BACKGROUND Above-average exercise capacity and a high threshold for symptoms such as dyspnea or chest pain in athletes can create false reassurance regarding the absence of clinically significant coronary artery disease (CAD). The aim of this report is to present the diagnostic reasoning and therapeutic management of an amateur endurance athlete who developed exertional dyspnea during a marathon run. CASE REPORT A 50-year-old man who was an amateur long-distance runner with a history of hypertension, hyperlipidemia reported recurrent exertional dyspnea with the onset approximately at the 20th kilometer of a marathon run, forcing a short rest but not preventing completion. Cardiopulmonary exercise testing (CPET) showed normal exercise capacity (peak oxygen uptake of 34 ml/min/kg, 104% of the predicted value). No dyspnea or chest pain occurred during maximal exertion, although ECG showed 1- to 2-mm ST-segment depression and T-wave changes in leads II, III, aVF, V5, and V6. Coronary computed tomography angiography (CCTA) showed a circumferential non-calcified plaque in the left anterior descending (LAD) artery, suggesting spontaneous coronary artery dissection. Coronary angiography confirmed severe left anterior descending artery (LAD) disease with 80% stenosis in segment 6 and a critical lesion in segment 7. Two drug-eluting stents were implanted into the LAD during a single procedure. CONCLUSIONS Firstly, supranormal exercise capacity and mildness of symptoms in endurance athletes can mask advanced CAD. Secondly, electrically positive CPET findings (1-2 mm ST-segment depression) warrant further anatomical assessment even in patients with low risk factor-weighted clinical likelihood. Finally, CCTA should be considered early in athletes with new-onset exertional symptoms, as it can reveal significant stenosis.

Takotsubo syndrome (TTS) is an acute cardiomyopathy characterized by transient left ventricular systolic dysfunction, often mimicking acute coronary syndrome. Current pathophysiological concepts emphasize sympathetic overactivity and catecholamine excess as major determinants of myocardial stunning, and experimental models further suggest that high epinephrine concentrations may induce a beta-2 adrenoceptor Gs-to-Gi signaling switch, contributing to severe but reversible myocardial dysfunction. Neurological triggers, particularly epileptic seizures, are increasingly recognized and may be associated with distinctive clinical profiles, arrhythmic complications, recurrence, and variable ventricular morphology. We report the case of a 57-year-old woman with epilepsy and chronic obstructive pulmonary disease who presented with acute chest pain immediately after a generalized tonic-clonic seizure. She had experienced a previous TTS episode 11 months earlier, documented as a mid-ventricular variant with a left ventricular ejection fraction (LVEF) of 50%. During the recurrent episode, electrocardiography showed sinus rhythm without ST-segment elevation, with known anteroseptal T-wave inversion. Serial laboratory testing demonstrated a relatively modest peak high-sensitivity troponin T level of 140 pg/mL despite severe left ventricular dysfunction, together with markedly elevated N-terminal pro-B-type natriuretic peptide. Transthoracic echocardiography showed an LVEF of 20%-25%, with apical hypokinesia extending to the adjacent mid-ventricular segments and relative basal hypercontractility. Coronary angiography showed no acute culprit lesion and was unchanged from the prior examination. Left ventriculography confirmed apical ballooning with mid-ventricular extension. By day 3, LVEF had improved to 52%, while cardiac magnetic resonance imaging showed normalized wall motion with mild residual myocardial edema. This case highlights recurrent seizure-triggered TTS with documented phenotypic switching and rapid functional recovery, emphasizing the value of multimodality imaging and coordinated neuro-cardiac management.

Preoperative echocardiography has long been used as an effective diagnostic tool in the preoperative assessment of surgical candidates. In elderly patients, hip fractures represent a critical medical emergency with a high risk of complications that can occur if not addressed promptly. Unnecessary preoperative investigations may lead to delays and potentially compromise the quality of patient care. The motivation to evaluate the utility of preoperative echocardiography in select clinical scenarios, particularly in low- and middle-income countries (LMICs) where resources are limited, arose from the case of a 72-year-old female who presented to a tertiary hospital in Nairobi, Kenya, with a right-sided intertrochanteric hip fracture following a traumatic fall. She was physically active with metabolic equivalents of tasks (METs) ≥4 and had no significant history of cardiovascular symptoms or risk factors. Preoperative electrocardiogram (ECG) was performed and revealed T-wave inversions in leads V5-V6, prompting a request for an echocardiogram. Technical difficulties led to a delay in the procedure, postponing surgery. The patient was later deemed fit for surgery by the cardiology team without the need for an echocardiogram, and she successfully underwent an open reduction and internal fixation (ORIF). Routine preoperative echocardiography serves minimal clinical benefit in asymptomatic and stable patients undergoing non-cardiac surgery. In such patients, metabolic equivalents of tasks (METs ≥4), normal N-terminal pro-B-type natriuretic peptide (NT-proBNP), and cardiac troponin levels can serve as sufficiently reliable tools for preoperative cardiovascular evaluation. Unnecessary echocardiograms have been associated with surgical delays, prolonged hospital stays, and increased healthcare costs. Evidence-based medical practices guided by established guidelines are essential in ensuring efficient patient care. In addition to obtaining a detailed patient history and thorough physical examination, it is also crucial to inform clinicians of the selective yet valuable role of echocardiograms in the preoperative assessments of surgical patients to prevent futile interventions and delays.

Marathon running is associated with transient elevations in cardiac and skeletal muscle biomarkers, which generally normalize within 72 h. However, persistent or extreme biomarker elevations may indicate underlying pathology, such as myocarditis. Early recognition and guideline-based management are essential to prevent complications and guide safe return to exercise.

Russell's viper envenomation is known to cause complications such as coagulopathy, acute kidney injury and haemolysis. Cardiac involvement, though rare, has been reported in the form of arrhythmias, myocardial infarction and ECG changes such as ST-segment elevation or T-wave inversions. We report a case of a middle-aged farmer who presented to our centre with Russell's viper envenomation, characterised by local envenomation, coagulopathy, haemolysis and ocular manifestations. His ECG showed a Brugada pattern, with no evidence of any structural cardiac abnormalities or elevated cardiac enzymes. A repeat ECG performed 72 hours after anti-snake venom therapy showed resolution of the ECG findings. A diagnosis of Brugada phenocopy secondary to Russell's viper envenomation was made. The most likely mechanism causing a Brugada phenocopy in Russell's viper envenomation may be due to phospholipase A2 present in the venom, causing alteration in the cardiac voltage-gated sodium channels.

A 38-year-old woman with a history of migraine headaches presented with episodic headaches, palpitations, chest pain, and worsening dyspnea. On arrival, she was hypertensive and tachycardic. Electrocardiography demonstrated inferolateral ST-segment depressions, QT interval prolongation, and elevated troponin levels, raising concern for acute myocardial infarction. Emergent coronary angiography revealed normal coronary arteries, while left ventriculography demonstrated basal hypokinesis with apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy. Abdominal computed tomography identified a 3 cm right adrenal nodule, and 24-hour urine metanephrine levels were elevated to >8× the upper limit of normal, suggestive of pheochromocytoma. The patient was managed conservatively with alpha-adrenergic blockade. Follow-up abdominal magnetic resonance imaging demonstrated a decrease in nodule size to 2.3 cm with evidence of intralesional hemorrhage, and catecholamine levels subsequently normalized, leading to deferral of adrenalectomy. At 6-month follow-up, transthoracic echocardiography showed normalization of left ventricular function, and repeat abdominal computed tomography revealed marked reduction in the adrenal mass. At 1 year, she remains asymptomatic with normal biochemical testing.

Out-of-hospital cardiac arrest (OHCA) without ST-segment elevation represents a challenging diagnostic scenario, particularly in young patients with low pretest probability of atherosclerotic disease. We report the case of a 25-year-old man with cystic fibrosis who presented with ventricular fibrillation during a pulmonary exacerbation complicated by hemoptysis and hypoxemia. After successful resuscitation, electrocardiography showed anterolateral T-wave inversions and highsensitivity troponin demonstrated a marked rise and fall. Transthoracic echocardiography revealed regional wall motion abnormalities with mildly reduced left ventricular ejection fraction. In the absence of ST-segment elevation, coronary computed tomography angiography was performed and excluded obstructive coronary artery disease and congenital anomalies. Early cardiac magnetic resonance demonstrated extensive transmural late gadolinium enhancement in a coronary distribution with microvascular obstruction, consistent with acute ischemic myocardial infarction despite normal epicardial coronaries, establishing a diagnosis of myocardial infarction with nonobstructive coronary arteries (MINOCA). This case illustrates a structured, stepwise, and entirely noninvasive multimodality imaging approach to OHCA without ST-elevation and highlights the central role of early cardiac magnetic resonance in mechanism clarification and clinical decision-making in suspected MINOCA.

A 62-year-old man presented with severe chest pain and hypotension. The ECG demonstrated deep ST-depression in leads V3-V5, fused with QRS complex and T wave, resembling an inverted "shark fin" pattern. We discuss the clinical significance of this unusual ECG pattern.

Takotsubo syndrome is characterized by transient left ventricular (LV) systolic dysfunction in the absence of obstructive coronary artery disease. ST-segment elevation is frequently observed in the acute phase and typically resolves within several days, evolving into T-wave inversion. Prolonged ST-segment elevation is uncommon, and its clinical significance remains incompletely understood. Here, we report the case of an elderly woman with takotsubo syndrome likely triggered by a urinary tract infection. The initial electrocardiogram showed marked ST-segment elevation with terminal T-wave inversion in leads V3-V6, with a maximum elevation of 3 mm in lead V4. ST-segment elevation persisted for at least 20 days, accompanied by persistent severe LV wall motion abnormalities and systemic inflammation, as evidenced by sustained elevation of C-reactive protein. Coronary angiography revealed no obstructive coronary artery disease. Furthermore, dual-isotope myocardial scintigraphy using 201Tl and 123I-β-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) revealed a marked perfusion-metabolism mismatch, with moderately reduced 201Tl uptake and severely reduced 123I-BMIPP uptake in the dysfunctional segments. This case suggests that recovery of LV function may occasionally be incomplete or substantially delayed, particularly in the context of systemic inflammation.