54–year–old woman with a family history of systemic sclerosis, with no significant cardiological history. She underwent anti–Covid vaccination in February and March 2021 with Spikevax (Moderna) and a booster dose (Spikevax) on 09/12/21. A few hours after this last administration, the patient presented with palpitations, asthenia, and intermittent chest tightness. In the following days, because of dyspnea for mild exertion, she went to the emergency department. ECG showed low QRS voltages in the peripheral leads, poor septal r wave growth and negative T waves in inferior leads and from V3 to V6. Echocardiography showed akinesia of apical and middle segments, LVEF 40%, mitral obstructive systolic anterior motion, moderate mitral regurgitation and mild pericardial effusion. In blood tests: increase in myocardiospecific enzymes and NTproBNP, modest increase in indices of inflammation. The patient was admitted to Cardiology Unit, where coronary angiography showed coronary arteries free from stenosing lesions and Takotsubo–like appearance on ventriculography. Cardiac MRI confirmed alterations in parietal kinetics, hyperintensity in the STIR sequences referable to apical and middle segments edema compatible with Takotsubo cardiomyopathy (CMT). Capillaroscopy excluded scleroderma pattern. The patient presented a progressive reduction of troponins and, the echocardiogram before discharge showed improved LV systolic function, regression of mitral obstructive systolic anterior motion with reduction of mitral regurgitation. Rare case reports of CMT after influenza vaccination [1] and a similar case to the one we described after Spikevax vaccine [2] and ChAdOx1 nCov–19 (AstraZeneca) [3] have been presented in the literature. The underlying pathophysiological mechanism appears to be related to a stress–induced systemic reaction with a predominantly adrenergic sympatho–vagal imbalance [4]. In this clinical setting, cardiac MRI can offer added value in the diagnostic process, especially to exclude post–vaccine myocarditis, which in our case seemed unlikely given the immediate onset of symptoms.

There are many clinical conditions in which symptoms and signs can overlap, resulting in a real "clinical dilemma". Differential diagnosis is essential for identifying the pathology affecting a patient and consequently making the best therapeutic decisions. Herein we report a case of a young patient, with strong smoking habit, who looked for medical attention after experiencing chest pain, associated to upper airways inflammation. EKG revealed ischemic abnormalities, echocardiography showed a preserved ejection fraction (EF: 55%) and global cardiac contractility, although akinesia of the mid–segment of the inferolateral wall, and the presence of a mild inferolateral pericardial effusion. A concomitant increase in myocardial necrosis enzymes and inflammatory markers was observed in blood tests, but the coronarography showed undamaged coronary arteries. This clinical picture characterized by the young age of the patient, by the intercurrent inflammatory event, by the presence of pericardial rubbing on physical examination, by the evidence of echocardiographic end EKG anomalies in the absence of documentable epicardial lesions and by the complete symptomatic remission after anti – inflammatory therapy with acetylsalicylic acid and Colchicine was highly suggestive of pseudoinfarct–presenting myopericarditis. To confirm such diagnosis, cardiac magnetic resonance (CMR) was requested, unexpectedly, it showed oedema on the mid–basal inferolateral T2–weighted STIR sequences, but also microvascular obstruction (MVO) on early EGE contrastographic sequences mid–basal inferolateral site, and finally evidence of transmural fibrosis in the same site to the DE sequences resulting in pathognomonic lesions for acute ischemia in absence of epicardial coronaropathy. CMR imaging, which is able to analyse cardiac structure and function and simultaneously provide tissue characterization, has been an essential investigation for the diagnosis of MINOCA, as CMR can readily pinpoint many conditions responsible for myocardial damage and allow pathological discrimination of patients. Our patient‘s final diagnosis was “STEMI, MINOCA, and concomitant pericarditis” implying a consequent therapeutic modification, introducing DAPT. Making differential diagnosis in similar clinical conditions characterized by overlapping presentations, allows the use of personalized therapeutic strategies for each patient and better final results.

Background A careful and integrated follow up after hospitalization for heart failure (HF) may represent a feasible strategy to optimize the adherence to ESC guidelines and reduce the occurrence of adverse events (mortality, re–hospitalizations). Methods A strict integration between hospital and local health district proximity office cardiologist through an integrated clinical data sharing software has been implemented in Apulia region, Italy, in order to optimize the management of the HF patient after an hospitalization: the PONTE (PDTA FOR INTEGRATED FOLLOW–UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) (bridge) project. As until December 2021, 1200 patients with HF have been enrolled in the project, both with reduced (HFrEF) and preserved ejection fraction (HFpEF). Adherence to ESC HF guidelines in HFrEF patients before vs after December 2020 was compared. Results In the HFrEF population (56%) the mean age was 63 years, 38% were hypertensive, 15% diabetic, 40% had ischemic heart disease, 42% were previously treated with coronary angioplasty, 56% had an ICD/CRT, 22% had atrial fibrillation. Mean NYHA class was 2.2, mean LVEF 30%, mean NT–proBNP values 4027 pg/mL, mean serum creatinine 1 mg/dL, 91% were taking beta–blockers (BB), 86% mineral corticoid receptor antagonists (MRA), 98% ACE–inhibitors/angiotensin–receptor–antagonists/neprilysin and angiotensin receptor antagonists (ACE/ARB/ARNI), and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs 13%, p < 0.001); in 30% ARNI were prescribed in hospital before discharge. Furthermore, in 10% of the population (most diabetics), sodium glucose cotransporter type 2 inhibitors (SGLT2i) have been prescribed as indicated by the latest ESC 2021 guidelines. Conclusions The implementation the PONTE project shows an improved adherence to ESC HF guidelines.

Over recent years, mainly due to a broad use of coronary angiography and intracoronary imaging techniques (IIT), SCAD has emerged as a no longer rare cause of acute coronary syndrome (ACS). Early diagnosis is extremely important to avoid potentially lethal complications; nevertheless, considerable uncertainty remains about optimal acute and post–discharge management. Current endorsed therapeutic strategy lean towards an initial conservative approach, relegating percutaneous or surgical coronary intervention to high–risk coronary anatomy or in case of hemodynamic instability. We report our experience in the field by presenting a clinical case of a 36–year–old woman admitted to emergency department with acute, anginal pain started 24 hours earlier, referring no medical history, except for a syncopal episode occurred four days earlier, in correspondence of a mournful event. She was hemodynamically stable, with work–up significant only for elevated troponin level of 3649.5 ng/ml (n.v. <11). Coronary angiogram showed atherosclerotic–like changes limited to right coronary artery (RCA), with focal subcritical stenosis at its proximal segment (Fig 1). In the absence of major precipitating factors for atherosclerotic coronary disease, SCAD was suspected. IVUS and OCT were performed, with evidence of dissection and intra–mural haematoma (Fig. 2), extending from proximal RCA to posterior descending branch take–off, compressing the true lumen. Considering both anatomical (coronary ostium not involved) and clinical (patient asymptomatic and hemodynamically stable) factors, conservative treatment with low dose aspirin and beta blocker was prescribed. After three days of hospitalization occurred a single episode, lasted 5 minutes, of anginal pain associated with ST elevation in inferior leads, managed with nitrates administration; subsequent cardiac computed tomography angiography excluded disease progression (Fig.2). On the 23rd day, due to angiographic evidence of SCAD partial healing (Fig.3), the patient was discharged. This case highlights the importance of keeping in mind the possibility of SCAD, especially when healthy young women with prior emotional stress present with ACS. IIT allow to shed light on the true mechanism of ACS without significant obstructive coronary disease. Finally, in case of conservative approach, close in–hospital monitoring is mandatory, given the highest probability of complications in the first days after clinical onset.