Case history/Examination
An 84-year-old woman with a history of high blood pressure and
cholecystitis on targeted antibiotic therapy in the previous 5 days was
admitted to the emergency department of a hospital specialising in
cardiology and cardiovascular surgery because she had an episode of
syncope while sitting in another hospital without referring other
symptoms to the questioning. Upon admission, his vital signs were within
the normal range, with abdominal pain on palpation in the right upper
quadrant of the abdomen, as well as a positive Murphy’s sign and
arrhythmic heart sounds discordant with the pulse, with no other
findings on the examination.
The initial ECG showed a typical atrial flutter with rapid ventricular
response, with a 0.1 mV rise in SST in aVR, as well as a decrease in SST
and inversion of the T wave in Dl, inferior derivatives, and from V2 to
V5 (Figure 1), suggesting a possible obstructive lesion of the LMCA. In
addition, acute myocardial injury was documented with high-sensitivity
troponin T; however, chest pain was not documented, so it was considered
secondary to the ongoing infectious process. Likewise, strikingly,
severe hypokalemia was documented (1.9 meq/L), which, when corrected,
showed the resolution of the initially mentioned electrocardiographic
findings suggestive of a LMCA lesion, also returning to a sinus rhythm
in the ECG (Figure 2).
For its part, the echocardiogram demonstrated preserved biventricular
function, with a left ventricular ejection fraction (LVEF) of 61%,
without contractility disorders, valvular heart disease, or other
relevant findings (Figure 3). Therefore, it was considered that the
electrocardiographic findings were secondary to hypocalcemia, thus
completing the broad-spectrum antibiotic therapy for his cholecystitis
and presenting a satisfactory clinical and paraclinical evolution during
follow-up.