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.
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.