T ransient apical ballooning syndrome, or takotsubo cardiomyopathy, is a syndrome characterized by reversible dilation of the left ventricular apex. It usually occurs in response to stress, and resolves completely in a few weeks. In the present report, we describe a patient who presented with recurrent episodes of chest pain and syncope in response to emotional stress; subsequently, she was diagnosed with recurrent takotsubo cardiomyopathy. Case PresentationA 55-year-old Caucasian woman with a medical history of hypertension, dyslipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis and depression presented to the hospital with a two-day history of chest pain, and a syncopal episode that lasted for a few minutes and resolved spontaneously. These symptoms occurred after an argument with a family member. The patient was a smoker, but denied any ethanol use or drug abuse. On arrival to the hospital, she had a blood pressure of 100/70 mmHg and a heart rate of 58 beats/min. Her cardiac examination was unremarkable. The initial electrocardiogram (ECG) reading showed deep T wave inversion in the anterolateral and inferior leads (Figure 1), with a corrected QT (QTc) interval of 509 ms. Her troponin I was positive at 7.2 µg/L (normal less than 0.5 µg/L), while her creatine kinase was not elevated. The patient was started on acetylsalicylic acid, heparin and beta-blockers. She continued to have chest pain despite medical therapy. The patient subsequently underwent cardiac catheterization, which showed apical akinesis on left ventriculography (Figure 2) with no significant coronary artery disease. Results from the ergotamine challenge showed no evidence of coronary artery spasm. Echocardiography ( Figure 3) showed abnormal left ventricular contraction with akinesis of the distal segment and apex. Overall, the ejection fraction (EF) was 49%. A wall motion study (WMS) showed an EF of 72% with a moderately dilated left ventricle and dyskinesia in the apex and apical inferior regions. Results from a 24 h urine collection were as follows: adrenaline 0 nmol/L; noradrenaline 292 nmol/L; and dopamine 834 nmol/L. All these readings were within normal limits. Results from autoimmune screening were negative.At that time, the patient was diagnosed with myocarditis and was discharged on the following medications: metoprolol, ramipril, warfarin, rosuvastatin, amlodipine and acetylsalicylic acid. A WMS repeated six months later was within normal limits and suggested the absence of the previously noted wall motion abnormalities.Eighteen months following the initial presentation, the patient was admitted to the hospital with similar symptoms after the sudden death of her husband. She was on acetylsalicylic acid, ramipril, amlodipine, hydrochlorothiazide, atorvastatin, hydromorphone, triazolam and escitalopram, which was started recently. Her ECG was similar to the previous presentation, with a QTc interval of 556 ms. Her troponin I was positive and there were no significant changes on repeat cardiac c...

Background As a result of the COVID-19 pandemic first wave, reductions in STEMI invasive care ranging from 23% to 76% have been reported from various countries. Whether it had any impact on coronary angiography (CA) volume or on mechanical support device use for ST-elevation myocardial infarction (STEMI) and post-STEMI mechanical complications in Canada is unknown. Methods We administered a Canada-wide survey to all Cardiac Catheterization Laboratory Directors seeking the volume of CA for STEMI performed during 01/03/2020-31/05/2020 (pandemic period) and from two control periods (01/03/2019-31/05/2019 and 01/03/2018-31/05/2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects or papillary muscle rupture cases diagnosed, were also recorded. We also assessed if the number of COVID-19 cases recorded in each province was associated with STEMI CA volume. Results Forty-one out of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (Incidence Rate Ratio or IRR 0.84; 95%CI 0.80-0.87) in CA for STEMI during the first wave of the pandemic compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95%CI 0.61-0.89) in the use of intra-aortic balloon pump in STEMI. Use of Impella® and mechanical complications from STEMI were exceedingly rare. Conclusion We observed a modest 16% decrease in CA for STEMI during the pandemic first wave in Canada, lower than reported in other countries. Provincial COVID-19 caseload did not influence this reduction.

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