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 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.