A Patient With Athlete's Heart Syndrome: When the Abnormal Is Normal

Long-term athletic training can result in structural and conduction changes within the heart, leading to Athlete's heart syndrome (AHS). This syndrome is characterized by increased left ventricle (LV) dimensions, thickness, and mass. Dynamic exercise significantly contributes to these alterations, with sinus bradycardia being a common conduction abnormality, often accompanied by first-degree atrioventricular (AV) block. However, higher degrees of AV conduction abnormalities, such as second- and third-degree blocks, though rare, might occur due to parasympathetic hypertonia. Prompt evaluation is necessary to rule out underlying structural or infiltrative heart diseases. We present the case of a 66-year-old lifelong long-distance runner with marked sinus bradycardia, AV dissociation, and junctional escape rhythm, alongside left ventricular hypertrophy (LVH) and T-wave repolarization abnormalities. Subsequent studies ruled out possible pathologies, and the patient was diagnosed with AHS, characterized by cardiac remodeling and bradycardia due to prolonged cardiac loading. This case underscores the importance of clinical assessment, cardiac imaging, and exclusion of pathologic causes to distinguish normal physiological adaptations from potentially concerning conditions.

A Rare Case of Kounis Syndrome Secondary to Infliximab

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or anaphylactic reactions. It manifests as coronary artery vasospasm, acute myocardial infarction, or coronary stent thrombosis, resulting from inflammatory cytokine release and inappropriate activation of platelets and mast cells. We present a case of an 85-year-old male with Crohn's disease who suffered anaphylaxis during infliximab infusion, culminating in non-ST myocardial infarction (NSTEMI). The patient's symptoms were effectively managed with epinephrine and diphenhydramine, and KS secondary to infliximab was diagnosed. Diagnosing KS can be challenging due to the overlapping signs of an allergic reaction and myocardial infarction. Timely recognition and appropriate management of KS are crucial to enhance patient outcomes. Therefore, healthcare providers should maintain a high index of suspicion for KS in patients with acute coronary syndromes linked to allergic reactions to optimize care and minimize potential risks. This case report underscores the significance of prompt intervention and awareness of Kounis syndrome in clinical practice.

Unusual Case of Acute Coronary Syndrome Due to Compression of the Left Main Coronary Artery From a Contained Aortic Root Perforation

We present an intriguing and rare case of a 71-year-old male who presented with a non-ST elevation myocardial infarction (NSTEMI). Initial coronary angiography revealed severe and unusual systolic extrinsic compression of the left main coronary artery (LM), warranting further advanced imaging investigations. Computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were employed to determine the underlying cause, which was identified as a contained aortic rupture leading to the formation of a pseudoaneurysm in the left coronary sinus of Valsalva and aortic root. This condition was found to be a sequela of previously undiagnosed endocarditis, likely secondary to lower extremity osteomyelitis and bacteremia, for which the patient received prolonged intravenous (IV) antibiotic therapy. This case highlights the critical role advanced imaging techniques play in accurately diagnosing and characterizing complex cardiovascular abnormalities, enabling early intervention and optimizing patient outcomes. Healthcare providers should remain vigilant for such atypical presentations to ensure timely and appropriate management.

An Unusual Presentation of Apical Hypertrophic Cardiomyopathy in an Orthotopic Heart Transplant Recipient

In this case study, we present the evaluation of an orthotopic heart transplant (OHT) patient who presented with persistent shortness of breath and dizziness upon standing. The investigation uncovered the presence of progressive hypertrophic cardiomyopathy (HCM) in the transplanted heart, a condition first detected 11 years after the transplantation. Utilizing echocardiography with global longitudinal strain (GLS), we determined that the HCM likely originated from genetic predominance inherited from the heart donor rather than hypertensive disease. This finding highlights the significance of genetic factors in post-transplant complications and warrants further investigation into the long-term effects of heart transplantation on recipient health.

An Uncommon Case of Myocarditis Secondary to Durvalumab Plus Tremelimumab

Tumor immunotherapy is an important clinical strategy for the treatment of various solid and hematological malignancies, and its use is on the rise. Immune checkpoint inhibitors (ICIs) are immunotherapies that boost anticancer immune responses by targeting receptors on the surface of T-lymphocytes. Two important ICIs are anti-programmed death ligand-1 (anti-PD-L1) monoclonal antibodies and anti-cytotoxic T-lymphocyte-associated antigen-4 (anti-CTLA-4) monoclonal antibodies. Tremelimumab (anti-CTLA-4) and durvalumab (anti-PD-L1) have been shown to be effective monotherapies. However, their combination has demonstrated effective and encouraging antitumor activity with manageable safety in patients with unresectable hepatocellular carcinoma. We present the case of an 80-year-old male with hepatocellular carcinoma who had undergone drug-eluting bead transarterial chemoembolization (DEB-TACE) on three occasions and had been started on a combination of ICIs, durvalumab, and tremelimumab. He subsequently developed various immune-related adverse effects in different organ systems, including hepatic and cardiovascular complications. Appropriate treatment was administered, but ultimately, he passed away. We aim to discuss the initial evaluation for suspected immune-related adverse events, specifically those related to myocarditis and its various manifestations, prognosis, and treatment.

Cardiac Platypnea-Orthodeoxia Syndrome: A Rare Case of Flow-Directed, Right-to-Left Shunt via a Patent Foramen Ovale Exacerbated by Aortic Root Enlargement

Cardiac platypnea-orthodeoxia is a unique clinical syndrome characterized by dyspnea and deoxygenation when moving from a supine to an upright position. In this case report, we detail the experience of a 78-year-old male with persistent hypoxemia following a paradoxical embolic ischemic stroke. Despite proper management of his respiratory symptoms, the patient continued to be affected by marked dyspnea and hypoxemia, particularly when upright or in a right-sided decubitus position. Subsequent investigation revealed that his hypoxemia was a result of cardiac platypnea-orthodeoxia syndrome (POS). This condition was attributed to the enlargement of his aortic root and ascending aorta, coupled with a counterclockwise rotation of the heart axis. These factors facilitated a flow-directed, right-to-left interatrial shunt through a patent foramen ovale, even in the absence of elevated right heart pressures.

Shark Fin Occlusive Myocardial Infarction ECG Pattern Post-cardiac Arrest Misinterpreted As Ventricular Tachycardia

In addition to the well-known convex ST-segment elevation myocardial infarction (STEMI) pattern associated with acute occlusive myocardial infarction (OMI), there are other cases that are recognized as OMI without fulfilling the established characteristic STEMI criteria. Over one-fourth of the patients initially classified as having non-STEMI can be re-classified as having OMI by recognizing other STEMI equivalent patterns. We report a case of a 79-year-old man with multiple comorbidities who was brought to the ED by paramedics with a two-hour history of ongoing chest pain. During transport, the patient suffered a cardiac arrest associated with ventricular fibrillation (VF) that required electric defibrillation and active cardiopulmonary resuscitation. Upon ED arrival, the patient was unresponsive, with a heart rate of 150 beats/min and ECG evidence of wide-QRS tachycardia that was misinterpreted as ventricular tachycardia (VT). He was further managed with intravenous amiodarone, mechanical ventilation, sedation, and unsuccessful defibrillation therapy. Upon persistence of the wide-QRS tachycardia and clinical instability, the cardiology team was emergently consulted for bedside assistance. On further review of the ECG, a shark fin (SF) OMI pattern was identified, indicative of an extensive anterolateral OMI. A bedside echocardiogram revealed a severe left ventricular systolic dysfunction with marked anterolateral and apical akinesia. The patient underwent a successful percutaneous coronary intervention (PCI) to an ostial left anterior descending (LAD) culprit occlusion with hemodynamic support but ultimately died due to multiorgan failure and refractory ventricular arrhythmias. This case illustrates an infrequent OMI presentation (<1.5%) formed by the fusion of the QRS, ST-segment elevation, and T-wave resulting in a wide triangular waveform, giving the appearance of an SF that can also potentially lead to ECG misinterpretation as VT. It also highlights the importance of recognizing STEMI-equivalent ECG patterns to avoid delays in reperfusion therapy. The SF OMI pattern has also been associated with a large amount of ischemic myocardium (such as with left main or proximal LAD occlusion) with a higher mortality risk from cardiogenic shock and/or VF. This high-risk OMI pattern should lead to a more definite reperfusion treatment, such as primary PCI and the possible need for backup hemodynamic support.

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.