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Cardiovascular involvement is one of the end-organ complications commonly reported in coronavirus disease 2019 (COVID-19). It has also been postulated to be an independent risk factor for increased mortality in COVID-19-infected patients. With such a significant effect of COVID-19 on the cardiovascular system and vice versa, it is pivotal for physicians to observe this association closely for improving management and understanding prognosis in these patients. Here, we present three patients and describe their baseline cardiac risk factors, the cardiac complications they developed in association with COVID-19 infection, and their varying outcomes.

Pericardial decompression syndrome (PDS) is an unusual clinical scenario with a reported incidence of 5% in all surgical or percutaneously managed pericardial tamponade patients. It is defined as a paradoxical hemodynamic instability leading to left ventricular (LV), right ventricular (RV), or biventricular dysfunction. An 84-year-old female with a history of a chronic pericardial effusion presented with symptoms of tamponade. She had had multiple prior admissions with an extensive and unyielding workup for the etiology of her pericardial effusion. During the present admission, a transthoracic echocardiogram (TTE) confirmed an augmenting pericardial effusion causing cardiac tamponade. She underwent a pericardial window with the removal of 1.2 liters of serous fluid. Postoperatively, she went into cardiogenic shock from right heart failure. Unfortunately, there also was re-accumulation of the pericardial effusion and worsening hemodynamic instability. Due to her poor prognosis, she was transitioned to comfort care. Although the etiology of PDS is unknown, it has been theorized to be caused by an imbalance of sympathetic-parasympathetic states after a rapid decompression. Currently, there are no clear guidelines or recommendations regarding the quantity of fluid that can be removed safely. More awareness leading to a more cautious and staged pericardial drainage might be the required solution.

Coronavirus has caused thousands of deaths due to several mechanisms of injury including acute kidney injury (AKI). Most of the patients have a fast progression of the disease leading to death in the second week of hospital admission, however, here we have a case of a 58-year-old female who died in less than 24 hours of admission due to severe metabolic acidosis, acute respiratory distress syndrome (ARDS) and renal failure.

BACKGROUND We are reporting a case of a Hispanic female who presented with a pericardial effusion as a complication of hypothyroidism, untreated due to lack of medical care, which demonstrates health disparities in chronic diseases. CLINICAL CASE The patient is a 48 year-old Hispanic female with PMHx of hypothyroidism, non-compliant with medical therapy, who presented to the ED with fatigue and dyspnea. Despite progressively worsening symptoms for the past 4 months, she had refused to be seen by a physician because she was uninsured. Her physical exam was notable for generalized pallor and bradycardia, with otherwise normal cardiopulmonary exam. Her initial laboratory data showed hemoglobin of 5.5 g/dl. CXR demonstrated an enlarged cardiac silhouette, which on CT was found to represent a large pericardial effusion. On admission her laboratory data demonstrated low ferritin, TSH of 94 mIU/L and T4 of 1.4 mcg/dl. m. Cortisol was 9 mcg/dl at 11 am. Repeat hemoglobin post-transfusion was 9 g/dl The patient was started on IV levothyroxine and hydrocortisone. Echocardiogram showed a large posterior wall pericardial effusion without evidence of RV strain. Pericardiocentesis was attempted but was unsuccessful because of difficult access to the fluid location. She was discharged on levothyroxine 88mcg QD and recommended to follow up with endocrinology and cardiology as an outpatient. It is well known that the United States spends a disproportionate amount of money in healthcare in comparison to developing countries (1). Underinvestment in social services and high prices set by pharmaceutical companies are likely contributing factors (1). Unfortunately, the resulting outcomes do not necessarily reflect the spending. Minorities are well known to have a higher morbidity and mortality as well as to present more frequently with dramatic manifestations of chronic diseases. This can often be attributed to a lack of access to medical care and poor follow up. Our patient was diagnosed with pericardial effusion as a complication of untreated hypothyroidism, a condition that is underdiagnosed despite a high incidence (3-37%). This pericardial effusion was initially concerning due to its large volume. The fact that she was hemodynamically stable reflects its chronicity, but it could have led to a fatal complication if she continued without appropriate therapy for a longer period of time. CONCLUSION A case such as this should make us question what more we can do to improve healthcare outcomes for minorities in the USA. REFERENCES (1). Papanicolas, Irene, Liana R. Woskie, and Ashish K. Jha. “Health care spending in the United States and other high-income countries.” Jama 319.10 (2018): 1024-1039.