shortness of breath or cough this time. Vitals were measured and blood pressure was 114/78 mm Hg with a pulse rate of 66/min. HbA1c% came out to be 9.6 gm%. An ECG was done and it showed a drastic reduction of the QTc to 425 ms (9.2% reduction) () with slight ST elevation in leads V4 and V5. An echocardiography was also performed and the EF came out to be 50%.
A 59-year-old female with no prior cardiac diagnosis presented to our hospital with 3 days of intermittent chest pain. Her cardiac risk factors included hypertension, hypercholesterolaemia, elevated body mass index, and impaired glucose tolerance. Her medical history was also significant for asthma, gastro-oesophageal reflux disease and depression. Cardiovascular examination was unremarkable with no signs of heart failure.\nHer admission electrocardiogram (ECG) showed sinus rhythm, normal axis, narrow QRS (80 ms) with no ischaemic change or conduction defects (Figure ). The patient’s serum troponin recorded a peak measurement of 0.31 µg/L (cTnI n < 0.04 µg/L). Her biochemistry and blood panels were otherwise unremarkable with normal renal and liver function. Echocardiography showed normal biventricular size and systolic function, with normal valves.\nRadial approach coronary angiography was performed and the culprit vessel was shown to be the left circumflex artery (non-dominant) with a long 80% stenosis in the mid-portion. This was treated with deployment of a Synergy 3.0 ×24 mm drug eluting stent and restoration of TIMI 3 flow (Figure ). Medical management was elected for the patient’s residual moderate diffuse left anterior descending artery disease. The right coronary artery was non-obstructed.\nAt conclusion of the procedure, an oral load of ticagrelor 180 mg was administered. Three hours after, whilst convalescing in the coronary care unit, she began complaining of dyspnoea and four pauses were observed on telemetry over a 20 min period (Figure ), the longest being 18.5 s in duration (Figure ). Correspondingly, the patient had intermittent lapses of consciousness and underwent emergency right femoral venous temporary pacing wire insertion.\nTicagrelor was considered as the probable cause for the pauses, for that reason no additional ticagrelor was given after the loading dose and clopidogrel was commenced in place. No further brady-arrhythmias were detected in the subsequent 24 h and the un-utilized temporary pacing wire was removed. The patient was also discharged with aspirin, atorvastatin, perindopril, and amlodipine. A loop recorder (Medtronic Reveal LINQ) was implanted. Beta-blocker therapy was not prescribed in view of preceding events. Notably, there had not been a prior personal or family history of syncope.\nNo cardiorespiratory symptoms were raised during regular follow-up over 12 months with no arrhythmic events recorded on loop recorder interrogation.