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Clinical Cases in the Management of Complex Cardiovascular Disease
 303124527X, 9783031245275

Table of contents :
Contents
Abbreviations
Chapter 1: Introduction
Chapter 2: Digoxin Toxicity in a Patient with Pacemaker
References
Chapter 3: Myocarditis and Cardiogenic Shock
References
Chapter 4: Tachycardia Mediated Cardiomyopathy and Cardiogenic Shock
References
Chapter 5: Cardiac Arrest in Cardiac Rehabilitation Then an Alarming ICD While on Vacation
Further Reading
Chapter 6: Atrioventricular Block in the Context of Inferior ST Elevation Myocardial Infarction (STEMI)
Further Reading
Chapter 7: Carcinoid Tumor and Peripheral Edema
Further Reading
Chapter 8: Saddle Pulmonary Embolism and Atrial Fibrillation
References
Chapter 9: Non-ST Elevation MI and Spontaneous Coronary Artery Dissection
References
Chapter 10: RV Lead Integrity Warning Following by Inappropriate ICD Shock
References
Chapter 11: Post Dialysis Hypotension, New Diagnosis of HOCM
Further Reading
Chapter 12: Mitral and Aortic Valve Disease in a Patient with End Stage Renal Disease
References
Chapter 13: Sustained Monomorphic Ventricular Tachycardia (SMVT) in a Patient with ICD. No Shock Delivered. What Is Going Wrong?
References
Chapter 14: MV Endocarditis and Stroke
References
Chapter 15: Recurrent Chest Pain and Lytic Lesion in the Spine
References
Chapter 16: Acute Type A Aortic Dissection in a Young Man
References
Chapter 17: Long QT and Atrial Fibrillation: Are These a Related Entity or Not?
References
Chapter 18: SCN5A Mutation and Syncope
References
Chapter 19: Tachycardia Mediated Cardiomyopathy Recovered After Successful Atrial Flutter and Fibrillation Ablation
References
Chapter 20: Recurrent Myocarditis
Further Reading
Chapter 21: ST Depression in Holter, Associated with Chest Pain
References
Chapter 22: Asymptomatic Mobile Cardiac Mass
Further Reading
Chapter 23: Shortness of Breath on Exertion and Mobitz Type 1 AV Block
References
Chapter 24: Asymptomatic Atrial Flutter with Rapid Ventricular Response Left Atrial Appendage (LAA) Clot and Heart Failure with Reduced EF
References
Chapter 25: Bradycardia and Hypotension in a Covid-19 Positive Patient
25.1 Physical Examination
25.2 Investigations
References
Chapter 26: Myotonic Dystrophy Type 2 and Cardiomyopathy
References
Chapter 27: Concomitant Hypertrophic Cardiomyopathy and Aortic Valve Stenosis in a Patient with Shortness of Breath
References
Chapter 28: Takotsubo Cardiomyopathy
References
Chapter 29: Frequent ICD Shock Despite Being on Amiodarone, a Double Edge Sword!
References
Chapter 30: RA MASS, Tumor or Clot in a Breast Cancer Patient
References
Index

Citation preview

Clinical Cases in Cardiology Series Editors: Ravi V. Shah · Siddique A. Abbasi · James L. Januzzi

Atooshe Rohani

Clinical Cases in the Management of Complex Cardiovascular Disease

Clinical Cases in Cardiology Series Editors Ravi V. Shah, Boston, MA, USA Siddique A. Abbasi, Providence, RI, USA James L. Januzzi, Boston, MA, USA

Clinical cases are a key component in modern medical education, assisting the trainee or recertifying clinician to work through unusual cases using best practice techniques. Cardiology is a key discipline in this regard and is a highly visual subject requiring the reader to describe often very subtle differences in the presentation of patients and define accurately the diagnostic and management criteria on which to base their clinical decision-making. This series of concise practical guides is designed to facilitate the clinical decision-making process by reviewing a number of cases and defining the various diagnostic and management decisions open to clinicians. Each title will be illustrated and diverse in scope, enabling the reader to obtain relevant clinical information regarding both standard and unusual cases in a rapid, easy to digest format.

Atooshe Rohani

Clinical Cases in the Management of Complex Cardiovascular Disease

Atooshe Rohani Northern Ontario School of Medicine Thunder Bay, ON, Canada

ISSN 2523-3009     ISSN 2523-3017 (electronic) Clinical Cases in Cardiology ISBN 978-3-031-24527-5    ISBN 978-3-031-24528-2 (eBook) https://doi.org/10.1007/978-3-031-24528-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1

Introduction���������������������������������������������������������������������   1

2

 igoxin Toxicity in a Patient with Pacemaker �����������   3 D References�����������������������������������������������������������������������   6

3

 yocarditis and Cardiogenic Shock�����������������������������   7 M References�����������������������������������������������������������������������  10

4

Tachycardia Mediated Cardiomyopathy and Cardiogenic Shock �������������������������������������������������  11 References�����������������������������������������������������������������������  14

5

Cardiac Arrest in Cardiac Rehabilitation Then an Alarming ICD While on Vacation���������������������������  15 Further Reading�������������������������������������������������������������  17

6

Atrioventricular Block in the Context of Inferior ST Elevation Myocardial Infarction (STEMI) �������������������������������������������������������������������������  19 Further Reading�������������������������������������������������������������  23

7

 arcinoid Tumor and Peripheral Edema���������������������  25 C Further Reading�������������������������������������������������������������  28

8

Saddle Pulmonary Embolism and Atrial Fibrillation�����������������������������������������������������������������������  29 References�����������������������������������������������������������������������  33

9

Non-ST Elevation MI and Spontaneous Coronary Artery Dissection �����������������������������������������  35 References�����������������������������������������������������������������������  38

vi

Contents

10 R  V Lead Integrity Warning Following by Inappropriate ICD Shock���������������������������������������������  41 References�����������������������������������������������������������������������  43 11 P  ost Dialysis Hypotension, New Diagnosis of HOCM�������������������������������������������������������������������������  45 Further Reading�������������������������������������������������������������  48 12 M  itral and Aortic Valve Disease in a Patient with End Stage Renal Disease �������������������������������������  49 References�����������������������������������������������������������������������  51 13 S  ustained Monomorphic Ventricular Tachycardia (SMVT) in a Patient with ICD. No Shock Delivered. What Is Going Wrong?�������������  53 References�����������������������������������������������������������������������  56 14 M  V Endocarditis and Stroke ���������������������������������������  59 References�����������������������������������������������������������������������  64 15 R  ecurrent Chest Pain and Lytic Lesion in the Spine���������������������������������������������������������������������  65 References�����������������������������������������������������������������������  67 16 A  cute Type A Aortic Dissection in a Young Man ���������������������������������������������������������������������  69 References�����������������������������������������������������������������������  74 17 L  ong QT and Atrial Fibrillation: Are These a Related Entity or Not?�����������������������������������������������  77 References�����������������������������������������������������������������������  80 18 S  CN5A Mutation and Syncope�������������������������������������  83 References�����������������������������������������������������������������������  86 19 T  achycardia Mediated Cardiomyopathy Recovered After Successful Atrial Flutter and Fibrillation Ablation�����������������������������������������������  89 References�����������������������������������������������������������������������  92 20 Recurrent Myocarditis���������������������������������������������������  95 Further Reading�������������������������������������������������������������  97

Contents

vii

21 S  T Depression in Holter, Associated with Chest Pain���������������������������������������������������������������  99 References�����������������������������������������������������������������������101 22 A  symptomatic Mobile Cardiac Mass��������������������������� 103 Further Reading������������������������������������������������������������� 105 23 S  hortness of Breath on Exertion and Mobitz Type 1 AV Block������������������������������������������������������������� 107 References����������������������������������������������������������������������� 109 24 A  symptomatic Atrial Flutter with Rapid Ventricular Response Left Atrial Appendage (LAA) Clot and Heart Failure with Reduced EF ����������������������������������������������������������� 111 References����������������������������������������������������������������������� 113 25 B  radycardia and Hypotension in a Covid-19 Positive Patient��������������������������������������������������������������� 115 25.1 Physical Examination������������������������������������������� 116 25.2 Investigations��������������������������������������������������������� 117 References����������������������������������������������������������������������� 118 26 M  yotonic Dystrophy Type 2 and Cardiomyopathy������������������������������������������������������������� 121 References����������������������������������������������������������������������� 124 27 C  oncomitant Hypertrophic Cardiomyopathy and Aortic Valve Stenosis in a Patient with Shortness of Breath����������������������������������������������� 125 References����������������������������������������������������������������������� 129 28 Takotsubo Cardiomyopathy ����������������������������������������� 131 References����������������������������������������������������������������������� 135 29 F  requent ICD Shock Despite Being on Amiodarone, a Double Edge Sword!��������������������������� 137 References����������������������������������������������������������������������� 140 30 R  A MASS, Tumor or Clot in a Breast Cancer Patient����������������������������������������������������������������� 141 References����������������������������������������������������������������������� 143 Index����������������������������������������������������������������������������������������� 145

Abbreviations

AF ARNI ATP AVR BNP BrS CAD CCU CHF CMR COPD CPAP

Atrial fibrillation Angiotensin receptor neprilysin inhibitor Antitachycardia pacing Aortic valve replacement Brain natriuretic peptide Brugada syndrome Coronary artery disease Critical care unit Congestive heart failure Cardiac magnetic resonance Chronic obstructive pulmonary disease Continuous positive airway pressure therapy CrCl Creatinine clearance CT Computed tomography CTA Computed tomography angiogram CTO Chronic total occlusion DCM Dilated cardiomyopathy DVT Deep vein thrombosis ECG Electrocardiography EF Ejection fraction GFR Glomerular filtration rate HFrEF Heart failure with reduced ejection fraction HOCM Hypertrophic obstructive cardiomyopathy ICD Implantable cardioverter-defibrillator INR International normalized ratio LAA Left atrial appendage

x

Abbreviations

LAD LCX LGE LMWH LQTS LV LVEDP LVEF LVOT LVOTO

Left anterior descending artery Left circumflex Late gadolinium enhancement Low-molecular-weight heparin Long QT syndrome Left ventricle Left ventricular end-diastolic pressure Left ventricle ejection fraction Left ventricular (LV) outflow tract Left ventricular outflow tract obstruction MR Mitral regurgitation MRA Aldosterone receptor antagonists MRI Magnetic resonance imaging NYHA New York Heart Association PCI Percutaneous coronary intervention PE Pulmonary embolism PERC Pulmonary embolism rule-out criterion PPM Permanent pacemaker RCA Right coronary artery RV Right ventricle SAM Systolic anterior motion of mitral valve SBP Systolic blood pressure SC Subcutaneously SCD Sudden cardiac death SSS Sick sinus syndrome SVT Supraventricular tachycardia tPA Tissue plasminogen activator TAVI Transcatheter aortic valve implantation TdP Torsades de pointes TIMI flow grade Thrombolysis in myocardial infarction, it is used for the assessment of coronary artery flow in acute coronary syndromes. [Grade 0 (no flow), grade 1 (penetration without perfusion), grade 2 (partial perfusion), or grade 3 (complete perfusion)]. UFH Unfractionated heparin

Abbreviations

V/Q Ventilation-perfusion VF Ventricular fibrillation VT Ventricular tachycardia VTE Venous thromboembolism VVI Ventricular demand pacing

xi

Chapter 1 Introduction

This book includes 30 complex clinical cardiology cases. Even though cardiac cases sometimes sound very straightforward, we should keep in mind that it can be quite tricky. For instance, an endocarditis case or three vessel coronary artery disease could present only with heart failure  symptoms. A smart cardiologist must investigate deep down and not just to the tip of the iceberg. I wrote this book to transfer my expertise in the field to internists, cardiology fellows, and hospitalists across the world. I would like to thank my patients, who gave their consent to use their clinical data and also Thunder Bay Regional Health Sciences Centre Chief of Staff, for his support in writing this book. I am also incredibly grateful for the love and support from my family and friends that helped me with creating this book. Finally, I want to dedicate this book to my lovely daughter Parmida, as a reminder to follow her dreams no matter how hard it seems to be. Please be advised that clinical  recommendations in this book  should not be used for clinical care  of patients. This should only be based on practical society guidelines.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Rohani, Clinical Cases in the Management of Complex Cardiovascular Disease, Clinical Cases in Cardiology, https://doi.org/10.1007/978-3-031-24528-2_1

1

Chapter 2 Digoxin Toxicity in a Patient with Pacemaker Abstract  The Patient is an 88-year-old female with chronic persistent atrial fibrillation and VVI pacemaker presented with confusion, nausea, vomiting, headache, visual hallucination, and abdominal pain. She was found to have increased digoxin level and hyperkalemia. She received digoxin Fab, and her clinical condition improved. Keywords  Digoxin Fab fragments · Pacemaker · Hyperkalemia Clinical Case The Patient is an 88-year-old female with chronic persistent atrial fibrillation. She has a VVI pacemaker because of atrial fibrillation with slow ventricular response (tachy-brady syndrome). She was on bisoprolol 2.5  mg/day, spironolactone 12.5 mg/day, apixaban 2.5 mg twice a day and digoxin 0.25 mg/ day. She arrived at the hospital with confusion, nausea, vomiting, headache, visual hallucination, and abdominal pain which was gradually worsening over the last couple of days. On presentation she had stable vital signs. She was alert but not oriented to time and place. Her abdominal exam was

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Rohani, Clinical Cases in the Management of Complex Cardiovascular Disease, Clinical Cases in Cardiology, https://doi.org/10.1007/978-3-031-24528-2_2

3

4

Chapter 2.  Digoxin Toxicity in a Patient with Pacemaker

Figure 2.1  ECG shows ventricular Pacemaker rhythm, underlying atrial fibrillation

unremarkable. On blood work, she had a potassium level of 5.5 mmol/L, GFR: 45 and 3 nmol/L digoxin level. She did not have leukocytosis or any lab evidence of infection. The ECG showed a pacemaker rhythm (Fig. 2.1). The Echocardiogram showed an ejection fraction of 50%, mild to moderate MR and severely enlarged left atrium. Given the fact that she had clinical symptoms of digoxin toxicity, hyperkalemia and increased digoxin level, digoxin Fab fragments were administered. This improved the patient’s clinical condition. At the time of discharge, digoxin and spironolactone stopped and the dose of bisoprolol increased to 2.5 mg twice a day. On follow up with Holter, she had an acceptable rate controlled atrial fibrillation. Clinical Pearls • Four hours after an intravenous dose or 6 h after an oral dose of digoxin is the best time to measure digoxin level [1]. • Each vial of DigiFab contains 40 mg digoxin immune fab and will bind to 0.5 mg digoxin [1].

2  Digoxin Toxicity in a Patient with Pacemaker

5

• If there is critical or life-threatening arrhythmia and digoxin level is unknown, or the cardiologist cannot wait for the result due to the patient’s clinical condition, ten vials of digoxin Fab fragments for adults needs to be administered, if not it could be calculated with this formulae [2]: ( serum digoxin concentration in ng / mL )   / 100 ( patient' s weight in kg ) 

Number of vials = 

• Indications for digoxin-specific antibody (Fab) fragments [3]: Elevated digoxin level and one of the following: –– Life-threatening tachy or bradyarrhythmia (like as ventricular fibrillation; ventricular tachycardia; Mobitz II heart block; symptomatic bradycardia, asystole; complete heart block) –– Hyperkalemia (serum potassium >5 to 5.5 mmol/L) –– Evidence of end-organ failure (altered mental status, renal failure) • In the context of hyperkalemia and digoxin toxicity, Calcium should be avoided, and hyperkalemia could be managed with digoxin-specific antibody fragments [4]. • Patients with renal dysfunction who are receiving Fab fragments should be monitored for a minimum of 72 h. • After Fab fragments are administered, a measurement of serum digoxin level is unreliable. • Cardioversion is relatively contraindicated in the context of digoxin toxicity as it might precipitate asystole or ventricular fibrillation. –– It sounds as though myocardium would be more sensitive to digoxin with Hypokalemia, so even with normal serum digoxin level, toxic effects could happen [5]. –– In a study published by Kotecha and colleagues, it was shown that low-dose digoxin may still safely be consid-

6

Chapter 2.  Digoxin Toxicity in a Patient with Pacemaker

ered as an alternative to β-blockers to achieve well heart rate control in patients with permanent AF [6].

References 1. Antman EM, Wenger TL, Butler VP Jr, Haber E, Smith TW. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation. 1990;81(6):1744–52. https://doi. org/10.1161/01.cir.81.6.1744. PMID: 2188752. 2. Hassan SA, Goyal A. Digoxin Immune Fab. [Updated 2020 Dec 9]. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. https://www.ncbi.nlm.nih.gov/books/NBK556101/. 3. Li-Saw-Hee FL, Lip GY. Digoxin revisited. QJM. 1998;91(4):259– 64. https://doi.org/10.1093/qjmed/91.4.259. PMID: 9666948. 4. Bayer MJ. Recognition and management of digitalis intoxication: implications for emergency medicine. Am J Emerg Med. 1991;9(2 Suppl 1):29–32. https://doi.org/10.1016/0735-­6757(91)90165-­g; discussion 33–4. PMID: 1997019. 5. Pfirman KS, Huffman TR, Singh A.  Digoxin-induced bidirectional ventricular tachycardia in a patient with hypokalemia. JAMA Intern Med. 2021;181(6):850–2. 6. Kotecha D, Bunting KV, Gill SK, et  al. Effect of digoxin vs bisoprolol for heart rate control in atrial fibrillation on patient-­ reported quality of life: the RATE-AF randomized clinical trial. JAMA. 2020;324(24):2497–508.

Chapter 3 Myocarditis and Cardiogenic Shock

Abstract  A 50-year-old man with fulminant heart failure, a condition secondary to acute myocarditis, most likely of a viral etiology, complicated with cardiogenic shock, transient high-grade AV block, subsequent septic shock and multiorgan failure treated with a course of steroid with full recovery of heart failure with reduced EF. Keywords  Myocarditis · Cardiogenic shock · Ventricular tachycardia Clinical Case The Patient is a 50-year-old diabetic male presented to the hospital with worsening shortness of breath, NYHA class 2–3 which began 1 week prior to his admission. His blood sugars, usually well controlled, at the time of presentation were extremely high. He denied any chest pain. On examination, he was awake, alert, oriented and was able to give a good history but seems to have some cognitive issues. He had a blood pressure of 94/55 mmHg, a pulse rate of 34 bpm, a respiratory rate of 14/min and he was Afebrile. On 2 L of oxygen, he had an oxygen saturation of 100%. The Abdomen was soft and non-tender and there was no peripheral edema.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Rohani, Clinical Cases in the Management of Complex Cardiovascular Disease, Clinical Cases in Cardiology, https://doi.org/10.1007/978-3-031-24528-2_3

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8

Chapter 3.  Myocarditis and Cardiogenic Shock

His ECG showed complete AV block (Fig. 3.1). He had a mixed lactic (lactate level of 8.8  mmol/L) and ketoacidosis (HCO3 9 mmol/L) in association with diabetic hyperglycemia. He had an elevated troponin, 18.9  ng/mL, an acute kidney injury, Creatinine 290 μmol/L and marked electrolyte abnormalities, profound critical hypomagnesemia, hypophosphatemia, and mild hypokalemia. Patient was admitted to the intensive care unit. Dopamine 5 μg/kg/min, insulin drip and fluids were promptly started. He underwent temporary pacemaker placement until correction of electrolyte abnormalities led to a resolution of the AV block. He underwent urgent cardiac catheterization, which demonstrated normal coronary arteries. The next day after angiogram, the Urine showed a growing Strep group B, which was treated with 1  g of Ampicillin, IV q 6 H.  The patient then developed ventricular tachycardia (Fig.  3.2), once propofol was given for cardioversion, he converted spontaneously to sinus rhythm, but developed respiratory distress, was intubated, placed on dopamine and Levophed for cardiogenic plus/minus septic shock. COVID swab was negative.

Figure 3.1  ECG strip shows complete heart block

Figure 3.2  ECG strip shows sustained ventricular tachycardia

3  Myocarditis and Cardiogenic Shock

9

The Echocardiogram showed marked LV dysfunction with ejection fraction of 20–25%. A CT head did not show any acute process. Cardiac MRI was completed showing evidence of myocardial edema. He then underwent endomyocardial biopsy. The biopsy showed active myocarditis with mix of lymphocytes, and no granulomas seen. Then he received a short course of prednisone, 30 mg for 5 days. After this, the echocardiogram showed recovery of LV ejection fraction to 57%. His Creatinine also normalized to 75, Lactic Acidosis resolved (3 days or surgery within 4 weeks

1.5

Previous DVT or PE

1.5

Hemoptysis

1

Malignancy

1

Wells score

High risk

Intermediate risk

Low risk

Score

>6

2–5.5

0–1.5

References

33

score, chest CT angiogram should be ordered directly to establish the diagnosis. • The most challenging part of treatment in a patient with pulmonary embolism is what decision to make about thrombolysis. The most widely accepted indication is presence of hypotension related to PE. Other indications include: [3–7] 1. Severe right ventricular dysfunction due to PE (intermediate risk PE) 2. Presence of severe hypoxemia 3. Extensive clot burden Catheter-directed approaches: In patients with high risk of bleeding with persistent hemodynamic instability or unstable patients despite the use thrombolysis, this modality could be considered.

References 1. Aujesky D, Obrosky DS, Stone RA, et  al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041–6. https://doi.org/10.1164/ rccm.200506-­862OC. 2. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170:1383–9. https://doi.org/10.1001/archinternmed.2010.199. 3. Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et  al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414–21. https:// doi.org/10.1001/jama.2014.5990. 4. Kucher N, Boekstegers P, Müller OJ, Kupatt C, Beyer-Westendorf J, et  al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129(4):479–86. https://doi. org/10.1161/CIRCULATIONAHA.113.005544.

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Chapter 8.  Saddle Pulmonary Embolism and Atrial...

5. Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, et  al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160(6):e545–608. https://doi.org/10.1016/j. chest.2021.07.055. 6. Stals MAM, Takada T, Kraaijpoel N, van Es N, Büller HR, Courtney DM, et  al. Safety and efficiency of diagnostic strategies for ruling out pulmonary embolism in clinically relevant patient subgroups: a systematic review and individual-patient data meta-analysis. Ann Intern Med. 2022;175(2):244–55. https:// doi.org/10.7326/M21-­2625. 7. Stein PD, Goldhaber SZ, Henry JW, Miller AC.  Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest. 1996;109(1):78–81. https://doi.org/10.1378/ chest.109.1.78.

Chapter 9 Non-ST Elevation MI and Spontaneous Coronary Artery Dissection Abstract Patient is a 36-year-old female who presented with an acute onset of chest pain. She had raised levels in troponin and negative d-dimer and negative Beta-Human Chorionic Gonadotropins (beta HCG). She underwent coronary angiogram which showed spontaneous coronary artery dissection in distal of LAD. She was treated with dual antiplatelet therapy and morphine for pain. On follow up angiogram dissection healed. Keywords Spontaneous coronary artery Myocardial infarction (MI) · Chest pain

dissection

Clinical Case Patient is a 36-year-old female who presented with acute onset of chest pain. It was a severe retrosternal chest pain which happened at rest with severity scale of 10/10. There was no radiation of pain. She had no history, personal or familial, of cardiac disease. She is a smoker and denied having ­palpitation or syncope. Physical exam revealed an anxious young female who was obviously in excruciating pain with stable vital sign and no murmur on cardiac examination. JVP was flat with no peripheral edema, and the chest was clear. On ECG (Fig. 9.1), she had 1 mm ST elevation in V2, V3 with absence of ST depression in inferior leads. She had raised in © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Rohani, Clinical Cases in the Management of Complex Cardiovascular Disease, Clinical Cases in Cardiology, https://doi.org/10.1007/978-3-031-24528-2_9

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Chapter 9.  Non-ST Elevation MI and Spontaneous…

Figure 9.1  ECG shows 1 mm ST elevation in V2, V3

troponin up to 0.6(cut off point20–30 pounds in women, and in men >50 pounds are suggested [2]. • Target exercise heart rate is recommended at 50–70% of heart rate reserve, and systolic blood pressure during exercise is limited to