A 47-year-old female with hypertension and hyperlipidemia was admitted to emergency department due to typical angina lasting 2 days. Her blood pressure was 150/80 mm Hg. On electrocardiogram (ECG), there was a sinus rhythm with heart rate of 67 bpm, along with ST depression of 0.5 mm on inferolateral derivations (). Echocardiography showed hypokinesis of mid-lateral wall with an ejection fraction of 48%. We detected slightly increased cardiac troponin level. Because of ACS (NSTEMI), acetylsalicylic acid (300 mg), ticagrelor (a loading dose of 180 mg and maintenance dose of 90 mg twice a day) and intravenous unfractionated heparin (10,000 IU) were given to the patient and then her coronary angiography was performed, which revealed a total occlusion of the distal ndLCx (). After the lesion was predilated with 2.0 × 15 mm sized balloon catheter, a drug eluting stent of 2.5 × 23 mm was implanted and full patency was achieved (). Thereafter, her symptoms dramatically improved. Since her heart rate was 67 beats/min, beta blocker therapy was not started. Approximately 10 h later, ECG showed first degree AVB without symptom (). Her therapy consisting of ASA, ticagrelor, ramipril and statin was continued unchanged. On the next (second) day, the patient experienced mild dizziness with complet AVB, without hemodynamic impairment (). Ticagrelor was stopped and prasugrel was initiated instead. On the third day, her ECG showed again first degree AVB without symptom (). On the fourth day, she had normal sinus rhythm without AVB and symptom (). On the fifth day, the patient was salubriously discharged from the hospital with therapy of ASA, prasugrel, rosuvastatin and ramipril. We did not observe any heart block and/or bradyarrhythmia during the 3 months of follow-up.
A 51-year-old male patient, with a history of hypertension and hyperlipidemia, presented to the emergency department with an anterior ST-elevation myocardial infarction (). A loading dose of both ticagrelor (180 mg) and aspirin (ASA, 250 mg i.v.) was administered and the patient sent to the cath-lab for primary percutaneous coronary intervention (PCI) on the left anterior descending coronary artery (Figures -). After revascularization, medical therapy included beta-blockers (carvedilol 6.25 mg b.i.d.), statins (atorvastatin 80 mg), and angiotensin II receptor antagonists (telmisartan 80 mg). Dual antiplatelet therapy was continued with ticagrelor (90 mg b.i.d.) and ASA (100 mg). At the echocardiography, performed the day after the revascularization, the ejection fraction was critically reduced (EF: 25%) with akinesia of the anteroseptal wall. Titration of carvedilol was performed during the following two days without significantly reducing the heart rate at target (90 bpm with 12.5 mg carvedilol b.i.d.). Ivabradine was then administered at 5 mg b.i.d. Few hours after the first dose, the patient presented with severe symptomatic bradycardia () and sinus arrest. Atropine and adrenaline i.v. were administered and both ivabradine and ticagrelor suspended and this latter changed with prasugrel. Any other similar event was not reported during the following days and the national competent authority was finally informed.