Unmasking The Silent Damage: A Case Of Cardiac Injury

HISTORY: 51-year-old former professional football player presented for a comprehensive annual wellness evaluation. The patient had no acute complaints or concerns. During the review of symptoms, he reported intermittent chest pain both at rest and with activity. He has a history of Paroxysmal Atrial Fibrillation (PAF) and reports the current symptoms are different from his prior PAF episodes. He believed that it was related to his acid reflux. At the time of the examination no chest pain was noted, nor did he have any chest pain recently or while exercising the day prior. PAST MEDICAL HISTORY: PAF, Bilateral Primary Knee Osteoarthritis, Right Shoulder Osteoarthritis Abnormal echo/ECG cMRI with 14 mm proximal septal hypertrophy, concentric LV remodeling - mild cardiomyopathy v athlete’s heart, asymptomatic and physically active PHYSICAL EXAM: BP 121/84 BMI 35.7 Regular Rate and Rhythm Normal S1 and S2 No murmur, rubs, or gallops Peripheral Pulses 2+ bilaterally. Capillary refill was less than 2 seconds. No chest wall tenderness TEST AND RESULTS: Initial ECG Acute MI/STEMI, anterior infarct, SR with 1st degree AV block Repeat ECG SB with 1st degree AV block, ST elevations in v1-4 in convex pattern, poor R wave progression in precordial leads ECG Jun 22 (comparison) NSR, NSST changes (early repolarization) Initial labs hsTroponin elevated at 480 A1C 5.2CMP/CBC/TSH normal DIFFERENTIAL DIAGNOSIS: Myocardial injury acute verse chronic. Discussed with Cardiology and referred to ER for evaluation and admission. Hospitalization Repeat hsTroponin 449 BNP <5 - normal Pro-BNP <35 normal Echocardiogram LV overall normal - mild increased wall thickness LV function is normal, EF 65% Normal RV and valves Coronary Artery CTA Non-calcified plaque in the proximal LAD, causing <10% stenosis, with positive remodeling and a small calcification in the distal end No evidence of flow-limiting coronary disease. hsTroponin (next day) 362Lipids TC 198, LDL 114, HDL 61, ApoB 83, LP(a) <7 FINAL WORKING DIAGNOSIS: Non-ischemic troponin elevation due to coronary artery bridging Coronary artery disease Hyperlipidemia TREATMENT AND OUTCOMES: Rosuvastatin 5 mg Outpatient hypertension evaluation as BP in hospital ranged high 140 s-160 s/90s