Sildenafil-inducing allergic angina in elderly with intertwining sinus arrhythmia, wavy triple sign, wavy double sign (Yasser’s signs), and mild covid-infection; interpretation and management

Rationale: Sildenafil is a phosphodiesterase-5 inhibitor (PDE5-I) drug used to treat erectile dysfunction (ED) and pulmonary arterial hypertension. Allergic angina and infarction are broad-spectrum mast cell activation disorders accompanied by acute coronary syndromes (ACS) and are known as Kounis-Zafras (KZ) syndrome. Sinus arrhythmia is a variation of normal sinus rhythm (NSR) that is associated with an irregular rate in which the change in the R-R interval is greater than 0.12 seconds. Wavy triple and Wavy double ECG signs (Yasser’s sign) are new specific diagnostic and therapeutic signs seen in the cases of hypocalcemia. Mild COVID-19 infection means you have symptoms like cough, sore throat, and fatigue, but no dyspnea. Patient concerns: An elderly married male farmer patient was admitted to the intensive care unit with angina, hypotension, generalized hives, Wavy triple, and Wavy double ECG signs after ingestion of sildenafil tablet with mild COVID-19 infection in a previous chronic obstructive pulmonary disease (COPD). Diagnosis: Sildenafil-inducing Kounis syndrome in the elderly with intertwining sinus arrhythmia, Wavy triple sign, Wavy double sign (Yasser’s signs), and mild COVID-19 infection. Interventions: Electrocardiography, oxygenation, IV fluids, and echocardiography. Outcomes: A dramatic clinical and electrocardiographic improvement had happened. Lessons: Sildenafil-inducing Allergic angina and anaphylaxis may be innovative cardiovascular findings. Mild COVID-19 infection, sometimes, can be insignificant. An associated sinus arrhythmia may be a good cardiovascular sign. The dramatic improvement in both clinical and electrocardiographic ST-segment depressions and elevations supports the efficacy of both anti-ischemic and anti-allergic measures.